Increased risk of acute coronary syndrome in patients with bronchiectasis: A population‐based cohort study

Background and objective

There are few studies on the relationship between bronchiectasis and acute coronary syndrome (ACS). We conducted a population‐based cohort study to assess whether bronchiectasis was associated with an increased risk of ACS.

Methods

We identified 3521 patients diagnosed with bronchiectasis between 2000 and 2010 (bronchiectasis cohort) and frequency matched them with 14 084 randomly selected people without bronchiectasis from the general population (comparison cohort) according to sex, age and index year using the Longitudinal Health Insurance Database. Both cohorts were followed until the end of 2010 to determine the ACS incidence. Hazard ratios of ACS were measured.

Results

Based on 17 340 person‐years for bronchiectasis patients and 73 639 person‐years for individuals without bronchiectasis, the overall ACS risk was 40% higher in the bronchiectasis cohort (adjusted hazard ratio (HR) = 1.40; 95% CI: 1.20–1.62). Compared with those in the comparison cohort with one respiratory infection‐related emergency room (ER) visit per year, the ACS risk was 5.46‐fold greater in bronchiectasis patients with three or more ER visits per year (adjusted HR = 5.46, 95% CI: 4.29–6.96). Patients with bronchiectasis and three or more respiratory infection‐related hospitalizations per year had an 8.15‐fold higher ACS risk (adjusted HR = 8.15, 95% CI: 6.27–10.61).

Conclusion

Bronchiectasis patients, particularly those experiencing frequent exacerbations with three or more ER visits and consequent hospitalization per year, are at an increased ACS risk.

     

External beam radiation therapy combined with airway stenting leads to better survival in patients with malignant airway obstruction

Background and objective

Malignant airway obstruction (MAO), a common complication of patients with advanced lung cancer, causes debilitating dyspnoea and poor quality of life. Two common interventions used in the treatment of MAO include bronchoscopy with airway stenting and external beam radiotherapy (EBRT). Data are limited regarding their clinical effectiveness and overall effect on survival.

Methods

A retrospective chart review of patients treated with airway stenting and/or EBRT at the Johns Hopkins Hospital for MAO between July 2010 and January 2017 was reviewed. Demographics, performance status, cancer histology, therapeutic intervention and date of death were recorded. Survival was calculated using cox regression analysis.

Results

Of the 606 patients who were treated for MAO, 237 were identified as having MAO and included in the study. Sixty‐eight patients underwent rigid bronchoscopy and stenting, 102 EBRT and 67 a combined approach. Patients who underwent stenting hand an increased hazard ratio (HR) of death in comparison to those who received combination therapy (HR: 2.12, 95% CI: 1.02, 4.39), while there was a trend towards significance in the EBRT alone group in comparison to the combination therapy group (HR: 1.62, 95% CI: 0.93, 2.83).

Conclusion

In this retrospective analysis, combination therapy with stenting and EBRT led to better survival in comparison to stenting or EBRT alone. Prospective cohort trials are needed to confirm these results.

     

Segmentectomy versus lobectomy in early non‐small cell lung cancer of 2 cm or less in size: A population‐based study

Background and objective

Standard surgical management for early stage lung cancer is lobectomy with mediastinal lymph node dissection. The feasibility of limited resection remains controversial; we retrospectively assessed lung cancer‐specific survival (LCSS) and overall survival (OS) in early stage non‐small cell lung cancer (NSCLC) to evaluate whether segmentectomy is comparable to standard lobectomy.

Methods

Patients with primary NSCLC of 20 mm or less who were diagnosed from 2000 to 2014 were extracted from the Surveillance, Epidemiology, and End Results (SEER) database. To compare the two surgical interventions, a propensity score analysis was performed between lobectomy and segmentectomy.

Results

Of the 15 358 patients analysed, there were 14 549 lobectomies and 809 segmentectomies. The 5‐year OS was 76% for the lobectomy group and 74.4% for the segmentectomy group. There were no significant differences in OS or LCSS among patients who underwent lobectomy versus segmentectomy, as demonstrated by the propensity‐matched hazard ratio (HR) for OS (HR: 1.195, 95% CI: 0.993–1.439) and LCSS (HR: 1.124, 95% CI: 0.860–1.469). The inverse propensity‐weighted analysis also supported these results. Segmentectomy was more likely to be performed in elderly patients. In the subset of patients aged ≥75 years, the segmentectomy group demonstrated comparable OS (HR: 1.17, 95% CI: 0.87–1.58, P = 0.31) and LCSS (HR: 0.94, 95% CI: 0.59–1.51, P = 0.81), compared with the lobectomy group.

Conclusion

Equivalent OS and LCSS were demonstrated in patients with primary NSCLC of 20 mm or less without lymph node or distant metastasis.

     

Multiple breath washout: A new and promising lung function test for patients with idiopathic pulmonary fibrosis

Background and objective

Idiopathic pulmonary fibrosis (IPF) is a devastating progressive lung disease affecting the parenchyma. Nitrogen multiple‐breath washout (N₂‐MBW) is a lung function test that measures ventilation inhomogeneity, a biomarker of small airway disease. We assessed clinical properties of N₂‐MBW in IPF.

Methods

In this prospective cohort pilot study, 25 IPF patients and 25 healthy controls were assessed at baseline and 10 patients at median 6.2 months later. Outcomes included the lung clearance index (LCI) from N₂‐MBW, forced vital capacity (FVC) from spirometry, diffusion capacity of the lungs for carbon monoxide (DL_CO), bronchiectasis score from computed tomography scans, the Gender–Age–Physiology (GAP score for IPF) stage and death or lung transplantation (LTx). Study end points were feasibility, repeatability, discriminative capacity and correlation with disease severity and structural lung damage.

Results

All patients were able to perform N₂‐MBW. LCI was repeatable and reproducible. Median (interquartile range (IQR)) LCI in IPF was 11.6 (10.1–13.8) in IPF versus 7.3 (6.9–8.4) in controls (P < 0.0001). LCI correlated with DL_CO corrected for haemoglobin (corrDL_CO; r = −0.49, P = 0.016), bronchiectasis score (r = 0.45, P = 0.024) and the GAP stage (r = 0.59, P = 0.002), but not with FVC. FVC was not related to bronchiectasis. During follow‐up, six patients died and one received LTx. LCI correlated with the latter compound outcome: hazard ratio (95% CI) was 2.43 (1.26; 4.69) per one LCI SD from the patient population.

Conclusion

N₂‐MBW is a feasible, reliable and valid lung function test in IPF. LCI correlates with diffusion impairment, structural airway damage and clinical disease severity. LCI is a promising surveillance tool in IPF that may predict mortality.

     

Regression equations to estimate the 2‐min walk distance in an adult Asian population aged 40–75 years

Background and objective

There is increased use of the 2‐min walk test (2MWT) to assess functional exercise capacity. However, the distance achieved during this test may be difficult to interpret in the absence of reference values from a local population. Regression equations to estimate the 2‐min walk distance (2MWD) only exist for American and Brazilian populations. The objective of this study was to develop regression equations to estimate the 2MWD in Malaysian adults who were free from major health problems.

Methods

Eighty‐seven adults (43 males; mean ± SD age: 57.1 ± 9.6 years) performed two 2MWT using a standardized protocol. Heart rate (HR) was recorded every 30 s during the test. Stepwise multiple regression analysis was performed using age, gender, height, weight and change in HR (ΔHR) as independent variables, and better of the two 2MWD as the dependent variable. A second regression equation, without ΔHR, was planned if ΔHR was retained as one of the predictors of the 2MWD in the first equation.

Results

The better of the two 2MWD was 200 ± 34 m. Males walked 33 ± 6 m further than females (P < 0.001). The two regression equations were 196 − 1.1 × age, years + 1.0 × ΔHR, bpm + 31.2 × gender (R² = 0.73) and 279 − 1.7 × age, years + 35.9 × gender (R² = 0.47) with females = 0 and males = 1.

Conclusion

The equations derived in this study may facilitate the interpretation of the 2MWD in clinical populations in Malaysia, as well as in countries with similar cultural backgrounds to Malaysia.

     

Radiographic fibrosis score predicts survival in systemic sclerosis‐associated interstitial lung disease

Background and objective

Interstitial lung disease (ILD ) is a common pulmonary manifestation of systemic sclerosis (SSc ). It is unknown whether radiographic fibrosis score predicts mortality in SSc ‐associated ILD (SSc‐ILD ). We retrospectively analysed patients with SSc‐ILD to evaluate whether radiographic fibrosis score was a useful predictor of mortality.

Methods

We identified SSc‐ILD patients evaluated at Kurashiki Central Hospital (Japan) from 2006 to 2016, and radiographic fibrosis scores based on the extent of reticulation and honeycombing on high‐resolution computed tomography (HRCT ) scanning were calculated by manually tracing around each fibrotic area. Independent predictors of overall survival were determined using the Cox proportional hazards model.

Results

The study included 48 patients, of whom 19 had usual interstitial pneumonia on HRCT . The median follow‐up period was 56.6 months, and over the follow‐up period 15 patients died. The 5‐year survival was 72.4%. In the multivariate analysis, radiographic fibrosis score, age, being male and forced vital capacity were independently associated with an increased risk of death, while HRCT pattern was not.

Conclusion

A high radiographic fibrosis score was a poor prognostic factor in SSc‐ILD . More widespread fibrosis was associated with an increased risk of death, independent of HRCT pattern.

     

Three‐dimensional photography for the evaluation of facial profiles in obstructive sleep apnoea

Background and objective

Craniofacial structure is an important determinant of obstructive sleep apnoea (OSA) syndrome risk. Three‐dimensional stereo‐photogrammetry (3dMD) is a novel technique which allows quantification of the craniofacial profile. This study compares the facial images of OSA patients captured by 3dMD to three‐dimensional computed tomography (3‐D CT) and two‐dimensional (2‐D) digital photogrammetry. Measurements were correlated with indices of OSA severity.

Methods

Thirty‐eight patients diagnosed with OSA were included, and digital photogrammetry, 3dMD and 3‐D CT were performed. Distances, areas, angles and volumes from the images captured by three methods were analysed.

Results

Almost all measurements captured by 3dMD showed strong agreement with 3‐D CT measurements. Results from 2‐D digital photogrammetry showed poor agreement with 3‐D CT. Mandibular width, neck perimeter size and maxillary volume measurements correlated well with the severity of OSA using all three imaging methods. Mandibular length, facial width, binocular width, neck width, cranial base triangle area, cranial base area 1 and middle cranial fossa volume correlated well with OSA severity using 3dMD and 3‐D CT, but not with 2‐D digital photogrammetry.

Conclusion

3dMD provided accurate craniofacial measurements of OSA patients, which were highly concordant with those obtained by CT, while avoiding the radiation associated with CT.

     

Old age and underlying interstitial abnormalities are risk factors for development of ARDS after pleurodesis using limited amount of large particle size talc

Background and objective

Talc pleurodesis is commonly performed to manage refractory pleural effusion or pneumothorax. It is considered as a safe procedure as long as a limited amount of large particle size talc is used. However, acute respiratory distress syndrome (ARDS) is a rare but serious complication after talc pleurodesis. We sought to determine the risk factors for the development of ARDS after pleurodesis using a limited amount of large particle size talc.

Methods

We retrospectively reviewed patients who underwent pleurodesis with talc or OK‐432 at the University of Tokyo Hospital.

Results

Twenty‐seven and 35 patients underwent chemical pleurodesis using large particle size talc (4 g or less) or OK‐432, respectively. Four of 27 (15%) patients developed ARDS after talc pleurodesis. Patients who developed ARDS were significantly older than those who did not (median 80 vs 66 years, P = 0.02) and had a higher prevalence of underlying interstitial abnormalities on chest computed tomography (CT; 2/4 vs 1/23, P < 0.05). No patient developed ARDS after pleurodesis with OK‐432. This is the first case series of ARDS after pleurodesis using a limited amount of large particle size talc.

Conclusion

Older age and underlying interstitial abnormalities on chest CT seem to be risk factors for developing ARDS after talc pleurodesis.

     

Complete versus incomplete revascularization with drug‐eluting stents for multi‐vessel disease in stable,unstable angina or non‐ST‐segment elevation myocardial infarction: A meta‐analysis

Objectives

To determine whether drug‐eluting stent (DES) coronary complete revascularization (CR) confers clinical benefit over incomplete revascularization (IR) in patients with multivessel coronary artery disease (MVD).

Background

Clinical benefit of CR over IR in patients with MVD with angina (both stable and unstable) and non‐ST‐segment elevation myocardial infarction (NSTEMI) in DES has not been well studied.

Methods

We conducted a systematic online literature search of PUBMED and EMBASE. Literatures that compared the clinical outcomes between CR and IR with exclusively or majority (>80%) using DES in patients without or included only small portion (<20%) of ST‐segment elevation myocardial infarction or single‐vessel coronary artery disease were included. Hazards ratio (HR) with 95% confidence interval (CI) was calculated with random‐effects model.

Results

No randomized clinical trials were identified. A total of 14 observational studies with total of 41 687 patients (CR 39.6% and IR 60.4%) were included in this meta‐analysis. CR was associated with lower incident of all‐cause mortality (HR 0.71, P = 0.001), major adverse events (HR 0.75, P < 0.001), cardiovascular mortality (HR 0.39, P < 0.001). Meta‐regression analysis showed that CR significantly reduced the risk of all‐cause mortality in advanced age, triple vessel disease and male sub‐groups.

Conclusions

CR with DES conferred favorable outcomes compared to IR in MVD patients with stable, unstable angina or NTEMI. Further research to achieve higher CR in MVD patients may lead to improvement in prognosis in these cohorts.

     

Defining ‘healthy’ in preschool‐aged children for forced oscillation technique reference equations

Background and objective

Selecting ‘healthy’ preschool‐aged children for reference ranges may not be straightforward. Relaxing inclusion criteria for normative data does not affect spirometry z‐scores. We therefore investigated the effect of similarly relaxing inclusion criteria in preschoolers on reference ranges for respiratory impedance (Zrs) using a modified forced oscillation technique (FOT).

Methods

The International Study of Asthma and Allergies in Childhood questionnaire classified 585 children into a healthy and five mutually exclusive groups. Zrs was measured between 4 and 26 Hz and resistance (R) and compliance (C) obtained by model fitting. Prediction models were determined using mixed effect models and z‐scores compared between healthy children and the five groups.

Results

Zrs data were obtained for 494 participants (4.30 ± 0.7 years) on 587 occasions. Comparison of the Zrs z‐scores between the healthy children and the health groups found significant differences in children with asthma, current wheeze and respiratory symptoms, but not in children born preterm or with early‐life wheeze. Adding these two groups to the healthy dataset had no significant effect on the distribution of z‐scores and increased the size of the dataset by 22.3%.

Conclusion

Our data suggest that preschool‐aged children born preterm or with early‐life wheeze can be included in FOT reference equations, while those with asthma, current wheeze and respiratory symptoms within 4 weeks of testing should be excluded. This more inclusive approach results in more robust FOT reference ranges.

     

Clinical outcome and its predictors in hemodialysis patients with critical limb ischemia undergoing endovascular therapy

Objectives

This study aimed to examine prognosis and causes of death in hemodialysis (HD) patients with critical limb ischemia (CLI) after endovascular therapy (EVT).

Background

EVT is becoming a first‐line treatment in patients with CLI. Nonetheless, only a few studies have examined prognosis and its predictors in HD patients with CLI undergoing EVT, who are known to be at high‐risk. Moreover, causes of death in this population are not clarified to date.

Methods

We examined 175 consecutive patients who underwent EVT for CLI between March 2009 and March 2014.

Results

Among these, 126 patients were dependent on HD and their 2‐year all‐cause death and 2‐year major amputation rates were 28% and 14%, respectively. Cox proportional hazards analyses revealed that lower body mass index (hazard ratio [HR] = 0.89, 95% confidence interval [CI] = 0.82‐0.98, P = 0.03) and prior stroke (HR = 2.34, 95%CI = 1.10‐4.85, P = 0.03) were independent predictors of all‐cause death, and lower serum albumin (HR = 0.44, 95%CI = 0.22‐0.92, P = 0.03) along with currently smoking (HR = 4.73, 95%CI = 1.43‐14.1, P = 0.01) were independent predictors of major amputation in HD patients. The leading cause of death in this population was infections, most of which were lower extremity infections.

Conclusions

The incidences of all‐cause death and major amputation seemed acceptable in HD patients undergoing EVT for CLI. In this high‐risk subset, management of infection might be a potential therapeutic target.

     

Men Lacking a Caregiver Have Greater Risk of Long‐Term Nursing Home Placement After Stroke

Background/Objectives

Social support can prevent or delay long‐term nursing home placement (NHP ). The purpose of our study was to understand how the availability of a caregiver can affect NHP after ischemic stroke and how this affects different subgroups differently.

Design

Nested cohort study.

Setting

Nationally based RE asons for Geographic and Racial Differences in Stroke (REGARDS ) study.

Participants

Stroke survivors aged 65 to 100 (256 men, 304 women).

Measurements

Data were from Medicare claims from January 2003 to December 2013 and REGARDS baseline interviews conducted from January 2003 to October 2007. Caregiver support was measured by asking, “If you had a serious illness or became disabled, do you have someone who would be able to provide care for you on an on‐going basis?” Diagnosis of ischemic stroke was derived from inpatient claims. NHP was determined using a validated claims algorithm for stays of 100 days and longer. Risk was estimated using Cox regression.

Results

Within 5 years of stroke, 119 (21.3%) participants had been placed in a nursing home. Risk of NHP was greater in those lacking available caregivers (log‐rank P  = .006). After adjustment for covariates, lacking an available caregiver increased the risk of NHP after stroke within 1 year by 70% (hazard ratio (HR ) = 1.70, 95% confidence interval (CI ) = 0.97–2.99) and within 5 years by 68% (HR  = 1.68, 95% CI  = 1.10–2.58). The effect of caregiver availability on NHP within 5 years was limited to men (HR  = 3.15, 95% CI  = 1.49–6.67).

Conclusion

In men aged 65 and older who have survived an ischemic stroke, the lack of an available caregiver is associated with triple the risk of NHP within 5 years.

     

Surfactant protein D multimerization and gene polymorphism in COPD and asthma

Background and objective

A structural single nucleotide polymorphism rs721917 in the surfactant protein D (SP‐D) gene, known as Met11Thr, was reported to influence the circulating levels and degree of multimerization of SP‐D and was associated with both COPD and atopy in asthma. Moreover, disease‐related processes are known to degrade multimerized SP‐D, however, the degree of the protein degradation in these diseases is not clarified. We aimed to determine the distribution of multimerized (high molecular weight (HMW)) and non‐multimerized (low molecular weight (LMW)) species of serum SP‐D and their correlation with genetic polymorphisms and presence of disease in Lebanese COPD and asthmatic patients.

Methods

Serum SP‐D levels were measured by ELISA in 88 COPD, 121 asthmatic patients and 223 controls. Randomly selected subjects were chosen for genotyping of rs721917 and multimerization studies. HMW and LMW SP‐D were separated by gel permeation chromatography.

Results

Serum SP‐D levels were significantly increased in patients with COPD, but not in asthmatic patients, when compared to controls. Met11Thr variation strongly affected serum SP‐D levels and the degree of multimerization, but was not associated with COPD and asthma in the study. Remarkably, HMW/LMW serum SP‐D ratio was significantly lower in Met11/Met11 COPD and asthmatic patients compared to controls.

Conclusion

Collectively, non‐multimerized species of serum SP‐D were dominant in COPD and asthmatic patients suggesting that degradation of SP‐D takes place to a significant degree in pulmonary disease. Assays that can separate SP‐D proteolytic breakdown products or modified forms from naturally occurring SP‐D trimers may result in optimal disease markers for pulmonary inflammatory diseases.

     

Efficacy and safety of transbronchial lung biopsy for the diagnosis of lymphangioleiomyomatosis: A report of 24 consecutive patients

Background and objective

Lymphangioleiomyomatosis (LAM) is a diffuse cystic lung disease that occurs in women of childbearing age. LAM can be diagnosed on a clinical basis in patients with typical high‐resolution computed tomography (HRCT) patterns and at least one other corroborating disease feature, such as chylothorax, angiomyolipoma, tuberous sclerosis complex or elevated serum vascular endothelial growth factor (VEGF)‐D. However, patients who do not meet these criteria require tissue confirmation for a definitive diagnosis, and the utility of methods that are less invasive than surgical lung biopsy, such as transbronchial lung biopsy (TBLB), are not well studied. We retrospectively studied the efficacy and safety of TBLB for the diagnosis of LAM.

Methods

From January 1991 to August 2015, 131 consecutive LAM patients were prospectively registered in our study, and a TBLB was conducted for 24 patients. We retrospectively studied the yield and safety of TBLB in this cohort.

Results

All 24 patients were women; the median age was 42 years. HRCT showed multiple round thin‐walled cysts diffusely scattered throughout the lungs. The median level of serum VEGF‐D was 2109 pg/mL. Characteristic pathological findings for LAM were identified in 17 patients (70.8%) by two expert pathologists. The %predicted value for diffusing capacity of carbon monoxide was significantly lower in the 17 TBLB‐positive LAM patients compared to the seven TBLB‐negative LAM patients (P = 0.046). There were no serious adverse events such as pneumothorax or uncontrollable bleeding due to TBLB.

Conclusion

TBLB is a safe and effective method for the pathological diagnosis of LAM.

     

The analysis of the parameters of 24‐hr ECG Holter monitoring in patients with blood neoplasms undergoing high‐dose chemotherapy and stem cell transplantation

Background

Hematopoietic stem cell transplantation (HSCT) is a widely used procedure in the treatment of malignant diseases, including blood neoplasms and has increased survival in hematological diseases. The aim of the study was to analyze parameters of 24‐hr ECG monitoring in patients with selected blood neoplasms in whom the procedure of hematopoietic stem cell transplantation was performed.

Methods

The study group consisted of 64 adults diagnosed with hematologic cancer qualified for HSCT with the previous high dose chemotherapy (HDC). In all patients 24‐hr Holter monitoring was carried out twice. First examination took place prior to the HSCT procedure, and the second after finishing the procedure of HSCT.

Results

The minimal and mean heart rate (HR min and HR max) from 24‐hr ECG recording was statistically significantly higher after the transplantation in comparison with the first test. The number of premature ventricular complexes (PVCs) was higher in the test after HSCT. In the second examination there was significantly higher percentage of premature ventricular complexes, incidents of tachycardia, and Mobitz type 1 second degree atrioventricular block. In regression analysis, in a group of patients with blood neoplasms after HSCT and HDC, administration of cyclophosphamide, fludarabine and total body irradiation were independent risk factors for electrocardiographic abnormalities in 24‐hr Holter monitoring, that is, the increase in HR min, HR mean and PVCs.

Conclusion

In patients with blood neoplasms undergoing HSCT more electrocardiographic abnormalities may be found after this procedure in comparison with the 24‐hr Holter monitoring before transplantation.

     

Education Preferences of People With Gout: Exploring Differences Between Indigenous and Nonindigenous Peoples from Rural and Urban Locations

Objective

Gout typically responds well to medications, but adherence might be improved by education that meets individuals’ needs in a way that is inclusive of their ethnicity and rurality. The aim of this study was to compare education preferences of Māori and New Zealand European (NZEuropean) individuals with gout, and of those living in rural or urban areas.

Methods

People with gout managed in primary care were recruited from 2 rural regions and 1 city within Aotearoa/New Zealand. Focus groups were held with 26 Māori and 42 NZEuropean participants (44 rural, 24 urban). Participants discussed education preferences for diet, medication, and ways of communicating. The nominal group technique was employed, whereby the group compiled a list of ideas and then participants individually ranked the 3 most important ideas for each topic.

Results

The most frequently prioritized ideas for the 3 topics were knowing one's own food triggers, knowing side effects of medications, and communicating via a general practitioner (GP) or specialist. More Māori participants prioritized natural remedies, easy to understand information, and communicating via television. More NZEuropean participants prioritized knowing the kinds of alcohol that trigger gout, communicating via GP/specialist, and receiving written information. More urban participants prioritized knowing to stay hydrated and medication doses as important information.

Conclusion

Māori and NZEuropean individuals with gout report different understandings and education preferences around personal triggers of gout, treatment options, and ways of receiving information about gout. Further research is required to develop ethnicity‐specific gout education resources internationally.

     

Overlap of interstitial pneumonia with autoimmune features with undifferentiated connective tissue disease and contribution of UIP to mortality

Background and objective

Criteria for interstitial pneumonia with autoimmune features (IPAF) were recently established for research purposes in a joint statement from the European Respiratory Society (ERS) and American Thoracic Society (ATS). We reviewed the utility of these criteria in patients previously diagnosed as broadly defined undifferentiated connective tissue disease (UCTD) and noted overlapping IPAF findings. Additional review was given to IPAF patients with usual interstitial pneumonia (UIP) on histopathology or radiology in terms of survival and outcome.

Methods

Patients with prior UCTD‐interstitial lung disease (ILD) were screened by ERS/ATS criteria for IPAF. Clinical data along with all‐cause mortality were collated and compared with selected idiopathic pulmonary fibrosis (IPF) patients from the same study period. Survival was compared between IPAF subgroups with and without UIP features.

Results

One hundred and one UCTD‐ILD subjects (91%) evaluated from 2005 to 2012 also met strict criteria for IPAF. Frequent clinical findings included Raynaud’s phenomenon, positive anti‐nuclear antibody (ANA) and non‐specific interstitial pneumonia (NSIP) pattern on chest computed tomography (CT). Nineteen had features of UIP either on histopathology or CT imaging. As compared with IPF, IPAF patients had overall better survival except in those with UIP features.

Conclusion

Current IPAF criteria encompassed the majority of broadly defined UCTD‐ILD and included those with UIP findings. Survival compared with IPF in those with UIP was similar. Further studies are necessary to refine IPAF definitions for clinical use and guide directed management strategies.

     

Performance of the St George’s Respiratory Questionnaire in patients with connective tissue disease‐associated interstitial lung disease

Background and objective

The St George’s Respiratory Questionnaire (SGRQ) is a self‐administered questionnaire used to assess health‐related quality of life (HRQoL) in various chronic respiratory diseases. Few studies have assessed the performance of the SGRQ in patients with connective tissue disease‐associated interstitial lung disease (CTD‐ILD). We aimed to examine the SGRQ’s performance characteristics and generate data to support its reliability and validity in patients with CTD‐ILD.

Methods

We used data from 193 CTD‐ILD patients evaluated at Tosei General Hospital from May 2007 to July 2016 to assess the cross‐sectional and longitudinal validity of the SGRQ.

Results

The mean age of the patients was 64.2 years and 122 (63.2%) were women. There were no significant differences in SGRQ scores between any of the CTD groups. Internal consistency (Cronbach’s α = 0.905) and repeatability (intraclass correlation coefficient (ICC) = 0.873) for the SGRQ total score were excellent. At baseline, SGRQ total score was significantly associated with clinically meaningful measures of physiological function, exercise capacity and dyspnoea. Change in SGRQ total score over 6 months was also associated with change in other measures. Cox proportional hazards models showed that higher baseline SGRQ total score was a significant predictor of mortality. The estimated minimal clinically important difference of SGRQ total score was 4–13 points.

Conclusion

These data support the validity and reliability of SGRQ as a sensitive measure for capturing HRQoL in patients with CTD‐ILD.

     

Oesophageal diameter is associated with severity but not progression of systemic sclerosis‐associated interstitial lung disease

Background and objective

It is unknown whether oesophageal disease is associated with systemic sclerosis‐associated interstitial lung disease (SSc‐ILD) severity, progression or mortality.

Methods

High‐resolution computed tomography (HRCT) scans from 145 SSc‐ILD patients were scored for fibrosis score, oesophageal diameter and presence of hiatal hernia. Fibrosis asymmetry was calculated as: (most affected side − least affected side)/(most affected side + least affected side). Mixed effects models were used for repeated measures analyses.

Results

Mean fibrosis score was 8.6%, and most patients had mild‐to‐moderate physiological impairment. Every 1 cm increase in oesophageal diameter was associated with 1.8% higher fibrosis score and 5.5% lower forced vital capacity (FVC; P ≤ 0.001 for unadjusted and adjusted analyses). Patients with hiatal hernia had 3.9% higher fibrosis score, with persistent differences on adjusted analysis (P = 0.001). Oesophageal diameter predicted worsening fibrosis score over the subsequent year (P = 0.02), but not when adjusting for baseline fibrosis score (P = 0.16). Oesophageal diameter was independently associated with mortality (P = 0.001). Oesophageal diameter was not associated with asymmetric disease or radiological features of gross aspiration.

Conclusion

Oesophageal diameter and hiatal hernia are independently associated with SSc‐ILD severity and mortality, but not with ILD progression or asymmetric disease. Oesophageal disease is unlikely to be a significant driver of ILD progression in SSc.

     

Incidence of thromboembolic and bleeding events in patients with newly diagnosed nonvalvular atrial fibrillation: An Asian multicenter retrospective cohort study in Singapore

Background

Real‐world effectiveness and safety of antithrombotics in nonvalvular atrial fibrillation (NVAF) patients in Singapore has not been thoroughly studied.

Hypothesis.

Users of various antithrombotics experience a significantly different risk of stroke and major bleed compared with warfarin users.

Methods

This multicenter retrospective cohort study included patients age ≥ 21 years newly diagnosed with NVAF between July 2012 and September 2015. Using electronic medical records, data on patients' demographics, antithrombotics prescribed, and CHA₂DS₂‐VASc and HAS‐BLED risk factors were collected. Patients were followed for 1 year from diagnosis for the primary effectiveness and safety endpoints of incident stroke or systemic embolism and major bleed, respectively. The secondary safety endpoint was overall bleed. Hazard ratios (HR) were determined from Cox regression.

Results

Of 743 patients included, 224 were on warfarin, 156 on direct oral anticoagulants (DOACs), 277 on single antiplatelet therapy (SAPT), 28 on dual antiplatelet therapy (DAPT), and 58 on no therapy. Mean age (±SD) was 68.7 ± 13.0 years. Compared with warfarin users, SAPT (adjusted [adj.] HR: 3.70, 95% confidence interval [CI]: 1.21‐11.3) and DAPT users (adj. HR: 10.1, 95% CI: 1.51‐67.2) were more likely to develop thromboembolic outcomes. Also, DOAC users (adj. HR: 0.304, 95% CI: 0.158‐0.585), SAPT users (adj. HR: 0.142, 95% CI: 0.0680‐0.295), and DAPT users (adj. HR: 0.112, 95% CI: 0.0146‐0.857) were less likely to experience any bleed compared with warfarin users.

Conclusions

SAPT and DAPT are less effective than warfarin in NVAF patients. DOACs may be considered in view of lower risk of overall bleed.