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Mincham KT, Akthar S, Patel DF, Meyer GF, Lloyd CM, Gaggar A, Blalock JE, Snelgrove RJ. Airway extracellular LTA 4H concentrations are governed by release from liver hepatocytes and changes in lung vascular permeability. Cell Rep 2024; 43:114630. [PMID: 39146180 DOI: 10.1016/j.celrep.2024.114630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Revised: 07/04/2024] [Accepted: 07/30/2024] [Indexed: 08/17/2024] Open
Abstract
Leukotriene A4 hydrolase (LTA4H) is a bifunctional enzyme, with dual activities critical in defining the scale of tissue inflammation and pathology. LTA4H classically operates intracellularly, primarily within myeloid cells, to generate pro-inflammatory leukotriene B4. However, LTA4H also operates extracellularly to degrade the bioactive collagen fragment proline-glycine-proline to limit neutrophilic inflammation and pathological tissue remodeling. While the dichotomous functions of LTA4H are dictated by location, the cellular source of extracellular enzyme remains unknown. We demonstrate that airway extracellular LTA4H concentrations are governed by the level of pulmonary vascular permeability and influx of an abundant repository of blood-borne enzyme. In turn, blood LTA4H originates from liver hepatocytes, being released constitutively but further upregulated during an acute phase response. These findings have implications for our understanding of how inflammation and repair are regulated and how perturbations to the LTA4H axis may manifest in pathologies of chronic diseases.
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Affiliation(s)
- Kyle T Mincham
- Inflammation Repair and Development, National Heart and Lung Institute, Imperial College London, London SW7 2AZ, UK
| | - Samia Akthar
- Inflammation Repair and Development, National Heart and Lung Institute, Imperial College London, London SW7 2AZ, UK
| | - Dhiren F Patel
- Inflammation Repair and Development, National Heart and Lung Institute, Imperial College London, London SW7 2AZ, UK; Department of Cellular Microbiology, Max Planck Institute for Infection Biology, Charitéplatz 1, 10117 Berlin, Germany
| | - Garance F Meyer
- Inflammation Repair and Development, National Heart and Lung Institute, Imperial College London, London SW7 2AZ, UK
| | - Clare M Lloyd
- Inflammation Repair and Development, National Heart and Lung Institute, Imperial College London, London SW7 2AZ, UK
| | - Amit Gaggar
- Division of Pulmonary, Allergy & Critical Care Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA; Program in Protease and Matrix Biology, University of Alabama at Birmingham, Birmingham, AL, USA; Lung Health Center and Gregory Fleming James CF Center, University of Alabama at Birmingham, Birmingham, AL, USA; Birmingham VA Medical Center, Birmingham, AL, USA
| | - James E Blalock
- Division of Pulmonary, Allergy & Critical Care Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA; Program in Protease and Matrix Biology, University of Alabama at Birmingham, Birmingham, AL, USA; Lung Health Center and Gregory Fleming James CF Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Robert J Snelgrove
- Inflammation Repair and Development, National Heart and Lung Institute, Imperial College London, London SW7 2AZ, UK.
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Kim DY, Cho SY, Lee K, Sohn CB. A Study of Projection-Based Attentive Spatial-Temporal Map for Remote Photoplethysmography Measurement. Bioengineering (Basel) 2022; 9:638. [PMID: 36354549 PMCID: PMC9687348 DOI: 10.3390/bioengineering9110638] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 10/21/2022] [Accepted: 10/28/2022] [Indexed: 08/27/2023] Open
Abstract
The photoplethysmography (PPG) signal contains various information that is related to CVD (cardiovascular disease). The remote PPG (rPPG) is a method that can measure a PPG signal using a face image taken with a camera, without a PPG device. Deep learning-based rPPG methods can be classified into three main categories. First, there is a 3D CNN approach that uses a facial image video as input, which focuses on the spatio-temporal changes in the facial video. The second approach is a method that uses a spatio-temporal map (STMap), and the video image is pre-processed using the point where it is easier to analyze changes in blood flow in time order. The last approach uses a preprocessing model with a dichromatic reflection model. This study proposed the concept of an axis projection network (APNET) that complements the drawbacks, in which the 3D CNN method requires significant memory; the STMap method requires a preprocessing method; and the dyschromatic reflection model (DRM) method does not learn long-term temporal characteristics. We also showed that the proposed APNET effectively reduced the network memory size, and that the low-frequency signal was observed in the inferred PPG signal, suggesting that it can provide meaningful results to the study when developing the rPPG algorithm.
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Affiliation(s)
- Dae-Yeol Kim
- AI Research Team, Tvstorm, Seoul 13875, Korea
- Department of Electronics and Communications Engineering, Kwangwoon University, Seoul 01897, Korea
| | - Soo-Young Cho
- Department of Information Contents, Kwangwoon University, Seoul 01897, Korea
| | | | - Chae-Bong Sohn
- Department of Electronics and Communications Engineering, Kwangwoon University, Seoul 01897, Korea
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Peng JC, Gong WW, Wu Y, Yan TY, Jiang XY. Development and validation of a prognostic nomogram among patients with acute exacerbation of chronic obstructive pulmonary disease in intensive care unit. BMC Pulm Med 2022; 22:306. [PMID: 35945553 PMCID: PMC9364535 DOI: 10.1186/s12890-022-02100-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 08/04/2022] [Indexed: 12/08/2022] Open
Abstract
Background Acute exacerbation of Chronic Obstructive Pulmonary Disease (AECOPD) contributes significantly to mortality among patients with COPD in Intensive care unit (ICU). This study aimed to develop a nomogram to predict 30-day mortality among AECOPD patients in ICU. Methods In this retrospective cohort study, we extracted AECOPD patients from Medical Information Mart for Intensive Care III (MIMIC-III) database. Multivariate logistic regression based on Akaike information criterion (AIC) was used to establish the nomogram. Internal validation was performed by a bootstrap resampling approach with 1000 replications. The discrimination and calibration of the nomogram were evaluated by Harrell’s concordance index (C-index) and Hosmer–Lemeshow (HL) goodness-of-fit test. Decision curve analysis (DCA) was performed to evaluate its clinical application. Results A total of 494 patients were finally included in the study with a mean age of 70.8 years old. 417 (84.4%) patients were in the survivor group and 77 (15.6%) patients were in the non-survivor group. Multivariate logistic regression analysis based on AIC included age, pO2, neutrophil-to-lymphocyte ratio (NLR), prognostic nutritional index (PNI), invasive mechanical ventilation and vasopressor use to construct the nomogram. The adjusted C-index was 0.745 (0.712, 0.778) with good calibration (HL test, P = 0.147). The Kaplan–Meier survival curves revealed a significantly lower survival probability in the high-risk group than that in the low-risk group (P < 0.001). DCA showed that nomogram was clinically useful. Conclusion The nomogram developed in this study could help clinicians to stratify AECOPD patients and provide appropriate care in clinical setting.
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Affiliation(s)
- Jiang-Chen Peng
- Department of Critical Care, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, 160 Pujian Road, Shanghai, 200127, China
| | - Wen-Wen Gong
- Department of Critical Care, Shanghai Baoshan Luodian Hospital, 121 Luoxi Road, Baoshan District, Shanghai, 201908, China
| | - Yan Wu
- Department of Critical Care, Shanghai Baoshan Luodian Hospital, 121 Luoxi Road, Baoshan District, Shanghai, 201908, China
| | - Tian-Yi Yan
- Department of Emergency, Shanghai Baoshan Luodian Hospital, 121 Luoxi Road, Baoshan District, Shanghai, 201908, China
| | - Xiao-Yan Jiang
- Department of Nursing, Shanghai Baoshan Luodian Hospital, 121 Luoxi Road, Baoshan District, Shanghai, 201908, China. .,Department of Nursing, Shanghai Baoshan Luodian Hospital, 121 Luoxi Road, Shanghai, 201908, China.
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Vlahakos V, Marathias K, Lionaki S, Loukides S, Zakynthinos S, Vlahakos D. The Paradigm Shift from Polycythemia to Anemia in COPD: The Critical Role of the Renin-Angiotensin System Inhibitors. Expert Rev Respir Med 2022; 16:391-398. [PMID: 35212601 DOI: 10.1080/17476348.2022.2045958] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Although polycythemia has been considered a common adverse event in COPD, anemia is reported more often and has gained more importance than polycythemia over the last thirty years. AREAS COVERED Factors considered to be associated with the development of anemia in COPD have included: Aging and kidney dysfunction with erythropoietin deficiency and bone marrow suppression due to uremic toxins; heart failure (HF), which is often encountered in COPD and is accompanied by anemia in one third of the cases; Low-grade chronic inflammation, which can directly suppresses the bone marrow and diminish iron absorption and utilization via increased hepcidin levels; long-term oxygen therapy (LTOT), which ameliorates chronic hypoxia, and most important, RAS inhibitors, which are widely used for the co-morbidities associated with COPD (hypertension, HF, CKD, diabetes) and have previously been shown to lower hematocrit values or cause anemia in various clinical conditions. EXPERT OPINION Introduction of LTOT in COPD and especially the established use of RAS inhibitors form the basis for the shift from polycythemia to anemia in COPD. Interestingly, when the SGLT2 inhibitors are introduced for cardiorenal protection in COPD, one could anticipate correction of anemia or even reemergence of polycythemia, since this new class of drugs can augment erythropoietin secretion and increase hematocrit values.
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Affiliation(s)
- Vassilios Vlahakos
- 1st Department of Intensive Care Medicine, National and Kapodistrian University of Athens, School of Medicine, Evangelismos General Hospital, Athens, Greece
| | - Katerina Marathias
- Department of Intensive Care Unit, Onassis Cardiac Surgery Center, Athens, Greece
| | - Sofia Lionaki
- 2nd Department of Medicine, Renal Unit, National and Kapodistrian University of Athens, School of Medicine, Attikon University Hospital, Athens, Greece
| | - Stelios Loukides
- 2nd Department of Respiratory Medicine, National and Kapodistrian University of Athens, School of Medicine, Attikon University Hospital, Athens, Greece
| | - Spyros Zakynthinos
- 1 Department of Intensive Care Medicine, National and Kapodistrian University of Athens, School of Medicine, Evangelismos General Hospital, Athens, Greece
| | - Demetrios Vlahakos
- 2 Department of Medicine, Renal Unit, National and Kapodistrian University of Athens, School of Medicine, Attikon University Hospital, Athens, Greece
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Chen D, Jiang L, Li J, Tan Y, Ma M, Cao C, Zhao J, Wan X. Interaction of Acute Respiratory Failure and Acute Kidney Injury on in-Hospital Mortality of Patients with Acute Exacerbation COPD. Int J Chron Obstruct Pulmon Dis 2021; 16:3309-3316. [PMID: 34908833 PMCID: PMC8665827 DOI: 10.2147/copd.s334219] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 11/23/2021] [Indexed: 02/03/2023] Open
Abstract
Purpose Both acute respiratory failure (ARF) and acute kidney injury (AKI) are two common complications in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD). Moreover, both ARF and AKI are reported as increasing the risk of mortality of patients with AECOPD. However, the interaction of ARF and AKI on the mortality of patients with AECOPD remains unknown. Therefore, the aim of this study is to investigate the joint effect of ARF and AKI on in-hospital mortality in AECOPD patients. Patients and Methods We performed a retrospective, observational cohort study of data from Nanjing First Hospital. The effect of AKI and ARF on in-hospital mortality was assessed using a multivariate logistic regression model. Additive interaction was assessed with the relative excess risk due to interaction. Results A total of 1647 participants were enrolled. ARF and AKI occurred in 515 (31.3%) and 357 (21.7%) patients, respectively. Overall, in-hospital mortality was 5.7%. The in-hospital mortality of the neither ARF nor AKI group, the ARF only group, the AKI only group, and both the ARF and AKI group were 0.8%, 7.0%, 7.5%, and 29.9%, respectively. After multivariate logistic regression analysis, the independent factors for in-hospital death included: albumin (OR 0.88, 95% CI 0.83–0.93, P < 0.001), ARF only (OR 8.53, 95% CI 3.64–19.99, P < 0.001), AKI only (OR 8.99, 95% CI 3.58–22.55, P < 0.001), and both ARF and AKI (OR 39.13, 95% CI 17.02–89.97, P < 0.001). The relative excess risk due to interaction was 22.62 (95% CI, 0.31 to 44.93), the attributable proportion due to interaction was 0.59 (95% CI, 0.36 to 0.79), and the synergy index was 2.46 (95% CI, 1.44 to 4.20), indicating ARF and AKI had a significant synergic effect on in-hospital mortality. Conclusion ARF and AKI had a synergistic effect on in-hospital mortality in AECOPD patients.
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Affiliation(s)
- Dawei Chen
- Department of Nephrology, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu, People's Republic of China
| | - Linglin Jiang
- Department of Nephrology, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu, People's Republic of China
| | - Jing Li
- Department of Nephrology, Affiliated Hospital of Jiangsu University, Zhenjiang, Jiangsu, People's Republic of China
| | - Yan Tan
- Department of Respiratory Medicine, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu, People's Republic of China
| | - Mengqing Ma
- Department of Nephrology, Sir Run Run Hospital, Nanjing Medical University, Nanjing, Jiangsu, People's Republic of China
| | - Changchun Cao
- Department of Nephrology, Sir Run Run Hospital, Nanjing Medical University, Nanjing, Jiangsu, People's Republic of China
| | - Jing Zhao
- Department of Nephrology, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu, People's Republic of China
| | - Xin Wan
- Department of Nephrology, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu, People's Republic of China
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Yu X, Zhu GP, Cai TF, Zheng JY. Establishment of risk prediction model and risk score for in-hospital mortality in patients with AECOPD. THE CLINICAL RESPIRATORY JOURNAL 2020; 14:1090-1098. [PMID: 32757441 DOI: 10.1111/crj.13246] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 07/18/2020] [Accepted: 07/31/2020] [Indexed: 12/08/2022]
Abstract
OBJECTIVE Risk stratification for patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) may help clinicians choose appropriate treatments and improve the quality of care. METHODS A total of 695 patients hospitalized with AECOPD from January 2015 to December 2017 were considered. They were assigned to a death and a survival cohort. The independent prognostic factors were determined by multivariate logistic regression analysis. Meanwhile, we also compared the new scale with three other scores and tested the new scale internally and externally. RESULTS A new risk score was created, made up of six independent variables: age, D-dimer, albumin, cardiac troponin I, partial pressure of carbon dioxide and oxygenation index. The area under the receiver operator characteristic curve (AUROC) for the model was 0.929, and the other three CURB-65, DECAF and BAP-65 models were 0.718, 0.922 and 0.708. The Cohen's kappa coefficient between the new scale and DECAF was calculated to be 0.648, suggesting that there is a substantial consistency between the two. In the internal and external validation cohorts, 490 and 500 patients were recruited with a total mortality rate of 5.15%. The AUROC for in-hospital mortality was 0.937 in the internal cohort and 0.914 in external cohort, which was significantly better than the scores for CURB-65 and BAP-65, but it was not significantly different from the DECAF. CONCLUSIONS The new scale may help to stratify the risk of in-hospital mortality of AECOPD. The DECAF performed as well as the new instrument, and it appears to be valid in Chinese patients.
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Affiliation(s)
- Xing Yu
- First Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou, People's Republic of China
| | - Gui-Ping Zhu
- First Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou, People's Republic of China
| | - Teng-Fei Cai
- First Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou, People's Republic of China
| | - Jian-Yi Zheng
- First Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou, People's Republic of China
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Das A, Das M, Ghosh S. Impact of nutritional status and anemia on COVID-19: Is it a public health concern? Evidence from National Family Health Survey-4 (2015-2016), India. Public Health 2020; 185:93-94. [PMID: 32593053 PMCID: PMC7280132 DOI: 10.1016/j.puhe.2020.06.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 06/01/2020] [Indexed: 12/25/2022]
Affiliation(s)
- A Das
- Department of Geography, University of Gour Banga, Malda, West Bengal, India.
| | - M Das
- Department of Geography, University of Gour Banga, Malda, West Bengal, India.
| | - S Ghosh
- Department of Geography, Kazi Nazrul University, Asansol, West Bengal, India.
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Recio Iglesias J, Díez-Manglano J, López García F, Díaz Peromingo JA, Almagro P, Varela Aguilar JM. Management of the COPD Patient with Comorbidities: An Experts Recommendation Document. Int J Chron Obstruct Pulmon Dis 2020; 15:1015-1037. [PMID: 32440113 PMCID: PMC7217705 DOI: 10.2147/copd.s242009] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 03/10/2020] [Indexed: 12/11/2022] Open
Abstract
Background Chronic obstructive pulmonary disease (COPD) is associated with multiple comorbidities, which impact negatively on patients and are often underdiagnosed, thus lacking a proper management due to the absence of clear guidelines. Purpose To elaborate expert recommendations aimed to help healthcare professionals to provide the right care for treating COPD patients with comorbidities. Methods A modified RAND-UCLA appropriateness method consisting of nominal groups to draw up consensus recommendations (6 Spanish experts) and 2-Delphi rounds to validate them (23 Spanish experts) was performed. Results A panel of Spanish internal medicine experts reached consensus on 73 recommendations and 81 conclusions on the clinical consequences of the presence of comorbidities. In general, the experts reached consensus on the issues raised with regard to cardiovascular comorbidity and metabolic disorders. Consensus was reached on the use of selective serotonin reuptake inhibitors in cases of depression and the usefulness of referring patients with anxiety to respiratory rehabilitation programmes. The results also showed consensus on the usefulness of investigating the quality of sleep, the treatment of pain with opioids and the evaluation of osteoporosis by lateral chest radiography. Conclusion This study provides conclusions and recommendations that are intended to improve the management of the complexity of patients with COPD and important comorbidities, usually excluded from clinical trials.
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Affiliation(s)
- Jesús Recio Iglesias
- Internal Medicine Department, Quironsalud Valencia Hospital, Valencia, Valencian Community, Spain
| | - Jesús Díez-Manglano
- Internal Medicine Department, Royo Villanova Hospital, Zaragoza, Aragon, Spain
| | - Francisco López García
- Internal Medicine Department General University Hospital of Elche, Alicante, Valencian Community, Spain
| | - José Antonio Díaz Peromingo
- Internal Medicine Department, University Clinical Hospital of Santiago de Compostela, a Coruña, Galicia, Spain
| | - Pere Almagro
- Internal Medicine Department, Mútua Terrassa University Hospital, Terrassa, Barcelona, Catalonia, Spain
| | - José Manuel Varela Aguilar
- Internal Medicine Department, University Hospital Virgen del Rocío, Seville, Andalusia, Spain
- CIBER of Epidemiology and Public Health, Madrid, Community of Madrid, Spain
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Shi QF, Sheng Y, Zhu N, Tan Y, Xie XH, Wang SY, Cai JF. The v-DECAF score can predict 90-day all-cause mortality in patients with COPD exacerbation requiring invasive mechanical ventilation. CLINICAL RESPIRATORY JOURNAL 2019; 13:438-445. [PMID: 30955228 DOI: 10.1111/crj.13028] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 03/06/2019] [Accepted: 03/31/2019] [Indexed: 11/28/2022]
Abstract
INTRODUCTION The DECAF score is a simple and effective tool for predicting mortality in patients hospitalized with acute exacerbations of chronic obstructive pulmonary disease (AECOPD); however, the DECAF score has not been validated in AECOPD patients requiring invasive mechanical ventilation (IMV). We devised the ventilator (v)-DECAF score, in which "anemia" replaces "acidaemia," for use in AECOPD patients requiring IMV. The objective of this study was to compare the predictive efficacy of the v-DECAF score and the DECAF score. METHODS This study prospectively recruited 112 consecutive AECOPD patients requiring IMV from a single center. The clinical endpoint was 90-day all-cause mortality. Demographic and clinical data were recorded, as well as APACHE II, GCS, CURB-65, BAP-65 and DECAF scores, and the newly devised v-DECAF score. The discriminatory value of the scoring systems in predicting 90-day all-cause mortality was determined using the area under the receiver operating characteristic (AUROC) curve. RESULTS In multivariate logistic regression analysis, the v-DECAF score was an independent predictor of 90-day all-cause mortality (odds ratio 3.004, 95% CI 1.658-5.445, P < 0.001). The AUROC of the v-DECAF and DECAF scores were 0.852 (95% CI 0.766-0.938) and 0.777 (95%CI: 0.676-0.878), respectively. The v-DECAF score had a better predictive value for 90-day all-cause mortality compared to the DECAF score (Z = 2.338, P = 0.019). CONCLUSION The v-DECAF score had good discriminatory power in predicting 90-day all-cause mortality in AECOPD patients requiring IMV.
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Affiliation(s)
- Qi-Fang Shi
- Department of Emergency and Critical Care Medicine Shanghai Pudong Hospital, Fudan University Pudong Medical Center, Pudong, China
| | - Ying Sheng
- Department of Emergency and Critical Care Medicine Shanghai Pudong Hospital, Fudan University Pudong Medical Center, Pudong, China
| | - Nian Zhu
- Department of Emergency and Critical Care Medicine Shanghai Pudong Hospital, Fudan University Pudong Medical Center, Pudong, China
| | - Yan Tan
- Department of Emergency and Critical Care Medicine Shanghai Pudong Hospital, Fudan University Pudong Medical Center, Pudong, China
| | - Xiao-Hong Xie
- Department of Emergency and Critical Care Medicine Shanghai Pudong Hospital, Fudan University Pudong Medical Center, Pudong, China
| | - Shu-Yun Wang
- Department of Emergency and Critical Care Medicine Shanghai Pudong Hospital, Fudan University Pudong Medical Center, Pudong, China
| | - Jin-Fang Cai
- Department of Emergency and Critical Care Medicine Shanghai Pudong Hospital, Fudan University Pudong Medical Center, Pudong, China
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Chen YC, Yu WK, Ko HK, Pan SW, Chen YW, Ho LI, Bien MY, Wang JH, Chan YJ, Kou YR. Post-intensive care unit respiratory failure in older patients liberated from intensive care unit and ventilator: The predictive value of the National Early Warning Score on intensive care unit discharge. Geriatr Gerontol Int 2019; 19:317-322. [PMID: 30788891 DOI: 10.1111/ggi.13626] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 12/12/2018] [Accepted: 01/01/2019] [Indexed: 11/28/2022]
Abstract
AIM The older adult population is continuously growing worldwide and there is increasing use of medical recourse in older patients, especially for those requiring intensive care unit (ICU) care and mechanical ventilation (MV). The present study aimed to investigate the burden and predictors of post-ICU respiratory failure in older ICU patients weaned from MV. METHODS In the present retrospective study, older ICU patients aged ≥60 years, who were successfully weaned from MV and discharged to the general ward from the ICU of Taipei Veterans General Hospital, Taipei, Taiwan, in 2011, were included. Biomarkers on ICU discharge, as well as the National Early Warning Score (NEWS) were recorded and calculated. The outcome measure was post-ICU respiratory failure before day 14 (PIRF-14) requiring reinstitution of MV. Logistical regression was used to assess the predictors for PIRF-14. RESULTS Of 272 patients included, 23 (8.5%) developed PIRF-14. The post-ICU in-hospital mortality rates were 47.8% and 6.8% in patients with and without PIRF-14 (adjusted OR 12.597, 95% CI 4.368-36.331). In a multivariate analysis, the levels of NEWS and hemoglobin on ICU discharge were independent predictors for PIRF-14 (adjusted OR 1.273, 95% CI 1.076-1.507 and 0.645, 95% CI 0.474-0.879). In particular, patients with a NEWS of ≥10 and subsequent PIRF-14 had a 15-fold increased risk of mortality as compared with those without both factors (adjusted OR 15.418, 95% CI 4.344-54.720). CONCLUSIONS PIRF-14 is associated with high mortality in older ICU patients, and NEWS is a significant predictor for PIRF-14, which could be used to early identify patients at risk of post-ICU respiratory failure in the specific population. Geriatr Gerontol Int 2019; 19: 317-322.
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Affiliation(s)
- Yu-Chun Chen
- Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Respiratory Therapy, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Institute of Emergency and Critical Care Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Wen-Kuang Yu
- Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan.,Institute of Physiology, National Yang-Ming University, Taipei, Taiwan
| | - Hsin-Kuo Ko
- Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan.,Institute of Physiology, National Yang-Ming University, Taipei, Taiwan
| | - Sheng-Wei Pan
- Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan.,Institute of Public Health, National Yang-Ming University, Taipei, Taiwan
| | - Yen-Wen Chen
- Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan.,Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Li-Ing Ho
- Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Mauo-Ying Bien
- School of Respiratory Therapy, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Division of Pulmonary Medicine, Department of Internal Medicine, Taipei Municipal Wanfang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Jia-Horng Wang
- Department of Critical Care Medicine, Far Eastern Memorial Hospital, New Taipei, Taiwan.,Critical Care Department and Hyperbaric Oxygen Center, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Yu-Jiun Chan
- Institute of Public Health, National Yang-Ming University, Taipei, Taiwan.,Division of Infectious Diseases, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yu Ru Kou
- Institute of Emergency and Critical Care Medicine, National Yang-Ming University, Taipei, Taiwan.,Institute of Physiology, National Yang-Ming University, Taipei, Taiwan
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Putcha N, Fawzy A, Paul GG, Lambert AA, Psoter KJ, Sidhaye VK, Woo J, Wells JM, Labaki WW, Doerschuk CM, Kanner RE, Han MK, Martinez C, Paulin LM, Martinez FJ, Wise RA, O’Neal WK, Barr RG. Anemia and Adverse Outcomes in a Chronic Obstructive Pulmonary Disease Population with a High Burden of Comorbidities. An Analysis from SPIROMICS. Ann Am Thorac Soc 2018; 15:710-717. [PMID: 30726108 PMCID: PMC6207135 DOI: 10.1513/annalsats.201708-687oc] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Accepted: 03/12/2018] [Indexed: 11/20/2022] Open
Abstract
RATIONALE Chronic obstructive pulmonary disease (COPD) is a common cause of morbidity and associated with a significant burden of comorbidities. Although anemia is associated with adverse outcomes in COPD, its contribution to outcomes in individuals with other comorbid chronic diseases is not well understood. OBJECTIVES This study examines the association of anemia with outcomes in a large, well-characterized COPD cohort, and attempts to understand the contribution of anemia to outcomes and phenotypes in individuals with other comorbidities. METHODS Participants with COPD from SPIROMICS (the Subpopulations and Intermediate Outcome Measures in COPD Study) were analyzed in adjusted models to determine the associations of normocytic anemia with clinical outcomes, computed tomographic measures, and biomarkers. Analysis was additionally performed to understand the independence and possible interactions related to cardiac and metabolic comorbidities. RESULTS A total of 1,789 individuals with COPD from SPIROMICS had data on hemoglobin, and of these 7.5% (n = 135) were found to have normocytic anemia. Anemic participants were older with worse airflow obstruction, a higher proportion of them were African Americans, and they had a higher burden of cardiac and metabolic comorbidities. Anemia was strongly associated with 6-minute walk distance (β, -61.43; 95% confidence interval [CI], -85.11 to -37.75), modified Medical Research Council dyspnea questionnaire (β, 0.27; 95% CI, 0.11-0.44), and St. George's Respiratory Questionnaire (β, 3.90; 95% CI, 1.09-6.71), and these adjusted associations were stronger among those with two or more cardiac and metabolic comorbidities. Anemia was associated with higher levels of serum C-reactive protein, soluble receptor for advanced glycosylation end-products, and epithelial cadherin-1, findings that persisted when in those with a high burden of comorbidities. CONCLUSIONS Anemia is associated with worse exercise capacity, greater dyspnea, and greater disease severity among adults with COPD, particularly among those with comorbid chronic cardiac and metabolic diseases. The biomarkers found in anemic individuals suggest inflammation, lung tissue injury, and oxidative stress as possible pathways for the adverse correlations of anemia with outcomes in COPD; however, substantial further study is required to better understand these potential mechanisms. Clinical trial registered with www.clinicaltrials.gov (NCT01969344).
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Affiliation(s)
- Nirupama Putcha
- Division of Pulmonary and Critical Care Medicine, Department of Medicine and
| | - Ashraf Fawzy
- Division of Pulmonary and Critical Care Medicine, Department of Medicine and
| | - Gabriel G. Paul
- Division of Pulmonary and Critical Care Medicine, Department of Medicine and
| | - Allison A. Lambert
- Division of Pulmonary and Critical Care Medicine, Department of Medicine and
| | - Kevin J. Psoter
- Division of General Pediatrics and Adolescent Medicine, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - John Woo
- Division of Pulmonary and Critical Care Medicine, Department of Medicine and
| | | | | | - Claire M. Doerschuk
- Marsico Lung Institute, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | | | - MeiLan K. Han
- University of Michigan Medical School, Ann Arbor, Michigan
| | | | - Laura M. Paulin
- Division of Pulmonary and Critical Care Medicine, Department of Medicine and
| | | | - Robert A. Wise
- Division of Pulmonary and Critical Care Medicine, Department of Medicine and
| | - Wanda K. O’Neal
- Marsico Lung Institute, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | | | - on behalf of the SPIROMICS Investigators
- Division of Pulmonary and Critical Care Medicine, Department of Medicine and
- Division of General Pediatrics and Adolescent Medicine, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
- University of Alabama at Birmingham, Birmingham, Alabama
- University of Michigan Medical School, Ann Arbor, Michigan
- Marsico Lung Institute, University of North Carolina School of Medicine, Chapel Hill, North Carolina
- University of Utah School of Medicine, Salt Lake City, Utah
- Cornell University School of Medicine, New York, New York; and
- Columbia University Medical Center, New York, New York
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12
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Pieralli F, Vannucchi V, De Marzi G, Mancini A, Bacci F, Para O, Nozzoli C, Falcone M. Performance status and in-hospital mortality of elderly patients with community acquired pneumonia. Intern Emerg Med 2018. [PMID: 29524081 DOI: 10.1007/s11739-018-1822-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
To evaluate the role of performance status evaluated by the Eastern Cooperative Oncology Group (ECOG) score in predicting 30-day mortality in subjects hospitalized for community acquired pneumonia (CAP), this was a prospective study of patients consecutively hospitalized for CAP at a large University Hospital in Italy. Performance status was evaluated using the ECOG score that in a 0-5 point scale indicates progressive functional deterioration. The end-point of the study is the 30-day mortality. Two-hundred-sixteen patients were enrolled, 75.9% were aged > 70 years, 31.5% had severe pneumonia at CURB-65 score (3-4), and 27.5% of patients had severe disability (ECOG 3-4). Thirty-day mortality is 15.3%. Progression in ECOG score independently increases the probability of 30-day mortality at multivariable logistic regression analysis (HR 2.19, 95% CI 1.60-3.01, p < 0.0001). ECOG 3 or 4 determines a four-fold increase in 30-day mortality (HR 4.07, 95% CI 1.84-9.02, p < 0.001). ECOG score 3 or 4 is highly predictive of death in patients classified at low risk of mortality by CURB-65 (0-2 points) score. Functional status is directly related to outcome in elderly patients hospitalized for CAP. The use of a very simple and fast tool, such as the ECOG score, might help to better stratify the risk of short-term mortality, especially in patients otherwise classified at low risk of death by CURB-65 score.
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Affiliation(s)
- Filippo Pieralli
- Subintensiva di Medicina, Internal and Emergency Medicine Department, Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50134, Florence, Italy.
| | - Vieri Vannucchi
- Internal Medicine, Santa Maria Nuova Hospital, USL Toscana Centro, Florence, Italy
| | - Giulia De Marzi
- Subintensiva di Medicina, Internal and Emergency Medicine Department, Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50134, Florence, Italy
| | - Antonio Mancini
- Subintensiva di Medicina, Internal and Emergency Medicine Department, Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50134, Florence, Italy
| | - Francesca Bacci
- Subintensiva di Medicina, Internal and Emergency Medicine Department, Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50134, Florence, Italy
| | - Ombretta Para
- Subintensiva di Medicina, Internal and Emergency Medicine Department, Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50134, Florence, Italy
| | - Carlo Nozzoli
- Subintensiva di Medicina, Internal and Emergency Medicine Department, Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50134, Florence, Italy
| | - Marco Falcone
- Department of Public Health and Infectious Diseases, "Sapienza" University of Rome, Rome, Italy
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13
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Shah NM, D'Cruz RF, Murphy PB. Update: non-invasive ventilation in chronic obstructive pulmonary disease. J Thorac Dis 2018; 10:S71-S79. [PMID: 29445530 DOI: 10.21037/jtd.2017.10.44] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) remains a common cause of morbidity and mortality worldwide. Patients with COPD and respiratory failure, whether acute or chronic have a poorer prognosis than patients without respiratory failure. Non-invasive ventilation (NIV) has been shown to be a useful tool in both the acute hospital and chronic home care setting. NIV has been well established as the gold standard therapy for acute decompensated respiratory failure complicating an acute exacerbation of COPD with reduced mortality and intubation rates compared to standard therapy. However, NIV has been increasingly used in other clinical situations such as for weaning from invasive ventilation and to palliate symptoms in patients not suitable for invasive ventilation. The equivocal evidence for the use of NIV in chronic hypercapnic respiratory failure complicating COPD has recently been challenged with data now supporting a role for therapy in selected subgroups of patients. Finally the review will discuss the emerging role of high flow humidified therapy to support or replace NIV in certain clinical situation.
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Affiliation(s)
- Neeraj Mukesh Shah
- Lane Fox Respiratory Unit, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Rebecca Francesca D'Cruz
- Lane Fox Respiratory Unit, Guy's and St Thomas' NHS Foundation Trust, London, UK.,National Institute for Health Research (NIHR) Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK
| | - Patrick B Murphy
- Lane Fox Respiratory Unit, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Lane Fox Clinical Respiratory Physiology Research Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Division of Asthma, Allergy and Lung Biology, King's College London, London, UK
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14
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Hemauer S, Kingeter AJ, Han X, Shotwell MS, Pandharipande PP, Weavind LM. Daily Lowest Hemoglobin and Risk of Organ Dysfunctions in Critically Ill Patients. Crit Care Med 2017; 45:e479-e484. [PMID: 28252537 PMCID: PMC5398896 DOI: 10.1097/ccm.0000000000002288] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To determine the association between hemoglobin levels and the daily risk of individual organ dysfunctions in critically ill patients. DESIGN Post hoc analysis of prospectively collected data. SETTING Vanderbilt University Medical Center and Saint Thomas Hospital Medical and Surgical ICUs. PATIENTS Medical and surgical ICU patients admitted with respiratory failure or shock. INTERVENTIONS Baseline demographic data, and detailed in-ICU and hospital data, including daily lowest hemoglobin, were collected up to hospital day 30. We assessed patients daily for brain dysfunction (delirium, using Confusion Assessment Method for ICU), for renal and respiratory dysfunction (using the ordinal renal and respiratory Sequential Organ Failure Assessment score), and for ICU mortality. Associations between the lowest hemoglobin on a given day and organ dysfunctions the following day were assessed using multivariable regressions, adjusting for age, Acute Physiology and Chronic Health Evaluation II score, Charlson comorbidity index, Framingham Stroke Risk Profile, ICU day, ICU type, sepsis, and current organ dysfunction status. A sensitivity analysis further adjusted for daily transfusions and fluid balance in a subset of our patients. MEASUREMENTS AND MAIN RESULTS We enrolled 821 patients with a median (interquartile range) age of 61 (51-71) years, Acute Physiology and Chronic Health Evaluation II score of 25 (19-31), and hemoglobin level of 10.0 (9.0-11.1) g/dL. There was no evidence of an association between lowest daily hemoglobin and brain dysfunction (p = 0.69 for delirium), renal dysfunction (p = 0.30), or ICU mortality (p = 0.95). The lowest hemoglobin on a given day was significantly associated with the respiratory Sequential Organ Failure Assessment score the following day; for each increasing hemoglobin unit, the odds of worsened respiratory Sequential Organ Failure Assessment score the following day were decreased by 36% (OR, 0.64; 95% CI, 0.53-0.77; p < 0.001). The sensitivity analysis including daily transfusions and fluid balance (in a subset of 518 patients) did not qualitatively change any of these associations. CONCLUSIONS In this study in ICU patients, lower hemoglobin was associated with a higher probability of worsening respiratory dysfunction scores the following day. There was no evidence of association between hemoglobin and brain or renal dysfunction, or ICU mortality. The possible differential effects of anemia on organ dysfunctions seen in this hypothesis-generating study will have to be studied in a larger prospective study before any alterations to present restrictive transfusion guidelines can be recommended.
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Affiliation(s)
- Sarah Hemauer
- Department of Anesthesiology/Division of Anesthesiology Critical Care Medicine, Nashville, TN
| | - Adam J Kingeter
- Department of Anesthesiology/Division of Anesthesiology Critical Care Medicine, Nashville, TN
| | - Xue Han
- Department of Biostatistics at the Vanderbilt University School of Medicine, Nashville, TN
| | - Matthew S Shotwell
- Department of Biostatistics at the Vanderbilt University School of Medicine, Nashville, TN
| | - Pratik P Pandharipande
- Department of Anesthesiology/Division of Anesthesiology Critical Care Medicine, Nashville, TN
| | - Liza M Weavind
- Department of Anesthesiology/Division of Anesthesiology Critical Care Medicine, Nashville, TN
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15
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Leuzzi G, Galeone C, Taverna F, Suatoni P, Morelli D, Pastorino U. C-reactive protein level predicts mortality in COPD: a systematic review and meta-analysis. Eur Respir Rev 2017; 26:26/143/160070. [PMID: 28143876 DOI: 10.1183/16000617.0070-2016] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Accepted: 10/06/2016] [Indexed: 12/12/2022] Open
Abstract
The prognostic role of baseline C-reactive protein (CRP) in chronic obstructive pulmonary disease (COPD) is controversial. In order to clarify this issue, we performed a systematic review and meta-analysis to assess the predictive effect of baseline CRP level in COPD patients. 15 eligible articles focusing on late mortality in COPD were included in our study. We performed a random-effects meta-analysis, and assessed heterogeneity and publication bias. We pooled hazard ratio (HR) estimates and their 95% confidence intervals on mortality for the comparison between the study-specific highest category of CRP level versus the lowest category. In overall analysis, elevated baseline CRP levels were significantly associated with higher mortality (HR 1.53, 95% CI 1.32-1.77, I2=68.7%, p<0.001). Similar results were observed across subgroups. However, higher mortality risk was reported in studies using a cut-off value of 3 mg·L-1 (HR 1.61, 95% CI 1.12-2.30) and in those enrolling an Asiatic population (HR 3.51, 95% CI 1.69-7.31). Our analysis indicates that baseline high CRP level is significantly associated with higher late mortality in patients with COPD. Further prospective controlled studies are needed to confirm these data.
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Affiliation(s)
- Giovanni Leuzzi
- Thoracic Surgery Unit, IRCCS Istituto Nazionale dei Tumori Foundation, Milan, Italy
| | - Carlotta Galeone
- Dept of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Francesca Taverna
- Immunohematology and Transfusion Medicine Service, IRCCS Istituto Nazionale dei Tumori Foundation, Milan, Italy
| | - Paola Suatoni
- Thoracic Surgery Unit, IRCCS Istituto Nazionale dei Tumori Foundation, Milan, Italy
| | - Daniele Morelli
- Dept of Pathology and Laboratory Medicine, IRCCS Istituto Nazionale dei Tumori Foundation, Milan, Italy
| | - Ugo Pastorino
- Thoracic Surgery Unit, IRCCS Istituto Nazionale dei Tumori Foundation, Milan, Italy
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16
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Toft-Petersen AP, Torp-Pedersen C, Weinreich UM, Rasmussen BS. Association between hemoglobin and prognosis in patients admitted to hospital for COPD. Int J Chron Obstruct Pulmon Dis 2016; 11:2813-2820. [PMID: 27877035 PMCID: PMC5108499 DOI: 10.2147/copd.s116269] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Low concentrations of hemoglobin have previously been demonstrated in many patients with COPD. There is evidence of anemia as a prognostic factor in acute exacerbations, but the detailed relationship between concentrations of hemoglobin and mortality is not known. A register-based cohort of patients admitted for the first time to Danish hospitals for acute exacerbations of COPD from 2007 through 2012 was established. Age, sex, comorbidities, medication, renal function, and concentrations of hemoglobin were retrieved. Sex-specific survival analyses were fitted for different rounded concentrations of hemoglobin. The cohort encompassed 6,969 patients. Hemoglobin below 130 g/L was present in 39% of males and below 120 g/L in 24% of females. The in-hospital mortality rates for patients with hemoglobin below or above these limits were 11.6% and 5.4%, respectively. After discharge, compared to hemoglobin 130 g/L, the hazard ratio (HR) for males with hemoglobin 120 g/L was 1.45 (95% confidence interval [CI] 1.22-1.73), adjusted HR 1.37 (95% CI 1.15-1.64). Compared to hemoglobin 120 g/L, the HR for females with hemoglobin 110 g/L was 1.4 (95% CI 1.17-1.68), adjusted HR 1.28 (95% CI 1.06-1.53). In conclusion, low concentrations of hemoglobin are frequent in COPD patients with acute exacerbations, and predict long-term mortality.
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Affiliation(s)
| | | | - Ulla Møller Weinreich
- Department of Clinical Medicine, Aalborg University
- Department of Respiratory Diseases, Aalborg University Hospital, Aalborg, Denmark
| | - Bodil Steen Rasmussen
- Department of Clinical Medicine, Aalborg University
- Department of Anaesthesia and Intensive Care
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17
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Ergan B, Ergün R. Impact of anemia on short-term survival in severe COPD exacerbations: a cohort study. Int J Chron Obstruct Pulmon Dis 2016; 11:1775-83. [PMID: 27536089 PMCID: PMC4976907 DOI: 10.2147/copd.s111758] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
PURPOSE Anemia is reported to be an independent predictor of hospitalizations and survival in COPD. However, little is known of its impact on short-term survival during severe COPD exacerbations. The primary objective of this study was to determine whether the presence of anemia increases the risk of death in acute respiratory failure due to severe COPD exacerbations. PATIENTS AND METHODS Consecutive patients with COPD exacerbation who were admitted to the intensive care unit with the diagnosis of acute respiratory failure and required either invasive or noninvasive ventilation (NIV) were analyzed. RESULTS A total of 106 patients (78.3% male; median age 71 years) were included in the study; of them 22 (20.8%) needed invasive ventilation immediately and 84 (79.2%) were treated with NIV. NIV failure was observed in 38 patients. Anemia was present in 50% of patients, and 39 patients (36.8%) died during hospital stay. When compared to nonanemic patients, hospital mortality was significantly higher in the anemic group (20.8% vs 52.8%, respectively; P=0.001). Stepwise multivariate logistic regression analysis showed that presence of anemia and NIV failure were independent predictors of hospital mortality with odds ratios (95% confidence interval) of 3.99 ([1.39-11.40]; P=0.010) and 2.56 ([1.60-4.09]; P<0.001), respectively. Anemia was not associated with long-term survival in this cohort. CONCLUSION Anemia may be a risk factor for hospital death in severe COPD exacerbations requiring mechanical ventilatory support.
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Affiliation(s)
- Begum Ergan
- Department of Pulmonary and Critical Care, Faculty of Medicine, Dokuz Eylül University, Izmir, Turkey
| | - Recai Ergün
- Medical Intensive Care Unit, Dışkapı Yıldırım Beyazıt Education and Research Hospital, Ankara, Turkey
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18
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Nikmah UA, Prijanti AR, Jusman SW, Sadikin M. Expression and specific activities of carbamoyl phosphate synthetase 1 in chronic hypoxic rats. MEDICAL JOURNAL OF INDONESIA 2016. [DOI: 10.13181/mji.v25i1.1213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
Background: Urea biosynthesis is a very important process in the liver which needs ATP, CO2 and functional mitochondria or aerobic condition. Liver can adapt to hypoxic condition, generally and locally. This study aimed to analyze the effect of chronic hypoxia on liver urea biosynthesis as indicated by the level and specific activity of mRNA of carbamoyl phosphate synthetase 1 (CPS1), a key enzyme in urea biosynthesis in hypoxic rats.Methods: 20 male Sprague-Dawley rats were placed in hypoxic chamber supplied by a mixture of 10% O2 and 90% N2. Five rats were sacrificed at 1, 3, 5, and 7 days after exposure. Liver homogenates were analyzed for HIF-1 (hypoxia inducible factor-1) by ELISA, CPS1 mRNA by real time RT-PCR and CPS1 enzymatic specific activities by Pierson method. Data were analyzed by ANOVA test and Pearson correlation.Results: The HIF-1 in liver increased significantly, as well as CPS1 mRNA and CPS1 enzymatic activities (p<0.05). There was a strong correlation (r=0.618; p<0.01) between the level of CPS1 mRNA and CPS1 enzymatic activities, moderate correlation between HIF-1 and CPS1 mRNA (r=0.419; p<0.05) but no correlation between HIF-1 and CPS1 enzymatic activities. The study indicated that urea biosynthesis in liver was affected by hypoxia and partially under HIF-1 regulation. The study also found increase of urea and NH3 biosynthesis related to proteolysis as indicated by the decrease of total body weight and liver weight.Conclusion: There was an increase in the expression and specific activities of CPS1 in urea biosynthesis as a result of increasing proteolysis in chronic hypoxic condition.
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19
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Tabernero Huguet E, Gil Alaña P, Arana-Arri E, Citores Martín L, Alkiza Basañez R, Hernandez Gil A, Gil Molet A. [Non-invasive ventilation in 'do-not-intubate' patients in a chronic disease hospital. One year follow-up study]. Rev Esp Geriatr Gerontol 2016; 51:221-4. [PMID: 26811123 DOI: 10.1016/j.regg.2015.11.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Revised: 11/23/2015] [Accepted: 11/26/2015] [Indexed: 11/30/2022]
Abstract
UNLABELLED Elderly patients with multiple morbidity and do not intubate (DNI) orders frequently present with acute respiratory failure. There are data supporting the effectiveness of non-invasive ventilation (NIV) in this context. Our chronic disease hospital developed an integrated care clinical pathway for the use of NIV in acute respiratory failure in the emergency room and wards in 2010. The aim of this study was to assess the outcome of NIV in patients with acute respiratory failure who had a DNI order in a sub-acute care hospital. METHODS Observational, one year-follow up study. The main variables were in-hospital mortality and one year mortality. Other variables recorded were: demographics, clinical data, functional data, performance of daily life activities, dementia, arterial blood gases and re-admissions. RESULTS The study included a total of 102 patients, of which 22% were in institutions. The mean age 81±7.47% males, with a Charlson index 3.7±1, and Barthel index 54±31. The overall mortality during the admission was 33% (34 patients). Among those patients ventilated outside the protocol indication, the mortality was significantly greater, at 71% (P>.05). Overall one-year survival rate was 46%. This survival rate was statistically higher in patients with obesity hypoventilation syndrome and a Barthel >50. CONCLUSIONS NIV is a useful technique in a hospital for chronic patients in an elderly population with a therapeutic ceiling. Despite their disease severity and comorbidity, acceptable survival rates are achieved. A correct case selection is needed. Obesity hypoventilation syndrome and those with Barthel index >50 have a better prognosis.
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Affiliation(s)
| | - Pilar Gil Alaña
- Servicio de Neumología, Hospital de Santa Marina, Bilbao, España
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20
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Putcha N, Drummond MB, Wise RA, Hansel NN. Comorbidities and Chronic Obstructive Pulmonary Disease: Prevalence, Influence on Outcomes, and Management. Semin Respir Crit Care Med 2015; 36:575-91. [PMID: 26238643 DOI: 10.1055/s-0035-1556063] [Citation(s) in RCA: 120] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Comorbidities impact a large proportion of patients with chronic obstructive pulmonary disease (COPD), with over 80% of patients with COPD estimated to have at least one comorbid chronic condition. Guidelines for the treatment of COPD are just now incorporating comorbidities to their management recommendations of COPD, and it is becoming increasingly clear that multimorbidity as well as specific comorbidities have strong associations with mortality and clinical outcomes in COPD, including dyspnea, exercise capacity, quality of life, healthcare utilization, and exacerbation risk. Appropriately, there has been an increased focus upon describing the burden of comorbidity in the COPD population and incorporating this information into existing efforts to better understand the clinical and phenotypic heterogeneity of this group. In this article, we summarize existing knowledge about comorbidity burden and specific comorbidities in COPD, focusing on prevalence estimates, association with outcomes, and existing knowledge about treatment strategies.
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Affiliation(s)
- Nirupama Putcha
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland
| | - M Bradley Drummond
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Robert A Wise
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Nadia N Hansel
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland
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21
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Chen CW, Chen YY, Lu CL, Chen SCC, Chen YJ, Lin MS, Chen W. Severe hypoalbuminemia is a strong independent risk factor for acute respiratory failure in COPD: a nationwide cohort study. Int J Chron Obstruct Pulmon Dis 2015; 10:1147-54. [PMID: 26124654 PMCID: PMC4476425 DOI: 10.2147/copd.s85831] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Acute respiratory failure (ARF) is a life-threatening event, which is frequently associated with the severe exacerbations of chronic obstructive pulmonary disease (COPD). Hypoalbuminemia is associated with increased mortality in patients with COPD. However, to date, little is known regarding whether or not hypoalbuminemia is a risk factor for developing ARF in COPD. Methods We conducted a retrospective cohort study using data from the National Health Insurance system of Taiwan. A total of 42,732 newly diagnosed COPD patients (age ≥40 years) from 1997 to 2011 were enrolled. Among them, 1,861 (4.36%) patients who had received albumin supplementation were defined as hypoalbuminemia, and 40,871 (95.6%) patients who had not received albumin supplementation were defined as no hypoalbuminemia. Results Of 42,732 newly diagnosed COPD patients, 5,248 patients (12.3%) developed ARF during the 6 years follow-up period. Patients with hypoalbuminemia were older, predominantly male, had more comorbidities, and required more steroid treatment and blood transfusions than patients without hypoalbuminemia. In a multivariable Cox regression analysis model, being elderly was the strongest independent risk factor for ARF (adjusted hazard ratio [HR]: 4.63, P<0.001), followed by hypoalbuminemia (adjusted HR: 2.87, P<0.001). However, as the annual average dose of albumin supplementation was higher than 13.8 g per year, the risk for ARF was the highest (adjusted HR: 11.13, 95% CI: 10.35–11.98, P<0.001). Conclusion Hypoalbuminemia is a strong risk factor for ARF in patients with COPD. Therefore, further prospective studies are required to verify whether or not albumin supplementation or nutritional support may help to reduce the risk of ARF in patients with COPD.
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Affiliation(s)
- Char-Wen Chen
- Division of Pulmonary and Critical Care Medicine, Chia-Yi Christian Hospital, Chiayi, Taiwan
| | - Yih-Yuan Chen
- Department of Internal Medicine, Chia-Yi Christian Hospital, Chiayi, Taiwan
| | - Chin-Li Lu
- Department of Medical Research, Ditmanson Medical Foundation, Chia-Yi Christian Hospital, Chiayi, Taiwan
| | - Solomon Chih-Cheng Chen
- Department of Medical Research, Ditmanson Medical Foundation, Chia-Yi Christian Hospital, Chiayi, Taiwan
| | - Yi-Jen Chen
- Division of Pulmonary and Critical Care Medicine, Chia-Yi Christian Hospital, Chiayi, Taiwan ; Department of Respiratory Care, Chang Gung University of Science and Technology, Chiayi Campus; Changhua, Taiwan
| | - Ming-Shian Lin
- Division of Pulmonary and Critical Care Medicine, Chia-Yi Christian Hospital, Chiayi, Taiwan ; Department of Respiratory Care, Chang Gung University of Science and Technology, Chiayi Campus; Changhua, Taiwan
| | - Wei Chen
- Division of Pulmonary and Critical Care Medicine, Chia-Yi Christian Hospital, Chiayi, Taiwan ; College of Nursing, Dayeh University, Changhua, Taiwan ; Department of Respiratory Therapy, China Medical University, Taichung, Taiwan
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Sanguinetti CM, Ambrosino N, Andò F, De Benedetto F, Donner CF, Nardini S, Polverino M, Torchio R, Vagheggini G, Visconti A. Standards of suitability for the management of chronic obstructive respiratory diseases. Multidiscip Respir Med 2014; 9:65. [PMID: 25584191 PMCID: PMC4290399 DOI: 10.1186/2049-6958-9-65] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Accepted: 11/28/2014] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Chronic Obstructive Pulmonary Disease (COPD) ranks third as cause of mortality and disability-adjusted life years (DALY) worldwide and also in Italy it imposes a huge health, social and economic load. Early symptoms of COPD are often disregarded by patients and physicians, spirometry is underutilized, and the diagnosis is delayed till the disease has reached a distinct severity level. Despite the availability of various guidelines, the behavior of health workers involved in the management of COPD is still rather unlike. These considerations are the reason why in October 2013 AIMAR (Interdisciplinary Scientific Association for Research in Lung Disease) devised and organized a "Third Consensus Conference", aimed at pointing out the standards of suitability for COPD management. In this context three important topics of discussion were identified: early and more widespread diagnosis, management of acute and subacute phases, long-term assistance to chronic patients. METHODS The procedure recommended by the Italian Health Superior Institute (ISS) for Consensus Conferences organization was applied. The Conference was structured in three sessions, each dealing with one of the above mentioned topics and including a short update of the subject-matter and presentation, discussion and voting of some statements with a choice ranging from total agreement to total disagreement or no knowledge. The results of voting were eventually recorded in the document, reviewed by an independent jury, that forms the substance of this paper. RESULTS The essential role of spirometry, the need for distinguish between different COPD phenotypes, and the obligatoriness to base on the blood gas analysis findings the long-term oxygen therapy, were largely agreed, as well as the need for interventions aimed at decreasing the rate of acute exacerbations. More specific topics like the use of noninvasive ventilation, recognizing the factors affecting outcome and mortality, the choice of pharmacological and non pharmacological treatments in COPD patients led to lively discussing, but they did not always reach the total agreement, probably because of insufficient familiarity with these problems and of diversities in organization and instruments availability. The chronic respiratory assistance was treated with particular regard to smoking cessation, whose implementation is still insufficient. Many doubts rose due to uncertainty, lack of ability and standardization of procedures, insufficient institutional support, and difficulties to realize a network for assistance to chronic patients. CONCLUSIONS The results of this Third Consensus Conference revealed some certainties and many doubts and diversities of view also on topics whose importance is well demonstrated in scientific literature. Thus, there is still a long distance to cover before reaching a suitable standardization of COPD management and such situation urges the need for improving not only the health professional's operativeness but also the organizational support by competent institutions. In this context some initiatives organized by AIMAR in cooperation with other respiratory scientific societies and patients' associations are going on.
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Affiliation(s)
- Claudio M Sanguinetti
- />Managing Director Multidisciplinary Respiratory Disease, Senior Consultant Respiratory Diseases, Quisisana Clinical Center, Rome, Italy, Rome, Italy
| | - Nicolino Ambrosino
- />Center of Respiratory Weaning and Rehabilitation Auxilium Vitae, Volterra, (PI) Italy
| | - Filippo Andò
- />Pneumology Unit, G.Martino General Hospital, Messina, Italy
| | | | - Claudio F Donner
- />Mondo Medico, Multidisciplinary and Rehabilitation Outpatient Clinic, Borgomanero, (NO) Italy
| | - Stefano Nardini
- />Pneumology Unit, General Hospital, Vittorio Veneto, (TV) Italy
| | - Mario Polverino
- />High Specialty Provincial Pulmonologic Unit, “Scarlato” Hospital, Scafati, (SA) Italy
| | - Roberto Torchio
- />Lung Function and Sleep Unit, AOU S. Luigi, Orbassano, (TO) Italy
| | - Guido Vagheggini
- />Internal Medicine and Respiratory Diseases, Center of Respiratory Weaning and Rehabilitation Auxilium Vitae, Volterra, (PI) Italy
| | | | - on behalf of the Consensus Conference 2013 Group
- />Managing Director Multidisciplinary Respiratory Disease, Senior Consultant Respiratory Diseases, Quisisana Clinical Center, Rome, Italy, Rome, Italy
- />Center of Respiratory Weaning and Rehabilitation Auxilium Vitae, Volterra, (PI) Italy
- />Pneumology Unit, G.Martino General Hospital, Messina, Italy
- />Pneumology Unit, SS.Annunziata General Hospital, Chieti, Italy
- />Mondo Medico, Multidisciplinary and Rehabilitation Outpatient Clinic, Borgomanero, (NO) Italy
- />Pneumology Unit, General Hospital, Vittorio Veneto, (TV) Italy
- />High Specialty Provincial Pulmonologic Unit, “Scarlato” Hospital, Scafati, (SA) Italy
- />Lung Function and Sleep Unit, AOU S. Luigi, Orbassano, (TO) Italy
- />Internal Medicine and Respiratory Diseases, Center of Respiratory Weaning and Rehabilitation Auxilium Vitae, Volterra, (PI) Italy
- />Scientific Secretariat, AIMAR, Arona, (NO) Italy
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Nardone G, Compare D, Scarpignato C, Rocco A. Long acting release-octreotide as "rescue" therapy to control angiodysplasia bleeding: A retrospective study of 98 cases. Dig Liver Dis 2014; 46:688-94. [PMID: 24893688 DOI: 10.1016/j.dld.2014.04.011] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2013] [Revised: 03/25/2014] [Accepted: 04/26/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND Gastrointestinal angiodysplasias are an important cause of difficult to manage bleeding, especially in older patients. AIM To retrospectively evaluate the long-term efficacy of long acting release-octreotide in controlling angiodysplasia bleeding. METHODS 98 patients with a history of bleeding due to gastrointestinal angiodysplasias lasting over 2 years were retrospectively selected among those treated from January 2000 to December 2008. All patients had received octreotide 0.1mg tid for 28 days and, then from day 14, long acting release-octreotide 20mg monthly, for 6 months. RESULTS The mean follow-up was 78 months. In all patients mean haemoglobin levels significantly increased and the number of bleeding episodes, hospitalizations, patients requiring blood transfusions and units of transfused red cells significantly decreased, compared to the two-year observation period before starting therapy. According to outcome patients were classified as: 40 full responders (40.8%), 32 relapsers (32.6%) and 26 poor responders (26.5%). At multivariate analysis age >65 years, male sex, chronic antiplatelet therapy, chronic obstructive pulmonary disease and chronic renal failure were the only covariates independently associated with poor response to therapy. CONCLUSION Our study suggests that long acting release-octreotide could be used as rescue therapy to control bleeding due to gastrointestinal angiodysplasias in patients not suitable for endoscopic or surgical treatments.
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Affiliation(s)
- Gerardo Nardone
- Department of Clinical Medicine and Surgery, Gastroenterology Unit, University "Federico II", Naples, Italy.
| | - Debora Compare
- Department of Clinical Medicine and Surgery, Gastroenterology Unit, University "Federico II", Naples, Italy
| | - Carmelo Scarpignato
- Laboratory of Clinical Pharmacology, Division of Gastroenterology, Department of Clinical Sciences, University of Parma, Parma, Italy
| | - Alba Rocco
- Department of Clinical Medicine and Surgery, Gastroenterology Unit, University "Federico II", Naples, Italy
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Circulating surfactant protein-D as a biomarker of severity in stable chronic obstructive pulmonary diseases. EGYPTIAN JOURNAL OF CHEST DISEASES AND TUBERCULOSIS 2014. [DOI: 10.1016/j.ejcdt.2014.03.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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25
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Lomholt FK, Laulund AS, Bjarnason NH, Jørgensen HL, Godtfredsen NS. Meta-analysis of routine blood tests as predictors of mortality in COPD. Eur Clin Respir J 2014; 1:24110. [PMID: 26557244 PMCID: PMC4629760 DOI: 10.3402/ecrj.v1.24110] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Accepted: 05/07/2014] [Indexed: 01/10/2023] Open
Abstract
Objective The purpose of this study was to examine whether routine blood tests can be useful in predicting mortality in COPD patients. Methods Eligible studies were found through a search conducted in the PubMed and Embase databases, the Cochrane Library, and the Web of Knowledge. Twelve studies were included for the meta-analysis of five biochemical markers. Pooled odds ratios (ORs), matching 95% confidence intervals (CIs), and p-values for each of the biochemical markers were calculated using the random effect model. Results The following four examined biochemical markers were shown to be associated with mortality in patients suffering from COPD: anemia (OR=2.62, 95% CI: 1.60; 4.29, p=0.01), hypoalbuminemia (OR=2.90, 95% CI: 1.56; 5.40, p=0.0008), elevated NT-proBNP (OR=7.54, 95% CI: 4.04; 14.10, p<0.00001), and elevated cardiac troponin T (OR=3.10, 95% CI: 1.11; 8.25, p=0.03). hs-CRP was not found to be associated with increased mortality. Conclusion In this study, we found that anemia, hypoalbuminemia, elevated NT-proBNP, and elevated cardiac troponin T were associated with increased mortality in patients suffering from COPD.
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Affiliation(s)
- Frederikke K Lomholt
- Department of Clinical Biochemistry, Bispebjerg University Hospital, Copenhagen, Denmark
| | - Anne S Laulund
- Department of Endocrinology and Metabolism, Odense University Hospital, Odense, Denmark
| | - Nina H Bjarnason
- Department of Lung Transplantation, Rigshospitalet, Copenhagen, Denmark
| | - Henrik L Jørgensen
- Department of Clinical Biochemistry, Bispebjerg University Hospital, Copenhagen, Denmark
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Ozyilmaz E, Ugurlu AO, Nava S. Timing of noninvasive ventilation failure: causes, risk factors, and potential remedies. BMC Pulm Med 2014; 14:19. [PMID: 24520952 PMCID: PMC3925956 DOI: 10.1186/1471-2466-14-19] [Citation(s) in RCA: 112] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2013] [Accepted: 01/29/2014] [Indexed: 12/29/2022] Open
Abstract
Background Identifying the predictors of noninvasive ventilation (NIV) failure has attracted significant interest because of the strong link between failure and poor outcomes. However, very little attention has been paid to the timing of the failure. This narrative review focuses on the causes of NIV failure and risk factors and potential remedies for NIV failure, based on the timing factor. Results The possible causes of immediate failure (within minutes to <1 h) are a weak cough reflex, excessive secretions, hypercapnic encephalopathy, intolerance, agitation, and patient-ventilator asynchrony. The major potential interventions include chest physiotherapeutic techniques, early fiberoptic bronchoscopy, changing ventilator settings, and judicious sedation. The risk factors for early failure (within 1 to 48 h) may differ for hypercapnic and hypoxemic respiratory failure. However, most cases of early failure are due to poor arterial blood gas (ABGs) and an inability to promptly correct them, increased severity of illness, and the persistence of a high respiratory rate. Despite a satisfactory initial response, late failure (48 h after NIV) can occur and may be related to sleep disturbance. Conclusions Every clinician dealing with NIV should be aware of these risk factors and the predicted parameters of NIV failure that may change during the application of NIV. Close monitoring is required to detect early and late signs of deterioration, thereby preventing unavoidable delays in intubation.
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Affiliation(s)
| | | | - Stefano Nava
- Department of Specialistic, Diagnostic and Experimental Medicine (DIMES), Respiratory and Critical Care, University of Bologna, Sant'Orsola Malpighi Hospital building #15, Alma Mater Studiorum, via Massarenti n,15, Bologna 40185, Italy.
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Esquinas AM, Confalonieri M. Anemia and health performance score evaluation as decisive factors for noninvasive mechanical ventilation decisions in AECOPD: are there new key cornerstones? Int J Chron Obstruct Pulmon Dis 2014; 9:151-2. [PMID: 24501539 PMCID: PMC3912044 DOI: 10.2147/copd.s57085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
| | - Marco Confalonieri
- Department of Pneumology, University Hospital of Trieste, Trieste, Italy
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