Bitter et al performed CPAP titration on 192 patients with congestive heart failure and obstructive sleep apnea, unmasking residual central sleep apnea (so-called complex sleep apnea) in 34 (18%). Providing adaptive servoventilation (dynamic delivery of pressure support to achieve a target minute ventilation) improved AHI, NYHA class, BNP levels, ejection fraction, and other variables, at ~1 year [… read more]
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]
Zinberg writes on predicted effects of the Affordable Care Act on reimbursements. As 30 million patients pour into the system, half onto Medicaid rolls, and cash-strapped state governments likely reduce payments for their visits (after federal prop-up payments shrink in 2016), Zinberg asks whether most physicians will see Medicaid patients at all, since many already [… read more]
Dyrbye & Shanafelt from Mayo sound a warning that the impending influx of 30 million newly insured patients into doctors’ offices after full implementation of health insurance reform, simultaneous with declining reimbursements, are likely to increase physician stress and burnout. They urge a lot of doctor-friendly policy measures (like a committee to set limits on [… read more]
Drug and device companies finance up to 60% of all CME in the U.S. Tabas et al surveyed 1,347 CME participants, 770 of whom responded. 88% felt that industry involvement biased their educational program…but only 42% said they’d be willing to pay higher CME fees to help reduce commercial influence. Participants almost universally (85-88%) underestimated the real [… read more]
Jones et al randomized 1,647 people with moderate to severe COPD for the two trials, to receive either aclidinium inhaled (a potential tiotropium competitor) once daily or placebo for 1 year. Aclidinium improved FEV1 by ~65 mL. An absolute ~8% more people taking the drug achieved a 4-point SGRQ improvement over those taking placebo. Time [… read more]
Most clinical trials for asthma drugs exclude ~95% of potential subjects and test under highly controlled conditions, limiting their results’ generalizability. Price et al publish results of 2 “pragmatic” open-label trials set in the real world. In #1, they randomized 300 symptomatic asthmatics in 53 U.K. primary care clinics to get either a leukotriene receptor [… read more]
Singh et al’s meta-analysis of 13 randomized trials of pioglitazone or rosiglitazone lasting for at least one year. There were 130 pneumonias among the 8,163 treated patients, and 100 among the 9,464 controls, for a relative risk of 1.40 for the thiazolidinedione group (CI 1.1-1.8, p=0.01). Pioglitazone showed more of a signal with a significant RR of [… read more]
Evans et al attempted a meta-analysis of 9 randomized trials (7 in adults) testing prolonged (4 to 52 weeks) antibiotics in people with bronchiectasis. There was an improvement in “clinical response rate,” a poorly-defined endpoint, in 2 trials, but no difference in exacerbation rates or lung function. Emergence of resistant bacteria was not tested or [… read more]
An attempted meta-analysis of 11 heterogeneous, moderate-quality randomized trials could demonstrate no benefit of incentive spirometry in preventing postoperative pulmonary complications or mortality, in 1,160 patients undergoing upper abdominal surgery, report Guimaraes et al. Cochrane Database Sys Rev 2011;3:CD006058.
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]
Prone positioning improves oxygenation in ARDS patients without improving outcome. Recruitment maneuvers do too. Rival et al prospectively tested the effects of both strategies together in 16 ARDS patients. Two extended sighs of 45 cm H2O in pressure control mode while lying prone improved PaO2/FiO2 from 98 to 166 mm Hg, without obvious adverse (or positive) effects. Critical [… read more]
Antibiotic dosing in multiple organ dysfunction syndrome: Ulldemolins et al, CHEST 2011;139:1210-1220.
Invasive aspergillosis is often lethal in lung transplant patients, and early diagnosis and treatment improve survival. Luong M et al showed that testing bronchoalveolar lavage fluid with new rapid-result Aspergillus PCR and galactomannan tests bring both sensitivity and specificity into the 93-100% range. 150 BAL samples from lung transplant patients at Pitt were tested (there were only [… read more]
In an observational study of 210 patients undergoing resection for lung cancer, those with a peak oxygen uptake (VO2 max) of <10 mL/kg/min were 4 times more likely to have cardiac or pulmonary complications than those with a VO2 > 17. ERJ 2011;37:1189-1198.
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]
Retrospectively looking at a database of 5,977 COPD patients’ hospital admissions (TARDIS), pharmacy data, and death records in Scotland, Short et al found an overall 22% lower mortality in those taking beta blockers (88% were cardioselective BBs). The benefit was seen equally in those also taking long-acting beta agonists or antimuscarinics. For those 2,712 patients with serial [… read more]
Diagnostic value of halo and reversed-halo signs in immune-compromised hosts. Georgiadou SP et al, Clin Infect Dis 2011;52:1144-1155. Review.
Waters et al tested 136 meat and poultry samples in U.S. grocery stores, and found 77% of the turkey, 42% of pork, 41% of chicken, and 37% of beef were contaminated with S. aureus. 96% of the isolates were resistant to at least one drug, and 52% of isolates were resistant to 3 antibiotic classes. In the Netherlands, [… read more]