OBJECTIVES::
Measurements of extravascular lung water (EVLW) correlate to the degree of pulmonary edema and have substantial prognostic information in critically ill patients. Prior studies using single indicator thermodilution have reported that 21% to 35% of patients with clinical acute respiratory distress syndrome (ARDS) have normal EVLW (<10 mL/kg). Given that lung size is independent of actual body weight, we sought to determine whether indexing EVLW to predicted or adjusted body weight affects the frequency of increased EVLW in patients with ARDS. DESIGN:: Prospective, observational cohort study. SETTING:: Medical and surgical intensive care units at two academic hospitals. PATIENTS:: Thirty patients within 72 hrs of meeting American-European Consensus Conference definition of ARDS and 14 severe sepsis patients without ARDS. INTERVENTIONS:: None. MEASUREMENT AND MAIN RESULTS:: EVLW was measured for 7 days by PiCCO transpulmonary thermodilution; 225 measurements of EVLW indexed to actual body weight (ActBW) were compared with EVLW indexed to predicted body weight (PBW) and adjusted body weight (AdjBW). Mean EVLW indexed to ActBW was 12.7 mg/kg for ARDS patients and 7.8 mg/kg for non-ARDS sepsis patients (p < .0001). In all patients, EVLW increased an average of 1.1 ± 2.1 mL/kg when indexed to AdjBW and 2.0 ± 4.1 mL/kg when indexed to PBW. Indexing EVLW to PBW or AdjBW increased the proportion of ARDS patients with elevated EVLW (each p < .05) without increasing the frequency of elevated EVLW in non-ARDS patients. EVLW indexed to PBW had a stronger correlation to Lung Injury Score (r = .39 vs. r = .17) and Pao2/Fio2 ratio (r = .25 vs. r = .10) than did EVLW indexed to ActBW. CONCLUSIONS:: Indexing EVLW to PBW or AdjBW reduces the number of ARDS patients with normal EVLW and correlates better to Lung Injury Score and oxygenation than using ActBW. Studies are needed to confirm the presumed superiority of this method for diagnosing ARDS and to determine the clinical treatment implications.
by
Marta C. Nunes;
Zachary Kuschner;
Zelda Rabede;
Richard Madimabe;
Nadia Van Niekerk;
Jackie Moloi;
Locadiah Kuwanda;
John W. Rossen;
Keith Klugman;
Peter V. Adrian;
Shabir A. Madhi
Background: Advances in molecular diagnostics have implicated newly-discovered respiratory viruses in the pathogenesis of pneumonia. We aimed to determine the prevalence and clinical characteristics of human bocavirus (hBoV), human rhinovirus (hRV), polyomavirus-WU (WUPyV) and -KI (KIPyV) and human coronaviruses (CoV)-OC43, -NL63, -HKU1 and -229E among children hospitalized with lower respiratory tract infections (LRTI). Methods: Multiplex real-time reverse-transcriptase polymerase chain reaction was undertaken on archived nasopharyngeal aspirates from HIV-infected and -uninfected children ( < 2 years age) hospitalized for LRTI, who had been previously investigated for respiratory syncytial virus, human metapneumovirus, parainfluenza I-III, adenovirus and influenza A/B. Results: At least one of these viruses were identified in 274 (53.0%) of 517 and in 509 (54.0%) of 943 LRTI-episodes in HIV-infected and -uninfected children, respectively. Human rhinovirus was the most prevalent in HIV-infected (31.7%) and - uninfected children (32.0%), followed by CoV-OC43 (12.2%) and hBoV (9.5%) in HIV-infected; and by hBoV (13.3%) and WUPyV (11.9%) in HIV-uninfected children. Polyomavirus-KI (8.9% vs. 4.8%; p = 0.002) and CoV-OC43 (12.2% vs. 3.6%; p < 0.001) were more prevalent in HIV-infected than -uninfected children. Combined with previously-tested viruses, respiratory viruses were identified in 60.9% of HIV-infected and 78.3% of HIV-uninfected children. The newly tested viruses were detected at high frequency in association with other respiratory viruses, including previously-investigated viruses (22.8% in HIV-infected and 28.5% in HIV-uninfected children). Conclusions: We established that combined with previously-investigated viruses, at least one respiratory virus was identified in the majority of HIV-infected and HIV-uninfected children hospitalized for LRTI. The high frequency of viral coinfections illustrates the complexities in attributing causality to specific viruses in the aetiology of LRTI and may indicate a synergetic role of viral co-infections in the pathogenesis of childhood LRTI.
Background: Assessment of patients for delirium in the Post Anesthesia Care Unit (PACU) is confounded by the residual effects of the varied anesthetic and analgesic regimens employed during surgery and by the physiological consequences of surgery such as pain. Nevertheless, delirium diagnosed at this early stage has been associated with adverse clinical outcomes. The last decade has seen the emergence of the confusion assessment method-intensive care unit (CAM-ICU) score as a quick practical method of detecting delirium in clinical situations. Nonetheless, this tool has not been specifically designed for use in this immediate postoperative setting. Methods: Patients enrolled in a larger observational study were administered the CAM-ICU delirium screening tool 15 min after the latter of return of responsiveness to command or arrival in the post-anesthesia care unit. Numerical pain rating scores were also recorded. In addition, we reviewed additional behavioral observations suggestive of disordered thinking, such as hallucinations, a non-reactive eyes-open state, or an inability to state a pain score. Results: Two-hundred and twenty-nine patients underwent CAM-ICU testing in PACU. 33 patients (14%) were diagnosed with delirium according to CAM-ICU criteria; 25 of these were inattentive with low arousal, seven were inattentive with high arousal, and one was inattentive and calm and with disordered thinking. Using our extended criteria an additional eleven patients showed signs of disordered thinking. CAM-ICU delirium was associated with increased length of operation (p = 0.028), but a positive CAM-PACU designation was associated with both increased operation length and age (p = 0.003 and 0.010 respectively). Two of the CAM-ICU positive patients with inattention and high arousal reported high pain scores and were not classified as CAM-PACU positive. Conclusion: Disordered thinking is correlated with older patients and longer operations. The sensitivity of the existing CAM-ICU score in diagnosing delirium or disordered thinking in PACU patients is improved by the inclusion of a few extra criteria, namely: patients having perceptual hallucinations, in an unreactive eyes-open state, or who cannot state a pain score. We present this alternative screening tool for use in the post-anesthetic period, which we have named CAM-PACU.
Background: Gains in life expectancy through optimal control of HIV infection with antiretroviral therapy (ART) may be threatened if other comorbidities, such as diabetes, are not optimally managed. Methods: We analyzed cross-sectional data of the Women's Interagency HIV Study (WIHS) from 2001, 2006, and 2015. We estimated the proportions of HIV-positive and HIV-negative women with diabetes who were engaged in care and achieved treatment goals (hemoglobin A1c [A1c] <7.0%, blood pressure [BP] <140/90 mmHg, low-density lipoprotein [LDL] cholesterol <100 mg/dL, not smoking) and viral suppression. Repeated-measures models were used to estimate the adjusted prevalence of achieving each diabetes treatment goal at each time point, by HIV status. Results: We included 486 HIV-positive and 258 HIV-negative women with diabetes. In 2001, 91.8% visited a health care provider, 60.7% achieved the A1c target, 70.5% achieved the BP target, 38.5% achieved the LDL cholesterol target, 49.2% were nonsmokers, 23.3% achieved combined ABC targets (A1c, BP, and cholesterol), and 10.9% met combined ABC targets and did not smoke. There were no differences by HIV status, and patterns were similar in 2006 and 2015. Among HIV-positive women, viral suppression increased from 41% in 2001 to 87% in 2015 compared with 8% and 13% achieving the ABC goals and not smoking. Viral suppression was not associated with achievement of diabetes care goals. Conclusions: Successful management of HIV is outpacing that of diabetes. Future studies are needed to identify factors associated with gaps in the HIV-diabetes care continuum and design interventions to better integrate effective diabetes management into HIV care.
Although patients with “severe” asthma tend to be characterized by ongoing symptoms and airway inflammation despite treatment with high doses of inhaled and systemic corticosteroids, there is increasing recognition of marked phenotypic heterogeneity within affected patients. Although “precision medicine” approaches for patients with severe asthma are needed, there are many hurdles that must be overcome in daily practice. The National Heart, Lung and Blood Institute's Severe Asthma Research Program (SARP) has been at the forefront of phenotype discovery in severe asthma for the past decade. SARP, along with other international groups, has described clinical severe asthma phenotypes in both adults and children that can be evaluated in the clinical setting. Although these clinical phenotypes provide a good “starting point” for addressing disease heterogeneity in severe asthma in everyday practice, more efforts are needed to understand how these phenotypes relate to underlying disease mechanisms and pharmacological treatment responses. This review highlights the clinical asthma phenotypes identified to date, their associations with underlying endotypes and potential biomarkers, and remaining knowledge gaps that must be addressed before precision medicine can become a reality for patients with severe asthma.
Since 2012, the FDA has approved 88 new oncologic therapies or indications, including 28 drugs for hematologic malignancies (centerwatch.com/drug-information/fda-approved). Correspondingly, the Surveillance, Epidemiology, and End Results (SEER) program reported a 20% decline in the overall cancer-attributable death rate over the past three decades.1 However, improvements in cancer therapy has been accompanied by a boom in health care expenditures from 125 billion in 2010, to a projected 173 billion by the year 20202. New drugs carry a wide range of expected therapeutic efficacy at the expense of increased cost for patients and payers. The shifting dynamics of novel therapies and increasing cost, have brought the concept of “value” to center stage. The meaning of value in reference to cancer treatment differs substantially from the patient, physician, and payer point of view, with different weights added to improvements survival, convenience, side effects, and cost.
Background: Use of nucleic acid amplification tests (NAAT) for the diagnosis of Mycobacterium tuberculosis (TB) has been recommended on respiratory specimens submitted for acid-fast bacilli (AFB) testing. It also helps distinguish between TB and non-tuberculous mycobacteria (NTM) species in a setting where NTM rates are relatively high. The purposes of this study are to describe the trend and characteristics of all AFB smear-positive respiratory samples that underwent amplified Mycobacterium tuberculosis direct (MTD) testing, a type of NAAT, and to evaluate the clinical utility and necessity of the test for diagnosis of TB in a population with high-HIV prevalence.
by
Ying Xian;
Ann Marie Navar;
Shuang Li;
Zhuokai Li;
Jennifer Robinson;
Salim S. Virani;
Michael J. Louie;
Andrew Koren;
Anne Goldberg;
Veronique L. Roger;
Peter W Wilson;
Eric D. Peterson;
Tracy Y. Wang
Background Current treatment guidelines strongly recommend statin therapy for secondary prevention. However, it remains unclear whether patients' perceptions of cardiovascular risk, beliefs on cholesterol, or the intensity of prescribed statin therapy differs for patients with coronary artery disease (CAD) versus cerebrovascular disease (CeVD) versus both CAD and CeVD (CAD&CeVD). Methods and Results The PALM (Patient and Provider Assessment of Lipid Management) registry collected data on statin use, intensity, and core laboratory low-density lipoprotein cholesterol levels for 3232 secondary prevention patients treated at 133 US clinics. Among individuals with CeVD only (n=403), CAD only (n=2202), and CeVD&CAD (n=627), no significant differences were observed in patient-perceived cardiovascular disease risk, beliefs on cholesterol lowering, or perceived effectiveness and safety of statin therapy. However, patients with CeVD only were less likely to receive any statin therapy (76.2% versus 86.2%; adjusted odds ratio 0.64, 95% CI 0.45-0.91), or guideline-recommended statin intensity (34.6% versus 50.4%; adjusted odds ratio 0.60, 95% CI 0.45-0.81) than those with CAD only. Individuals with CeVD only were also less likely to achieve low-density lipoprotein cholesterol <100 mg/dL (59.2% versus 69.7%; adjusted odds ratio 0.79, 95% CI 0.64-0.99) than individuals with CAD alone. There were no significant differences in the use of any statin therapy or guideline-recommended statin intensity between individuals with CAD&CeVD and those with CAD only. Conclusions Despite lack of significant differences in patient-perceived cardiovascular risk or statin beliefs, patients with CeVD were significantly less likely to receive higher intensity statin or achieve low-density lipoprotein cholesterol <100 mg/dL than those with CAD only.
by
Ariela R. Orkaby;
Lisa Nussbaum;
Yuk-Lam Ho;
David Gagnon;
Lien Quach;
Rachel Ward;
Rachel Quaden;
Enzo Yaksic;
Kelly Harrington;
Julie M. Paik;
Dae H. Kim;
Peter W Wilson;
J. Michael Gaziano;
Luc Djousse;
Kelly Cho;
Jane A. Driver
Background: Frailty is a key determinant of clinical outcomes. We sought to describe frailty among U.S. Veterans and its association with mortality.
Methods: Nationwide retrospective cohort study of regular Veterans Affairs (VA) users, aged at least 65 years in 2002-2012, followed through 2014, using national VA administrative and Medicare and Medicaid data. A frailty index (FI) for VA (VA-FI) was calculated using the cumulative deficit method. Thirty-one age-related deficits in health from diagnostic and procedure codes were included and were updated biennially. Survival analysis assessed associations between VA-FI and mortality.
Results: A VA-FI was calculated for 2,837,152 Veterans over 10 years. In 2002, 35.5% were non-frail (FI = 0-0.10), 32.6% were pre-frail (FI = 0.11-0.20), 18.9% were mildly frail (FI = 0.21-0.30), 8.7% were moderately frail (FI = 0.31-0.40), and 4.3% were severely frail (FI > 0.40). From 2002 to 2012, the prevalence of moderate frailty increased to 12.7%and severe frailty to 14.1%. Frailty was strongly associated with survival and was independent of age, sex, race, and smoking; the VA-FI better predicted mortality than age alone. Although prevalence of frailty rose over time, compared to non-frail Veterans, 2 years' hazard ratios (95% confidence intervals) for mortality declined from a peak in 2004 of 2.01 (1.97-2.04), 3.49 (3.44-3.55), 5.88 (5.79-5.97), and 10.39 (10.23-10.56) for pre-frail, mildly, moderately, and severely frail, respectively, to 1.51 (1.49-1.53), 2.36 (2.33-2.39), 3.68 (3.63-3.73), 6.62 (6.53-6.71) in 2012. At every frailty level, risk of mortality was lower for women versus men and higher for blacks versus whites.
Conclusions: Frailty affects at least 3 of every 10 U.S. Veterans aged 65 years and older, and is strongly associated with mortality. The VA-FI could be used to more accurately estimate life expectancy and individualize care for Veterans.