Chronic Obstructive Pulmonary Disease Individualized Therapy: Tailored Approach to Symptom Management

Chronic obstructive pulmonary disease (COPD) is associated with high morbidity and mortality. COPD is typified by persistent, progressive airflow limitation and a range of respiratory and systemic symptoms such as breathlessness, coughing, wheezing, depression, anxiety, general fatigue, and sleeping difficulties. Despite receiving treatment for COPD, many patients suffer from regular symptoms that affect their daily lives and lead to increased morbidity. These symptoms vary in severity, frequency, and type, and can occur at any time throughout the 24-h day, with over half of patients with COPD experiencing symptoms in the morning, during the day, and at nighttime. Despite the prevalence of symptoms, patient and physician perception of the impact of COPD symptoms on patients’ lives is not always in concordance. Dual bronchodilator therapy with a long-acting muscarinic antagonist (LAMA) and long-acting beta agonist (LABA) has the potential to treat the symptoms of COPD in addition to improving lung function. This review therefore examines the burden of symptoms experienced throughout the day by patients with COPD and the evidence for combined LAMA/LABA treatment in terms of symptom management. As patients with COPD experience varying symptoms throughout the course of their disease, the role of tailoring treatment to the individual needs of the patient is also examined. We conclude that the symptoms of COPD are troublesome, variable, can occur during all parts of the 24-h day, and have a substantial impact on patients’ health status and quality of life. In order to provide effective, patient-orientated care, patients with COPD should be evaluated on the basis of lung function, the frequency of symptoms, and patient-perceived impact of symptoms on their lives. Therapy should be chosen carefully based on individualized assessment, ensuring personalization to the individual needs of the patient.     

Cardiac Intensive Care Unit Management of Patients After Cardiac Arrest: Now the Real Work Begins

Survival with a good quality of life after cardiac arrest continues to be abysmal. Coordinated resuscitative care does not end with the effective return of spontaneous circulation (ROSC)—in fact, quite the contrary is true. Along with identifying and appropriately treating the precipitating cause, various components of the post–cardiac arrest syndrome also require diligent observation and management, including post–cardiac arrest neurologic injury and myocardial dysfunction, systemic ischemia-reperfusion phenomenon with potential consequent multiorgan failure, and the various sequelae of critical illness. There is growing evidence that an early invasive approach to coronary reperfusion with percutaneous coronary intervention, together with active targeted temperature management and optimization of hemodynamic, ventilator, and metabolic parameters, may improve survival and neurologic outcomes in cardiac arrest survivors. Neuroprognostication is complex, as are survivorship issues and long-term rehabilitation. Our paramedics, emergency physicians, and resuscitation specialists are all to be congratulated for ever-increasing success with ROSC… but now the real work begins.     

Contemporary and Historical Evidence to Suggest that Women’s Preference for Age at Birth of First Child Remains Consistent Across Time

Women’s ability to reproduce is restricted by menarche and menopause. First children are, however, not typically born until some years after the onset of puberty. Other factors therefore contribute towards this delay. In this context, women’s hips do not reach full adult form until they are in their mid-20s. Therefore, physiological and morphological factors appear to determine an optimum age-range for reproduction. The following studies were conducted in order to investigate this hypothesis. Study 1 asked nulliparous women questions about ages at which particular life events related to reproduction should ideally occur. This revealed their preferred age at birth of first child to be approximately 27 years old. Study 2 replicated these findings and further showed that women with children actually had their first child at a very similar age (27.93 [±0.79]). Findings from Study 3 were also remarkably consistent (28.15 [±0.39]). Study 4 examined the 1901 UK Census record and incorporated an analysis of the influence of wealth. Middle class women were on average 24.88 (±0.22) years old at the birth of their first child. Poor women were on average 23.50 (±0.20) years old. These figures at least approximate to findings from Studies 1–3, which is noteworthy given that modern contraceptive methods were not widely available at the time. It is concluded that female strategies to delay giving birth to their first child until they are of an age that approaches or coincides with their full hip maturation are enduring across time.     

Recent Developments in the Role of Coenzyme Q10 for Coronary Heart Disease: a Systematic Review

Purpose of Review

This review examines recent randomized clinical trials evaluating the role of coenzyme Q10 (CoQ10) in the management of coronary heart disease.

Recent Findings

CoQ10 is one of the most commonly used dietary supplements in the USA. Due to its antioxidant and anti-inflammatory effects, CoQ10 has been studied extensively for possible use in managing coronary heart disease. One of the most common applications of CoQ10 is to mitigate statin-associated muscle symptoms (SAMS) based on the theory that SAMS are caused by statin depletion of CoQ10 in the muscle. Although previous studies of CoQ10 for SAMS have produced mixed results, CoQ10 appears to be safe. Because CoQ10 is a cofactor in the generation of adenosine triphosphate, supplementation has also recently been studied in patients with heart failure, which is inherently an energy deprived state. The Q-SYMBIO trial found that CoQ10 supplementation in patients with heart failure not only improved functional capacity, but also significantly reduced cardiovascular events and mortality. Despite these positive findings, a larger prospective trial is warranted to support routine use of CoQ10. Less impressive are the effects of CoQ10 on specific cardiovascular risk factors such as blood pressure, dyslipidemia, and glycemic control.

Summary

Current evidence does not support routine use of CoQ10 in patients with coronary heart disease. Additional studies are warranted to fully determine the benefit of CoQ10 in patients with heart failure before including it in guideline-directed medical therapy.

     

Obstructive sleep apnea, obesity, and the risk of incident atrial fibrillation.

OBJECTIVES: This study sought to identify whether obesity and obstructive sleep apnea (OSA) independently predict incident atrial fibrillation/flutter (AF). BACKGROUND: Obesity is a risk factor for AF, and OSA is highly prevalent in obesity. Obstructive sleep apnea is associated with AF, but it is unknown whether OSA predicts new-onset AF independently of obesity. METHODS: We conducted a retrospective cohort study of 3,542 Olmsted County adults without past or current AF who were referred for an initial diagnostic polysomnogram from 1987 to 2003. New-onset AF was assessed and confirmed by electrocardiography during a mean follow-up of 4.7 years. RESULTS: Incident AF occurred in 133 subjects (cumulative probability 14%, 95% confidence interval [CI] 9% to 19%). Univariate predictors of AF were age, male gender, hypertension, coronary artery disease, heart failure, smoking, body mass index, OSA (hazard ratio 2.18, 95% CI 1.34 to 3.54) and multiple measures of OSA severity. In subjects <65 years old, independent predictors of incident AF were age, male gender, coronary artery disease, body mass index (per 1 kg/m2, hazard ratio 1.07, 95% CI 1.05 to 1.10), and the decrease in nocturnal oxygen saturation (per 0.5 U log change, hazard ratio 3.29, 95% CI 1.35 to 8.04). Heart failure, but neither obesity nor OSA, predicted incident AF in subjects > or =65 years of age. CONCLUSIONS: Obesity and the magnitude of nocturnal oxygen desaturation, which is an important pathophysiological consequence of OSA, are independent risk factors for incident AF in individuals <65 years of age.     

Dissolution Curve Comparisons Through the F2 Parameter,a Bayesian Extension of the f2 Statistic

Dissolution (or in vitro release) studies constitute an important aspect of pharmaceutical drug development. One important use of such studies is for justifying a biowaiver for post-approval changes which requires establishing equivalence between the new and old product. We propose a statistically rigorous modeling approach for this purpose based on the estimation of what we refer to as the F₂ parameter, an extension of the commonly used f₂ statistic. A Bayesian test procedure is proposed in relation to a set of composite hypotheses that capture the similarity requirement on the absolute mean differences between test and reference dissolution profiles. Several examples are provided to illustrate the application. Results of our simulation study comparing the performance of f₂ and the proposed method show that our Bayesian approach is comparable to or in many cases superior to the f₂ statistic as a decision rule. Further useful extensions of the method, such as the use of continuous-time dissolution modeling, are considered.