Airway Obstruction and Bronchodilator Responsiveness in Adults With Acute Cough

PURPOSE

We sought to determine the prevalence of airway obstruction and bronchodilator responsiveness in adults consulting for acute cough in primary care.

METHODS

Family physicians recruited 3,105 adult patients with acute cough (28 days or shorter) attending primary care practices in 12 European countries. After exclusion of patients with preexisting physician-diagnosed asthma or chronic obstructive pulmonary disease (COPD), we undertook complete case analysis of spirometry results (n = 1,947) 28 to 35 days after inclusion. Bronchodilator responsiveness was diagnosed if there were recurrent complaints of wheezing, cough, or dyspnea and an increase of the forced expiratory volume in 1 second (FEV₁) of 12% or more after bronchodilation. Airway obstruction was diagnosed according to 2 thresholds for the (postbronchodilator) ratio of FEV₁ to forced vital capacity (FEV₁:FVC): less than 0.7 and less than the lower limit of normal.

RESULTS

There were 240 participants who showed bronchodilator responsiveness (12%), 193 (10%) had a FEV₁/FVC ratio of less than 0.7, and 126 (6%) had a ratio of less than the lower limit of normal. Spearman''s correlation between the 2 definitions of obstruction was 0.71 (P <.001), with discordance most pronounced among those younger than 30 years and in older participants.

CONCLUSIONS

Both bronchodilator responsiveness and persistent airway obstruction are common in adults without established asthma or COPD who consult for acute cough in primary care, which suggests a high risk of undiagnosed asthma and COPD. Different accepted methods to define airway obstruction detected different numbers of patients, especially at the extremes of age. As both conditions benefit from appropriate and timely interventions, clinicians should be aware and responsive to potential underdiagnosis.Key words: acute cough, asthma, chronic obstructive pulmonary disease, primary health care, spirometry     

Incidental Findings in a Federally-Sponsored Cancer Screening Program

The volume of non-cancer related clinical services and referrals for medical care of women as a consequence of their enrollment in a federally-sponsored breast and cervical cancer screening program was examined. We randomly sampled 100 medical records from among 389 individuals who received cancer screening services through the Connecticut Breast and Cervical Cancer Early Detection Program. Medical record audits tabulated occasions when women were offered or received diagnostic or therapeutic procedures as a by product of their program participation. Breast screening was provided to 100 women and 49 individuals received cervical cancer screening. In addition, 87 percent of the sample were offered or received one or more non-cancer related health services. Physical exams were provided to 86 women, laboratory tests were ordered for 11 individuals and 55 referrals were made to address a myriad of specific medical needs that were uncovered incidental to breast and cervical cancer screening. Among 26 women who did not heed recommendations for follow-up care, cost, inconvenience and beliefs that medical problems were not immediate concerns were cited. Local screening program sponsors should be cognizant that the health care needs and limited resources of some target populations may be substantial. Mechanisms to assure that needed health care is available to individuals should be built and into all categorical health service programs.     

Combining Procalcitonin and Rapid Multiplex Respiratory Virus Testing for Antibiotic Stewardship in Older Adult Patients With Severe Acute Respiratory Infection

ObjectivesVirus infection is underevaluated in older adults with severe acute respiratory infections (SARIs). We aimed to evaluate the clinical impact of combining point-of-care molecular viral test and serum procalcitonin (PCT) level for antibiotic stewardship in the emergency department (ED).DesignA prospective twin-center cohort study was conducted between January 2017 and March 2018.Setting and ParticipantsOlder adult patients who presented to the ED with SARIs received a rapid molecular test for 17 respiratory viruses and a PCT test.MeasuresTo evaluate the clinical impact, we compared the outcomes of SARI patients between the experimental cohort and a propensity score–matched historical cohort. The primary outcome was the proportion of antibiotics discontinuation or de-escalation in the ED. The secondary outcomes included duration of intravenous antibiotics, length of hospital stay, and mortality.ResultsA total of 676 patients were included, of which 169 patients were in the experimental group and 507 patients were in the control group. More than one-fourth (27.9%) of the patients in the experimental group tested positive for virus. Compared with controls, the experimental group had a significantly higher proportion of antibiotics discontinuation or de-escalation in the ED (26.0% vs 16.1%, P = .007), neuraminidase inhibitor uses (8.9% vs 0.6%, P < .001), and shorter duration of intravenous antibiotics (10.0 vs 14.5 days, P < .001).Conclusions and ImplicationsCombining rapid viral surveillance and PCT test is a useful strategy for early detection of potential viral epidemics and antibiotic stewardship. Clustered viral respiratory infections in a nursing home is common. Patients transferred from nursing homes to ED may benefit from this approach.     

高氧液治疗急性脑梗死的临床研究

目的通过临床研究,对高氧液治疗急性脑梗死的疗效和安全性进行客观评价。方法将90例脑梗死患者随机分为高氧液治疗组,高压氧治疗组和常规治疗组,进行前瞻性研究,通过比较三组治疗前后血液流变学指标和神经功能缺损程度评分,予方差分析和t检验。结果高氧液治疗组与高压氧治疗组对血液流变学指标改善显著(P<0.05),两组均未发现任何副反应,与常规治疗组相比神经功能评分下降(P<0.05)。结论高氧液对急性脑梗死治疗疗效显著,安全可靠、方便;为脑梗死后神经功能缺损改善及脑梗塞的二级预防提供新的手段。     

急性白血病患者VEGF水平测定及意义探讨

目的探讨VEGF水平和白血病类型、病情的关系,为白血病的治疗和预后的判断提供依据。方法测定不同病程时期急性淋巴细胞白血病(ALL)和急性非淋巴细胞白血病(ANLL)外周血、骨髓和骨髓有核细胞培养上清液中VEGF水平,同时检测骨髓幼稚细胞水平,分析VEGF与白血病类型、病情及预后的关系。结果ALL组和ANLL组的不同病程时期,外周血、骨髓血及骨髓细胞培养上清液VEGF水平均明显高于对照组,ALL和ANLL组间差别无显著性意义。同一组内,骨髓血VEGF水平高于外周血,外周血高于骨髓细胞培养上清液。急性白血病初诊、缓解、难治/复发各组外周血VEGF水平均高于对照组(P值均<0.01)。其中以例难治/复发者最高。化疗缓解后VEGF水平下降,但仍高于对照。白血病患者外周血VEGF水平与骨髓原幼细胞比例变化一致。结论外周血、骨髓VEGF水平与白血病病情正相关,对白血病的诊断、治疗和预后的判断有一定意义。     

急性心肌梗死合并心力衰竭患者和肽素分析

目的分析急性心肌梗死合并心力衰竭患者和肽素的变化。方法2017年8月30日—2019年8月30日,本院共收治57例急性心肌梗死合并心力衰竭患者,回顾分析57例患者全部资料并将其定为研究对象,并纳入观察组,同期选择我院57例健康体检人员作为对照组,对两组患者入院、入院后3 h、6 h、12 h、24 h以及72 h的和肽素水平进行检测,评价分析和肽素水平的变化意义。结果观察组入院、入院后3 h、6 h、12 h、24 h以及72 h的和肽素水平高于对照组,P<0.05,随着入院时间延长,和肽素水平逐渐降低。结论与健康人员相比较,急性心肌梗死合并心力衰竭患者的和肽素水平会显著升高,可作为急性心肌梗死合并心力衰竭早期诊断生物学标志物,及时监测有利于作出正确的诊疗方案。     

胸部肿瘤患者术后肺炎的危险因素分析

目的探讨胸部肿瘤患者术后肺炎的病原菌分布及其危险因素。方法对医院ICU收治的279例胸部肿瘤术后患者进行回顾性分析,并对其病原菌进行检验。结果开胸术后肺炎以革兰阴性杆菌为主,占41.4%,革兰阳性球菌占32.6%,真菌占26.0%;高龄、严重基础疾病、先前广谱抗菌药物的应用、手术创伤、术后机械通气及侵入性治疗等为胸部肿瘤术后肺炎的危险因素。结论加强围手术期的综合管理措施是降低其发生率及病死率的重要手段。     

急性心肌梗塞患者血管内皮生长因子的动态表达

目的　探讨急性心肌梗塞 (AMI)后血清血管内皮生长因子 (VEGF)表达及意义。方法　分别抽取 2 5例AMI患者发病后第 1、5、10和 15d的外周静脉血 ,用酶联免疫吸附法 (ELISA)测定VEGF浓度。结果　AMI患者血清VEGF在AMI后第 10d达高峰 ,显著高于对照组 ( 178 9± 48 9pg/mlvs 64 9± 16 7pg/ml,P <0 0 5 )。血清中VEGF峰值与肌酸激酶 (CK)峰值呈显著正相关 (γ =0 73 ,P <0 0 1)。结论　AMI患者血清VEGF水平持续升高与心肌梗塞程度有关。     

急性白血病患者血脂变化的初步探讨

有关肿瘤患者血脂异常的报道已有不少 ,但绝大多数集中于实体瘤 ,且以消化系肿瘤为最。而有关急性白血病 (ＡＬ)与血脂关系的研究则进行得较少 ,特别是经治疗达到完全缓解 ,而后复发的患者是否也有血脂异常则未见报道。为此 ,笔者对 10 7例ＡＬ患者的血脂变化作一初步探讨 ,以期了解其变化规律 ,为临床工作提供帮助。1　资料与方法1·1　一般资料　 10 7例ＡＬ患者为中山一院 1997年 9月至 2 0 0 0年 6月间的初治病例 ,全部经外周血、骨髓细胞形态学和组织化学检查而确诊 ,部分还经免疫学和细胞遗传学检查。 10 7例ＡＬ患者中男性 73例 ,女…     

急性中风眩晕患者实施中医综合护理的效果观察

目的观察对急性中风眩晕患者实施中医综合护理的临床效果。方法抽选2018年1月-2019年4月本院急性中风眩晕患者80例,并随机分为观察组与对照组,每组40例;对照组给予常规护理,而观察组则加以中医综合护理干预。评估两组护理干预的临床效果、生活质量综合评分量表(generic quality of life inventory-74,GQOLI-74)评分和彼得需求满意度调查表(nursing satosfaction quality,NSQ)评分情况。结果干预前两组GQOLI-74评分无明显差异,干预后观察组GQOLI-74评分明显高于对照组,差异有统计学意义(P<0.01);观察组NSQ评分明显高于对照组,差异有统计学意义(P<0.01)。结论中医综合护理应用于急性中风眩晕患者当中,能明显提高临床效果、生活质量和护理满意度。     

Discharge Communication in Patients Presenting to the Emergency Department With Chest Pain: Defining the Ideal Content

In an emergency department (ED), discharge communication represents a crucial step in medical care. In theory, it fosters patient satisfaction and adherence to medication, reduces anxiety, and ultimately promotes better outcomes. In practice, little is known about the extent to which patients receiving discharge information understand their medical condition and are able to memorize and retrieve instructions. Even less is known about the ideal content of these instructions. Focusing on patients with chest pain, we systematically assessed physicians’ and patients’ informational preferences and created a memory aid to support both the provision of information (physicians) and its retrieval (patients). In an iterative process, physicians of different specialties (N = 47) first chose which of 81 items to include in an ED discharge communication for patients with acute chest pain. A condensed list of 34 items was then presented to 51 such patients to gauge patients’ preferences. Patients’ and physicians’ ratings of importance converged in 32 of the 34 items. Finally, three experts grouped the 34 items into five categories: (1) information on diagnosis; (2) follow-up suggestions; (3) advice on self-care; (4) red flags; and (5) complete treatment, from which we generated the mnemonic acronym “InFARcT.” Defining and structuring the content of discharge information seems especially important for ED physicians and patients, as stress and time constraints jeopardize effective communication in this context.

Chest pain accounts for up to 10% of all patient presentations in emergency departments (EDs) (Konkelberg & Esterman, 2003). The majority of these patients will usually be discharged within hours, after exclusion of serious conditions such as myocardial infarction (Goodacre et al., 2011). A comprehensive workup of low- to intermediate-risk patients is not feasible in the ED (Reichlin et al., 2009). Yet many of these patients go on to suffer from repeated episodes of chest pain, associated with anxiety and uncertainty about diagnosis and outcome (Jones & Mountain, 2009). Effective discharge communication, empowering patients to understand and memorize medical information, should therefore be an integral part of patient care. It is a likely contributor to better outcomes (Bishop, Barlow, Hartley, & William, 1997; Kessels, 2003), higher patient satisfaction (Kessels, 2003), better adherence to medication (Cameron, 1996; Kessels, 2003), more adequate disease management, and reduced anxiety (Galloway et al., 1997; Mossman, Boudioni, & Slevin, 1999).     

Ultrasound Imaging for Tailored Treatment of Patients With Acute Shoulder Pain

PURPOSEThe objective of this study was to assess the frequencies of ultrasound findings in patients with acute rotator cuff disorders in family medicine.METHODSIn a prospective observational study, 129 patients aged 18 to 65 years with acute shoulder pain in whom the family physician suspected rotator cuff disease underwent ultrasound imaging.RESULTSRotator cuff disease was present in 81% of the patients, and 50% of them had multiple disorders. Calcific tendonitis was the most frequently diagnosed specific disorder. An age of 40 years or older was most strongly related to rotator cuff disease.CONCLUSIONSUltrasound imaging enables family physicians to rationalize treatment in nearly all patients who are aged 40 years and older with acute shoulder pain.     

长期生存急性髓性白血病23例临床分析

目的总结分析我院收治的生存五年以上急性髓性白血病23例(AML)患者的临床情况,并探讨其影响预后的多种相关因素。方法分析1990～2003年167例中长期生存5年以上23例AML患者的临床及实验室资料。结果23例生存5年以上者,M1 1例,M2 5例,M3 13例,M4 1例,M5 3例,达完全缓解时间较短,完全缓解后坚持强化,化疗时间为3～5年。结论白血病细胞类型、达初次缓解的疗程和时间、年龄、个体化治疗是影响急性白血病患者生存的重要原因。     

The Cost-Effectiveness of Stem Cell Transplantations from Unrelated Donors in Adult Patients with Acute Leukemia

OBJECTIVE: Hematopoietic stem cell transplantation is an accepted treatment of hematological malignancies, but the cost-effectiveness of this technology has not been fully explored. This study aims to assess the cost-effectiveness of stem cell transplantation from either cord blood or bone marrow/peripheral blood compared with no transplantation in adult patients with acute leukemias not expected to be cured with chemotherapy. METHODS: A systematic review was performed to estimate the efficacy of unrelated cord blood and bone marrow/peripheral blood stem cells (BM/PBSC) transplantations in adults with acute leukemia. A Markov decision analysis model using Monte Carlo simulations was used to calculate the incremental cost-effectiveness ratio (ICER) and 95% confidence intervals (CIs). RESULTS: The estimated cumulative survival at 1 and 10 years were 27.9% and 14%, respectively, for cord blood recipients and 47% and 17.7%, respectively, for BM/PBSC recipients. Using conservative assumptions, the cost per life-year gained compared with no transplantation was US 16,346 dollars (95% CI 8695 dollars, 38,006 dollars) for BM/PBSC transplantation and US 34,360 dollars (95% CI 23,101 dollars, 89,417 dollars) for cord blood transplantation. CONCLUSIONS: Although both types of stem cell transplantations are associated with a high short-term mortality and high cost, the cumulative gains in life-years of survivors can be substantial, resulting in ICERs compared with no transplantation that are usually considered acceptable. However there is less certainty about this conclusion with cord blood transplantation.     

FRAIL Scale also Predicts Long-Term Outcomes in Older Patients With Acute Coronary Syndromes

ObjectivesNo previous studies have assessed the role of the FRAIL scale in predicting long-term outcomes in older patients with acute coronary syndromes (ACS).Design, Setting and ParticipantsThe multicenter observational LONGEVO-SCA registry included unselected patients ≥80 years of age with ACS from 44 centers. A comprehensive geriatric assessment was performed during hospitalization.MeasuresFrailty was measured by the FRAIL scale. For the purpose of this study, main outcome measured was mortality or readmission at 24 months.ResultsA total of 498 patients were included. Mean age was 84.3 years. A total of 198 patients (33.1%) were prefrail and 135 (27.1%) frail. Patients who were prefrail and frail had a higher degree of comorbidities, and higher prevalence of disability, cognitive impairment, and nutritional risk. A total of 165 out of 498 patients (33.1%) died, and 331 patients (66.7%) died or were readmitted at 24 months. Both prefrailty and frailty were associated with a higher mortality compared with robust patients (P < .001). The incidence of mortality or readmission was also higher in patients who were prefrail or frail (P < .001). After adjusting for potential confounders, the association between frailty and mortality or readmission remained significant (hazard ratio 1.28 for prefrailty and hazard ratio 1.96 for frailty, P < .001). The FRAIL scale showed an optimal ability for predicting mortality or readmission (area under the receiver operating characteristics curve 0.86, 95% confidence interval 0.83‒0.89). The area under the receiver operating characteristics curve from the Global Registry of Acute Coronary Events risk score was 0.89. No significant differences were observed between both AUC values (P = .163).Conclusions and ImplicationsThe FRAIL scale independently predicted long-term outcomes in older patients with ACS. The predictive ability of this scale was comparable to the strongly recommended Global Registry of Acute Coronary Events risk score. Frailty assessment is mandatory for improving risk prediction in these complex patients.     

构建医联体平台下急性胸痛患者智慧化管理模式

从复旦大学附属中山医院总院、紧密型医联体医院及患者3方面,分析急性胸痛患者管理现状。针对急性胸痛患者病史采集规范性、正确判断率、诊治流程等多个攻坚点拟定对策并加以筛选,形成3大方策群组予以实施:（1）建立急性胸痛规范化、同质化诊治流程;（2）基于大数据构建胸痛智慧化疾病诊断系统;（3）依托医联体增强胸痛患者早期预警意识。通过对策实施,形成了多项胸痛诊治标准流程,建立了胸痛诊断数据模型,为后续实践提供了参考。     

Radiotherapy for Chest Cancers in Patients with Tuberculosis

With adequate cover by antitubercular drugs, reactivation and spread of tuberculosis can be avoided despite the use of cancericidal doses of radiation, and life can be prolonged for patients having both tuberculosis and pulmonary neoplasms. The author draws on 15 years of clinical experience to demonstrate that the traditional contraindication of irradiation in tuberculars no longer holds true.