Search

STUDY OBJECTIVES: To develop simple clinical tools predictive of acute asthma care and to identify modifiable risk factors. DESIGN: Prospective cohort study. SETTING: A large health maintenance organization (430,000 members). Patients/participants: Adult members (18 to 55 years old) with asthma. INTERVENTIONS: Data from a questionnaire, skin-prick testing for inhalant allergens, and spirometry were collected at the baseline visit. Acute care utilization data were obtained from administrative databases for a subsequent 30-month period. METHODS: This two-phase study first identified and performed a split-sample validation on three clinical tools to determine their predictive ability by employing data from a questionnaire, questionnaire plus spirometry, and questionnaire plus spirometry and skin-prick testing. Second, it identified modifiable independent risk factors. MEASUREMENTS AND RESULTS: The 554 study participants generated 173 episodes of acute care over 1,258 person-years of follow-up (0.14 episodes per person per year). Of these, 101 participants had at least one episode, and one third of this group had two or more episodes. Clinical scoring into risk groups was done by reverse stepwise regression analyses. Using relative risks (RRs) as a guide, high-risk, moderate-risk, and low-risk groups were identified. The high-risk groups, 13 to 21% of the validation sample, had a 7- to 11-fold increased risk for hospital care compared to the low-risk groups. The moderate-risk groups, 46 to 50% of the validation sample, had a twofold- to fourfold-increased risk. FEV(1) was the most significant predictor (RR, 4.33). Of the four potentially modifiable risk factors identified, current cigarette smoke exposure (RR, 1.6) and ownership and skin-prick test positivity to cat or dog (RR, 1.5) were the most significant. CONCLUSIONS: These models stratify asthma patients at risk for acute care. Patients with lower FEV(1) values are at significantly higher risk, underscoring the importance of spirometry in asthma care. [ABSTRACT FROM AUTHOR]

Background: Although inhaled therapy reduces exacerbations among patients with COPD, the effectiveness of providing inhaled treatment per risk stratification models remains unclear., Research Question: Are inhaled regimens that align with the 2017 Global Initiative for Chronic Obstructive Lung Disease (GOLD) strategy associated with clinically important outcomes?, Study Design and Methods: We conducted secondary analyses of Long-term Oxygen Treatment Trial (LOTT) data. The trial enrolled patients with COPD with moderate resting or exertional hypoxemia between 2009 and 2015. Our exposure was the patient-reported inhaled regimen at enrollment, categorized as either aligning with, undertreating, or potentially overtreating per the 2017 GOLD strategy. Our primary composite outcome was time to death or first hospitalization for COPD. Additional outcomes included individual components of the composite outcome and time to first exacerbation. We generated multivariable Cox proportional hazard models across strata of GOLD-predicted exacerbation risk (high vs low) to estimate between-group hazard ratios for time to event outcomes. We adjusted models a priori for potential confounders, clustered by site., Results: The trial enrolled 738 patients (73.4% men; mean age, 68.8 years). Of the patients, 571 (77.4%) were low risk for future exacerbations. Of the patients, 233 (31.6%) reported regimens aligning with GOLD recommendations; most regimens (54.1%) potentially overtreated. During a 2.3-year median follow-up, 332 patients (44.9%) experienced the composite outcome. We found no difference in time to composite outcome or death among patients reporting regimens aligning with recommendations compared with undertreated patients. Among patients at low risk, potential overtreatment was associated with higher exacerbation risk (hazard ratio, 1.42; 95% CI, 1.09-1.87), whereas inhaled corticosteroid treatment was associated with 64% higher risk of pneumonia (incidence rate ratio, 1.64; 95% CI, 1.01-2.66)., Interpretation: Among patients with COPD with moderate hypoxemia, we found no difference in clinical outcomes between inhaled regimens aligning with the 2017 GOLD strategy compared with those that were undertreated. These findings suggest the need to reevaluate the effectiveness of risk stratification model-based inhaled treatment strategies., (Copyright © 2020 American College of Chest Physicians. All rights reserved.)

Rationale: Characteristics associated with adherence to long-term oxygen therapy (LTOT) in COPD remain unclear., Objectives: To identify patient characteristics at the time of oxygen initiation associated with its adherence., Methods: We conducted a secondary analysis of data from 359 COPD participants assigned to oxygen in the Long-term Oxygen Treatment Trial. Participants were prescribed continuous (n = 214) or intermittent (n = 145) oxygen based on desaturation patterns at study entry. At the time of initial prescription, participants rated their perceived readiness, confidence, and importance to use oxygen on a 0-10 scale (0 = not at all, 10 = very much). During follow-up, they self-reported average hours per day of use (adherence). Adherence was averaged over short-term (0-30 days), medium-term (months 9-12), and long-term (month 13 to last follow-up) intervals. Multivariable logistic regression models explored characteristics associated with high adherence (≥16 h/day [continuous] or ≥8 h/day [intermittent]) during each time interval., Results: Participant readiness, confidence, and importance at the time of oxygen initiation were associated with high short- and medium-term adherence. For each unit increase in baseline readiness, the odds of high short-term adherence increased by 21% (odds ratio [OR] 1.21, 95% confidence interval [CI] 1.05-1.40) and 94% (OR 1.94, 95% CI 1.45-2.59) in the continuous and intermittent groups, respectively. In both groups, high adherence in the medium-term was associated with high adherence in the long-term (continuous, OR 12.49, 95% CI 4.90-31.79; intermittent, OR 38.08, 95% CI 6.96-208.20)., Conclusions: Readiness, confidence, and importance to use LTOT at initiation, and early high adherence, are significantly associated with long-term oxygen adherence., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

The Long-Term Oxygen Treatment Trial demonstrated that long-term supplemental oxygen did not reduce time to hospital admission or death for patients who have stable chronic obstructive pulmonary disease and resting and/or exercise-induced moderate oxyhemoglobin desaturation, nor did it provide benefit for any other outcome measured in the trial. Nine months after initiation of patient screening, after randomization of 34 patients to treatment, a trial design amendment broadened the eligible population, expanded the primary outcome, and reduced the goal sample size. Within a few years, the protocol underwent minor modifications, and a second trial design amendment lowered the required sample size because of lower than expected treatment group crossover rates. After 5.5 years of recruitment, the trial met its amended sample size goal, and 1 year later, it achieved its follow-up goal. The process of publishing the trial results brought renewed scrutiny of the study design and the amendments. This article expands on the previously published design and methods information, provides the rationale for the amendments, and gives insight into the investigators' decisions about trial conduct. The story of the Long-Term Oxygen Treatment Trial may assist investigators in future trials, especially those that seek to assess the efficacy and safety of long-term oxygen therapy. Clinical trial registered with clinicaltrials.gov (NCT00692198).

Background: Long-term treatment with supplemental oxygen has unknown efficacy in patients with stable chronic obstructive pulmonary disease (COPD) and resting or exercise-induced moderate desaturation., Methods: We originally designed the trial to test whether long-term treatment with supplemental oxygen would result in a longer time to death than no use of supplemental oxygen among patients who had stable COPD with moderate resting desaturation (oxyhemoglobin saturation as measured by pulse oximetry [Spo 2 ], 89 to 93%). After 7 months and the randomization of 34 patients, the trial was redesigned to also include patients who had stable COPD with moderate exercise-induced desaturation (during the 6-minute walk test, Spo 2 ≥80% for ≥5 minutes and <90% for ≥10 seconds) and to incorporate the time to the first hospitalization for any cause into the new composite primary outcome. Patients were randomly assigned, in a 1:1 ratio, to receive long-term supplemental oxygen (supplemental-oxygen group) or no long-term supplemental oxygen (no-supplemental-oxygen group). In the supplemental-oxygen group, patients with resting desaturation were prescribed 24-hour oxygen, and those with desaturation only during exercise were prescribed oxygen during exercise and sleep. The trial-group assignment was not masked., Results: A total of 738 patients at 42 centers were followed for 1 to 6 years. In a time-to-event analysis, we found no significant difference between the supplemental-oxygen group and the no-supplemental-oxygen group in the time to death or first hospitalization (hazard ratio, 0.94; 95% confidence interval [CI], 0.79 to 1.12; P=0.52), nor in the rates of all hospitalizations (rate ratio, 1.01; 95% CI, 0.91 to 1.13), COPD exacerbations (rate ratio, 1.08; 95% CI, 0.98 to 1.19), and COPD-related hospitalizations (rate ratio, 0.99; 95% CI, 0.83 to 1.17). We found no consistent between-group differences in measures of quality of life, lung function, and the distance walked in 6 minutes., Conclusions: In patients with stable COPD and resting or exercise-induced moderate desaturation, the prescription of long-term supplemental oxygen did not result in a longer time to death or first hospitalization than no long-term supplemental oxygen, nor did it provide sustained benefit with regard to any of the other measured outcomes. (Funded by the National Heart, Lung, and Blood Institute and the Centers for Medicare and Medicaid Services; LOTT ClinicalTrials.gov number, NCT00692198 .).

Objective: To test the ability of an automated telephone outreach intervention to reduce acute healthcare utilization and improve quality of life among adult asthma patients in a large managed care organization., Study Design: Randomized clinical trial., Methods: Patients with persistent asthma were randomly assigned to telephone outreach (automated = 3389, live caller = 192) or usual care (n = 3367). Intervention participants received 3 outreach calls over a 10-month period. The intervention provided brief, supportive information and flagged individuals with poor asthma control for follow-up by a provider. A survey was mailed to 792 intervention participants and 236 providers after the intervention. Additional feedback was obtained as part of the final intervention contact., Results: The intent-to-treat analysis found no significant differences between the intervention and usual-care groups for medication use, healthcare utilization, asthma control, or quality of life. Post hoc analyses found that, compared with the control group, individuals who actually participated in the intervention were significantly more likely to use inhaled steroids and to have had a routine medical visit for asthma during the follow-up period and less likely to use short-acting beta-agonists. They also reported higher satisfaction with their asthma care and better asthma-specific quality of life. Of surveyed providers, 59% stated the program helped them to clinically manage their asthma patients and 70% thought the program should be continued., Conclusions: This study did not find improved health outcomes in the primary analyses. The intervention was well accepted by providers, however, and the individuals who participated in the calls appeared to have benefited from them. These findings suggest that further studies of automated telephone outreach interventions seem warranted.

This paper describes the approach taken to build Kaiser Permanente's national clinical intranet. A primary objective for the site is to facilitate resource discovery, which is enabled by the use of "metadata", or data (fields and field values) that describe the various resources available. Users can perform full text queries and/or fielded searching against the metadata. Metadata serves as the organizing principle of the site--it is used to index documents, sort search results, and structure the site's table of contents. The site's use of metadata--what it is, how it is created, how it is applied to documents, how it is indexed, how it is presented to the user in the search and the search results interface, and how it is used to construct the table of contents for the web site--will be discussed in detail. The result is that KP's national clinical intranet has coupled the power of Internet-like full text search engines with the power of MedLine-like fielded searching in order to maximize search precision and recall. Organizing content on the site in accordance with the metadata promotes overall consistency. Issues currently under investigation include how to better exploit the power of the controlled terminology within the metadata; whether the value gained is worth the cost of collecting metadata; and how automatic classification algorithms might obviate the need for manual document indexing.

Spirometry, respiratory symptom questionnaires, and chest radiographs were obtained from 688 loggers in Oregon and Washington. These were compared against previously published National Institute for Occupational Safety and Health studies of nonexposed blue-collar workers to determine if these predictions fit our population. The loggers forced expiratory volume in 1 second and forced vital capacity values were significantly greater than predicted, and their forced expiratory volume in 1 second/forced vital capacity values were less than predicted. The only consistent difference in symptoms between the sample and reference populations was for recent chest illnesses, which were more prevalent in the loggers than in the reference population. The chest radiographs showed a small excess of pleural thickening that we believe is most likely due to chest trauma. We conclude that the National Institute for Occupational Safety and Health studies spirometry prediction equations may not be generalized to other blue-collar populations.

Purpose: A variety of abnormalities in pulmonary function have been attributed to, or are believed to be, exacerbated by congestive heart failure. Separating out specific contributions from cardiac versus pulmonary disease is difficult. In order to investigate the impact of cardiac disease on pulmonary function, we performed spirometry on patients immediately before and after cardiac transplantation., Patients and Methods: Seventeen patients (13 men, 4 women) with a mean age of 44 years (range: 20 to 62 years) were studied before and 15 +/- 10 (mean +/- SD) months after cardiac transplantation. Eleven patients had a significant smoking history., Results: In comparing pre- and post-transplant spirometric results, forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV1) increased substantially after transplant (3.34 +/- 0.96 L versus 3.89 +/- 1.00 L, p = 0.0054, and 2.63 +/- 0.80 L versus 2.95 +/- 0.83 L, p = 0.042, respectively). FEV1/FVC was not significantly different between study states in the entire group (0.78 +/- 0.10 versus 0.76 +/- 0.10, p = NS), nor was it different in those patients with and without a smoking history (0.76 +/- 0.11 versus 0.72 +/- 0.10, p = NS, and 0.87 +/- 0.06 versus 0.84 +/- 0.02, p = NS, respectively). Furthermore, normal lung volumes were obtained after transplant in those patients without a smoking history in contrast to those with a smoking history. Finally, the increase in FVC after cardiac transplantation directly correlated with the decrease in cardiac volume with cardiac replacement (r = 0.83, p less than 0.0001)., Conclusion: We conclude that in patients selected as cardiac transplant candidates (those without severe obstructive lung disease), restrictive but not obstructive pulmonary physiology can be attributed in part to congestive heart failure, and a major part of the reduction in lung volumes is secondary to the space occupied by a large heart. Other factors, such as accompanying pleural effusions and interstitial edema, likely contribute to the reduction in lung volumes. Abnormal pulmonary function secondary to chronic congestive heart failure in this selected population is completely reversible with normalization of cardiovascular physiology and anatomy.

Renography using a gamma camera, a minicomputer, [123I]orthoiodohippurate ([123I]OIH), and a canine model was employed to evaluate computer-generated maps of regional renal function. Renograms were obtained before and after ligations of the right renal arterial branch in four dogs, with subsequent angiographic and histologic confirmation of the lesions. Postoperative time-activity curves were normal. Washout and persistence index in three of four right kidneys showed regional abnormality. Functional renal mapping may provide a clinical technique for evaluating human renal vascular hypertension.

Purpose: Acinetobacter calcoaceticus subspecies anitratus (A. anitratus) can cause nosocomially and community acquired pneumonia. Source identification of the organism is often difficult. An outbreak of respiratory infection and colonization with A. anitratus affecting 93 ventilated patients in all six of a hospital's intensive care units (ICUs) over 10 months is described., Patients and Methods: In April 1984, the infection control staff started to review positive culture results from all patients in all ICUs. At this point, information on significant isolates was recorded by patient, site, date, genus and species, and antimicrobial susceptibility. During the month of August 1984, an increased number of A. anitratus isolates from sputum began to be detected. Information was expanded to include the date of hospital admission, ICU admission, intubation, and extubation; the dates and types of all surgical procedures; the results and dates of all prior sputum cultures; and the use of nebulized bronchodilator medications. Monthly numbers of cases were compared for four months prior to the outbreak, during the outbreak, and for seven months after the outbreak. Plasmid DNA from isolates was prepared, electrophoresed, and visualized. Isolates were designated according to the molecular weights of visualized plasmids., Results: Barrier precautions and improved staff handwashing did not diminish the frequency of new cases. When pasteurized, reusable ventilator circuits and resuscitation bags were cultured for the possibility of low-level contamination, 18 percent were positive for A. anitratus. Terminal ethylene oxide sterilization of these devices was associated with prompt control of the outbreak. Plasmid DNA analysis of isolates from patients involved in the outbreak, contaminated devices, and the hands of personnel responsible for device disinfection revealed two predominant plasmid profiles. After outbreak control, isolates with these profiles were found much less frequently in patient specimens., Conclusion: Contaminated, reusable ventilator support equipment may be a leading cause for the extent of A. anitratus in the sputum of intubated patients. This problem is potentially correctable by the use of terminal etyhlene oxide sterilization of reusable ventilator circuits and resuscitation bags.

Asthma represents a readily treatable disease that today is still associated with significant morbidity and mortality, much of which may be preventable with prompt and correct therapy. An understanding of the clinical presentations of this disease, as well as an understanding of effective, multiagent therapy, is the goal of this article.