Zager et al examined registry data on 38,917 patients admitted to Beth Israel and Brigham & Women’s hospitals between 1997-2007, and concluded that low socioeconomic status (as determined by census tract neighborhood of residence) did not influence 30- or 365-day mortality after admission to these hospitals’ ICU. CHEST 2011;139:1368-1379.
Hargreave and Nair (PRO) argue the boutique technique is underrated and underused, citing trials showing improvement in severe asthma outcomes when sputum eosinophils are used to guide therapy (1, 2, and studies on IL-5 blockers). Peters (CON) questions the findings of those trials, doubts eosinophil count adds to clinical measures of asthma control, and compares [... read more]
Wrist actigraphy: Martin JL, Hakim AD. CHEST 2011;139:1514-1527.
In severe congestive heart failure, lymphatic drainage can increase 10-fold. Pastis et al hypothesize this could result in enlarged mediastinal lymph nodes. They retrospectively examined chest CT scans for 118 patients undergoing heart transplantation. Fifty-three had mediastinal LNs > 1 cm. In the 9 who had post-transplant CT scans available, mediastinal lymph nodes shrank after [... read more]
Masclans et al followed 38 patients with ARDS in 3 ICUs for 6 months. Health-related quality of life (Nottingham Test Profile) was lower than expected at 6 months, with 40% reporting limitations in daily activities mainly due to low energy, mobility and social functioning. Mild radiographic abnormalities and restrictive physiology were usually present on HRCT [... read more]
After 25 years of declines in coal workers’ pneumoconiosis (thanks to federal regulation of tolerable concentrations of coal dust and radiographic surveillance of miners), CWP and progressive massive fibrosis have been on the upswing since 2001, killing or disabling dozens of relatively young miners. Wade et al describe the trend in a cohort of 138 [... read more]
Pulmonary rehabilitation, realities in clinical practice. Birnbaum S, CHEST 2011;139:1498-1502. Having trouble finding a pulmonary rehab program to refer your COPD patient into? That may be because in 2011, according to Mr. Birnbaum, Medicare paid outpatient centers $28 per rehabilitation session, per patient.
Gershengorn et al retrospectively compared two MICUs at Beth Israel: one with “midlevels” (nurse practitioners and physician assistants during the day with attending coverage overnight) and one that was all house staff 24/7. There were no differences in important outcomes (mortality, MICU or hospital LOS), although the study was nonrandomized and subject to bias. CHEST [... read more]
Salaun et al publish their experience using a simple algorithm for management of 321 consecutive patients with suspected pulmonary embolism at one center in France. The tool sought to avoid CT-angiography (and associated radiation) wherever possible, instead favoring leg ultrasounds and ventilation-perfusion scans. Only the indeterminate cases (a mere 35, or 11%) underwent CT-A. In [... read more]
In association with United Biosource Corp., Jones et al are championing a patient questionnaire called EXACT-PRO that seeks to standardize the definition of a COPD exacerbation. Here, they report on the production of their proposed 14-item measure to diagnose and grade the severity of COPD exacerbations. Breathlessness, cough-and-sputum, and chest symptoms form the core of [... read more]
Bafadhel et al collected procalcitonin and CRP on 161 people admitted for COPD exacerbations, 96 for asthma exacerbations, and 62 for pneumonia (groups were discriminated by presence of consolidation on chest film), at 2 UK hospitals. The assays performed extremely well (area under the curve >0.93 for each) at differentiating pneumonia from non-infectious causes of [... read more]
Sharma et al retrospectively observed >200,000 total patient-days for 9 months before and 27 months after implementation of a rapid response team at a single institution (U of Texas Galveston). Code rates and mortality did not change. CHEST 2011;139:1361-1367. Many cohort studies with historical controls over the past decade suggested benefits of RRTs, although others [... read more]
A brief historical and theoretical perspective on patient autonomy and medical decision making: Part II: the autonomy model. Will JF, CHEST 2011;139:1491-1497. ICU Ethics review.
Zanobetti et al prospectively evaluated 404 consecutive people presenting to one emergency room for dyspnea with point-of-care ultrasonography (all done by one MD) followed by chest radiograph. In the 118 instances when the tests provided discordant diagnoses, chest CT was obtained and was used as the gold standard. Concordance between US and CXR was high across all [... read more]
Janssen et alsurveyed and prospectively followed 105 Dutch patients with severe COPD and 80 with severe heart failure. Seventy percent of the respondents with COPD wanted full life support in the event of an arrest; ~64% of the CHF patients did. Sixteen to 20% of the doctors reported they had discussed these issues. However, only 4-6% [... read more]
Antibiotic dosing in multiple organ dysfunction syndrome: Ulldemolins et al, CHEST 2011;139:1210-1220.
A retrospective and somewhat subjective case series (n=39) reporting successful reduction in steroid doses in those with a diagnosis of difficult asthma who were found to have non-pulmonary causes of dyspnea on CPET. CHEST 2011;139:1117-1123.
Complete mediastinal lymph node dissection (MLND) is recommended during all surgical reactions of lung cancer — yet “complete” has never been defined, and in a community study, 43% of patients got no MLND. In prospective randomized clinical trial data on 524 patients, Darling et al found that 99% of patients had at least 6 LNs removed, and 90% had 10 [... read more]
In a community-based sample of 3,802 Spaniards aged 40-80, 4.6% had FEV1/FVC <0.7 but above the lower limit of normal. Mostly older men, they had the same respiratory exacerbation frequency, activity levels, cardiovascular risk, and 6-minute walk distances as matched controls with a ratio >0.7. They did report lower health-related quality of life in all [... read more]
Rich et al from U. of Chicago add to the “we said, they said” record on echocardiography’s accuracy in measuring PA pressures (and by implication, whether it can be used to justify oral therapy for PAH without invasive testing). They measured 160 people’s PAP by right heart catheterization and ECHO, both tests within one month; they then [... read more]