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Anzueto A, Cohen M, Echazarreta AL, Elassal G, Godoy I, Paramo R, Sayiner A, Torres-Duque CA, Acharya S, Aggarwal B, Erkus H, Levy G. Delphi Consensus on Clinical Applications of GOLD 2023 Recommendations in COPD Management: How Aligned are Recommendations with Clinical Practice? Pulm Ther 2024; 10:69-84. [PMID: 38112909 PMCID: PMC10881920 DOI: 10.1007/s41030-023-00248-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 11/20/2023] [Indexed: 12/21/2023] Open
Abstract
INTRODUCTION The objective of this Delphi study was to understand and assess the level of consensus among respiratory experts on the clinical application of GOLD 2023 recommendations in management of patients with chronic obstructive pulmonary disease (COPD). METHODS The study comprised two online surveys and a participant meeting with 34 respiratory experts from 16 countries. Responses of 73 questions were recorded using a Likert scale ranging from 0 (disagreement) to 9 (agreement). The consensus threshold was 75%. RESULTS Survey 1 and survey 2 had 34 and 32 participants, respectively; and 25 attended the participant meeting. Consensus was reached on survey 1: 28/42; survey 2: 18/30 close-ended questions. A consensus was reached on the clinical relevance of most updates in definitions and diagnosis of COPD. Mixed results for the treatment recommendations by GOLD were noted: 74% agreed with the recommendation to initiate treatment with dual bronchodilators for group E patients; 63% agreed for including inhaled corticosteroids (ICS)/long-acting β2 agonist(LABA)/ Long-acting muscarinic receptor antagonists (LAMA) as a treatment option for GOLD B patients. Also, consensus lacked on removing ICS + LABA as an initial therapeutic option, in countries with challenges in access to other treatment option;. 88% agreed that they use GOLD recommendations in their daily clinical practice. CONCLUSIONS This Delphi study demonstrated a high level of consensus regarding key concepts of GOLD 2023 report, with most participants favoring recent updates in definitions, diagnosis, management, and prevention of COPD. More evidence on the etiotype based management and treatment options for group B and E are required which could further strengthen clinical application of the GOLD report.
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Affiliation(s)
- Antonio Anzueto
- University of Texas Health and South Texas Veterans Health Care System, San Antonio, TX, USA.
| | - Mark Cohen
- Hospital Centro Medico, Guatemala City, Guatemala
| | | | - Gehan Elassal
- Department of Pulmonology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Irma Godoy
- Department of Internal Medicine, Botucatu Medical School, UNESP - Univ Estadual Paulista, Botucatu Campus, Pneumology Area, São Paulo, Brazil
| | | | - Abdullah Sayiner
- Department of Chest Diseases, Faculty of Medicine, Ege University, Izmir, Turkey
| | | | | | | | | | - Gur Levy
- Emerging Markets, GSK, Panama City, Panama
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Anzueto A, Barjaktarevic IZ, Siler TM, Rheault T, Bengtsson T, Rickard K, Sciurba F. Reply to Gan et al., to Calzetta et al., and to Poor. Am J Respir Crit Care Med 2024; 209:226-228. [PMID: 37939377 PMCID: PMC10806414 DOI: 10.1164/rccm.202309-1657le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 11/08/2023] [Indexed: 11/10/2023] Open
Affiliation(s)
- Antonio Anzueto
- South Texas Veterans Health Care System, San Antonio, Texas
- University of Texas Health, San Antonio, Texas
| | - Igor Z. Barjaktarevic
- Division of Pulmonary and Critical Care, University of California Los Angeles, Los Angeles, California
| | | | - Tara Rheault
- Verona Pharma Plc, London, United Kingdom and Raleigh, North Carolina
| | | | - Kathleen Rickard
- Verona Pharma Plc, London, United Kingdom and Raleigh, North Carolina
| | - Frank Sciurba
- Division of Pulmonary and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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Miravitlles M, Anzueto A, Barrecheguren M. Nine controversial questions about augmentation therapy for alpha-1 antitrypsin deficiency: a viewpoint. Eur Respir Rev 2023; 32:230170. [PMID: 38056890 DOI: 10.1183/16000617.0170-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 10/16/2023] [Indexed: 12/08/2023] Open
Abstract
Augmentation therapy with intravenous alpha-1 antitrypsin is the only specific treatment for alpha-1 antitrypsin deficiency (AATD)-associated emphysema. This treatment has been available and remained basically unchanged for more than 35 years, but many questions persist regarding its indications, regimen of administration and efficacy. Because AATD is a rare disease, it has not been possible to conduct randomised, placebo-controlled trials that are adequately powered for the usual outcomes analysed in non-AATD-related COPD, such as lung function decline, exacerbations, symptoms or quality of life. New outcomes such as lung densitometry measured by computed tomography are more sensitive for identifying emphysema progression but are not widely accepted by regulatory agencies. In addition, clinical manifestations, severity and the natural history of lung disease associated with AATD are very heterogeneous, which means that individual prediction of prognosis is challenging. Therefore, the indication for augmentation is sometimes a dilemma between initiating treatment in individuals who may not develop significant lung disease or in whom disease will not progress and delaying it in patients who will otherwise rapidly and irreversibly progress.Other areas of debate are the possible indication for augmentation in patients with severe AATD and respiratory diseases other than emphysema, such as bronchiectasis or asthma, and the use of therapy after lung transplant in AATD patients. All these uncertainties imply that the indication for treatment must be personalised in expert reference centres after in-depth discussion of the pros and cons of augmentation with the patient.
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Affiliation(s)
- Marc Miravitlles
- Pneumology Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | - Antonio Anzueto
- Pulmonary Disease/Critical Care, University of Texas Health, and South Texas Veterans Health Care System, San Antonio, TX, USA
| | - Miriam Barrecheguren
- Pneumology Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
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Silverman EK, Kim AY, Make BJ, Regan EA, Morrow JD, Hersh CP, O'Brien J, Crapo JD, Hansel NN, Criner G, Flenaugh EL, Conrad D, Casaburi R, Bowler RP, Hanania NA, Barr RG, Bhatt SP, Sciurba FC, Anzueto A, Han MK, McEvoy CE, Comellas AP, DeMeo DL, Rosiello R, Curtis JL, Uchida T, Wilson C, O'Rourke PP. Returning incidentally discovered Hepatitis C RNA-seq results to COPDGene study participants. NPJ Genom Med 2023; 8:36. [PMID: 37903807 PMCID: PMC10616181 DOI: 10.1038/s41525-023-00379-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 10/10/2023] [Indexed: 11/01/2023] Open
Abstract
The consequences of returning infectious pathogen test results identified incidentally in research studies have not been well-studied. Concerns include identification of an important health issue for individuals, accuracy of research test results, public health impact, potential emotional distress for participants, and need for IRB permissions. Blood RNA-sequencing analysis for non-human RNA in 3984 participants from the COPDGene study identified 228 participants with evidence suggestive for hepatitis C virus (HCV) infection. We hypothesized that incidentally discovered HCV results could be effectively returned to COPDGene participants with attention to the identified concerns. In conjunction with a COPDGene Participant Advisory Panel, we developed and obtained IRB approval for a process of returning HCV research results and an HCV Follow-Up Study questionnaire to capture information about previous HCV diagnosis and treatment information and participant reactions to return of HCV results. During phone calls following the initial HCV notification letter, 84 of 124 participants who could be contacted (67.7%) volunteered that they had been previously diagnosed with HCV infection. Thirty-one of these 124 COPDGene participants were enrolled in the HCV Follow-Up Study. Five of the 31 HCV Follow-Up Study participants did not report a previous diagnosis of HCV. For four of these participants, subsequent clinical HCV testing confirmed HCV infection. Thus, 30/31 Follow-Up Study participants had confirmed HCV diagnoses, supporting the accuracy of the HCV research test results. However, the limited number of participants in the Follow-Up Study precludes an accurate assessment of the false-positive and false-negative rates of the research RNA sequencing evidence for HCV. Most HCV Follow-Up Study participants (29/31) were supportive of returning HCV research results, and most participants found the process for returning HCV results to be informative and not upsetting. Newly diagnosed participants were more likely to be pleased to learn about a potentially curable infection (p = 0.027) and showed a trend toward being more frightened by the potential health risks of HCV (p = 0.11). We conclude that HCV results identified incidentally during transcriptomic research studies can be successfully returned to research study participants with a carefully designed process.
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Affiliation(s)
- Edwin K Silverman
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Arthur Y Kim
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Barry J Make
- Department of Medicine, National Jewish Health, Denver, CO, USA
| | | | - Jarrett D Morrow
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Craig P Hersh
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - James O'Brien
- Department of Medicine, National Jewish Health, Denver, CO, USA
| | - James D Crapo
- Department of Medicine, National Jewish Health, Denver, CO, USA
| | - Nadia N Hansel
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Gerard Criner
- Department of Thoracic Medicine and Surgery, Temple University, Philadelphia, PA, USA
| | - Eric L Flenaugh
- Pulmonary and Critical Care and Interventional Pulmonary Medicine, Morehouse School of Medicine, Atlanta, GA, USA
| | - Douglas Conrad
- Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Richard Casaburi
- Rehabilitation Clinical Trials Center, Division of Respiratory and Critical Care Physiology and Medicine, Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA, USA
| | | | - Nicola A Hanania
- Section of Pulmonary and Critical Care Medicine, Baylor College of Medicine, Houston, TX, USA
| | - R Graham Barr
- Departments of Medicine and Epidemiology, Columbia University Medical Center, New York, NY, USA
| | - Surya P Bhatt
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Frank C Sciurba
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Antonio Anzueto
- Pulmonary and Critical Care, University of Texas Health, and South Texas Veterans Health Care System, San Antonio, TX, USA
| | - MeiLan K Han
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Michigan, Ann Arbor, MI, USA
| | | | - Alejandro P Comellas
- Division of Pulmonary, Critical Care and Occupational Medicine, University of Iowa Hospital and Clinics, Iowa City, IA, USA
| | - Dawn L DeMeo
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Richard Rosiello
- Department of Pulmonary and Critical Care, Reliant Medical Group, Worcester, MA, USA
| | - Jeffrey L Curtis
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Michigan, Ann Arbor, MI, USA
- Medical Service, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Tricia Uchida
- Research Informatics Services, National Jewish Health, Denver, CO, USA
| | - Carla Wilson
- Research Informatics Services, National Jewish Health, Denver, CO, USA
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Anzueto A, Barjaktarevic IZ, Siler TM, Rheault T, Bengtsson T, Rickard K, Sciurba F. Ensifentrine, a Novel Phosphodiesterase 3 and 4 Inhibitor for the Treatment of Chronic Obstructive Pulmonary Disease: Randomized, Double-Blind, Placebo-controlled, Multicenter Phase III Trials (the ENHANCE Trials). Am J Respir Crit Care Med 2023; 208:406-416. [PMID: 37364283 PMCID: PMC10449067 DOI: 10.1164/rccm.202306-0944oc] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 06/26/2023] [Indexed: 06/28/2023] Open
Abstract
Rationale: Ensifentrine is a novel, selective, dual phosphodiesterase (PDE)3 and PDE4 inhibitor with bronchodilator and antiinflammatory effects. Replicate phase III trials of nebulized ensifentrine were conducted (ENHANCE-1 and ENHANCE-2) to assess these effects in patients with chronic obstructive pulmonary disease (COPD). Objectives: To evaluate the efficacy of ensifentrine compared with placebo for lung function, symptoms, quality of life, and exacerbations in patients with COPD. Methods: These phase III, multicenter, randomized, double-blind, parallel-group, placebo-controlled trials were conducted between September 2020 and December 2022 at 250 research centers and pulmonology practices in 17 countries. Patients aged 40-80 years with moderate to severe symptomatic COPD were enrolled. Measurements and Main Results: Totals of 760 (ENHANCE-1) and 789 (ENHANCE-2) patients were randomized and treated, with 69% and 55% receiving concomitant long-acting muscarinic antagonists or long-acting β2-agonists, respectively. Post-bronchodilator FEV1 percentage predicted values were 52% and 51% of predicted normal. Ensifentrine treatment significantly improved average FEV1 area under the curve at 0-12 hours versus placebo (ENHANCE-1, 87 ml [95% confidence interval, 55, 119]; ENHANCE-2, 94 ml [65, 124]; both P < 0.001). Ensifentrine treatment significantly improved symptoms (Evaluating Respiratory Symptoms) and quality of life (St. George's Respiratory Questionnaire) versus placebo at Week 24 in ENHANCE-1 but not in ENHANCE-2. Ensifentrine treatment reduced the rate of moderate or severe exacerbations versus placebo over 24 weeks (ENHANCE-1, rate ratio, 0.64 [0.40, 1.00]; P = 0.050; ENHANCE-2, rate ratio, 0.57 [0.38, 0.87]; P = 0.009) and increased time to first exacerbation (ENHANCE-1, hazard ratio, 0.62 [0.39, 0.97]; P = 0.038; ENHANCE-2, hazard ratio, 0.58 [0.38, 0.87]; P = 0.009). Adverse event rates were similar to those for placebo. Conclusions: Ensifentrine significantly improved lung function in both trials, with results supporting exacerbation rate and risk reduction in a broad COPD population and in addition to other classes of maintenance therapies. Clinical trial registered with www. CLINICALTRIALS gov and EudraCT (ENHANCE-1, www. CLINICALTRIALS gov identifier NCT04535986, EudraCT identifier 2020-002086-34; ENHANCE-2, www. CLINICALTRIALS gov identifier NCT04542057, EudraCT identifier 2020-002069-32).
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Affiliation(s)
- Antonio Anzueto
- South Texas Veterans Health Care System, San Antonio, Texas
- University of Texas Health, San Antonio, Texas
| | - Igor Z. Barjaktarevic
- Division of Pulmonary and Critical Care, University of California, Los Angeles, Los Angeles, California
| | | | | | | | | | - Frank Sciurba
- Division of Pulmonary and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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Cazzola M, Page CP, Wedzicha JA, Celli BR, Anzueto A, Matera MG. Use of thiols and implications for the use of inhaled corticosteroids in the presence of oxidative stress in COPD. Respir Res 2023; 24:194. [PMID: 37517999 PMCID: PMC10388561 DOI: 10.1186/s12931-023-02500-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 07/25/2023] [Indexed: 08/01/2023] Open
Abstract
BACKGROUND Oxidative stress and persistent airway inflammation are thought to be important contributors to the development of chronic obstructive pulmonary disease (COPD). This review summarizes the evidence for targeting oxidative stress and inflammation in patients with COPD with mucolytic/antioxidant thiols and inhaled corticosteroids (ICS), either alone or in combination. MAIN BODY Oxidative stress is increased in COPD, particularly during acute exacerbations. It can be triggered by oxidant air pollutants and cigarette smoke and/or by endogenous reactive oxygen species (ROS) released from mitochondria and activated inflammatory, immune and epithelial cells in the airways, together with a reduction in endogenous antioxidants such as glutathione (GSH). Oxidative stress also drives chronic inflammation and disease progression in the airways by activating intracellular signalling pathways and the release of further inflammatory mediators. ICS are anti-inflammatory agents currently recommended for use with long-acting bronchodilators to prevent exacerbations in patients with moderate-to-severe COPD, especially those with eosinophilic airway inflammation. However, corticosteroids can also increase oxidative stress, which may in turn reduce corticosteroid sensitivity in patients by several mechanisms. Thiol-based agents such as erdosteine, N-acetyl L-cysteine (NAC) and S-carboxymethylcysteine (S-CMC) are mucolytic agents that also act as antioxidants. These agents may reduce oxidative stress directly through the free sulfhydryl groups, serving as a source of reducing equivalents and indirectly though intracellular GSH replenishment. Few studies have compared the effects of corticosteroids and thiol agents on oxidative stress, but there is some evidence for greater antioxidant effects when they are administered together. The current Global Initiative for Chronic Obstructive Lung Disease (GOLD) report supports treatment with antioxidants (erdosteine, NAC, S-CMC) in addition to standard-of-care therapy as they have been demonstrated to reduce COPD exacerbations. However, such studies have demonstrated that NAC and S-CMC reduced the exacerbation risk only in patients not treated with ICS, whereas erdosteine reduced COPD exacerbations irrespective of concomitant ICS use suggesting that erdosteine has additional pharmacological actions to ICS. CONCLUSIONS Further clinical trials of antioxidant agents with and without ICS are needed to better understand the place of thiol-based drugs in the treatment of patients with COPD.
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Affiliation(s)
- Mario Cazzola
- Chair of Respiratory Medicine, Department of Experimental Medicine, University of Rome Tor Vergata, Rome, Italy.
| | - Clive P Page
- Sackler Institute of Pulmonary Pharmacology, Institute of Pharmaceutical Science, King's College London, London, UK
| | - Jadwiga A Wedzicha
- Respiratory Medicine Division, National Heart and Lung Institute, Imperial College London, London, UK
| | - Bartolome R Celli
- Pulmonary and Critical Care Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Antonio Anzueto
- Department of Pulmonary Medicine and Critical Care, University of Texas Health and South Texas Veterans Health Care System, San Antonio, TX, USA
| | - Maria Gabriella Matera
- Unit of Pharmacology, Department of Experimental Medicine, University of Campania Luigi Vanvitelli, Naples, Italy
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Ahuja SK, Manoharan MS, Lee GC, McKinnon LR, Meunier JA, Steri M, Harper N, Fiorillo E, Smith AM, Restrepo MI, Branum AP, Bottomley MJ, Orrù V, Jimenez F, Carrillo A, Pandranki L, Winter CA, Winter LA, Gaitan AA, Moreira AG, Walter EA, Silvestri G, King CL, Zheng YT, Zheng HY, Kimani J, Blake Ball T, Plummer FA, Fowke KR, Harden PN, Wood KJ, Ferris MT, Lund JM, Heise MT, Garrett N, Canady KR, Abdool Karim SS, Little SJ, Gianella S, Smith DM, Letendre S, Richman DD, Cucca F, Trinh H, Sanchez-Reilly S, Hecht JM, Cadena Zuluaga JA, Anzueto A, Pugh JA, Agan BK, Root-Bernstein R, Clark RA, Okulicz JF, He W. Immune resilience despite inflammatory stress promotes longevity and favorable health outcomes including resistance to infection. Nat Commun 2023; 14:3286. [PMID: 37311745 PMCID: PMC10264401 DOI: 10.1038/s41467-023-38238-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 04/17/2023] [Indexed: 06/15/2023] Open
Abstract
Some people remain healthier throughout life than others but the underlying reasons are poorly understood. Here we hypothesize this advantage is attributable in part to optimal immune resilience (IR), defined as the capacity to preserve and/or rapidly restore immune functions that promote disease resistance (immunocompetence) and control inflammation in infectious diseases as well as other causes of inflammatory stress. We gauge IR levels with two distinct peripheral blood metrics that quantify the balance between (i) CD8+ and CD4+ T-cell levels and (ii) gene expression signatures tracking longevity-associated immunocompetence and mortality-associated inflammation. Profiles of IR metrics in ~48,500 individuals collectively indicate that some persons resist degradation of IR both during aging and when challenged with varied inflammatory stressors. With this resistance, preservation of optimal IR tracked (i) a lower risk of HIV acquisition, AIDS development, symptomatic influenza infection, and recurrent skin cancer; (ii) survival during COVID-19 and sepsis; and (iii) longevity. IR degradation is potentially reversible by decreasing inflammatory stress. Overall, we show that optimal IR is a trait observed across the age spectrum, more common in females, and aligned with a specific immunocompetence-inflammation balance linked to favorable immunity-dependent health outcomes. IR metrics and mechanisms have utility both as biomarkers for measuring immune health and for improving health outcomes.
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Affiliation(s)
- Sunil K Ahuja
- VA Center for Personalized Medicine, South Texas Veterans Health Care System, San Antonio, TX, 78229, USA.
- Department of Microbiology, Immunology & Molecular Genetics, University of Texas Health Science Center at San Antonio, San Antonio, TX, 78229, USA.
- South Texas Veterans Health Care System, San Antonio, TX, 78229, USA.
- Department of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, 78229, USA.
| | - Muthu Saravanan Manoharan
- VA Center for Personalized Medicine, South Texas Veterans Health Care System, San Antonio, TX, 78229, USA
- Department of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, 78229, USA
| | - Grace C Lee
- VA Center for Personalized Medicine, South Texas Veterans Health Care System, San Antonio, TX, 78229, USA
- South Texas Veterans Health Care System, San Antonio, TX, 78229, USA
- Pharmacotherapy Education and Research Center, School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, 78229, USA
- College of Pharmacy, The University of Texas at Austin, Austin, TX, 78712, USA
| | - Lyle R McKinnon
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, 4001, South Africa
- Department of Medical Microbiology and Infectious Diseases, University of Manitoba, Winnipeg, MB, R3T 2N2, Canada
| | - Justin A Meunier
- VA Center for Personalized Medicine, South Texas Veterans Health Care System, San Antonio, TX, 78229, USA
- The Foundation for Advancing Veterans' Health Research, San Antonio, TX, 78229, USA
| | - Maristella Steri
- Istituto di Ricerca Genetica e Biomedica (IRGB), CNR, Monserrato, 09042, Italy
| | - Nathan Harper
- VA Center for Personalized Medicine, South Texas Veterans Health Care System, San Antonio, TX, 78229, USA
- The Foundation for Advancing Veterans' Health Research, San Antonio, TX, 78229, USA
| | - Edoardo Fiorillo
- Istituto di Ricerca Genetica e Biomedica (IRGB), CNR, Monserrato, 09042, Italy
| | - Alisha M Smith
- VA Center for Personalized Medicine, South Texas Veterans Health Care System, San Antonio, TX, 78229, USA
- Department of Microbiology, Immunology & Molecular Genetics, University of Texas Health Science Center at San Antonio, San Antonio, TX, 78229, USA
- The Foundation for Advancing Veterans' Health Research, San Antonio, TX, 78229, USA
| | - Marcos I Restrepo
- VA Center for Personalized Medicine, South Texas Veterans Health Care System, San Antonio, TX, 78229, USA
- South Texas Veterans Health Care System, San Antonio, TX, 78229, USA
- Department of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, 78229, USA
| | - Anne P Branum
- VA Center for Personalized Medicine, South Texas Veterans Health Care System, San Antonio, TX, 78229, USA
- The Foundation for Advancing Veterans' Health Research, San Antonio, TX, 78229, USA
| | - Matthew J Bottomley
- Transplantation Research Immunology Group, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, OX1 2JD, UK
- Oxford Kidney Unit, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 7LE, UK
| | - Valeria Orrù
- Istituto di Ricerca Genetica e Biomedica (IRGB), CNR, Monserrato, 09042, Italy
| | - Fabio Jimenez
- VA Center for Personalized Medicine, South Texas Veterans Health Care System, San Antonio, TX, 78229, USA
- The Foundation for Advancing Veterans' Health Research, San Antonio, TX, 78229, USA
| | - Andrew Carrillo
- VA Center for Personalized Medicine, South Texas Veterans Health Care System, San Antonio, TX, 78229, USA
- The Foundation for Advancing Veterans' Health Research, San Antonio, TX, 78229, USA
| | - Lavanya Pandranki
- VA Center for Personalized Medicine, South Texas Veterans Health Care System, San Antonio, TX, 78229, USA
- Department of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, 78229, USA
| | - Caitlyn A Winter
- VA Center for Personalized Medicine, South Texas Veterans Health Care System, San Antonio, TX, 78229, USA
- Department of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, 78229, USA
- The Foundation for Advancing Veterans' Health Research, San Antonio, TX, 78229, USA
- Department of Pediatrics, University of Texas Health Science Center at San Antonio, San Antonio, TX, 78229, USA
| | - Lauryn A Winter
- VA Center for Personalized Medicine, South Texas Veterans Health Care System, San Antonio, TX, 78229, USA
- Department of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, 78229, USA
- The Foundation for Advancing Veterans' Health Research, San Antonio, TX, 78229, USA
- Department of Pediatrics, University of Texas Health Science Center at San Antonio, San Antonio, TX, 78229, USA
| | - Alvaro A Gaitan
- VA Center for Personalized Medicine, South Texas Veterans Health Care System, San Antonio, TX, 78229, USA
- The Foundation for Advancing Veterans' Health Research, San Antonio, TX, 78229, USA
| | - Alvaro G Moreira
- VA Center for Personalized Medicine, South Texas Veterans Health Care System, San Antonio, TX, 78229, USA
- Department of Pediatrics, University of Texas Health Science Center at San Antonio, San Antonio, TX, 78229, USA
| | - Elizabeth A Walter
- VA Center for Personalized Medicine, South Texas Veterans Health Care System, San Antonio, TX, 78229, USA
- South Texas Veterans Health Care System, San Antonio, TX, 78229, USA
- Department of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, 78229, USA
| | - Guido Silvestri
- Department of Pathology, Emory University School of Medicine & Emory National Primate Research Center, Atlanta, GA, 30322, USA
| | - Christopher L King
- Center for Global Health and Diseases, Case Western Reserve University, Cleveland, OH, 44106, USA
| | - Yong-Tang Zheng
- Key Laboratory of Animal Models and Human Disease Mechanisms of the Chinese Academy of Sciences, KIZ-CUHK Joint Laboratory of Bioresources and Molecular Research in Common Diseases, Kunming Institute of Zoology, Chinese Academy of Sciences, Kunming, Yunnan, 650223, China
- National Resource Center for Non-Human Primates, Center for Biosafety Mega-Science, Kunming Institute of Zoology, Chinese Academy of Sciences, Kunming, Yunnan, 650107, China
| | - Hong-Yi Zheng
- Key Laboratory of Animal Models and Human Disease Mechanisms of the Chinese Academy of Sciences, KIZ-CUHK Joint Laboratory of Bioresources and Molecular Research in Common Diseases, Kunming Institute of Zoology, Chinese Academy of Sciences, Kunming, Yunnan, 650223, China
- National Resource Center for Non-Human Primates, Center for Biosafety Mega-Science, Kunming Institute of Zoology, Chinese Academy of Sciences, Kunming, Yunnan, 650107, China
| | - Joshua Kimani
- Department of Medical Microbiology and Infectious Diseases, University of Manitoba, Winnipeg, MB, R3T 2N2, Canada
| | - T Blake Ball
- Department of Medical Microbiology and Infectious Diseases, University of Manitoba, Winnipeg, MB, R3T 2N2, Canada
| | - Francis A Plummer
- Department of Medical Microbiology and Infectious Diseases, University of Manitoba, Winnipeg, MB, R3T 2N2, Canada
| | - Keith R Fowke
- Department of Medical Microbiology and Infectious Diseases, University of Manitoba, Winnipeg, MB, R3T 2N2, Canada
| | - Paul N Harden
- Oxford Kidney Unit, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 7LE, UK
| | - Kathryn J Wood
- Transplantation Research Immunology Group, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, OX1 2JD, UK
| | - Martin T Ferris
- Department of Genetics, University of North Carolina, Chapel Hill, NC, 27599, USA
| | - Jennifer M Lund
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, 98109, USA
- Department of Global Health, University of Washington, Seattle, WA, 98195, USA
| | - Mark T Heise
- Department of Genetics, University of North Carolina, Chapel Hill, NC, 27599, USA
| | - Nigel Garrett
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, 4001, South Africa
| | - Kristen R Canady
- VA Center for Personalized Medicine, South Texas Veterans Health Care System, San Antonio, TX, 78229, USA
| | - Salim S Abdool Karim
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, 4001, South Africa
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, 10032, USA
| | - Susan J Little
- Department of Medicine, University of California, La Jolla, CA, 92093, USA
- San Diego Center for AIDS Research, University of California San Diego, La Jolla, CA, 92093, USA
| | - Sara Gianella
- Department of Medicine, University of California, La Jolla, CA, 92093, USA
- San Diego Center for AIDS Research, University of California San Diego, La Jolla, CA, 92093, USA
| | - Davey M Smith
- Department of Medicine, University of California, La Jolla, CA, 92093, USA
- San Diego Center for AIDS Research, University of California San Diego, La Jolla, CA, 92093, USA
- Veterans Affairs San Diego Healthcare System, San Diego, CA, 92161, USA
| | - Scott Letendre
- Department of Medicine, University of California, La Jolla, CA, 92093, USA
| | - Douglas D Richman
- San Diego Center for AIDS Research, University of California San Diego, La Jolla, CA, 92093, USA
| | - Francesco Cucca
- Istituto di Ricerca Genetica e Biomedica (IRGB), CNR, Monserrato, 09042, Italy
- Dipartimento di Scienze Biomediche, Università di Sassari, Sassari, 07100, Italy
| | - Hanh Trinh
- South Texas Veterans Health Care System, San Antonio, TX, 78229, USA
| | - Sandra Sanchez-Reilly
- South Texas Veterans Health Care System, San Antonio, TX, 78229, USA
- Department of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, 78229, USA
| | - Joan M Hecht
- South Texas Veterans Health Care System, San Antonio, TX, 78229, USA
- The Foundation for Advancing Veterans' Health Research, San Antonio, TX, 78229, USA
| | - Jose A Cadena Zuluaga
- South Texas Veterans Health Care System, San Antonio, TX, 78229, USA
- Department of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, 78229, USA
| | - Antonio Anzueto
- South Texas Veterans Health Care System, San Antonio, TX, 78229, USA
- Department of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, 78229, USA
| | - Jacqueline A Pugh
- VA Center for Personalized Medicine, South Texas Veterans Health Care System, San Antonio, TX, 78229, USA
- South Texas Veterans Health Care System, San Antonio, TX, 78229, USA
- Department of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, 78229, USA
| | - Brian K Agan
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD, 20814, USA
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, 20817, USA
| | | | - Robert A Clark
- VA Center for Personalized Medicine, South Texas Veterans Health Care System, San Antonio, TX, 78229, USA
- Department of Microbiology, Immunology & Molecular Genetics, University of Texas Health Science Center at San Antonio, San Antonio, TX, 78229, USA
- South Texas Veterans Health Care System, San Antonio, TX, 78229, USA
- Department of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, 78229, USA
- The Foundation for Advancing Veterans' Health Research, San Antonio, TX, 78229, USA
| | - Jason F Okulicz
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD, 20814, USA
- Department of Medicine, Infectious Diseases Service, Brooke Army Medical Center, San Antonio, TX, 78234, USA
| | - Weijing He
- VA Center for Personalized Medicine, South Texas Veterans Health Care System, San Antonio, TX, 78229, USA
- The Foundation for Advancing Veterans' Health Research, San Antonio, TX, 78229, USA
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8
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Agustí A, Anzueto A, Celli BR, Mortimer K, Salvi S, Vogelmeier CF. GOLD 2023 Executive Summary: responses from the GOLD Scientific Committee. Eur Respir J 2023; 61:2300616. [PMID: 37321613 PMCID: PMC10269375 DOI: 10.1183/13993003.00616-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 04/21/2023] [Indexed: 06/17/2023]
Abstract
We thank the authors of the five letters received in relation to the recent publication of the Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2023 Executive Summary in the European Respiratory Journal [1] for their interest and insightful comments. We address them below, albeit necessarily briefly, under three categories: a global perspective, diagnostic issues, and management of exacerbations. The GOLD Scientific Committee respond to five letters to the Editor in relation to the GOLD 2023 Executive Summary https://bit.ly/41wJzhk
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Affiliation(s)
- Alvar Agustí
- Univ. Barcelona, Hospital Clinic, IDIBAPS and CIBERES, Barcelona, Spain
| | - Antonio Anzueto
- South Texas Veterans Health Care System, University of Texas, San Antonio, TX, USA
| | - Bartolome R Celli
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Kevin Mortimer
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
- National Heart and Lung Institute, Imperial College London, London, UK
- School of Clinical Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Sundeep Salvi
- Pulmocare Research and Education (PURE) Foundation, Pune, India
| | - Claus F Vogelmeier
- Department of Medicine, Pulmonary and Critical Care Medicine, University Medical Center Giessen and Marburg, Philipps-University, German Center for Lung Research (DZL), Marburg, Germany
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9
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Sin DD, Doiron D, Agusti A, Anzueto A, Barnes PJ, Celli BR, Criner GJ, Halpin D, Han MK, Martinez FJ, Montes de Oca M, Papi A, Pavord I, Roche N, Singh D, Stockley R, Lopez Varlera MV, Wedzicha J, Vogelmeier C, Bourbeau J. Air pollution and COPD: GOLD 2023 committee report. Eur Respir J 2023; 61:2202469. [PMID: 36958741 DOI: 10.1183/13993003.02469-2022] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 03/04/2023] [Indexed: 03/25/2023]
Abstract
Exposure to air pollution is a major contributor to the pathogenesis of COPD worldwide. Indeed, most recent estimates suggest that 50% of the total attributable risk of COPD may be related to air pollution. In response, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) Scientific Committee performed a comprehensive review on this topic, qualitatively synthesised the evidence to date and proffered recommendations to mitigate the risk. The review found that both gaseous and particulate components of air pollution are likely contributors to COPD. There are no absolutely safe levels of ambient air pollution and the relationship between air pollution levels and respiratory events is supra-linear. Wildfires and extreme weather events such as heat waves, which are becoming more common owing to climate change, are major threats to COPD patients and acutely increase their risk of morbidity and mortality. Exposure to air pollution also impairs lung growth in children and as such may lead to developmental COPD. GOLD recommends strong public health policies around the world to reduce ambient air pollution and for implementation of public warning systems and advisories, including where possible the use of personalised apps, to alert patients when ambient air pollution levels exceed acceptable minimal thresholds. When household particulate content exceeds acceptable thresholds, patients should consider using air cleaners and filters where feasible. Air pollution is a major health threat to patients living with COPD and actions are urgently required to reduce the morbidity and mortality related to poor air quality around the world.
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Affiliation(s)
- Don D Sin
- Centre for Heart Lung Innovation, St Paul's Hospital and University of British Columbia Division of Respiratory Medicine, Vancouver, BC, Canada
| | - Dany Doiron
- McGill University Health Centre, McGill University, Montreal, QC, Canada
| | - Alvar Agusti
- Respiratory Institute, Hospital Clinic, IDIBAPS, University of Barcelona and CIBERES, Barcelona, Spain
| | - Antonio Anzueto
- South Texas Veterans Health Care System, University of Texas, San Antonio, TX, USA
| | - Peter J Barnes
- National Heart and Lung Institute, Imperial College London, London, UK
| | | | | | - David Halpin
- University of Exeter Medical School, College of Medicine and Health, University of Exeter, Exeter, UK
| | | | - Fernando J Martinez
- Weill Cornell Medical Center/New York-Presbyterian Hospital, New York, NY, USA
| | - Maria Montes de Oca
- Hospital Universitario de Caracas, Universidad Central de Venezuela, Centro Médico de Caracas, Caracas, Venezuela
| | - Alberto Papi
- Respiratory Medicine, University of Ferrara, Ferrara, Italy
| | - Ian Pavord
- Respiratory Medicine Unit and Oxford Respiratory NIHR Biomedical Research Centre, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Nicolas Roche
- Service de Pneumologie, Hôpital Cochin, AP-HP, Université Paris Cité, UMR 1016, Institut Cochin, Paris, France
| | - Dave Singh
- University of Manchester, Manchester, UK
| | | | | | - Jadwiga Wedzicha
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Claus Vogelmeier
- Department of Medicine, Pulmonary and Critical Care Medicine, University Hospital Giessen and Marburg, German Center for Lung Research (DZL), University of Marburg, Marburg, Germany
| | - Jean Bourbeau
- McGill University Health Centre, McGill University, Montreal, QC, Canada
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10
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Agustí A, Celli BR, Criner GJ, Halpin D, Anzueto A, Barnes P, Bourbeau J, Han MK, Martinez FJ, Montes de Oca M, Mortimer K, Papi A, Pavord I, Roche N, Salvi S, Sin DD, Singh D, Stockley R, López Varela MV, Wedzicha JA, Vogelmeier CF. Global Initiative for Chronic Obstructive Lung Disease 2023 Report: GOLD Executive Summary. Am J Respir Crit Care Med 2023; 207:819-837. [PMID: 36856433 PMCID: PMC10111975 DOI: 10.1164/rccm.202301-0106pp] [Citation(s) in RCA: 104] [Impact Index Per Article: 104.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 02/28/2023] [Indexed: 03/02/2023] Open
Affiliation(s)
- Alvar Agustí
- Univ. Barcelona, Hospital Clinic, IDIBAPS and CIBERES, Spain
| | - Bartolome R. Celli
- Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Gerard J. Criner
- Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania, USA
| | - David Halpin
- University of Exeter Medical School College of Medicine and Health, University of Exeter, Exeter, Devon, UK
| | - Antonio Anzueto
- South Texas Veterans Health Care System, University of Texas Health, San Antonio, Texas, USA
| | - Peter Barnes
- National Heart & Lung Institute, Imperial College London, United Kingdom
| | - Jean Bourbeau
- McGill University Health Centre, McGill University, Montreal, Canada
| | | | - Fernando J. Martinez
- Weill Cornell Medical Center/ New York-Presbyterian Hospital, New York, New York, USA
| | - Maria Montes de Oca
- Hospital Universitario de Caracas Universidad Central de Venezuela Centro Médico de Caracas, Caracas, Venezuela
| | - Kevin Mortimer
- Liverpool University Hospitals NHS Foundation Trust, UK / National Heart and Lung Institute, Imperial College, London, UK / School of Clinical Medicine, College of Health Sciences, University of Kwazulu-Natal, South Africa
| | | | - Ian Pavord
- Respiratory Medicine Unit and Oxford Respiratory NIHR Biomedical Research Centre, Nuffield Department of Medicine, University of Oxford, UK
| | - Nicolas Roche
- Pneumologie, Hôpital Cochin AP-HP.Centre, Université Paris, France
| | - Sundeep Salvi
- Pulmocare Research and Education (PURE) Foundation, Pune, India
| | - Don D. Sin
- St. Paul’s Hospital University of British Columbia, Vancouver, Canada
| | - Dave Singh
- University of Manchester, Manchester, UK
| | | | | | | | - Claus F. Vogelmeier
- Department of Medicine, Pulmonary and Critical Care Medicine, University Medical Center Giessen and Marburg, Philipps-University, German Center for Lung Research (DZL), Marburg, Germany
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11
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Agustí A, Celli BR, Criner GJ, Halpin D, Anzueto A, Barnes P, Bourbeau J, Han MK, Martinez FJ, de Oca MM, Mortimer K, Papi A, Pavord I, Roche N, Salvi S, Sin DD, Singh D, Stockley R, López Varela MV, Wedzicha JA, Vogelmeier CF. Global Initiative for Chronic Obstructive Lung Disease 2023 Report: GOLD Executive Summary. Eur Respir J 2023; 61:13993003.00239-2023. [PMID: 36858443 PMCID: PMC10066569 DOI: 10.1183/13993003.00239-2023] [Citation(s) in RCA: 165] [Impact Index Per Article: 165.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 02/10/2023] [Indexed: 03/03/2023]
Affiliation(s)
- Alvar Agustí
- Univ. Barcelona, Hospital Clinic, IDIBAPS and CIBERES, Spain .,co-first authors
| | - Bartolome R Celli
- Brigham and Women's Hospital. Harvard Medical School, Boston, Massachusetts, USA.,co-first authors
| | - Gerard J Criner
- Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania, USA
| | - David Halpin
- University of Exeter Medical School College of Medicine and Health University of Exeter, Exeter Devon, UK
| | - Antonio Anzueto
- South Texas Veterans Health Care System University of Texas, Health San Antonio, Texas, USA
| | - Peter Barnes
- National Heart & Lung Institute Imperial College London, United Kingdom
| | - Jean Bourbeau
- McGill University Health Centre McGill University Montreal, Canada
| | | | - Fernando J Martinez
- Weill Cornell Medical Center/New York-Presbyterian Hospital, New York, NY, USA
| | - Maria Montes de Oca
- Hospital Universitario de Caracas Universidad Central de Venezuela Centro Médico de Caracas, Caracas, Venezuela
| | - Kevin Mortimer
- Liverpool University Hospitals NHS Foundation Trust, UK.,National Heart and Lung Institute, Imperial College, London, UK.,School of Clinical Medicine, College of Health Sciences, University of Kwazulu-Natal, South Africa
| | | | - Ian Pavord
- Respiratory Medicine Unit and Oxford Respiratory NIHR Biomedical Research Centre, Nuffield Department of Medicine University of Oxford, UK
| | - Nicolas Roche
- Pneumologie, Hôpital Cochin AP-HP.Centre, Université Paris, France
| | - Sundeep Salvi
- Pulmocare Research and Education (PURE) Foundation, Pune, India
| | - Don D Sin
- St. Paul's Hospital University of British Columbia, Vancouver, Canada
| | - Dave Singh
- University of Manchester, Manchester, UK
| | | | | | | | - Claus F Vogelmeier
- Department of Medicine, Pulmonary and Critical Care Medicine, University Medical Center Giessen and Marburg, Philipps-University, German Center for Lung Research (DZL), Marburg, Germany
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12
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Agustí A, Celli BR, Criner GJ, Halpin D, Anzueto A, Barnes P, Bourbeau J, Han MK, Martinez FJ, Montes de Oca M, Mortimer K, Papi A, Pavord I, Roche N, Salvi S, Sin DD, Singh D, Stockley R, López Varela MV, Wedzicha JA, Vogelmeier CF. Global Initiative for Chronic Obstructive Lung Disease 2023 Report: GOLD Executive Summary. Arch Bronconeumol 2023; 59:232-248. [PMID: 36933949 DOI: 10.1016/j.arbres.2023.02.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 02/06/2023] [Indexed: 03/05/2023]
Affiliation(s)
- Alvar Agustí
- University of Barcelona, Hospital Clinic, IDIBAPS and CIBERES, Spain.
| | - Bartolome R Celli
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Gerard J Criner
- Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - David Halpin
- University of Exeter Medical School, College of Medicine and Health, University of Exeter, Exeter, Devon, UK
| | - Antonio Anzueto
- South Texas Veterans Health Care System, University of Texas, Health San Antonio, Texas, USA
| | - Peter Barnes
- National Heart & Lung Institute, Imperial College London, United Kingdom
| | - Jean Bourbeau
- McGill University Health Centre, McGill University, Montreal, Canada
| | | | - Fernando J Martinez
- Weill Cornell Medical Center/New York-Presbyterian Hospital, New York, NY, USA
| | - Maria Montes de Oca
- Hospital Universitario de Caracas, Universidad Central de Venezuela, Centro Médico de Caracas, Caracas, Venezuela
| | - Kevin Mortimer
- Liverpool University Hospitals NHS Foundation Trust, UK; National Heart and Lung Institute, Imperial College London, UK; School of Clinical Medicine, College of Health Sciences, University of Kwazulu-Natal, South Africa
| | | | - Ian Pavord
- Respiratory Medicine Unit and Oxford Respiratory NIHR Biomedical Research Centre, Nuffield Department of Medicine, University of Oxford, UK
| | - Nicolas Roche
- Pneumologie, Hôpital Cochin AP-HP.Centre, Université Paris, France
| | - Sundeep Salvi
- Pulmocare Research and Education (PURE) Foundation, Pune, India
| | - Don D Sin
- St. Paul's Hospital, University of British Columbia, Vancouver, Canada
| | - Dave Singh
- University of Manchester, Manchester, UK
| | | | | | - Jadwiga A Wedzicha
- National Heart & Lung Institute, Imperial College London, United Kingdom
| | - Claus F Vogelmeier
- Department of Medicine, Pulmonary and Critical Care Medicine, University Medical Center Giessen and Marburg, Philipps-University, German Center for Lung Research (DZL), Marburg, Germany
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13
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Agustí A, Celli BR, Criner GJ, Halpin D, Anzueto A, Barnes P, Bourbeau J, Han MK, Martinez FJ, de Oca MM, Mortimer K, Papi A, Pavord I, Roche N, Salvi S, Sin DD, Singh D, Stockley R, Varela MVL, Wedzicha JA, Vogelmeier CF. Global Initiative for Chronic Obstructive Lung Disease 2023 Report: GOLD Executive Summary. Respirology 2023; 28:316-338. [PMID: 36856440 DOI: 10.1111/resp.14486] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 02/09/2023] [Indexed: 03/02/2023]
Affiliation(s)
- Alvar Agustí
- University of Barcelona, Hospital Clinic, IDIBAPS and CIBERES, Spain
| | - Bartolome R Celli
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Gerard J Criner
- Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania, USA
| | - David Halpin
- University of Exeter Medical School College of Medicine and Health University of Exeter, Exeter, Devon, UK
| | - Antonio Anzueto
- South Texas Veterans Health Care System University of Texas, Health San Antonio, Texas, USA
| | - Peter Barnes
- National Heart & Lung Institute Imperial College London, UK
| | - Jean Bourbeau
- McGill University Health Centre McGill University Montreal, Canada
| | - MeiLan K Han
- University of Michigan, Ann Arbor, Michigan, USA
| | - Fernando J Martinez
- Weill Cornell Medical Center/ New York-Presbyterian Hospital New York, New York, USA
| | - Maria Montes de Oca
- Hospital Universitario de Caracas Universidad Central de Venezuela Centro Médico de Caracas, Caracas, Venezuela
| | - Kevin Mortimer
- Liverpool University Hospitals NHS Foundation Trust, UK / National Heart and Lung Institute, Imperial College, London, UK / School of Clinical Medicine, College of Health Sciences, University of Kwazulu-Natal, South Africa
| | | | - Ian Pavord
- Respiratory Medicine Unit and Oxford Respiratory NIHR Biomedical Research Centre, Nuffield Department of Medicine University of Oxford, UK
| | - Nicolas Roche
- Pneumologie, Hôpital Cochin AP-HP.Centre, Université Paris, France
| | - Sundeep Salvi
- Pulmocare Research and Education (PURE) Foundation, Pune, India
| | - Don D Sin
- St. Paul's Hospital University of British Columbia, Vancouver, Canada
| | - Dave Singh
- University of Manchester, Manchester, UK
| | | | | | | | - Claus F Vogelmeier
- Department of Medicine, Pulmonary and Critical Care Medicine, University Medical Center Giessen and Marburg, Philipps-University, German Center for Lung Research (DZL), Marburg, Germany
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14
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Miravitlles M, Anzueto A. Use of Computed Tomography Lung Densitometry as an Outcome Measure for Emphysema Progression: The Case of Losartan. Am J Respir Crit Care Med 2022; 206:804-806. [PMID: 35653703 PMCID: PMC9799282 DOI: 10.1164/rccm.202205-0927ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Affiliation(s)
- Marc Miravitlles
- Pneumology Department, Hospital Universitari Vall d’Hebron andVall d’Hebron Institut de Recerca (VHIR)Barcelona, Spain
| | - Antonio Anzueto
- Pulmonary Disease/Critical CareUniversity of Texas Health and South Texas Veterans Health Care SystemSan Antonio, Texas
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15
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Meduri GU, Shih MC, Bridges L, Martin TJ, El-Solh A, Seam N, Davis-Karim A, Umberger R, Anzueto A, Sriram P, Lan C, Restrepo MI, Guardiola JJ, Buck T, Johnson DP, Suffredini A, Bell WA, Lin J, Zhao L, Uyeda L, Nielsen L, Huang GD. Low-dose methylprednisolone treatment in critically ill patients with severe community-acquired pneumonia. Intensive Care Med 2022; 48:1009-1023. [PMID: 35723686 PMCID: PMC9208259 DOI: 10.1007/s00134-022-06684-3] [Citation(s) in RCA: 59] [Impact Index Per Article: 29.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 03/16/2022] [Indexed: 12/15/2022]
Abstract
Purpose Severe community-acquired pneumonia (CAP) requiring intensive care unit admission is associated with significant acute and long-term morbidity and mortality. We hypothesized that downregulation of systemic and pulmonary inflammation with prolonged low-dose methylprednisolone treatment would accelerate pneumonia resolution and improve clinical outcomes. Methods This double-blind, randomized, placebo-controlled clinical trial recruited adult patients within 72–96 h of hospital presentation. Patients were randomized in 1:1 ratio; an intravenous 40 mg loading bolus was followed by 40 mg/day through day 7 and progressive tapering during the 20-day treatment course. Randomization was stratified by site and need for mechanical ventilation (MV) at the time of randomization. Outcomes included a primary endpoint of 60-day all-cause mortality and secondary endpoints of morbidity and mortality up to 1 year of follow-up. Results Between January 2012 and April 2016, 586 patients from 42 Veterans Affairs Medical Centers were randomized, short of the 1420 target sample size because of low recruitment. 584 patients were included in the analysis. There was no significant difference in 60-day mortality between the methylprednisolone and placebo arms (16% vs. 18%; adjusted odds ratio 0.90, 95% CI 0.57–1.40). There were no significant differences in secondary outcomes or complications. Conclusions In patients with severe CAP, prolonged low-dose methylprednisolone treatment did not significantly reduce 60-day mortality. Treatment was not associated with increased complications. Supplementary Information The online version contains supplementary material available at 10.1007/s00134-022-06684-3.
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Affiliation(s)
- G Umberto Meduri
- Pulmonary, Critical Care and Sleep Medicine Services, Memphis VA Medical Center, Memphis, USA. .,University of Tennessee Health Science Center, Memphis, USA.
| | - Mei-Chiung Shih
- VA Cooperative Studies Program Coordinating Center, Palo Alto, USA.,Department of Biomedical Data Sciences, Stanford University, Stanford, USA
| | - Lisa Bridges
- Pulmonary, Critical Care and Sleep Medicine Services, Memphis VA Medical Center, Memphis, USA.,University of Tennessee Health Science Center, Memphis, USA
| | - Thomas J Martin
- Salem VA Health Care System, Salem, USA.,Virginia Tech Carilion School of Medicine, Roanoke, USA.,Edward Via Virginia College of Osteopathic Medicine, Blacksburg, USA
| | - Ali El-Solh
- VA Western New York Health Care System, Buffalo, USA.,University at Buffalo, Buffalo, USA
| | - Nitin Seam
- National Institutes of Health Clinical Center, Bethesda, USA
| | - Anne Davis-Karim
- VA Cooperative Studies Program Pharmacy Coordinating Center, Albuquerque, USA
| | - Reba Umberger
- University of Tennessee Health Science Center, Memphis, USA
| | - Antonio Anzueto
- South Texas Veterans Health San Antonio, San Antonio, USA.,University of Texas Health Science Center, Houston, USA
| | | | - Charlie Lan
- Michael E Debakey VA Medical Center, Houston, USA
| | - Marcos I Restrepo
- South Texas Veterans Health San Antonio, San Antonio, USA.,University of Texas Health Science Center, Houston, USA
| | - Juan J Guardiola
- Robley Rex VA Medical Center, Louisville, USA.,University of Louisville, Louisville, USA
| | - Teresa Buck
- Bay Pines VA Healthcare Center, Bay Pines, USA
| | | | | | | | - Julia Lin
- VA Cooperative Studies Program Coordinating Center, Palo Alto, USA
| | - Lan Zhao
- VA Cooperative Studies Program Coordinating Center, Palo Alto, USA
| | - Lauren Uyeda
- VA Cooperative Studies Program Coordinating Center, Palo Alto, USA
| | - Lori Nielsen
- VA Cooperative Studies Program Coordinating Center, Palo Alto, USA
| | - Grant D Huang
- Office of Research and Development, Department of Veterans Affairs, Baltimore, USA
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16
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DerSarkissian M, Young-Xu Y, Duh MS, Bhak RH, Palmetto N, Mortensen E, Anzueto A, Nguyen C, Cheng M, Frajzyngier V, Park S, Lax A, Weatherby LB, Walker AM. The Acute Effects of Azithromycin Use on Cardiovascular Mortality as Compared with Amoxicillin-Clavulanate in United States Veterans. Pharmacoepidemiol Drug Saf 2022; 31:840-850. [PMID: 35560969 DOI: 10.1002/pds.5451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 04/27/2022] [Accepted: 05/09/2022] [Indexed: 11/08/2022]
Abstract
PURPOSE Azithromycin is a common first-line antibiotic for respiratory infection; however, there is conflicting evidence regarding risk of cardiovascular death. We assessed cardiovascular and non-cardiovascular mortality associated with azithromycin versus amoxicillin-clavulanate among United States (US) Veterans treated for non-ear-nose-throat respiratory infection ("respiratory") or ear-nose-throat infection indication. METHODS Electronic health record data from the US Veterans Health Administration database was used to identify Veterans (30-74 years) with outpatient dispensings of oral azithromycin versus amoxicillin-clavulanate for respiratory or ear-nose-throat infection (01/01/2000-12/31/2014). Outcomes assessed were risk of cardiovascular death and non-cardiovascular death within 1-5 and 6-10 days post-dispensing. Inverse probability of treatment-weighted proportional hazards models and binomial regression models were used to estimate hazard ratios (HR) and compute risk differences (RD) per million courses of therapy. Cardiac death (subset of cardiovascular death) was assessed in sensitivity analyses. RESULTS There were 629,345 azithromycin and 168,429 amoxicillin-clavulanate dispensings for respiratory indications, 143,783 azithromycin, and 203,142 amoxicillin-clavulanate dispensings for ear-nose-throat indications. For respiratory indications, azithromycin was not associated with significantly different risk of cardiovascular death versus amoxicillin-clavulanate within 1-5 days post-dispensing (HR [95% confidence interval (CI)]: 1.12 [0.63-2.00]; RD [95%CI]: 11 [-43 - +64] deaths/million courses of therapy). No elevated risk for azithromycin was found for ear-nose-throat indications. Pooled results for both indications via meta-analysis showed no association between antibiotics and cardiovascular mortality. There was no significant difference in risk of non-cardiovascular or cardiac death between antibiotics post-dispensing. CONCLUSION Azithromycin was not associated with elevated risk of cardiovascular or non-cardiovascular death versus amoxicillin-clavulanate among US Veterans. This article is protected by copyright. All rights reserved.
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Affiliation(s)
| | | | | | | | | | - Eric Mortensen
- University of Connecticut School of Medicine, Farmington, CT
| | - Antonio Anzueto
- University of Texas Health, and South Texas Veterans Health Care System, San Antonio, San Antonio, TX
| | | | - Mu Cheng
- Analysis Group, Inc., Boston, MA
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17
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Ohar JA, Ferguson GT, Mahler DA, Drummond MB, Dhand R, Pleasants RA, Anzueto A, Halpin DMG, Price DB, Drescher GS, Hoy HM, Haughney J, Hess MW, Usmani OS. Measuring Peak Inspiratory Flow in Patients with Chronic Obstructive Pulmonary Disease. Int J Chron Obstruct Pulmon Dis 2022; 17:79-92. [PMID: 35023914 PMCID: PMC8747625 DOI: 10.2147/copd.s319511] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 10/25/2021] [Indexed: 12/03/2022] Open
Abstract
Dry powder inhalers (DPIs) are breath actuated, and patients using DPIs need to generate an optimal inspiratory flow during the inhalation maneuver for effective drug delivery to the lungs. However, practical and standardized recommendations for measuring peak inspiratory flow (PIF)—a potential indicator for effective DPI use in chronic obstructive pulmonary disease (COPD)—are lacking. To evaluate recommended PIF assessment approaches, we reviewed the Instructions for Use of the In-Check™ DIAL and the prescribing information for eight DPIs approved for use in the treatment of COPD in the United States. To evaluate applied PIF assessment approaches, we conducted a PubMed search from inception to August 31, 2021, for reports of clinical and real-life studies where PIF was measured using the In-Check™ DIAL or through a DPI in patients with COPD. Evaluation of collective sources, including 47 applicable studies, showed that instructions related to the positioning of the patient with their DPI, instructions for exhalation before the inhalation maneuver, the inhalation maneuver itself, and post-inhalation breath-hold times varied, and in many instances, appeared vague and/or incomplete. We observed considerable variation in how PIF was measured in clinical and real-life studies, underscoring the need for a standardized method of PIF measurement. Standardization of technique will facilitate comparisons among studies. Based on these findings and our clinical and research experience, we propose specific recommendations for PIF measurement to standardize the process and better ensure accurate and reliable PIF values in clinical trials and in daily clinical practice.
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Affiliation(s)
- Jill A Ohar
- Section of Pulmonary, Critical Care, Allergy, and Immunology, School of Medicine, Wake Forest University, Winston-Salem, NC, USA
| | - Gary T Ferguson
- Pulmonary Research Institute of Southeast Michigan, Farmington Hills, MI, USA
| | | | - M Bradley Drummond
- Division of Pulmonary Diseases and Critical Care Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Rajiv Dhand
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Tennessee Graduate School of Medicine, Knoxville, TN, USA
| | - Roy A Pleasants
- Division of Pulmonary Diseases and Critical Care Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Department of Quality, University of Michigan, Ann Arbor, MI, USA
| | - Antonio Anzueto
- Pulmonology Section, University of Texas Health, and South Texas Veterans Health Care System, San Antonio, TX, USA
| | - David M G Halpin
- University of Exeter Medical School, College of Medicine and Health, University of Exeter, Exeter, UK
| | - David B Price
- Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK.,Observational and Pragmatic Research Institute, Singapore
| | - Gail S Drescher
- Pulmonary Services Department, MedStar Washington Hospital Center, Washington, DC, USA
| | - Haley M Hoy
- Transplant Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - John Haughney
- Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | | | - Omar S Usmani
- National Heart and Lung Institute, Imperial College London and Royal Brompton Hospital, London, UK
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18
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Uddin M, Mohammed T, Metersky M, Anzueto A, Alvarez CA, Mortensen EM. Effectiveness of Beta-Lactam plus Doxycycline for Patients Hospitalized with Community-Acquired Pneumonia. Clin Infect Dis 2021; 75:118-124. [PMID: 34751745 DOI: 10.1093/cid/ciab863] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Despite clinical practice guideline recommendations to use doxycycline as part of combination therapy for some patients hospitalized with pneumonia, there is minimal evidence supporting this recommendation. Our aim was to examine the association between beta-lactam plus doxycycline and mortality for patients hospitalized with community-acquired pneumonia. METHODS We identified patients > 65 years of age admitted to any United States Department of Veterans Affairs hospital in fiscal years 2002-2012 with a discharge diagnosis of pneumonia. We excluded those patients who did not receive antibiotic therapy concordant with the 2019 ATS/IDSA clinical practice guidelines. Using propensity score matching, we examined the association of doxycycline with 30- and 90-day mortality. RESULTS Our overall cohort was comprised of 70,533 patients and 5,282 (7.49%) received doxycycline. Unadjusted 30-day mortality was 6.4% for those who received a beta-lactam plus doxycycline vs. 9.1% in those who did not (p<0.0001), and 90-day mortality was 13.8% for those who received a beta-lactam + doxycycline vs. 16.8% for those who did not (p<0.0001). In the propensity score matched models, both 30- (odds ratio 0.72, 95% confidence interval, 0.63-0.84) and 90-day (0.83, 0.74-0.92) mortality were significantly lower for those who received doxycycline. CONCLUSIONS In this retrospective observational cohort study, we found that doxycycline use, as part of guideline-concordant antibiotic therapy, was associated with lower 30- and 90-day mortality than regimens without doxycycline. While this supports the safety and effectiveness of antibiotic regimes that include doxycycline, additional studies, especially randomized clinical trials, are needed to confirm this.
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Affiliation(s)
- Moe Uddin
- Department of Medicine, University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Turab Mohammed
- Department of Medicine, University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Mark Metersky
- Department of Medicine, University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Antonio Anzueto
- Department of Medicine, South Texas Veterans Health Care System, San Antonio, Texas, USA.,Department of Medicine, University of Texas Health San Antonio, San Antonio, Texas, USA
| | - Carlos A Alvarez
- VA North Texas Health Care System, Dallas, Texas, USA.,Department of Pharmacy Practice, Texas Tech University Health Sciences Center Jerry H. Hodge School of Pharmacy, Dallas, Texas, USA
| | - Eric M Mortensen
- Department of Medicine, University of Connecticut School of Medicine, Farmington, Connecticut, USA.,VA North Texas Health Care System, Dallas, Texas, USA
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Lee GC, Restrepo MI, Harper N, Manoharan MS, Smith AM, Meunier JA, Sanchez-Reilly S, Ehsan A, Branum AP, Winter C, Winter L, Jimenez F, Pandranki L, Carrillo A, Perez GL, Anzueto A, Trinh H, Lee M, Hecht JM, Martinez-Vargas C, Sehgal RT, Cadena J, Walter EA, Oakman K, Benavides R, Pugh JA, Letendre S, Steri M, Orrù V, Fiorillo E, Cucca F, Moreira AG, Zhang N, Leadbetter E, Agan BK, Richman DD, He W, Clark RA, Okulicz JF, Ahuja SK. Immunologic resilience and COVID-19 survival advantage. J Allergy Clin Immunol 2021; 148:1176-1191. [PMID: 34508765 PMCID: PMC8425719 DOI: 10.1016/j.jaci.2021.08.021] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 08/13/2021] [Accepted: 08/20/2021] [Indexed: 01/07/2023]
Abstract
BACKGROUND The risk of severe coronavirus disease 2019 (COVID-19) varies significantly among persons of similar age and is higher in males. Age-independent, sex-biased differences in susceptibility to severe COVID-19 may be ascribable to deficits in a sexually dimorphic protective attribute that we termed immunologic resilience (IR). OBJECTIVE We sought to examine whether deficits in IR that antedate or are induced by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection independently predict COVID-19 mortality. METHODS IR levels were quantified with 2 novel metrics: immune health grades (IHG-I [best] to IHG-IV) to gauge CD8+ and CD4+ T-cell count equilibrium, and blood gene expression signatures. IR metrics were examined in a prospective COVID-19 cohort (n = 522); primary outcome was 30-day mortality. Associations of IR metrics with outcomes in non-COVID-19 cohorts (n = 13,461) provided the framework for linking pre-COVID-19 IR status to IR during COVID-19, as well as to COVID-19 outcomes. RESULTS IHG-I, tracking high-grade equilibrium between CD8+ and CD4+ T-cell counts, was the most common grade (73%) among healthy adults, particularly in females. SARS-CoV-2 infection was associated with underrepresentation of IHG-I (21%) versus overrepresentation (77%) of IHG-II or IHG-IV, especially in males versus females (P < .01). Presentation with IHG-I was associated with 88% lower mortality, after controlling for age and sex; reduced risk of hospitalization and respiratory failure; lower plasma IL-6 levels; rapid clearance of nasopharyngeal SARS-CoV-2 burden; and gene expression signatures correlating with survival that signify immunocompetence and controlled inflammation. In non-COVID-19 cohorts, IR-preserving metrics were associated with resistance to progressive influenza or HIV infection, as well as lower 9-year mortality in the Framingham Heart Study, especially in females. CONCLUSIONS Preservation of immunocompetence with controlled inflammation during antigenic challenges is a hallmark of IR and associates with longevity and AIDS resistance. Independent of age, a male-biased proclivity to degrade IR before and/or during SARS-CoV-2 infection predisposes to severe COVID-19.
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Affiliation(s)
- Grace C. Lee
- Veterans Administration Research Center for AIDS and HIV-1 Infection and Center for Personalized Medicine, South Texas Veterans Health Care System, San Antonio, Tex,Pharmacotherapy Education and Research Center, School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Tex,College of Pharmacy, The University of Texas at Austin, Austin, Tex
| | - Marcos I. Restrepo
- Veterans Administration Research Center for AIDS and HIV-1 Infection and Center for Personalized Medicine, South Texas Veterans Health Care System, San Antonio, Tex,South Texas Veterans Health Care System, San Antonio, Tex,Department of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Tex
| | - Nathan Harper
- Veterans Administration Research Center for AIDS and HIV-1 Infection and Center for Personalized Medicine, South Texas Veterans Health Care System, San Antonio, Tex,The Foundation for Advancing Veterans’ Health Research, San Antonio, Tex
| | - Muthu Saravanan Manoharan
- Veterans Administration Research Center for AIDS and HIV-1 Infection and Center for Personalized Medicine, South Texas Veterans Health Care System, San Antonio, Tex,Department of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Tex
| | - Alisha M. Smith
- Veterans Administration Research Center for AIDS and HIV-1 Infection and Center for Personalized Medicine, South Texas Veterans Health Care System, San Antonio, Tex,The Foundation for Advancing Veterans’ Health Research, San Antonio, Tex,Department of Microbiology, Immunology & Molecular Genetics, University of Texas Health Science Center at San Antonio, San Antonio, Tex
| | - Justin A. Meunier
- Veterans Administration Research Center for AIDS and HIV-1 Infection and Center for Personalized Medicine, South Texas Veterans Health Care System, San Antonio, Tex,The Foundation for Advancing Veterans’ Health Research, San Antonio, Tex
| | - Sandra Sanchez-Reilly
- South Texas Veterans Health Care System, San Antonio, Tex,Department of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Tex
| | - Aamir Ehsan
- South Texas Veterans Health Care System, San Antonio, Tex
| | - Anne P. Branum
- Veterans Administration Research Center for AIDS and HIV-1 Infection and Center for Personalized Medicine, South Texas Veterans Health Care System, San Antonio, Tex,The Foundation for Advancing Veterans’ Health Research, San Antonio, Tex
| | - Caitlyn Winter
- Veterans Administration Research Center for AIDS and HIV-1 Infection and Center for Personalized Medicine, South Texas Veterans Health Care System, San Antonio, Tex,Department of Pediatrics, University of Texas Health Science Center at San Antonio, San Antonio, Tex
| | - Lauryn Winter
- Veterans Administration Research Center for AIDS and HIV-1 Infection and Center for Personalized Medicine, South Texas Veterans Health Care System, San Antonio, Tex,Department of Pediatrics, University of Texas Health Science Center at San Antonio, San Antonio, Tex
| | - Fabio Jimenez
- Veterans Administration Research Center for AIDS and HIV-1 Infection and Center for Personalized Medicine, South Texas Veterans Health Care System, San Antonio, Tex,The Foundation for Advancing Veterans’ Health Research, San Antonio, Tex
| | - Lavanya Pandranki
- Veterans Administration Research Center for AIDS and HIV-1 Infection and Center for Personalized Medicine, South Texas Veterans Health Care System, San Antonio, Tex,Department of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Tex
| | - Andrew Carrillo
- Veterans Administration Research Center for AIDS and HIV-1 Infection and Center for Personalized Medicine, South Texas Veterans Health Care System, San Antonio, Tex,The Foundation for Advancing Veterans’ Health Research, San Antonio, Tex
| | - Graciela L. Perez
- Veterans Administration Research Center for AIDS and HIV-1 Infection and Center for Personalized Medicine, South Texas Veterans Health Care System, San Antonio, Tex,The Foundation for Advancing Veterans’ Health Research, San Antonio, Tex
| | - Antonio Anzueto
- South Texas Veterans Health Care System, San Antonio, Tex,Department of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Tex
| | - Hanh Trinh
- South Texas Veterans Health Care System, San Antonio, Tex
| | - Monica Lee
- South Texas Veterans Health Care System, San Antonio, Tex
| | - Joan M. Hecht
- South Texas Veterans Health Care System, San Antonio, Tex,The Foundation for Advancing Veterans’ Health Research, San Antonio, Tex
| | | | - Raj T. Sehgal
- South Texas Veterans Health Care System, San Antonio, Tex,Department of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Tex
| | - Jose Cadena
- South Texas Veterans Health Care System, San Antonio, Tex,Department of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Tex
| | - Elizabeth A. Walter
- Veterans Administration Research Center for AIDS and HIV-1 Infection and Center for Personalized Medicine, South Texas Veterans Health Care System, San Antonio, Tex,South Texas Veterans Health Care System, San Antonio, Tex,Department of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Tex
| | | | - Raymond Benavides
- Pharmacotherapy Education and Research Center, School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Tex,College of Pharmacy, The University of Texas at Austin, Austin, Tex
| | - Jacqueline A. Pugh
- Veterans Administration Research Center for AIDS and HIV-1 Infection and Center for Personalized Medicine, South Texas Veterans Health Care System, San Antonio, Tex,South Texas Veterans Health Care System, San Antonio, Tex,Department of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Tex
| | | | - Scott Letendre
- Department of Medicine, University of California, San Diego, Calif,HIV Neurobehavioral Research Center Antiviral Research Center, University of California, San Diego, Calif
| | - Maristella Steri
- Institute for Genetic and Biomedical Research, National Research Council (CNR), Sardinia, Italy
| | - Valeria Orrù
- Institute for Genetic and Biomedical Research, National Research Council (CNR), Sardinia, Italy
| | - Edoardo Fiorillo
- Institute for Genetic and Biomedical Research, National Research Council (CNR), Sardinia, Italy
| | - Francesco Cucca
- Institute for Genetic and Biomedical Research, National Research Council (CNR), Sardinia, Italy,Department of Biomedical Sciences, University of Sassari, Sassari, Italy
| | - Alvaro G. Moreira
- Veterans Administration Research Center for AIDS and HIV-1 Infection and Center for Personalized Medicine, South Texas Veterans Health Care System, San Antonio, Tex,Department of Pediatrics, University of Texas Health Science Center at San Antonio, San Antonio, Tex
| | - Nu Zhang
- Veterans Administration Research Center for AIDS and HIV-1 Infection and Center for Personalized Medicine, South Texas Veterans Health Care System, San Antonio, Tex,Department of Microbiology, Immunology & Molecular Genetics, University of Texas Health Science Center at San Antonio, San Antonio, Tex
| | - Elizabeth Leadbetter
- Veterans Administration Research Center for AIDS and HIV-1 Infection and Center for Personalized Medicine, South Texas Veterans Health Care System, San Antonio, Tex,Department of Microbiology, Immunology & Molecular Genetics, University of Texas Health Science Center at San Antonio, San Antonio, Tex
| | - Brian K. Agan
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Md,The Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Md
| | | | - Weijing He
- Veterans Administration Research Center for AIDS and HIV-1 Infection and Center for Personalized Medicine, South Texas Veterans Health Care System, San Antonio, Tex,The Foundation for Advancing Veterans’ Health Research, San Antonio, Tex
| | - Robert A. Clark
- Veterans Administration Research Center for AIDS and HIV-1 Infection and Center for Personalized Medicine, South Texas Veterans Health Care System, San Antonio, Tex,South Texas Veterans Health Care System, San Antonio, Tex,Department of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Tex
| | - Jason F. Okulicz
- Infectious Disease Service, San Antonio Military Medical Center, Fort Sam Houston, San Antonio, Tex
| | - Sunil K. Ahuja
- Veterans Administration Research Center for AIDS and HIV-1 Infection and Center for Personalized Medicine, South Texas Veterans Health Care System, San Antonio, Tex,South Texas Veterans Health Care System, San Antonio, Tex,Department of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Tex,Department of Microbiology, Immunology & Molecular Genetics, University of Texas Health Science Center at San Antonio, San Antonio, Tex,Corresponding author: Sunil K. Ahuja, MD, South Texas Veterans Health Care System, 7400 Merton Minter, San Antonio, TX 78229; Department of Medicine, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, San Antonio, TX 78229
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Roca O, Peñuelas O, Muriel A, García-de-Acilu M, Laborda C, Sacanell J, Riera J, Raymondos K, Du B, Thille AW, Ríos F, González M, Del-Sorbo L, Del Carmen Marín M, Soares MA, Pinheiro BV, Nin N, Maggiore SM, Bersten A, Amin P, Çakar N, Suh GY, Abroug F, Jibaja M, Matamis D, Zeggwagh AA, Sutherasan Y, Anzueto A, Esteban A, Frutos-Vivar F. Driving Pressure Is a Risk Factor for ARDS in Mechanically Ventilated Subjects Without ARDS. Respir Care 2021; 66:1505-1513. [PMID: 34344717 PMCID: PMC9993559 DOI: 10.4187/respcare.08587] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Driving pressure (ΔP) has been described as a risk factor for mortality in patients with ARDS. However, the role of ΔP in the outcome of patients without ARDS and on mechanical ventilation has received less attention. Our objective was to evaluate the association between ΔP on the first day of mechanical ventilation with the development of ARDS. METHODS This was a post hoc analysis of a multicenter, prospective, observational, international study that included subjects who were on mechanical ventilation for > 12 h. Our objective was to evaluate the association between ΔP on the first day of mechanical ventilation with the development of ARDS. To assess the effect of ΔP, a logistic regression analysis was performed when adjusting for other potential risk factors. Validation of the results obtained was performed by using a bootstrap method and by repeating the same analyses at day 2. RESULTS A total of 1,575 subjects were included, of whom 65 (4.1%) developed ARDS. The ΔP was independently associated with ARDS (odds ratio [OR] 1.12, 95% CI 1.07-1.18 for each cm H2O of ΔP increase, P < .001). The same results were observed at day 2 (OR 1.14, 95% CI 1.07-1.21; P < .001) and after bootstrap validation (OR 1.13, 95% CI 1.04-1.22; P < .001). When taking the prevalence of ARDS in the lowest quartile of ΔP (≤9 cm H2O) as a reference, the subjects with ΔP > 12-15 cm H2O and those with ΔP > 15 cm H2O presented a higher probability of ARDS (OR 3.65, 95% CI 1.32-10.04 [P = .01] and OR 7.31, 95% CI, 2.89-18.50 [P < .001], respectively). CONCLUSIONS In the subjects without ARDS, a higher level of ΔP on the first day of mechanical ventilation was associated with later development of ARDS. (ClinicalTrials.gov registration NCT02731898.).
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Affiliation(s)
- Oriol Roca
- Servei de Medicina Intensiva, Hospital Universitari Vall d'Hebron, Institut de Recerca Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain.
- Ciber Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
| | - Oscar Peñuelas
- Ciber Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
- Hospital Universitario de Getafe, Madrid, Spain
| | - Alfonso Muriel
- Unidad de Bioestadística Clínica Hospital Ramón y Cajal, Instituto Ramón y Cajal de Investigaciones Sanitarias & Centro de Investigación en Red de Epidemiología y Salud Pública
| | - Marina García-de-Acilu
- Servei de Medicina Intensiva, Hospital Universitari Vall d'Hebron, Institut de Recerca Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - César Laborda
- Servei de Medicina Intensiva, Hospital Universitari Vall d'Hebron, Institut de Recerca Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Judit Sacanell
- Servei de Medicina Intensiva, Hospital Universitari Vall d'Hebron, Institut de Recerca Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Jordi Riera
- Servei de Medicina Intensiva, Hospital Universitari Vall d'Hebron, Institut de Recerca Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
- Ciber Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
| | | | - Bin Du
- Peking Union Medical College Hospital, Beijing, People's Republic of China
| | | | - Fernando Ríos
- Hospital Nacional Alejandro Posadas, Buenos Aires, Argentina
| | - Marco González
- Clínica Medellín & Universidad Pontificia Bolivariana, Medellín, Colombia
| | - Lorenzo Del-Sorbo
- Interdepartmental Division of Critical Care Medicine, Toronto, Ontario, Canada
| | - Maria Del Carmen Marín
- Hospital Regional 1° de Octubre, Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado, México DF, México
| | | | | | - Nicolas Nin
- Hospital Universitario de Montevideo, Uruguay
| | - Salvatore M Maggiore
- Department of Anesthesiology, Critical Care Medicine and Emergency, SS. Annunziata Hospital, Chieti, Italy and University and Department of Innovative Technologies in Medicine and Dentistry, Gabriele d'Annunzio University of Chieti-Pescara, Chieti, Italy
| | - Andrew Bersten
- Department of Critical Care Medicine, Flinders University, Adelaide, South Australia, Australia
| | - Pravin Amin
- Bombay Hospital Institute of Medical Sciences, Mumbai, India
| | | | - Gee Young Suh
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | | | - Manuel Jibaja
- Hospital de Especialidades Eugenio Espejo, Ecuador and Escuela de Medicina de la Universidad Internacional, Ecuador
| | | | - Amine Ali Zeggwagh
- Centre Hospitalier Universitarie Ibn Sina - Mohammed V University, Rabat, Morocco
| | - Yuda Sutherasan
- Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Antonio Anzueto
- South Texas Veterans Health Care System and University of Texas Health Science Center, San Antonio, Texas
| | - Andrés Esteban
- Ciber Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
- Hospital Universitario de Getafe, Madrid, Spain
| | - Fernando Frutos-Vivar
- Ciber Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
- Hospital Universitario de Getafe, Madrid, Spain
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21
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Maselli DJ, Yen A, Wang W, Okajima Y, Dolliver WR, Mercugliano C, Anzueto A, Restrepo MI, Aksamit TR, Basavaraj A, Aliberti S, Young KA, Kinney GL, Wells JM, San José Estépar R, Lynch DA, Diaz AA. Small Airway Disease and Emphysema Are Associated with Future Exacerbations in Smokers with CT-derived Bronchiectasis and COPD: Results from the COPDGene Cohort. Radiology 2021; 300:706-714. [PMID: 34156303 DOI: 10.1148/radiol.2021204052] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background Chronic obstructive pulmonary disease (COPD) and bronchiectasis can overlap and share pathologic features, such as small airway disease (SAD). Whether the presence of SAD and emphysema in smokers with CT-derived bronchiectasis is associated with exacerbations is unknown. Purpose To assess whether SAD and emphysema in smokers with CT-derived bronchiectasis are associated with future exacerbations. Materials and Methods SAD and emphysema were quantified using the parametric response map method in former and current heavy smokers with and without bronchiectasis at CT from the COPDGene Study (from July 2009 to July 2018). Exacerbations were prospectively assessed through biannual follow-up. An exacerbation was defined as an increase in or new onset of respiratory symptoms treated with antibiotics and/or corticosteroids. Severe exacerbations were defined as those that required hospitalization. The association of a high burden of SAD (≥15.6%) and high burden of emphysema (≥5%) at CT with exacerbations was assessed with generalized linear mixed models. Results Of 737 participants, 387 (median age, 64 years [interquartile range, 58-71 years]; 223 women) had CT-derived bronchiectasis. During a 9-year follow-up, after adjustment for age, sex, race, body mass index, current smoking status, pack-years, exacerbations before study entry, forced expiratory volume in 1 second, or FEV1, and bronchiectasis severity CT score, high burden of SAD and high burden of emphysema were associated with a higher number of exacerbations per year (relative risk [RR], 1.89 [95% CI: 1.54, 2.33] and 1.37 [95% CI: 1.13, 1.66], respectively; P ≤ .001 for both). Results were comparable among participants with bronchiectasis meeting criteria for COPD (n = 197) (RR, 1.67 [95% CI: 1.23, 2.27] for high burden of SAD and 1.51 [95% CI: 1.20, 1.91] for high burden of emphysema; P ≤ .001 for both). Conclusion In smokers with CT-derived bronchiectasis and chronic obstructive pulmonary disease, structural damage to lung parenchyma and small airways was associated with a higher number of exacerbations per year. Clinical trial registration no. NCT00608764 © RSNA, 2021.
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Affiliation(s)
- Diego Jose Maselli
- From the Division of Pulmonary Diseases and Critical Care, the University of Texas Health Science Center at San Antonio, San Antonio, Tex (D.J.M., A.A., M.I.R.); Department of Radiology, University of California, San Diego, Calif (A.Y.); Division of Sleep Medicine and Circadian Disorders (W.W.), Division of Pulmonary and Critical Care Medicine, Department of Medicine (W.R.D., A.A.D.), and Department of Radiology (R.S.J.E.), Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115; Department of Radiology, St. Luke's International Hospital, Chuo-ku, Tokyo, Japan (Y.O.); Quinnipiac University School of Medicine, Hamden, Conn (C.M.); South Texas Veterans Health Care System, San Antonio, Tex (A.A., M.I.R.); Pulmonary Disease and Critical Care Medicine, Mayo Clinic, Rochester, Minn (T.R.A.); Division of Pulmonary, Critical Care & Sleep Medicine, New York University School of Medicine, New York, NY (A.B.); Department of Pathophysiology and Transplantation, University of Milan Internal Medicine, and Respiratory Unit and Cystic Fibrosis Adult Center, Milan, Italy (S.A.); Department of Epidemiology, Colorado School of Public Health, University of Colorado, Aurora, Colo (K.A.Y., G.L.K.); Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, Ala (J.M.W.); and Department of Radiology, National Jewish Health, Denver, Colo (D.A.L.)
| | - Andrew Yen
- From the Division of Pulmonary Diseases and Critical Care, the University of Texas Health Science Center at San Antonio, San Antonio, Tex (D.J.M., A.A., M.I.R.); Department of Radiology, University of California, San Diego, Calif (A.Y.); Division of Sleep Medicine and Circadian Disorders (W.W.), Division of Pulmonary and Critical Care Medicine, Department of Medicine (W.R.D., A.A.D.), and Department of Radiology (R.S.J.E.), Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115; Department of Radiology, St. Luke's International Hospital, Chuo-ku, Tokyo, Japan (Y.O.); Quinnipiac University School of Medicine, Hamden, Conn (C.M.); South Texas Veterans Health Care System, San Antonio, Tex (A.A., M.I.R.); Pulmonary Disease and Critical Care Medicine, Mayo Clinic, Rochester, Minn (T.R.A.); Division of Pulmonary, Critical Care & Sleep Medicine, New York University School of Medicine, New York, NY (A.B.); Department of Pathophysiology and Transplantation, University of Milan Internal Medicine, and Respiratory Unit and Cystic Fibrosis Adult Center, Milan, Italy (S.A.); Department of Epidemiology, Colorado School of Public Health, University of Colorado, Aurora, Colo (K.A.Y., G.L.K.); Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, Ala (J.M.W.); and Department of Radiology, National Jewish Health, Denver, Colo (D.A.L.)
| | - Wei Wang
- From the Division of Pulmonary Diseases and Critical Care, the University of Texas Health Science Center at San Antonio, San Antonio, Tex (D.J.M., A.A., M.I.R.); Department of Radiology, University of California, San Diego, Calif (A.Y.); Division of Sleep Medicine and Circadian Disorders (W.W.), Division of Pulmonary and Critical Care Medicine, Department of Medicine (W.R.D., A.A.D.), and Department of Radiology (R.S.J.E.), Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115; Department of Radiology, St. Luke's International Hospital, Chuo-ku, Tokyo, Japan (Y.O.); Quinnipiac University School of Medicine, Hamden, Conn (C.M.); South Texas Veterans Health Care System, San Antonio, Tex (A.A., M.I.R.); Pulmonary Disease and Critical Care Medicine, Mayo Clinic, Rochester, Minn (T.R.A.); Division of Pulmonary, Critical Care & Sleep Medicine, New York University School of Medicine, New York, NY (A.B.); Department of Pathophysiology and Transplantation, University of Milan Internal Medicine, and Respiratory Unit and Cystic Fibrosis Adult Center, Milan, Italy (S.A.); Department of Epidemiology, Colorado School of Public Health, University of Colorado, Aurora, Colo (K.A.Y., G.L.K.); Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, Ala (J.M.W.); and Department of Radiology, National Jewish Health, Denver, Colo (D.A.L.)
| | - Yuka Okajima
- From the Division of Pulmonary Diseases and Critical Care, the University of Texas Health Science Center at San Antonio, San Antonio, Tex (D.J.M., A.A., M.I.R.); Department of Radiology, University of California, San Diego, Calif (A.Y.); Division of Sleep Medicine and Circadian Disorders (W.W.), Division of Pulmonary and Critical Care Medicine, Department of Medicine (W.R.D., A.A.D.), and Department of Radiology (R.S.J.E.), Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115; Department of Radiology, St. Luke's International Hospital, Chuo-ku, Tokyo, Japan (Y.O.); Quinnipiac University School of Medicine, Hamden, Conn (C.M.); South Texas Veterans Health Care System, San Antonio, Tex (A.A., M.I.R.); Pulmonary Disease and Critical Care Medicine, Mayo Clinic, Rochester, Minn (T.R.A.); Division of Pulmonary, Critical Care & Sleep Medicine, New York University School of Medicine, New York, NY (A.B.); Department of Pathophysiology and Transplantation, University of Milan Internal Medicine, and Respiratory Unit and Cystic Fibrosis Adult Center, Milan, Italy (S.A.); Department of Epidemiology, Colorado School of Public Health, University of Colorado, Aurora, Colo (K.A.Y., G.L.K.); Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, Ala (J.M.W.); and Department of Radiology, National Jewish Health, Denver, Colo (D.A.L.)
| | - Wojciech R Dolliver
- From the Division of Pulmonary Diseases and Critical Care, the University of Texas Health Science Center at San Antonio, San Antonio, Tex (D.J.M., A.A., M.I.R.); Department of Radiology, University of California, San Diego, Calif (A.Y.); Division of Sleep Medicine and Circadian Disorders (W.W.), Division of Pulmonary and Critical Care Medicine, Department of Medicine (W.R.D., A.A.D.), and Department of Radiology (R.S.J.E.), Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115; Department of Radiology, St. Luke's International Hospital, Chuo-ku, Tokyo, Japan (Y.O.); Quinnipiac University School of Medicine, Hamden, Conn (C.M.); South Texas Veterans Health Care System, San Antonio, Tex (A.A., M.I.R.); Pulmonary Disease and Critical Care Medicine, Mayo Clinic, Rochester, Minn (T.R.A.); Division of Pulmonary, Critical Care & Sleep Medicine, New York University School of Medicine, New York, NY (A.B.); Department of Pathophysiology and Transplantation, University of Milan Internal Medicine, and Respiratory Unit and Cystic Fibrosis Adult Center, Milan, Italy (S.A.); Department of Epidemiology, Colorado School of Public Health, University of Colorado, Aurora, Colo (K.A.Y., G.L.K.); Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, Ala (J.M.W.); and Department of Radiology, National Jewish Health, Denver, Colo (D.A.L.)
| | - Christina Mercugliano
- From the Division of Pulmonary Diseases and Critical Care, the University of Texas Health Science Center at San Antonio, San Antonio, Tex (D.J.M., A.A., M.I.R.); Department of Radiology, University of California, San Diego, Calif (A.Y.); Division of Sleep Medicine and Circadian Disorders (W.W.), Division of Pulmonary and Critical Care Medicine, Department of Medicine (W.R.D., A.A.D.), and Department of Radiology (R.S.J.E.), Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115; Department of Radiology, St. Luke's International Hospital, Chuo-ku, Tokyo, Japan (Y.O.); Quinnipiac University School of Medicine, Hamden, Conn (C.M.); South Texas Veterans Health Care System, San Antonio, Tex (A.A., M.I.R.); Pulmonary Disease and Critical Care Medicine, Mayo Clinic, Rochester, Minn (T.R.A.); Division of Pulmonary, Critical Care & Sleep Medicine, New York University School of Medicine, New York, NY (A.B.); Department of Pathophysiology and Transplantation, University of Milan Internal Medicine, and Respiratory Unit and Cystic Fibrosis Adult Center, Milan, Italy (S.A.); Department of Epidemiology, Colorado School of Public Health, University of Colorado, Aurora, Colo (K.A.Y., G.L.K.); Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, Ala (J.M.W.); and Department of Radiology, National Jewish Health, Denver, Colo (D.A.L.)
| | - Antonio Anzueto
- From the Division of Pulmonary Diseases and Critical Care, the University of Texas Health Science Center at San Antonio, San Antonio, Tex (D.J.M., A.A., M.I.R.); Department of Radiology, University of California, San Diego, Calif (A.Y.); Division of Sleep Medicine and Circadian Disorders (W.W.), Division of Pulmonary and Critical Care Medicine, Department of Medicine (W.R.D., A.A.D.), and Department of Radiology (R.S.J.E.), Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115; Department of Radiology, St. Luke's International Hospital, Chuo-ku, Tokyo, Japan (Y.O.); Quinnipiac University School of Medicine, Hamden, Conn (C.M.); South Texas Veterans Health Care System, San Antonio, Tex (A.A., M.I.R.); Pulmonary Disease and Critical Care Medicine, Mayo Clinic, Rochester, Minn (T.R.A.); Division of Pulmonary, Critical Care & Sleep Medicine, New York University School of Medicine, New York, NY (A.B.); Department of Pathophysiology and Transplantation, University of Milan Internal Medicine, and Respiratory Unit and Cystic Fibrosis Adult Center, Milan, Italy (S.A.); Department of Epidemiology, Colorado School of Public Health, University of Colorado, Aurora, Colo (K.A.Y., G.L.K.); Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, Ala (J.M.W.); and Department of Radiology, National Jewish Health, Denver, Colo (D.A.L.)
| | - Marcos I Restrepo
- From the Division of Pulmonary Diseases and Critical Care, the University of Texas Health Science Center at San Antonio, San Antonio, Tex (D.J.M., A.A., M.I.R.); Department of Radiology, University of California, San Diego, Calif (A.Y.); Division of Sleep Medicine and Circadian Disorders (W.W.), Division of Pulmonary and Critical Care Medicine, Department of Medicine (W.R.D., A.A.D.), and Department of Radiology (R.S.J.E.), Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115; Department of Radiology, St. Luke's International Hospital, Chuo-ku, Tokyo, Japan (Y.O.); Quinnipiac University School of Medicine, Hamden, Conn (C.M.); South Texas Veterans Health Care System, San Antonio, Tex (A.A., M.I.R.); Pulmonary Disease and Critical Care Medicine, Mayo Clinic, Rochester, Minn (T.R.A.); Division of Pulmonary, Critical Care & Sleep Medicine, New York University School of Medicine, New York, NY (A.B.); Department of Pathophysiology and Transplantation, University of Milan Internal Medicine, and Respiratory Unit and Cystic Fibrosis Adult Center, Milan, Italy (S.A.); Department of Epidemiology, Colorado School of Public Health, University of Colorado, Aurora, Colo (K.A.Y., G.L.K.); Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, Ala (J.M.W.); and Department of Radiology, National Jewish Health, Denver, Colo (D.A.L.)
| | - Timothy R Aksamit
- From the Division of Pulmonary Diseases and Critical Care, the University of Texas Health Science Center at San Antonio, San Antonio, Tex (D.J.M., A.A., M.I.R.); Department of Radiology, University of California, San Diego, Calif (A.Y.); Division of Sleep Medicine and Circadian Disorders (W.W.), Division of Pulmonary and Critical Care Medicine, Department of Medicine (W.R.D., A.A.D.), and Department of Radiology (R.S.J.E.), Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115; Department of Radiology, St. Luke's International Hospital, Chuo-ku, Tokyo, Japan (Y.O.); Quinnipiac University School of Medicine, Hamden, Conn (C.M.); South Texas Veterans Health Care System, San Antonio, Tex (A.A., M.I.R.); Pulmonary Disease and Critical Care Medicine, Mayo Clinic, Rochester, Minn (T.R.A.); Division of Pulmonary, Critical Care & Sleep Medicine, New York University School of Medicine, New York, NY (A.B.); Department of Pathophysiology and Transplantation, University of Milan Internal Medicine, and Respiratory Unit and Cystic Fibrosis Adult Center, Milan, Italy (S.A.); Department of Epidemiology, Colorado School of Public Health, University of Colorado, Aurora, Colo (K.A.Y., G.L.K.); Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, Ala (J.M.W.); and Department of Radiology, National Jewish Health, Denver, Colo (D.A.L.)
| | - Ashwin Basavaraj
- From the Division of Pulmonary Diseases and Critical Care, the University of Texas Health Science Center at San Antonio, San Antonio, Tex (D.J.M., A.A., M.I.R.); Department of Radiology, University of California, San Diego, Calif (A.Y.); Division of Sleep Medicine and Circadian Disorders (W.W.), Division of Pulmonary and Critical Care Medicine, Department of Medicine (W.R.D., A.A.D.), and Department of Radiology (R.S.J.E.), Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115; Department of Radiology, St. Luke's International Hospital, Chuo-ku, Tokyo, Japan (Y.O.); Quinnipiac University School of Medicine, Hamden, Conn (C.M.); South Texas Veterans Health Care System, San Antonio, Tex (A.A., M.I.R.); Pulmonary Disease and Critical Care Medicine, Mayo Clinic, Rochester, Minn (T.R.A.); Division of Pulmonary, Critical Care & Sleep Medicine, New York University School of Medicine, New York, NY (A.B.); Department of Pathophysiology and Transplantation, University of Milan Internal Medicine, and Respiratory Unit and Cystic Fibrosis Adult Center, Milan, Italy (S.A.); Department of Epidemiology, Colorado School of Public Health, University of Colorado, Aurora, Colo (K.A.Y., G.L.K.); Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, Ala (J.M.W.); and Department of Radiology, National Jewish Health, Denver, Colo (D.A.L.)
| | - Stefano Aliberti
- From the Division of Pulmonary Diseases and Critical Care, the University of Texas Health Science Center at San Antonio, San Antonio, Tex (D.J.M., A.A., M.I.R.); Department of Radiology, University of California, San Diego, Calif (A.Y.); Division of Sleep Medicine and Circadian Disorders (W.W.), Division of Pulmonary and Critical Care Medicine, Department of Medicine (W.R.D., A.A.D.), and Department of Radiology (R.S.J.E.), Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115; Department of Radiology, St. Luke's International Hospital, Chuo-ku, Tokyo, Japan (Y.O.); Quinnipiac University School of Medicine, Hamden, Conn (C.M.); South Texas Veterans Health Care System, San Antonio, Tex (A.A., M.I.R.); Pulmonary Disease and Critical Care Medicine, Mayo Clinic, Rochester, Minn (T.R.A.); Division of Pulmonary, Critical Care & Sleep Medicine, New York University School of Medicine, New York, NY (A.B.); Department of Pathophysiology and Transplantation, University of Milan Internal Medicine, and Respiratory Unit and Cystic Fibrosis Adult Center, Milan, Italy (S.A.); Department of Epidemiology, Colorado School of Public Health, University of Colorado, Aurora, Colo (K.A.Y., G.L.K.); Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, Ala (J.M.W.); and Department of Radiology, National Jewish Health, Denver, Colo (D.A.L.)
| | - Kendra A Young
- From the Division of Pulmonary Diseases and Critical Care, the University of Texas Health Science Center at San Antonio, San Antonio, Tex (D.J.M., A.A., M.I.R.); Department of Radiology, University of California, San Diego, Calif (A.Y.); Division of Sleep Medicine and Circadian Disorders (W.W.), Division of Pulmonary and Critical Care Medicine, Department of Medicine (W.R.D., A.A.D.), and Department of Radiology (R.S.J.E.), Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115; Department of Radiology, St. Luke's International Hospital, Chuo-ku, Tokyo, Japan (Y.O.); Quinnipiac University School of Medicine, Hamden, Conn (C.M.); South Texas Veterans Health Care System, San Antonio, Tex (A.A., M.I.R.); Pulmonary Disease and Critical Care Medicine, Mayo Clinic, Rochester, Minn (T.R.A.); Division of Pulmonary, Critical Care & Sleep Medicine, New York University School of Medicine, New York, NY (A.B.); Department of Pathophysiology and Transplantation, University of Milan Internal Medicine, and Respiratory Unit and Cystic Fibrosis Adult Center, Milan, Italy (S.A.); Department of Epidemiology, Colorado School of Public Health, University of Colorado, Aurora, Colo (K.A.Y., G.L.K.); Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, Ala (J.M.W.); and Department of Radiology, National Jewish Health, Denver, Colo (D.A.L.)
| | - Gregory L Kinney
- From the Division of Pulmonary Diseases and Critical Care, the University of Texas Health Science Center at San Antonio, San Antonio, Tex (D.J.M., A.A., M.I.R.); Department of Radiology, University of California, San Diego, Calif (A.Y.); Division of Sleep Medicine and Circadian Disorders (W.W.), Division of Pulmonary and Critical Care Medicine, Department of Medicine (W.R.D., A.A.D.), and Department of Radiology (R.S.J.E.), Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115; Department of Radiology, St. Luke's International Hospital, Chuo-ku, Tokyo, Japan (Y.O.); Quinnipiac University School of Medicine, Hamden, Conn (C.M.); South Texas Veterans Health Care System, San Antonio, Tex (A.A., M.I.R.); Pulmonary Disease and Critical Care Medicine, Mayo Clinic, Rochester, Minn (T.R.A.); Division of Pulmonary, Critical Care & Sleep Medicine, New York University School of Medicine, New York, NY (A.B.); Department of Pathophysiology and Transplantation, University of Milan Internal Medicine, and Respiratory Unit and Cystic Fibrosis Adult Center, Milan, Italy (S.A.); Department of Epidemiology, Colorado School of Public Health, University of Colorado, Aurora, Colo (K.A.Y., G.L.K.); Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, Ala (J.M.W.); and Department of Radiology, National Jewish Health, Denver, Colo (D.A.L.)
| | - J Michael Wells
- From the Division of Pulmonary Diseases and Critical Care, the University of Texas Health Science Center at San Antonio, San Antonio, Tex (D.J.M., A.A., M.I.R.); Department of Radiology, University of California, San Diego, Calif (A.Y.); Division of Sleep Medicine and Circadian Disorders (W.W.), Division of Pulmonary and Critical Care Medicine, Department of Medicine (W.R.D., A.A.D.), and Department of Radiology (R.S.J.E.), Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115; Department of Radiology, St. Luke's International Hospital, Chuo-ku, Tokyo, Japan (Y.O.); Quinnipiac University School of Medicine, Hamden, Conn (C.M.); South Texas Veterans Health Care System, San Antonio, Tex (A.A., M.I.R.); Pulmonary Disease and Critical Care Medicine, Mayo Clinic, Rochester, Minn (T.R.A.); Division of Pulmonary, Critical Care & Sleep Medicine, New York University School of Medicine, New York, NY (A.B.); Department of Pathophysiology and Transplantation, University of Milan Internal Medicine, and Respiratory Unit and Cystic Fibrosis Adult Center, Milan, Italy (S.A.); Department of Epidemiology, Colorado School of Public Health, University of Colorado, Aurora, Colo (K.A.Y., G.L.K.); Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, Ala (J.M.W.); and Department of Radiology, National Jewish Health, Denver, Colo (D.A.L.)
| | - Raúl San José Estépar
- From the Division of Pulmonary Diseases and Critical Care, the University of Texas Health Science Center at San Antonio, San Antonio, Tex (D.J.M., A.A., M.I.R.); Department of Radiology, University of California, San Diego, Calif (A.Y.); Division of Sleep Medicine and Circadian Disorders (W.W.), Division of Pulmonary and Critical Care Medicine, Department of Medicine (W.R.D., A.A.D.), and Department of Radiology (R.S.J.E.), Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115; Department of Radiology, St. Luke's International Hospital, Chuo-ku, Tokyo, Japan (Y.O.); Quinnipiac University School of Medicine, Hamden, Conn (C.M.); South Texas Veterans Health Care System, San Antonio, Tex (A.A., M.I.R.); Pulmonary Disease and Critical Care Medicine, Mayo Clinic, Rochester, Minn (T.R.A.); Division of Pulmonary, Critical Care & Sleep Medicine, New York University School of Medicine, New York, NY (A.B.); Department of Pathophysiology and Transplantation, University of Milan Internal Medicine, and Respiratory Unit and Cystic Fibrosis Adult Center, Milan, Italy (S.A.); Department of Epidemiology, Colorado School of Public Health, University of Colorado, Aurora, Colo (K.A.Y., G.L.K.); Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, Ala (J.M.W.); and Department of Radiology, National Jewish Health, Denver, Colo (D.A.L.)
| | - David A Lynch
- From the Division of Pulmonary Diseases and Critical Care, the University of Texas Health Science Center at San Antonio, San Antonio, Tex (D.J.M., A.A., M.I.R.); Department of Radiology, University of California, San Diego, Calif (A.Y.); Division of Sleep Medicine and Circadian Disorders (W.W.), Division of Pulmonary and Critical Care Medicine, Department of Medicine (W.R.D., A.A.D.), and Department of Radiology (R.S.J.E.), Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115; Department of Radiology, St. Luke's International Hospital, Chuo-ku, Tokyo, Japan (Y.O.); Quinnipiac University School of Medicine, Hamden, Conn (C.M.); South Texas Veterans Health Care System, San Antonio, Tex (A.A., M.I.R.); Pulmonary Disease and Critical Care Medicine, Mayo Clinic, Rochester, Minn (T.R.A.); Division of Pulmonary, Critical Care & Sleep Medicine, New York University School of Medicine, New York, NY (A.B.); Department of Pathophysiology and Transplantation, University of Milan Internal Medicine, and Respiratory Unit and Cystic Fibrosis Adult Center, Milan, Italy (S.A.); Department of Epidemiology, Colorado School of Public Health, University of Colorado, Aurora, Colo (K.A.Y., G.L.K.); Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, Ala (J.M.W.); and Department of Radiology, National Jewish Health, Denver, Colo (D.A.L.)
| | - Alejandro A Diaz
- From the Division of Pulmonary Diseases and Critical Care, the University of Texas Health Science Center at San Antonio, San Antonio, Tex (D.J.M., A.A., M.I.R.); Department of Radiology, University of California, San Diego, Calif (A.Y.); Division of Sleep Medicine and Circadian Disorders (W.W.), Division of Pulmonary and Critical Care Medicine, Department of Medicine (W.R.D., A.A.D.), and Department of Radiology (R.S.J.E.), Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115; Department of Radiology, St. Luke's International Hospital, Chuo-ku, Tokyo, Japan (Y.O.); Quinnipiac University School of Medicine, Hamden, Conn (C.M.); South Texas Veterans Health Care System, San Antonio, Tex (A.A., M.I.R.); Pulmonary Disease and Critical Care Medicine, Mayo Clinic, Rochester, Minn (T.R.A.); Division of Pulmonary, Critical Care & Sleep Medicine, New York University School of Medicine, New York, NY (A.B.); Department of Pathophysiology and Transplantation, University of Milan Internal Medicine, and Respiratory Unit and Cystic Fibrosis Adult Center, Milan, Italy (S.A.); Department of Epidemiology, Colorado School of Public Health, University of Colorado, Aurora, Colo (K.A.Y., G.L.K.); Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, Ala (J.M.W.); and Department of Radiology, National Jewish Health, Denver, Colo (D.A.L.)
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Mekov E, Nuñez A, Sin DD, Ichinose M, Rhee CK, Maselli DJ, Coté A, Suppli Ulrik C, Maltais F, Anzueto A, Miravitlles M. Update on Asthma-COPD Overlap (ACO): A Narrative Review. Int J Chron Obstruct Pulmon Dis 2021; 16:1783-1799. [PMID: 34168440 PMCID: PMC8216660 DOI: 10.2147/copd.s312560] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 05/20/2021] [Indexed: 12/14/2022] Open
Abstract
Although chronic obstructive pulmonary disease (COPD) and asthma are well-characterized diseases, they can coexist in a given patient. The term asthma-COPD overlap (ACO) was introduced to describe patients that have clinical features of both diseases and may represent around 25% of COPD patients and around 20% of asthma patients. Despite the increasing interest in ACO, there are still substantial controversies regarding its definition and its position within clinical guidelines for patients with obstructive lung disease. In general, most definitions indicate that ACO patients must present with non-reversible airflow limitation, significant exposure to smoking or other noxious particles or gases, together with features of asthma. In patients with a primary diagnosis of COPD, the identification of ACO has therapeutic implication because the asthmatic component should be treated with inhaled corticosteroids and some studies suggest that the most severe patients may respond to biological agents indicated for severe asthma. This manuscript aims to summarize the current state-of-the-art of ACO. The definitions, prevalence, and clinical manifestations will be reviewed and some innovative aspects, such as genetics, epigenetics, and biomarkers will be addressed. Lastly, the management and prognosis will be outlined as well as the position of ACO in the COPD and asthma guidelines.
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Affiliation(s)
- Evgeni Mekov
- Department of Occupational Diseases, Medical Faculty, Medical University of Sofia, Sofia, Bulgaria
| | - Alexa Nuñez
- Pneumology Department, Hospital Universitari Vall d´Hebron, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Hospital Campus, CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | - Don D Sin
- Centre for Heart Lung Innovation, St. Paul’s Hospital, Department of Medicine (Respiratory Division), University of British Columbia, Vancouver, BC, Canada
| | | | - Chin Kook Rhee
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Diego Jose Maselli
- Division of Pulmonary Diseases & Critical Care, University of Texas Health, South Texas Veterans Health Care System, San Antonio, TX, USA
| | - Andréanne Coté
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, QC, Canada
| | - Charlotte Suppli Ulrik
- Department of Pulmonary Medicine, Copenhagen University Hospital-Hvidovre, Hvidovre, Denmark
- Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - François Maltais
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, QC, Canada
| | - Antonio Anzueto
- Division of Pulmonary Diseases & Critical Care, University of Texas Health, South Texas Veterans Health Care System, San Antonio, TX, USA
| | - Marc Miravitlles
- Pneumology Department, Hospital Universitari Vall d´Hebron, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Hospital Campus, CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
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Frutos-Vivar F, Peñuelas O, Muriel A, Mancebo J, García-Jiménez A, de Pablo R, Valledor M, Ferrer M, León M, Quiroga JM, Temprano S, Vallverdú I, Fernández R, Gordo F, Anzueto A, Esteban A. Mechanical ventilation in Spain, 1998-2016: changes in the disconnection of mechanical ventilation. Med Intensiva 2021; 46:S0210-5691(21)00079-6. [PMID: 34092422 DOI: 10.1016/j.medin.2021.04.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 03/02/2021] [Accepted: 04/15/2021] [Indexed: 12/31/2022]
Abstract
PURPOSE To evaluate changes in the disconnection of mechanical ventilation in Spain from 1998 to 2016. DESIGN Post-hoc analysis of four cohort studies. AMBIT 138 Spanish ICUs. PATIENTS 2141 patients scheduled extubated. INTERVENTIONS None. VARIABLES OF INTEREST Demographics, reason for mechanical ventilation, complications, methods for disconnection, failure on the first attempt at disconnection, duration of weaning, reintubation, post-reintubation tracheotomy, ICU stay and mortality. RESULTS There was a significant increase (p<0.001) in the use of gradual reduction of support pressure. The adjusted probability of using the gradual reduction in pressure support versus a spontaneous breathing trial has increased over time, both for the first attempt at disconnection (taking the 1998 study as a reference: odds ratio 0.99 in 2004, 0.57 in 2010 and 2.43 in 2016) and for difficult/prolonged disconnection (taking the 1998 study as a reference: odds ratio 2.29 in 2004, 1.23 in 2010 and 2.54 in 2016). The proportion of patients extubated after the first attempt at disconnection has increased over time. There is a decrease in the ventilation time dedicated to weaning (from 45% in 1998 to 36% in 2016). However, the duration in difficult/prolonged weaning has not decreased (median 3 days in all studies, p=0.435). CONCLUSIONS There have been significant changes in the mode of disconnection of mechanical ventilation, with a progressive increase in the use of gradual reduction of pressure support. No relevant changes in outcomes have been observed.
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Affiliation(s)
| | - O Peñuelas
- Hospital Universitario de Getafe, Madrid, España
| | - A Muriel
- Unidad de Bioestadística Clínica Hospital Ramón y Cajal, Instituto Ramón y Cajal de Investigaciones Sanitarias (IRYCIS), Centro de Investigación en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, España
| | - J Mancebo
- Hospital Universitari de la Santa Creu i Sant Pau, Barcelona, España
| | | | | | | | - M Ferrer
- Hospital Clinic-IDIBAPS, Barcelona, España
| | - M León
- Hospital Arnau de Vilanova, Lleida, España
| | | | | | - I Vallverdú
- Hospital Universitari San Juan, Reus, España
| | - R Fernández
- Hospital Sant Joan de Déu, Fundació Althaia, Manresa, España
| | - F Gordo
- Grupo de Investigación en Patología Crítica. Universidad Francisco de Vitoria, Pozuelo de Alarcón. Hospital Universitario del Henares, Coslada, España
| | - A Anzueto
- South Texas Veterans Health Care System and University of Texas Health, San Antonio, Texas, Estados Unidos
| | - A Esteban
- Hospital Universitario de Getafe, Madrid, España
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24
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Bansal S, Anderson M, Anzueto A, Brown N, Compton C, Corbridge TC, Erb D, Harvey C, Kaisermann MC, Kaye M, Lipson DA, Martin N, Zhu CQ, Papi A. Single-inhaler fluticasone furoate/umeclidinium/vilanterol (FF/UMEC/VI) triple therapy versus tiotropium monotherapy in patients with COPD. NPJ Prim Care Respir Med 2021; 31:29. [PMID: 34035312 PMCID: PMC8149706 DOI: 10.1038/s41533-021-00241-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 04/19/2021] [Indexed: 11/20/2022] Open
Abstract
Chronic obstructive pulmonary disease (COPD) treatment guidelines do not currently include recommendations for escalation directly from monotherapy to triple therapy. This 12-week, double-blind, double-dummy study randomized 800 symptomatic moderate-to-very-severe COPD patients receiving tiotropium (TIO) for ≥3 months to once-daily fluticasone furoate/umeclidinium/vilanterol (FF/UMEC/VI) 100/62.5/25 mcg via ELLIPTA (n = 400) or TIO 18 mcg via HandiHaler (n = 400) plus matched placebo. Study endpoints included change from baseline in trough forced expiratory volume in 1 s (FEV1) at Days 85 (primary), 28 and 84 (secondary), health status (St George’s Respiratory Questionnaire [SGRQ] and COPD Assessment Test [CAT]) and safety. FF/UMEC/VI significantly improved trough FEV1 at all timepoints (Day 85 treatment difference [95% CI] 95 mL [62–128]; P < 0.001), and significantly improved SGRQ and CAT versus TIO. Treatment safety profiles were similar. Once-daily single-inhaler FF/UMEC/VI significantly improved lung function and health status versus once-daily TIO in symptomatic moderate-to-very-severe COPD patients, with a similar safety profile.
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Affiliation(s)
- Sandeep Bansal
- The Lung Center, Penn Highlands Healthcare, Du Bois, PA, USA
| | | | - Antonio Anzueto
- Division of Pulmonary Diseases and Critical Care Medicine, School of Medicine, The University of Texas Health Science Center, San Antonio, TX, USA.,Audie L. Murphy Memorial VA Hospital, South Texas Veterans Health Care System, San Antonio, TX, USA
| | - Nicola Brown
- GSK, Stockley Park West, Iron Bridge Road North, West Drayton, Uxbridge, Middlesex, UK
| | | | - Thomas C Corbridge
- GSK, Research Triangle Park, NC, USA.,Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - David Erb
- VitaLink Research Gaffney, Gaffney, SC, USA
| | - Catherine Harvey
- GSK, Stockley Park West, Iron Bridge Road North, West Drayton, Uxbridge, Middlesex, UK
| | | | | | - David A Lipson
- GSK, Collegeville, PA, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Neil Martin
- GSK, Brentford, Middlesex, UK.,University of Leicester, Leicester, Leicestershire, UK
| | - Chang-Qing Zhu
- GSK, Stockley Park West, Iron Bridge Road North, West Drayton, Uxbridge, Middlesex, UK
| | - Alberto Papi
- Respiratory Unit, Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, FE, Italy.
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25
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Mamandipoor B, Frutos-Vivar F, Peñuelas O, Rezar R, Raymondos K, Muriel A, Du B, Thille AW, Ríos F, González M, del-Sorbo L, del Carmen Marín M, Pinheiro BV, Soares MA, Nin N, Maggiore SM, Bersten A, Kelm M, Bruno RR, Amin P, Cakar N, Suh GY, Abroug F, Jibaja M, Matamis D, Zeggwagh AA, Sutherasan Y, Anzueto A, Wernly B, Esteban A, Jung C, Osmani V. Machine learning predicts mortality based on analysis of ventilation parameters of critically ill patients: multi-centre validation. BMC Med Inform Decis Mak 2021; 21:152. [PMID: 33962603 PMCID: PMC8102841 DOI: 10.1186/s12911-021-01506-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 04/26/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Mechanical Ventilation (MV) is a complex and central treatment process in the care of critically ill patients. It influences acid-base balance and can also cause prognostically relevant biotrauma by generating forces and liberating reactive oxygen species, negatively affecting outcomes. In this work we evaluate the use of a Recurrent Neural Network (RNN) modelling to predict outcomes of mechanically ventilated patients, using standard mechanical ventilation parameters. METHODS We performed our analysis on VENTILA dataset, an observational, prospective, international, multi-centre study, performed to investigate the effect of baseline characteristics and management changes over time on the all-cause mortality rate in mechanically ventilated patients in ICU. Our cohort includes 12,596 adult patients older than 18, associated with 12,755 distinct admissions in ICUs across 37 countries and receiving invasive and non-invasive mechanical ventilation. We carry out four different analysis. Initially we select typical mechanical ventilation parameters and evaluate the machine learning model on both, the overall cohort and a subgroup of patients admitted with respiratory disorders. Furthermore, we carry out sensitivity analysis to evaluate whether inclusion of variables related to the function of other organs, improve the predictive performance of the model for both the overall cohort as well as the subgroup of patients with respiratory disorders. RESULTS Predictive performance of RNN-based model was higher with Area Under the Receiver Operating Characteristic (ROC) Curve (AUC) of 0.72 (± 0.01) and Average Precision (AP) of 0.57 (± 0.01) in comparison to RF and LR for the overall patient dataset. Higher predictive performance was recorded in the subgroup of patients admitted with respiratory disorders with AUC of 0.75 (± 0.02) and AP of 0.65 (± 0.03). Inclusion of function of other organs further improved the performance to AUC of 0.79 (± 0.01) and AP 0.68 (± 0.02) for the overall patient dataset and AUC of 0.79 (± 0.01) and AP 0.72 (± 0.02) for the subgroup with respiratory disorders. CONCLUSION The RNN-based model demonstrated better performance than RF and LR in patients in mechanical ventilation and its subgroup admitted with respiratory disorders. Clinical studies are needed to evaluate whether it impacts decision-making and patient outcomes. TRIAL REGISTRATION NCT02731898 ( https://clinicaltrials.gov/ct2/show/NCT02731898 ), prospectively registered on April 8, 2016.
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Affiliation(s)
| | - Fernando Frutos-Vivar
- Hospital Universitario de Getafe & Centro de Investigación en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Oscar Peñuelas
- Hospital Universitario de Getafe & Centro de Investigación en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Richard Rezar
- Clinic of Internal Medicine II, Department of Cardiology, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria
| | | | - Alfonso Muriel
- Clinic of Internal Medicine II, Department of Cardiology, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria
- Unidad de Bioestadística Clinica Hospital Ramón y Cajal, Instituto Ramón y Cajal de Investigaciones Sanitarias (IRYCIS) & Centro de Investigación en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Bin Du
- Peking Union Medical College Hospital, Beijing, People’s Republic of China
| | | | - Fernando Ríos
- Hospital Nacional Alejandro Posadas, Buenos Aires, Argentina
| | - Marco González
- Clínica Medellín & Universidad Pontificia Bolivariana, Medellín, Colombia
| | - Lorenzo del-Sorbo
- Interdepartmental Division of Critical Care Medicine, Toronto, ON Canada
| | - Maria del Carmen Marín
- Hospital Regional 1° de Octubre, Instituto de Seguridad Y Servicios Sociales de Los Trabajadores del Estado (ISSSTE), México, DF México
| | - Bruno Valle Pinheiro
- Pulmonary Research Laboratory, Federal University of Juiz de Fora, Juiz de Fora, Brazil
| | | | | | | | - Andrew Bersten
- Department of Critical Care Medicine, Flinders University, Adelaide, South Australia Australia
| | - Malte Kelm
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, University of Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany
| | - Raphael Romano Bruno
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, University of Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany
| | - Pravin Amin
- Bombay Hospital Institute of Medical Sciences, Mumbai, India
| | - Nahit Cakar
- Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Gee Young Suh
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | | | - Manuel Jibaja
- Hospital de Especialidades Eugenio Espejo, Quito, Ecuador
| | | | - Amine Ali Zeggwagh
- Centre Hospitalier Universitarie Ibn Sina - Mohammed V University, Rabat, Morocco
| | - Yuda Sutherasan
- Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Antonio Anzueto
- South Texas Veterans Health Care System and University of Texas Health Science Center, San Antonio, TX USA
| | - Bernhard Wernly
- Clinic of Internal Medicine II, Department of Cardiology, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria
| | - Andrés Esteban
- Hospital Universitario de Getafe & Centro de Investigación en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Christian Jung
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, University of Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany
| | - Venet Osmani
- Fondazione Bruno Kessler Research Institute, Trento, Italy
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26
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Wernly B, Bruno RR, Frutos-Vivar F, Peñuelas O, Rezar R, Raymondos K, Muriel A, Du B, Thille AW, Ríos F, González M, Del-Sorbo L, Marín MDC, Pinheiro BV, Soares MA, Nin N, Maggiore SM, Bersten A, Kelm M, Amin P, Cakar N, Young Suh G, Abroug F, Jibaja M, Matamis D, Zeggwagh AA, Sutherasan Y, Guidet B, De Lange DW, Beil M, Svri S, van Heerden V, Flaatten H, Anzueto A, Osmani V, Esteban A, Jung C. Propensity-Adjusted Comparison of Mortality of Elderly Versus Very Elderly Ventilated Patients. Respir Care 2021; 66:814-821. [PMID: 33653910 PMCID: PMC9994107 DOI: 10.4187/respcare.08547] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The growing proportion of elderly intensive care patients constitutes a public health challenge. The benefit of critical care in these patients remains unclear. We compared outcomes in elderly versus very elderly subjects receiving mechanical ventilation. METHODS In total, 5,557 mechanically ventilated subjects were included in our post hoc retrospective analysis, a subgroup of the VENTILA study. We divided the cohort into 2 subgroups on the basis of age: very elderly subjects (age ≥ 80 y; n = 1,430), and elderly subjects (age 65-79 y; n = 4,127). A propensity score on being very elderly was calculated. Evaluation of associations with 28-d mortality was done with logistic regression analysis. RESULTS Very elderly subjects were clinically sicker as expressed by higher SAPS II scores (53 ± 18 vs 50 ± 18, P < .001), and their rates of plateau pressure < 30 cm H2O were higher, whereas other parameters did not differ. The 28-d mortality was higher in very elderly subjects (42% vs 34%, P < .001) and remained unchanged after propensity score adjustment (adjusted odds ratio 1.31 [95% CI 1.16-1.49], P < .001). CONCLUSIONS Age was an independent and unchangeable risk factor for death in mechanically ventilated subjects. However, survival rates of very elderly subjects were > 50%. Denial of critical care based solely on age is not justified. (ClinicalTrials.gov registration NCT02731898.).
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Affiliation(s)
- Bernhard Wernly
- Clinic of Internal Medicine II, Department of Cardiology, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Raphael Romano Bruno
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, University of Düsseldorf, Düsseldorf, Germany
| | - Fernando Frutos-Vivar
- Hospital Universitario de Getafe & Centro de Investigación en Red de Enfermedades Respiratorias, Getafe, Spain
| | | | - Richard Rezar
- Clinic of Internal Medicine II, Department of Cardiology, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | | | - Alfonso Muriel
- Hospital Universitario de Getafe & Centro de Investigación en Red de Enfermedades Respiratorias, Getafe, Spain
- Unidad de Bioestadística, Clinica Hospital Ramón y Cajal, Instituto Ramón y Cajal de Investigaciones Sanitarias & Centro de Investigación en Red de Opidemiología y Salud Pública, Madrid, Spain
| | - Bin Du
- Peking Union Medical College Hospital, Beijing, People's Republic of China
| | | | - Fernando Ríos
- Hospital Nacional Alejandro Posadas, Buenos Aires, Argentina
| | - Marco González
- Clínica Medellín & Universidad Pontificia Bolivariana, Medellín, Colombia
| | - Lorenzo Del-Sorbo
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Maria Del Carmen Marín
- Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado, Hospital Regional 1 de Octubre, México City, México
| | - Bruno Valle Pinheiro
- Pulmonary Research Laboratory, Federal University of Juiz de Fora, Juiz de Fora, Brazil
| | | | - Nicolas Nin
- Hospital Universitario de Montevideo, Montevideo, Uruguay
| | | | - Andrew Bersten
- Department of Critical Care Medicine, Flinders University, Adelaide, South Australia, Australia
| | - Malte Kelm
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, University of Düsseldorf, Düsseldorf, Germany
| | - Pravin Amin
- Bombay Hospital Institute of Medical Sciences, Mumbai, India
| | - Nahit Cakar
- Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Gee Young Suh
- Center for Clinical Epidemiology, Samsung Medical Center, Seoul, Republic of Korea
| | | | - Manuel Jibaja
- Hospital de Especialidades Eugenio Espejo, Quito, Ecuador
| | | | - Amine Ali Zeggwagh
- Centre Hospitalier Universitarie, Ibn Sina - Mohammed V University, Rabat, Morocco
| | - Yuda Sutherasan
- Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Bertrand Guidet
- Hôpitaux de Paris, Hôpital Saint-Antoine, service de réanimation médicale, Sorbonne Universités, Paris, France
| | - Dylan W De Lange
- Department of Intensive Care Medicine, University Medical Center, University Utrecht, Utrecht, The Netherlands
| | - Michael Beil
- Medical Intensive Care Unit, Hadassah University Hospital, Jerusalem, Israel
| | - Sigal Svri
- Medical Intensive Care Unit, Hadassah University Hospital, Jerusalem, Israel
| | - Vernon van Heerden
- Medical Intensive Care Unit, Hadassah University Hospital, Jerusalem, Israel
| | - Hans Flaatten
- Department of Anesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway
| | - Antonio Anzueto
- South Texas Veterans Health Care System and University of Texas Health Science Center, San Antonio, Texas
| | - Venet Osmani
- Fondazione Bruno Kessler Research Institute, Trento, Italy
| | - Andrés Esteban
- Hospital Universitario de Getafe & Centro de Investigación en Red de Enfermedades Respiratorias, Getafe, Spain
| | - Christian Jung
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, University of Düsseldorf, Düsseldorf, Germany.
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27
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Hughes CG, Mailloux PT, Devlin JW, Swan JT, Sanders RD, Anzueto A, Jackson JC, Hoskins AS, Pun BT, Orun OM, Raman R, Stollings JL, Kiehl AL, Duprey MS, Bui LN, O'Neal HR, Snyder A, Gropper MA, Guntupalli KK, Stashenko GJ, Patel MB, Brummel NE, Girard TD, Dittus RS, Bernard GR, Ely EW, Pandharipande PP. Dexmedetomidine or Propofol for Sedation in Mechanically Ventilated Adults with Sepsis. N Engl J Med 2021; 384:1424-1436. [PMID: 33528922 PMCID: PMC8162695 DOI: 10.1056/nejmoa2024922] [Citation(s) in RCA: 107] [Impact Index Per Article: 35.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Guidelines currently recommend targeting light sedation with dexmedetomidine or propofol for adults receiving mechanical ventilation. Differences exist between these sedatives in arousability, immunity, and inflammation. Whether they affect outcomes differentially in mechanically ventilated adults with sepsis undergoing light sedation is unknown. METHODS In a multicenter, double-blind trial, we randomly assigned mechanically ventilated adults with sepsis to receive dexmedetomidine (0.2 to 1.5 μg per kilogram of body weight per hour) or propofol (5 to 50 μg per kilogram per minute), with doses adjusted by bedside nurses to achieve target sedation goals set by clinicians according to the Richmond Agitation-Sedation Scale (RASS, on which scores range from -5 [unresponsive] to +4 [combative]). The primary end point was days alive without delirium or coma during the 14-day intervention period. Secondary end points were ventilator-free days at 28 days, death at 90 days, and age-adjusted total score on the Telephone Interview for Cognitive Status questionnaire (TICS-T; scores range from 0 to 100, with a mean of 50±10 and lower scores indicating worse cognition) at 6 months. RESULTS Of 432 patients who underwent randomization, 422 were assigned to receive a trial drug and were included in the analyses - 214 patients received dexmedetomidine at a median dose of 0.27 μg per kilogram per hour, and 208 received propofol at a median dose of 10.21 μg per kilogram per minute. The median duration of receipt of the trial drugs was 3.0 days (interquartile range, 2.0 to 6.0), and the median RASS score was -2.0 (interquartile range, -3.0 to -1.0). We found no difference between dexmedetomidine and propofol in the number of days alive without delirium or coma (adjusted median, 10.7 vs. 10.8 days; odds ratio, 0.96; 95% confidence interval [CI], 0.74 to 1.26), ventilator-free days (adjusted median, 23.7 vs. 24.0 days; odds ratio, 0.98; 95% CI, 0.63 to 1.51), death at 90 days (38% vs. 39%; hazard ratio, 1.06; 95% CI, 0.74 to 1.52), or TICS-T score at 6 months (adjusted median score, 40.9 vs. 41.4; odds ratio, 0.94; 95% CI, 0.66 to 1.33). Safety end points were similar in the two groups. CONCLUSIONS Among mechanically ventilated adults with sepsis who were being treated with recommended light-sedation approaches, outcomes in patients who received dexmedetomidine did not differ from outcomes in those who received propofol. (Funded by the National Institutes of Health; ClinicalTrials.gov number, NCT01739933.).
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Affiliation(s)
- Christopher G Hughes
- From the Critical Illness, Brain Dysfunction, and Survivorship Center (C.G.H., J.C.J., A.S.H., B.T.P., O.M.O., R.R., J.L.S., A.L.K, M.B.P., N.E.B., T.D.G., R.S.D., G.R.B., E.W.E., P.P.P.), the Center for Health Services Research (C.G.H., J.C.J., R.R., M.B.P., T.D.G., R.S.D., E.W.E., P.P.P.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (C.G.H., P.P.P.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., B.T.P., G.R.B., E.W.E.), and the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Departments of Biostatistics (O.M.O., R.R.) and Pharmaceutical Services (J.L.S.), and Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), Vanderbilt University Medical Center, and the Anesthesia Service (C.G.H., P.P.P.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education and Clinical Center (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - both in Nashville; the Neuroscience Institute and Department of Critical Care Medicine, Maine Medical Center, Portland (P.T.M.); the Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston (J.W.D., M.S.D.); the Departments of Pharmacy (J.T.S., L.N.B.) and Surgery (J.T.S.) and the Center for Outcomes Research (J.T.S.), Houston Methodist, and the Pulmonary, Critical Care and Sleep Medicine Section, Ben Taub Hospital, Baylor College of Medicine (K.K.G.), Houston; the Division of Pulmonary/Critical Care Medicine, University of Texas Health, and the South Texas Veterans Health Care System, San Antonio (A.A.); and Texas Health Harris Methodist Hospital Fort Worth, Fort Worth (A.S.) - all in Texas; the University of Sydney, and the Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, and the Department of Anesthesiology, University of Wisconsin, Madison (R.D.S.); Pulmonary and Critical Care Medicine, Baton Rouge General Medical Center and Our Lady of the Lake Regional Medical Center, Baton Rouge, LA (H.R.O.); the Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco (M.A.G.); Pulmonary and Critical Care, Mission Hospital, Asheville, NC (G.J.S.); the Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus (N.E.B.); and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.)
| | - Patrick T Mailloux
- From the Critical Illness, Brain Dysfunction, and Survivorship Center (C.G.H., J.C.J., A.S.H., B.T.P., O.M.O., R.R., J.L.S., A.L.K, M.B.P., N.E.B., T.D.G., R.S.D., G.R.B., E.W.E., P.P.P.), the Center for Health Services Research (C.G.H., J.C.J., R.R., M.B.P., T.D.G., R.S.D., E.W.E., P.P.P.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (C.G.H., P.P.P.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., B.T.P., G.R.B., E.W.E.), and the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Departments of Biostatistics (O.M.O., R.R.) and Pharmaceutical Services (J.L.S.), and Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), Vanderbilt University Medical Center, and the Anesthesia Service (C.G.H., P.P.P.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education and Clinical Center (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - both in Nashville; the Neuroscience Institute and Department of Critical Care Medicine, Maine Medical Center, Portland (P.T.M.); the Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston (J.W.D., M.S.D.); the Departments of Pharmacy (J.T.S., L.N.B.) and Surgery (J.T.S.) and the Center for Outcomes Research (J.T.S.), Houston Methodist, and the Pulmonary, Critical Care and Sleep Medicine Section, Ben Taub Hospital, Baylor College of Medicine (K.K.G.), Houston; the Division of Pulmonary/Critical Care Medicine, University of Texas Health, and the South Texas Veterans Health Care System, San Antonio (A.A.); and Texas Health Harris Methodist Hospital Fort Worth, Fort Worth (A.S.) - all in Texas; the University of Sydney, and the Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, and the Department of Anesthesiology, University of Wisconsin, Madison (R.D.S.); Pulmonary and Critical Care Medicine, Baton Rouge General Medical Center and Our Lady of the Lake Regional Medical Center, Baton Rouge, LA (H.R.O.); the Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco (M.A.G.); Pulmonary and Critical Care, Mission Hospital, Asheville, NC (G.J.S.); the Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus (N.E.B.); and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.)
| | - John W Devlin
- From the Critical Illness, Brain Dysfunction, and Survivorship Center (C.G.H., J.C.J., A.S.H., B.T.P., O.M.O., R.R., J.L.S., A.L.K, M.B.P., N.E.B., T.D.G., R.S.D., G.R.B., E.W.E., P.P.P.), the Center for Health Services Research (C.G.H., J.C.J., R.R., M.B.P., T.D.G., R.S.D., E.W.E., P.P.P.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (C.G.H., P.P.P.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., B.T.P., G.R.B., E.W.E.), and the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Departments of Biostatistics (O.M.O., R.R.) and Pharmaceutical Services (J.L.S.), and Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), Vanderbilt University Medical Center, and the Anesthesia Service (C.G.H., P.P.P.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education and Clinical Center (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - both in Nashville; the Neuroscience Institute and Department of Critical Care Medicine, Maine Medical Center, Portland (P.T.M.); the Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston (J.W.D., M.S.D.); the Departments of Pharmacy (J.T.S., L.N.B.) and Surgery (J.T.S.) and the Center for Outcomes Research (J.T.S.), Houston Methodist, and the Pulmonary, Critical Care and Sleep Medicine Section, Ben Taub Hospital, Baylor College of Medicine (K.K.G.), Houston; the Division of Pulmonary/Critical Care Medicine, University of Texas Health, and the South Texas Veterans Health Care System, San Antonio (A.A.); and Texas Health Harris Methodist Hospital Fort Worth, Fort Worth (A.S.) - all in Texas; the University of Sydney, and the Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, and the Department of Anesthesiology, University of Wisconsin, Madison (R.D.S.); Pulmonary and Critical Care Medicine, Baton Rouge General Medical Center and Our Lady of the Lake Regional Medical Center, Baton Rouge, LA (H.R.O.); the Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco (M.A.G.); Pulmonary and Critical Care, Mission Hospital, Asheville, NC (G.J.S.); the Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus (N.E.B.); and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.)
| | - Joshua T Swan
- From the Critical Illness, Brain Dysfunction, and Survivorship Center (C.G.H., J.C.J., A.S.H., B.T.P., O.M.O., R.R., J.L.S., A.L.K, M.B.P., N.E.B., T.D.G., R.S.D., G.R.B., E.W.E., P.P.P.), the Center for Health Services Research (C.G.H., J.C.J., R.R., M.B.P., T.D.G., R.S.D., E.W.E., P.P.P.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (C.G.H., P.P.P.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., B.T.P., G.R.B., E.W.E.), and the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Departments of Biostatistics (O.M.O., R.R.) and Pharmaceutical Services (J.L.S.), and Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), Vanderbilt University Medical Center, and the Anesthesia Service (C.G.H., P.P.P.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education and Clinical Center (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - both in Nashville; the Neuroscience Institute and Department of Critical Care Medicine, Maine Medical Center, Portland (P.T.M.); the Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston (J.W.D., M.S.D.); the Departments of Pharmacy (J.T.S., L.N.B.) and Surgery (J.T.S.) and the Center for Outcomes Research (J.T.S.), Houston Methodist, and the Pulmonary, Critical Care and Sleep Medicine Section, Ben Taub Hospital, Baylor College of Medicine (K.K.G.), Houston; the Division of Pulmonary/Critical Care Medicine, University of Texas Health, and the South Texas Veterans Health Care System, San Antonio (A.A.); and Texas Health Harris Methodist Hospital Fort Worth, Fort Worth (A.S.) - all in Texas; the University of Sydney, and the Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, and the Department of Anesthesiology, University of Wisconsin, Madison (R.D.S.); Pulmonary and Critical Care Medicine, Baton Rouge General Medical Center and Our Lady of the Lake Regional Medical Center, Baton Rouge, LA (H.R.O.); the Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco (M.A.G.); Pulmonary and Critical Care, Mission Hospital, Asheville, NC (G.J.S.); the Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus (N.E.B.); and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.)
| | - Robert D Sanders
- From the Critical Illness, Brain Dysfunction, and Survivorship Center (C.G.H., J.C.J., A.S.H., B.T.P., O.M.O., R.R., J.L.S., A.L.K, M.B.P., N.E.B., T.D.G., R.S.D., G.R.B., E.W.E., P.P.P.), the Center for Health Services Research (C.G.H., J.C.J., R.R., M.B.P., T.D.G., R.S.D., E.W.E., P.P.P.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (C.G.H., P.P.P.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., B.T.P., G.R.B., E.W.E.), and the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Departments of Biostatistics (O.M.O., R.R.) and Pharmaceutical Services (J.L.S.), and Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), Vanderbilt University Medical Center, and the Anesthesia Service (C.G.H., P.P.P.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education and Clinical Center (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - both in Nashville; the Neuroscience Institute and Department of Critical Care Medicine, Maine Medical Center, Portland (P.T.M.); the Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston (J.W.D., M.S.D.); the Departments of Pharmacy (J.T.S., L.N.B.) and Surgery (J.T.S.) and the Center for Outcomes Research (J.T.S.), Houston Methodist, and the Pulmonary, Critical Care and Sleep Medicine Section, Ben Taub Hospital, Baylor College of Medicine (K.K.G.), Houston; the Division of Pulmonary/Critical Care Medicine, University of Texas Health, and the South Texas Veterans Health Care System, San Antonio (A.A.); and Texas Health Harris Methodist Hospital Fort Worth, Fort Worth (A.S.) - all in Texas; the University of Sydney, and the Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, and the Department of Anesthesiology, University of Wisconsin, Madison (R.D.S.); Pulmonary and Critical Care Medicine, Baton Rouge General Medical Center and Our Lady of the Lake Regional Medical Center, Baton Rouge, LA (H.R.O.); the Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco (M.A.G.); Pulmonary and Critical Care, Mission Hospital, Asheville, NC (G.J.S.); the Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus (N.E.B.); and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.)
| | - Antonio Anzueto
- From the Critical Illness, Brain Dysfunction, and Survivorship Center (C.G.H., J.C.J., A.S.H., B.T.P., O.M.O., R.R., J.L.S., A.L.K, M.B.P., N.E.B., T.D.G., R.S.D., G.R.B., E.W.E., P.P.P.), the Center for Health Services Research (C.G.H., J.C.J., R.R., M.B.P., T.D.G., R.S.D., E.W.E., P.P.P.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (C.G.H., P.P.P.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., B.T.P., G.R.B., E.W.E.), and the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Departments of Biostatistics (O.M.O., R.R.) and Pharmaceutical Services (J.L.S.), and Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), Vanderbilt University Medical Center, and the Anesthesia Service (C.G.H., P.P.P.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education and Clinical Center (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - both in Nashville; the Neuroscience Institute and Department of Critical Care Medicine, Maine Medical Center, Portland (P.T.M.); the Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston (J.W.D., M.S.D.); the Departments of Pharmacy (J.T.S., L.N.B.) and Surgery (J.T.S.) and the Center for Outcomes Research (J.T.S.), Houston Methodist, and the Pulmonary, Critical Care and Sleep Medicine Section, Ben Taub Hospital, Baylor College of Medicine (K.K.G.), Houston; the Division of Pulmonary/Critical Care Medicine, University of Texas Health, and the South Texas Veterans Health Care System, San Antonio (A.A.); and Texas Health Harris Methodist Hospital Fort Worth, Fort Worth (A.S.) - all in Texas; the University of Sydney, and the Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, and the Department of Anesthesiology, University of Wisconsin, Madison (R.D.S.); Pulmonary and Critical Care Medicine, Baton Rouge General Medical Center and Our Lady of the Lake Regional Medical Center, Baton Rouge, LA (H.R.O.); the Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco (M.A.G.); Pulmonary and Critical Care, Mission Hospital, Asheville, NC (G.J.S.); the Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus (N.E.B.); and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.)
| | - James C Jackson
- From the Critical Illness, Brain Dysfunction, and Survivorship Center (C.G.H., J.C.J., A.S.H., B.T.P., O.M.O., R.R., J.L.S., A.L.K, M.B.P., N.E.B., T.D.G., R.S.D., G.R.B., E.W.E., P.P.P.), the Center for Health Services Research (C.G.H., J.C.J., R.R., M.B.P., T.D.G., R.S.D., E.W.E., P.P.P.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (C.G.H., P.P.P.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., B.T.P., G.R.B., E.W.E.), and the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Departments of Biostatistics (O.M.O., R.R.) and Pharmaceutical Services (J.L.S.), and Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), Vanderbilt University Medical Center, and the Anesthesia Service (C.G.H., P.P.P.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education and Clinical Center (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - both in Nashville; the Neuroscience Institute and Department of Critical Care Medicine, Maine Medical Center, Portland (P.T.M.); the Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston (J.W.D., M.S.D.); the Departments of Pharmacy (J.T.S., L.N.B.) and Surgery (J.T.S.) and the Center for Outcomes Research (J.T.S.), Houston Methodist, and the Pulmonary, Critical Care and Sleep Medicine Section, Ben Taub Hospital, Baylor College of Medicine (K.K.G.), Houston; the Division of Pulmonary/Critical Care Medicine, University of Texas Health, and the South Texas Veterans Health Care System, San Antonio (A.A.); and Texas Health Harris Methodist Hospital Fort Worth, Fort Worth (A.S.) - all in Texas; the University of Sydney, and the Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, and the Department of Anesthesiology, University of Wisconsin, Madison (R.D.S.); Pulmonary and Critical Care Medicine, Baton Rouge General Medical Center and Our Lady of the Lake Regional Medical Center, Baton Rouge, LA (H.R.O.); the Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco (M.A.G.); Pulmonary and Critical Care, Mission Hospital, Asheville, NC (G.J.S.); the Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus (N.E.B.); and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.)
| | - Aimee S Hoskins
- From the Critical Illness, Brain Dysfunction, and Survivorship Center (C.G.H., J.C.J., A.S.H., B.T.P., O.M.O., R.R., J.L.S., A.L.K, M.B.P., N.E.B., T.D.G., R.S.D., G.R.B., E.W.E., P.P.P.), the Center for Health Services Research (C.G.H., J.C.J., R.R., M.B.P., T.D.G., R.S.D., E.W.E., P.P.P.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (C.G.H., P.P.P.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., B.T.P., G.R.B., E.W.E.), and the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Departments of Biostatistics (O.M.O., R.R.) and Pharmaceutical Services (J.L.S.), and Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), Vanderbilt University Medical Center, and the Anesthesia Service (C.G.H., P.P.P.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education and Clinical Center (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - both in Nashville; the Neuroscience Institute and Department of Critical Care Medicine, Maine Medical Center, Portland (P.T.M.); the Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston (J.W.D., M.S.D.); the Departments of Pharmacy (J.T.S., L.N.B.) and Surgery (J.T.S.) and the Center for Outcomes Research (J.T.S.), Houston Methodist, and the Pulmonary, Critical Care and Sleep Medicine Section, Ben Taub Hospital, Baylor College of Medicine (K.K.G.), Houston; the Division of Pulmonary/Critical Care Medicine, University of Texas Health, and the South Texas Veterans Health Care System, San Antonio (A.A.); and Texas Health Harris Methodist Hospital Fort Worth, Fort Worth (A.S.) - all in Texas; the University of Sydney, and the Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, and the Department of Anesthesiology, University of Wisconsin, Madison (R.D.S.); Pulmonary and Critical Care Medicine, Baton Rouge General Medical Center and Our Lady of the Lake Regional Medical Center, Baton Rouge, LA (H.R.O.); the Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco (M.A.G.); Pulmonary and Critical Care, Mission Hospital, Asheville, NC (G.J.S.); the Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus (N.E.B.); and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.)
| | - Brenda T Pun
- From the Critical Illness, Brain Dysfunction, and Survivorship Center (C.G.H., J.C.J., A.S.H., B.T.P., O.M.O., R.R., J.L.S., A.L.K, M.B.P., N.E.B., T.D.G., R.S.D., G.R.B., E.W.E., P.P.P.), the Center for Health Services Research (C.G.H., J.C.J., R.R., M.B.P., T.D.G., R.S.D., E.W.E., P.P.P.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (C.G.H., P.P.P.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., B.T.P., G.R.B., E.W.E.), and the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Departments of Biostatistics (O.M.O., R.R.) and Pharmaceutical Services (J.L.S.), and Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), Vanderbilt University Medical Center, and the Anesthesia Service (C.G.H., P.P.P.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education and Clinical Center (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - both in Nashville; the Neuroscience Institute and Department of Critical Care Medicine, Maine Medical Center, Portland (P.T.M.); the Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston (J.W.D., M.S.D.); the Departments of Pharmacy (J.T.S., L.N.B.) and Surgery (J.T.S.) and the Center for Outcomes Research (J.T.S.), Houston Methodist, and the Pulmonary, Critical Care and Sleep Medicine Section, Ben Taub Hospital, Baylor College of Medicine (K.K.G.), Houston; the Division of Pulmonary/Critical Care Medicine, University of Texas Health, and the South Texas Veterans Health Care System, San Antonio (A.A.); and Texas Health Harris Methodist Hospital Fort Worth, Fort Worth (A.S.) - all in Texas; the University of Sydney, and the Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, and the Department of Anesthesiology, University of Wisconsin, Madison (R.D.S.); Pulmonary and Critical Care Medicine, Baton Rouge General Medical Center and Our Lady of the Lake Regional Medical Center, Baton Rouge, LA (H.R.O.); the Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco (M.A.G.); Pulmonary and Critical Care, Mission Hospital, Asheville, NC (G.J.S.); the Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus (N.E.B.); and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.)
| | - Onur M Orun
- From the Critical Illness, Brain Dysfunction, and Survivorship Center (C.G.H., J.C.J., A.S.H., B.T.P., O.M.O., R.R., J.L.S., A.L.K, M.B.P., N.E.B., T.D.G., R.S.D., G.R.B., E.W.E., P.P.P.), the Center for Health Services Research (C.G.H., J.C.J., R.R., M.B.P., T.D.G., R.S.D., E.W.E., P.P.P.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (C.G.H., P.P.P.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., B.T.P., G.R.B., E.W.E.), and the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Departments of Biostatistics (O.M.O., R.R.) and Pharmaceutical Services (J.L.S.), and Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), Vanderbilt University Medical Center, and the Anesthesia Service (C.G.H., P.P.P.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education and Clinical Center (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - both in Nashville; the Neuroscience Institute and Department of Critical Care Medicine, Maine Medical Center, Portland (P.T.M.); the Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston (J.W.D., M.S.D.); the Departments of Pharmacy (J.T.S., L.N.B.) and Surgery (J.T.S.) and the Center for Outcomes Research (J.T.S.), Houston Methodist, and the Pulmonary, Critical Care and Sleep Medicine Section, Ben Taub Hospital, Baylor College of Medicine (K.K.G.), Houston; the Division of Pulmonary/Critical Care Medicine, University of Texas Health, and the South Texas Veterans Health Care System, San Antonio (A.A.); and Texas Health Harris Methodist Hospital Fort Worth, Fort Worth (A.S.) - all in Texas; the University of Sydney, and the Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, and the Department of Anesthesiology, University of Wisconsin, Madison (R.D.S.); Pulmonary and Critical Care Medicine, Baton Rouge General Medical Center and Our Lady of the Lake Regional Medical Center, Baton Rouge, LA (H.R.O.); the Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco (M.A.G.); Pulmonary and Critical Care, Mission Hospital, Asheville, NC (G.J.S.); the Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus (N.E.B.); and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.)
| | - Rameela Raman
- From the Critical Illness, Brain Dysfunction, and Survivorship Center (C.G.H., J.C.J., A.S.H., B.T.P., O.M.O., R.R., J.L.S., A.L.K, M.B.P., N.E.B., T.D.G., R.S.D., G.R.B., E.W.E., P.P.P.), the Center for Health Services Research (C.G.H., J.C.J., R.R., M.B.P., T.D.G., R.S.D., E.W.E., P.P.P.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (C.G.H., P.P.P.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., B.T.P., G.R.B., E.W.E.), and the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Departments of Biostatistics (O.M.O., R.R.) and Pharmaceutical Services (J.L.S.), and Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), Vanderbilt University Medical Center, and the Anesthesia Service (C.G.H., P.P.P.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education and Clinical Center (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - both in Nashville; the Neuroscience Institute and Department of Critical Care Medicine, Maine Medical Center, Portland (P.T.M.); the Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston (J.W.D., M.S.D.); the Departments of Pharmacy (J.T.S., L.N.B.) and Surgery (J.T.S.) and the Center for Outcomes Research (J.T.S.), Houston Methodist, and the Pulmonary, Critical Care and Sleep Medicine Section, Ben Taub Hospital, Baylor College of Medicine (K.K.G.), Houston; the Division of Pulmonary/Critical Care Medicine, University of Texas Health, and the South Texas Veterans Health Care System, San Antonio (A.A.); and Texas Health Harris Methodist Hospital Fort Worth, Fort Worth (A.S.) - all in Texas; the University of Sydney, and the Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, and the Department of Anesthesiology, University of Wisconsin, Madison (R.D.S.); Pulmonary and Critical Care Medicine, Baton Rouge General Medical Center and Our Lady of the Lake Regional Medical Center, Baton Rouge, LA (H.R.O.); the Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco (M.A.G.); Pulmonary and Critical Care, Mission Hospital, Asheville, NC (G.J.S.); the Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus (N.E.B.); and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.)
| | - Joanna L Stollings
- From the Critical Illness, Brain Dysfunction, and Survivorship Center (C.G.H., J.C.J., A.S.H., B.T.P., O.M.O., R.R., J.L.S., A.L.K, M.B.P., N.E.B., T.D.G., R.S.D., G.R.B., E.W.E., P.P.P.), the Center for Health Services Research (C.G.H., J.C.J., R.R., M.B.P., T.D.G., R.S.D., E.W.E., P.P.P.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (C.G.H., P.P.P.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., B.T.P., G.R.B., E.W.E.), and the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Departments of Biostatistics (O.M.O., R.R.) and Pharmaceutical Services (J.L.S.), and Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), Vanderbilt University Medical Center, and the Anesthesia Service (C.G.H., P.P.P.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education and Clinical Center (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - both in Nashville; the Neuroscience Institute and Department of Critical Care Medicine, Maine Medical Center, Portland (P.T.M.); the Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston (J.W.D., M.S.D.); the Departments of Pharmacy (J.T.S., L.N.B.) and Surgery (J.T.S.) and the Center for Outcomes Research (J.T.S.), Houston Methodist, and the Pulmonary, Critical Care and Sleep Medicine Section, Ben Taub Hospital, Baylor College of Medicine (K.K.G.), Houston; the Division of Pulmonary/Critical Care Medicine, University of Texas Health, and the South Texas Veterans Health Care System, San Antonio (A.A.); and Texas Health Harris Methodist Hospital Fort Worth, Fort Worth (A.S.) - all in Texas; the University of Sydney, and the Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, and the Department of Anesthesiology, University of Wisconsin, Madison (R.D.S.); Pulmonary and Critical Care Medicine, Baton Rouge General Medical Center and Our Lady of the Lake Regional Medical Center, Baton Rouge, LA (H.R.O.); the Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco (M.A.G.); Pulmonary and Critical Care, Mission Hospital, Asheville, NC (G.J.S.); the Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus (N.E.B.); and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.)
| | - Amy L Kiehl
- From the Critical Illness, Brain Dysfunction, and Survivorship Center (C.G.H., J.C.J., A.S.H., B.T.P., O.M.O., R.R., J.L.S., A.L.K, M.B.P., N.E.B., T.D.G., R.S.D., G.R.B., E.W.E., P.P.P.), the Center for Health Services Research (C.G.H., J.C.J., R.R., M.B.P., T.D.G., R.S.D., E.W.E., P.P.P.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (C.G.H., P.P.P.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., B.T.P., G.R.B., E.W.E.), and the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Departments of Biostatistics (O.M.O., R.R.) and Pharmaceutical Services (J.L.S.), and Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), Vanderbilt University Medical Center, and the Anesthesia Service (C.G.H., P.P.P.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education and Clinical Center (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - both in Nashville; the Neuroscience Institute and Department of Critical Care Medicine, Maine Medical Center, Portland (P.T.M.); the Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston (J.W.D., M.S.D.); the Departments of Pharmacy (J.T.S., L.N.B.) and Surgery (J.T.S.) and the Center for Outcomes Research (J.T.S.), Houston Methodist, and the Pulmonary, Critical Care and Sleep Medicine Section, Ben Taub Hospital, Baylor College of Medicine (K.K.G.), Houston; the Division of Pulmonary/Critical Care Medicine, University of Texas Health, and the South Texas Veterans Health Care System, San Antonio (A.A.); and Texas Health Harris Methodist Hospital Fort Worth, Fort Worth (A.S.) - all in Texas; the University of Sydney, and the Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, and the Department of Anesthesiology, University of Wisconsin, Madison (R.D.S.); Pulmonary and Critical Care Medicine, Baton Rouge General Medical Center and Our Lady of the Lake Regional Medical Center, Baton Rouge, LA (H.R.O.); the Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco (M.A.G.); Pulmonary and Critical Care, Mission Hospital, Asheville, NC (G.J.S.); the Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus (N.E.B.); and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.)
| | - Matthew S Duprey
- From the Critical Illness, Brain Dysfunction, and Survivorship Center (C.G.H., J.C.J., A.S.H., B.T.P., O.M.O., R.R., J.L.S., A.L.K, M.B.P., N.E.B., T.D.G., R.S.D., G.R.B., E.W.E., P.P.P.), the Center for Health Services Research (C.G.H., J.C.J., R.R., M.B.P., T.D.G., R.S.D., E.W.E., P.P.P.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (C.G.H., P.P.P.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., B.T.P., G.R.B., E.W.E.), and the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Departments of Biostatistics (O.M.O., R.R.) and Pharmaceutical Services (J.L.S.), and Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), Vanderbilt University Medical Center, and the Anesthesia Service (C.G.H., P.P.P.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education and Clinical Center (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - both in Nashville; the Neuroscience Institute and Department of Critical Care Medicine, Maine Medical Center, Portland (P.T.M.); the Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston (J.W.D., M.S.D.); the Departments of Pharmacy (J.T.S., L.N.B.) and Surgery (J.T.S.) and the Center for Outcomes Research (J.T.S.), Houston Methodist, and the Pulmonary, Critical Care and Sleep Medicine Section, Ben Taub Hospital, Baylor College of Medicine (K.K.G.), Houston; the Division of Pulmonary/Critical Care Medicine, University of Texas Health, and the South Texas Veterans Health Care System, San Antonio (A.A.); and Texas Health Harris Methodist Hospital Fort Worth, Fort Worth (A.S.) - all in Texas; the University of Sydney, and the Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, and the Department of Anesthesiology, University of Wisconsin, Madison (R.D.S.); Pulmonary and Critical Care Medicine, Baton Rouge General Medical Center and Our Lady of the Lake Regional Medical Center, Baton Rouge, LA (H.R.O.); the Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco (M.A.G.); Pulmonary and Critical Care, Mission Hospital, Asheville, NC (G.J.S.); the Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus (N.E.B.); and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.)
| | - Lan N Bui
- From the Critical Illness, Brain Dysfunction, and Survivorship Center (C.G.H., J.C.J., A.S.H., B.T.P., O.M.O., R.R., J.L.S., A.L.K, M.B.P., N.E.B., T.D.G., R.S.D., G.R.B., E.W.E., P.P.P.), the Center for Health Services Research (C.G.H., J.C.J., R.R., M.B.P., T.D.G., R.S.D., E.W.E., P.P.P.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (C.G.H., P.P.P.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., B.T.P., G.R.B., E.W.E.), and the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Departments of Biostatistics (O.M.O., R.R.) and Pharmaceutical Services (J.L.S.), and Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), Vanderbilt University Medical Center, and the Anesthesia Service (C.G.H., P.P.P.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education and Clinical Center (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - both in Nashville; the Neuroscience Institute and Department of Critical Care Medicine, Maine Medical Center, Portland (P.T.M.); the Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston (J.W.D., M.S.D.); the Departments of Pharmacy (J.T.S., L.N.B.) and Surgery (J.T.S.) and the Center for Outcomes Research (J.T.S.), Houston Methodist, and the Pulmonary, Critical Care and Sleep Medicine Section, Ben Taub Hospital, Baylor College of Medicine (K.K.G.), Houston; the Division of Pulmonary/Critical Care Medicine, University of Texas Health, and the South Texas Veterans Health Care System, San Antonio (A.A.); and Texas Health Harris Methodist Hospital Fort Worth, Fort Worth (A.S.) - all in Texas; the University of Sydney, and the Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, and the Department of Anesthesiology, University of Wisconsin, Madison (R.D.S.); Pulmonary and Critical Care Medicine, Baton Rouge General Medical Center and Our Lady of the Lake Regional Medical Center, Baton Rouge, LA (H.R.O.); the Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco (M.A.G.); Pulmonary and Critical Care, Mission Hospital, Asheville, NC (G.J.S.); the Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus (N.E.B.); and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.)
| | - Hollis R O'Neal
- From the Critical Illness, Brain Dysfunction, and Survivorship Center (C.G.H., J.C.J., A.S.H., B.T.P., O.M.O., R.R., J.L.S., A.L.K, M.B.P., N.E.B., T.D.G., R.S.D., G.R.B., E.W.E., P.P.P.), the Center for Health Services Research (C.G.H., J.C.J., R.R., M.B.P., T.D.G., R.S.D., E.W.E., P.P.P.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (C.G.H., P.P.P.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., B.T.P., G.R.B., E.W.E.), and the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Departments of Biostatistics (O.M.O., R.R.) and Pharmaceutical Services (J.L.S.), and Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), Vanderbilt University Medical Center, and the Anesthesia Service (C.G.H., P.P.P.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education and Clinical Center (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - both in Nashville; the Neuroscience Institute and Department of Critical Care Medicine, Maine Medical Center, Portland (P.T.M.); the Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston (J.W.D., M.S.D.); the Departments of Pharmacy (J.T.S., L.N.B.) and Surgery (J.T.S.) and the Center for Outcomes Research (J.T.S.), Houston Methodist, and the Pulmonary, Critical Care and Sleep Medicine Section, Ben Taub Hospital, Baylor College of Medicine (K.K.G.), Houston; the Division of Pulmonary/Critical Care Medicine, University of Texas Health, and the South Texas Veterans Health Care System, San Antonio (A.A.); and Texas Health Harris Methodist Hospital Fort Worth, Fort Worth (A.S.) - all in Texas; the University of Sydney, and the Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, and the Department of Anesthesiology, University of Wisconsin, Madison (R.D.S.); Pulmonary and Critical Care Medicine, Baton Rouge General Medical Center and Our Lady of the Lake Regional Medical Center, Baton Rouge, LA (H.R.O.); the Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco (M.A.G.); Pulmonary and Critical Care, Mission Hospital, Asheville, NC (G.J.S.); the Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus (N.E.B.); and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.)
| | - Allison Snyder
- From the Critical Illness, Brain Dysfunction, and Survivorship Center (C.G.H., J.C.J., A.S.H., B.T.P., O.M.O., R.R., J.L.S., A.L.K, M.B.P., N.E.B., T.D.G., R.S.D., G.R.B., E.W.E., P.P.P.), the Center for Health Services Research (C.G.H., J.C.J., R.R., M.B.P., T.D.G., R.S.D., E.W.E., P.P.P.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (C.G.H., P.P.P.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., B.T.P., G.R.B., E.W.E.), and the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Departments of Biostatistics (O.M.O., R.R.) and Pharmaceutical Services (J.L.S.), and Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), Vanderbilt University Medical Center, and the Anesthesia Service (C.G.H., P.P.P.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education and Clinical Center (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - both in Nashville; the Neuroscience Institute and Department of Critical Care Medicine, Maine Medical Center, Portland (P.T.M.); the Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston (J.W.D., M.S.D.); the Departments of Pharmacy (J.T.S., L.N.B.) and Surgery (J.T.S.) and the Center for Outcomes Research (J.T.S.), Houston Methodist, and the Pulmonary, Critical Care and Sleep Medicine Section, Ben Taub Hospital, Baylor College of Medicine (K.K.G.), Houston; the Division of Pulmonary/Critical Care Medicine, University of Texas Health, and the South Texas Veterans Health Care System, San Antonio (A.A.); and Texas Health Harris Methodist Hospital Fort Worth, Fort Worth (A.S.) - all in Texas; the University of Sydney, and the Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, and the Department of Anesthesiology, University of Wisconsin, Madison (R.D.S.); Pulmonary and Critical Care Medicine, Baton Rouge General Medical Center and Our Lady of the Lake Regional Medical Center, Baton Rouge, LA (H.R.O.); the Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco (M.A.G.); Pulmonary and Critical Care, Mission Hospital, Asheville, NC (G.J.S.); the Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus (N.E.B.); and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.)
| | - Michael A Gropper
- From the Critical Illness, Brain Dysfunction, and Survivorship Center (C.G.H., J.C.J., A.S.H., B.T.P., O.M.O., R.R., J.L.S., A.L.K, M.B.P., N.E.B., T.D.G., R.S.D., G.R.B., E.W.E., P.P.P.), the Center for Health Services Research (C.G.H., J.C.J., R.R., M.B.P., T.D.G., R.S.D., E.W.E., P.P.P.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (C.G.H., P.P.P.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., B.T.P., G.R.B., E.W.E.), and the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Departments of Biostatistics (O.M.O., R.R.) and Pharmaceutical Services (J.L.S.), and Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), Vanderbilt University Medical Center, and the Anesthesia Service (C.G.H., P.P.P.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education and Clinical Center (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - both in Nashville; the Neuroscience Institute and Department of Critical Care Medicine, Maine Medical Center, Portland (P.T.M.); the Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston (J.W.D., M.S.D.); the Departments of Pharmacy (J.T.S., L.N.B.) and Surgery (J.T.S.) and the Center for Outcomes Research (J.T.S.), Houston Methodist, and the Pulmonary, Critical Care and Sleep Medicine Section, Ben Taub Hospital, Baylor College of Medicine (K.K.G.), Houston; the Division of Pulmonary/Critical Care Medicine, University of Texas Health, and the South Texas Veterans Health Care System, San Antonio (A.A.); and Texas Health Harris Methodist Hospital Fort Worth, Fort Worth (A.S.) - all in Texas; the University of Sydney, and the Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, and the Department of Anesthesiology, University of Wisconsin, Madison (R.D.S.); Pulmonary and Critical Care Medicine, Baton Rouge General Medical Center and Our Lady of the Lake Regional Medical Center, Baton Rouge, LA (H.R.O.); the Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco (M.A.G.); Pulmonary and Critical Care, Mission Hospital, Asheville, NC (G.J.S.); the Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus (N.E.B.); and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.)
| | - Kalpalatha K Guntupalli
- From the Critical Illness, Brain Dysfunction, and Survivorship Center (C.G.H., J.C.J., A.S.H., B.T.P., O.M.O., R.R., J.L.S., A.L.K, M.B.P., N.E.B., T.D.G., R.S.D., G.R.B., E.W.E., P.P.P.), the Center for Health Services Research (C.G.H., J.C.J., R.R., M.B.P., T.D.G., R.S.D., E.W.E., P.P.P.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (C.G.H., P.P.P.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., B.T.P., G.R.B., E.W.E.), and the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Departments of Biostatistics (O.M.O., R.R.) and Pharmaceutical Services (J.L.S.), and Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), Vanderbilt University Medical Center, and the Anesthesia Service (C.G.H., P.P.P.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education and Clinical Center (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - both in Nashville; the Neuroscience Institute and Department of Critical Care Medicine, Maine Medical Center, Portland (P.T.M.); the Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston (J.W.D., M.S.D.); the Departments of Pharmacy (J.T.S., L.N.B.) and Surgery (J.T.S.) and the Center for Outcomes Research (J.T.S.), Houston Methodist, and the Pulmonary, Critical Care and Sleep Medicine Section, Ben Taub Hospital, Baylor College of Medicine (K.K.G.), Houston; the Division of Pulmonary/Critical Care Medicine, University of Texas Health, and the South Texas Veterans Health Care System, San Antonio (A.A.); and Texas Health Harris Methodist Hospital Fort Worth, Fort Worth (A.S.) - all in Texas; the University of Sydney, and the Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, and the Department of Anesthesiology, University of Wisconsin, Madison (R.D.S.); Pulmonary and Critical Care Medicine, Baton Rouge General Medical Center and Our Lady of the Lake Regional Medical Center, Baton Rouge, LA (H.R.O.); the Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco (M.A.G.); Pulmonary and Critical Care, Mission Hospital, Asheville, NC (G.J.S.); the Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus (N.E.B.); and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.)
| | - Gregg J Stashenko
- From the Critical Illness, Brain Dysfunction, and Survivorship Center (C.G.H., J.C.J., A.S.H., B.T.P., O.M.O., R.R., J.L.S., A.L.K, M.B.P., N.E.B., T.D.G., R.S.D., G.R.B., E.W.E., P.P.P.), the Center for Health Services Research (C.G.H., J.C.J., R.R., M.B.P., T.D.G., R.S.D., E.W.E., P.P.P.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (C.G.H., P.P.P.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., B.T.P., G.R.B., E.W.E.), and the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Departments of Biostatistics (O.M.O., R.R.) and Pharmaceutical Services (J.L.S.), and Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), Vanderbilt University Medical Center, and the Anesthesia Service (C.G.H., P.P.P.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education and Clinical Center (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - both in Nashville; the Neuroscience Institute and Department of Critical Care Medicine, Maine Medical Center, Portland (P.T.M.); the Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston (J.W.D., M.S.D.); the Departments of Pharmacy (J.T.S., L.N.B.) and Surgery (J.T.S.) and the Center for Outcomes Research (J.T.S.), Houston Methodist, and the Pulmonary, Critical Care and Sleep Medicine Section, Ben Taub Hospital, Baylor College of Medicine (K.K.G.), Houston; the Division of Pulmonary/Critical Care Medicine, University of Texas Health, and the South Texas Veterans Health Care System, San Antonio (A.A.); and Texas Health Harris Methodist Hospital Fort Worth, Fort Worth (A.S.) - all in Texas; the University of Sydney, and the Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, and the Department of Anesthesiology, University of Wisconsin, Madison (R.D.S.); Pulmonary and Critical Care Medicine, Baton Rouge General Medical Center and Our Lady of the Lake Regional Medical Center, Baton Rouge, LA (H.R.O.); the Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco (M.A.G.); Pulmonary and Critical Care, Mission Hospital, Asheville, NC (G.J.S.); the Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus (N.E.B.); and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.)
| | - Mayur B Patel
- From the Critical Illness, Brain Dysfunction, and Survivorship Center (C.G.H., J.C.J., A.S.H., B.T.P., O.M.O., R.R., J.L.S., A.L.K, M.B.P., N.E.B., T.D.G., R.S.D., G.R.B., E.W.E., P.P.P.), the Center for Health Services Research (C.G.H., J.C.J., R.R., M.B.P., T.D.G., R.S.D., E.W.E., P.P.P.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (C.G.H., P.P.P.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., B.T.P., G.R.B., E.W.E.), and the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Departments of Biostatistics (O.M.O., R.R.) and Pharmaceutical Services (J.L.S.), and Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), Vanderbilt University Medical Center, and the Anesthesia Service (C.G.H., P.P.P.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education and Clinical Center (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - both in Nashville; the Neuroscience Institute and Department of Critical Care Medicine, Maine Medical Center, Portland (P.T.M.); the Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston (J.W.D., M.S.D.); the Departments of Pharmacy (J.T.S., L.N.B.) and Surgery (J.T.S.) and the Center for Outcomes Research (J.T.S.), Houston Methodist, and the Pulmonary, Critical Care and Sleep Medicine Section, Ben Taub Hospital, Baylor College of Medicine (K.K.G.), Houston; the Division of Pulmonary/Critical Care Medicine, University of Texas Health, and the South Texas Veterans Health Care System, San Antonio (A.A.); and Texas Health Harris Methodist Hospital Fort Worth, Fort Worth (A.S.) - all in Texas; the University of Sydney, and the Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, and the Department of Anesthesiology, University of Wisconsin, Madison (R.D.S.); Pulmonary and Critical Care Medicine, Baton Rouge General Medical Center and Our Lady of the Lake Regional Medical Center, Baton Rouge, LA (H.R.O.); the Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco (M.A.G.); Pulmonary and Critical Care, Mission Hospital, Asheville, NC (G.J.S.); the Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus (N.E.B.); and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.)
| | - Nathan E Brummel
- From the Critical Illness, Brain Dysfunction, and Survivorship Center (C.G.H., J.C.J., A.S.H., B.T.P., O.M.O., R.R., J.L.S., A.L.K, M.B.P., N.E.B., T.D.G., R.S.D., G.R.B., E.W.E., P.P.P.), the Center for Health Services Research (C.G.H., J.C.J., R.R., M.B.P., T.D.G., R.S.D., E.W.E., P.P.P.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (C.G.H., P.P.P.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., B.T.P., G.R.B., E.W.E.), and the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Departments of Biostatistics (O.M.O., R.R.) and Pharmaceutical Services (J.L.S.), and Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), Vanderbilt University Medical Center, and the Anesthesia Service (C.G.H., P.P.P.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education and Clinical Center (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - both in Nashville; the Neuroscience Institute and Department of Critical Care Medicine, Maine Medical Center, Portland (P.T.M.); the Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston (J.W.D., M.S.D.); the Departments of Pharmacy (J.T.S., L.N.B.) and Surgery (J.T.S.) and the Center for Outcomes Research (J.T.S.), Houston Methodist, and the Pulmonary, Critical Care and Sleep Medicine Section, Ben Taub Hospital, Baylor College of Medicine (K.K.G.), Houston; the Division of Pulmonary/Critical Care Medicine, University of Texas Health, and the South Texas Veterans Health Care System, San Antonio (A.A.); and Texas Health Harris Methodist Hospital Fort Worth, Fort Worth (A.S.) - all in Texas; the University of Sydney, and the Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, and the Department of Anesthesiology, University of Wisconsin, Madison (R.D.S.); Pulmonary and Critical Care Medicine, Baton Rouge General Medical Center and Our Lady of the Lake Regional Medical Center, Baton Rouge, LA (H.R.O.); the Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco (M.A.G.); Pulmonary and Critical Care, Mission Hospital, Asheville, NC (G.J.S.); the Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus (N.E.B.); and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.)
| | - Timothy D Girard
- From the Critical Illness, Brain Dysfunction, and Survivorship Center (C.G.H., J.C.J., A.S.H., B.T.P., O.M.O., R.R., J.L.S., A.L.K, M.B.P., N.E.B., T.D.G., R.S.D., G.R.B., E.W.E., P.P.P.), the Center for Health Services Research (C.G.H., J.C.J., R.R., M.B.P., T.D.G., R.S.D., E.W.E., P.P.P.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (C.G.H., P.P.P.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., B.T.P., G.R.B., E.W.E.), and the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Departments of Biostatistics (O.M.O., R.R.) and Pharmaceutical Services (J.L.S.), and Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), Vanderbilt University Medical Center, and the Anesthesia Service (C.G.H., P.P.P.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education and Clinical Center (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - both in Nashville; the Neuroscience Institute and Department of Critical Care Medicine, Maine Medical Center, Portland (P.T.M.); the Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston (J.W.D., M.S.D.); the Departments of Pharmacy (J.T.S., L.N.B.) and Surgery (J.T.S.) and the Center for Outcomes Research (J.T.S.), Houston Methodist, and the Pulmonary, Critical Care and Sleep Medicine Section, Ben Taub Hospital, Baylor College of Medicine (K.K.G.), Houston; the Division of Pulmonary/Critical Care Medicine, University of Texas Health, and the South Texas Veterans Health Care System, San Antonio (A.A.); and Texas Health Harris Methodist Hospital Fort Worth, Fort Worth (A.S.) - all in Texas; the University of Sydney, and the Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, and the Department of Anesthesiology, University of Wisconsin, Madison (R.D.S.); Pulmonary and Critical Care Medicine, Baton Rouge General Medical Center and Our Lady of the Lake Regional Medical Center, Baton Rouge, LA (H.R.O.); the Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco (M.A.G.); Pulmonary and Critical Care, Mission Hospital, Asheville, NC (G.J.S.); the Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus (N.E.B.); and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.)
| | - Robert S Dittus
- From the Critical Illness, Brain Dysfunction, and Survivorship Center (C.G.H., J.C.J., A.S.H., B.T.P., O.M.O., R.R., J.L.S., A.L.K, M.B.P., N.E.B., T.D.G., R.S.D., G.R.B., E.W.E., P.P.P.), the Center for Health Services Research (C.G.H., J.C.J., R.R., M.B.P., T.D.G., R.S.D., E.W.E., P.P.P.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (C.G.H., P.P.P.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., B.T.P., G.R.B., E.W.E.), and the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Departments of Biostatistics (O.M.O., R.R.) and Pharmaceutical Services (J.L.S.), and Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), Vanderbilt University Medical Center, and the Anesthesia Service (C.G.H., P.P.P.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education and Clinical Center (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - both in Nashville; the Neuroscience Institute and Department of Critical Care Medicine, Maine Medical Center, Portland (P.T.M.); the Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston (J.W.D., M.S.D.); the Departments of Pharmacy (J.T.S., L.N.B.) and Surgery (J.T.S.) and the Center for Outcomes Research (J.T.S.), Houston Methodist, and the Pulmonary, Critical Care and Sleep Medicine Section, Ben Taub Hospital, Baylor College of Medicine (K.K.G.), Houston; the Division of Pulmonary/Critical Care Medicine, University of Texas Health, and the South Texas Veterans Health Care System, San Antonio (A.A.); and Texas Health Harris Methodist Hospital Fort Worth, Fort Worth (A.S.) - all in Texas; the University of Sydney, and the Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, and the Department of Anesthesiology, University of Wisconsin, Madison (R.D.S.); Pulmonary and Critical Care Medicine, Baton Rouge General Medical Center and Our Lady of the Lake Regional Medical Center, Baton Rouge, LA (H.R.O.); the Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco (M.A.G.); Pulmonary and Critical Care, Mission Hospital, Asheville, NC (G.J.S.); the Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus (N.E.B.); and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.)
| | - Gordon R Bernard
- From the Critical Illness, Brain Dysfunction, and Survivorship Center (C.G.H., J.C.J., A.S.H., B.T.P., O.M.O., R.R., J.L.S., A.L.K, M.B.P., N.E.B., T.D.G., R.S.D., G.R.B., E.W.E., P.P.P.), the Center for Health Services Research (C.G.H., J.C.J., R.R., M.B.P., T.D.G., R.S.D., E.W.E., P.P.P.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (C.G.H., P.P.P.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., B.T.P., G.R.B., E.W.E.), and the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Departments of Biostatistics (O.M.O., R.R.) and Pharmaceutical Services (J.L.S.), and Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), Vanderbilt University Medical Center, and the Anesthesia Service (C.G.H., P.P.P.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education and Clinical Center (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - both in Nashville; the Neuroscience Institute and Department of Critical Care Medicine, Maine Medical Center, Portland (P.T.M.); the Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston (J.W.D., M.S.D.); the Departments of Pharmacy (J.T.S., L.N.B.) and Surgery (J.T.S.) and the Center for Outcomes Research (J.T.S.), Houston Methodist, and the Pulmonary, Critical Care and Sleep Medicine Section, Ben Taub Hospital, Baylor College of Medicine (K.K.G.), Houston; the Division of Pulmonary/Critical Care Medicine, University of Texas Health, and the South Texas Veterans Health Care System, San Antonio (A.A.); and Texas Health Harris Methodist Hospital Fort Worth, Fort Worth (A.S.) - all in Texas; the University of Sydney, and the Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, and the Department of Anesthesiology, University of Wisconsin, Madison (R.D.S.); Pulmonary and Critical Care Medicine, Baton Rouge General Medical Center and Our Lady of the Lake Regional Medical Center, Baton Rouge, LA (H.R.O.); the Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco (M.A.G.); Pulmonary and Critical Care, Mission Hospital, Asheville, NC (G.J.S.); the Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus (N.E.B.); and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.)
| | - E Wesley Ely
- From the Critical Illness, Brain Dysfunction, and Survivorship Center (C.G.H., J.C.J., A.S.H., B.T.P., O.M.O., R.R., J.L.S., A.L.K, M.B.P., N.E.B., T.D.G., R.S.D., G.R.B., E.W.E., P.P.P.), the Center for Health Services Research (C.G.H., J.C.J., R.R., M.B.P., T.D.G., R.S.D., E.W.E., P.P.P.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (C.G.H., P.P.P.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., B.T.P., G.R.B., E.W.E.), and the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Departments of Biostatistics (O.M.O., R.R.) and Pharmaceutical Services (J.L.S.), and Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), Vanderbilt University Medical Center, and the Anesthesia Service (C.G.H., P.P.P.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education and Clinical Center (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - both in Nashville; the Neuroscience Institute and Department of Critical Care Medicine, Maine Medical Center, Portland (P.T.M.); the Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston (J.W.D., M.S.D.); the Departments of Pharmacy (J.T.S., L.N.B.) and Surgery (J.T.S.) and the Center for Outcomes Research (J.T.S.), Houston Methodist, and the Pulmonary, Critical Care and Sleep Medicine Section, Ben Taub Hospital, Baylor College of Medicine (K.K.G.), Houston; the Division of Pulmonary/Critical Care Medicine, University of Texas Health, and the South Texas Veterans Health Care System, San Antonio (A.A.); and Texas Health Harris Methodist Hospital Fort Worth, Fort Worth (A.S.) - all in Texas; the University of Sydney, and the Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, and the Department of Anesthesiology, University of Wisconsin, Madison (R.D.S.); Pulmonary and Critical Care Medicine, Baton Rouge General Medical Center and Our Lady of the Lake Regional Medical Center, Baton Rouge, LA (H.R.O.); the Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco (M.A.G.); Pulmonary and Critical Care, Mission Hospital, Asheville, NC (G.J.S.); the Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus (N.E.B.); and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.)
| | - Pratik P Pandharipande
- From the Critical Illness, Brain Dysfunction, and Survivorship Center (C.G.H., J.C.J., A.S.H., B.T.P., O.M.O., R.R., J.L.S., A.L.K, M.B.P., N.E.B., T.D.G., R.S.D., G.R.B., E.W.E., P.P.P.), the Center for Health Services Research (C.G.H., J.C.J., R.R., M.B.P., T.D.G., R.S.D., E.W.E., P.P.P.), the Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology (C.G.H., P.P.P.), the Division of Allergy, Pulmonary, and Critical Care Medicine (J.C.J., B.T.P., G.R.B., E.W.E.), and the Division of General Internal Medicine and Public Health (R.S.D.), Department of Medicine, the Departments of Biostatistics (O.M.O., R.R.) and Pharmaceutical Services (J.L.S.), and Division of Trauma and Surgical Critical Care, Department of Surgery (M.B.P.), Vanderbilt University Medical Center, and the Anesthesia Service (C.G.H., P.P.P.), Research Service (J.C.J.), Surgical Service (M.B.P.), and Geriatric Research, Education and Clinical Center (R.S.D., E.W.E.), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System - both in Nashville; the Neuroscience Institute and Department of Critical Care Medicine, Maine Medical Center, Portland (P.T.M.); the Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston (J.W.D., M.S.D.); the Departments of Pharmacy (J.T.S., L.N.B.) and Surgery (J.T.S.) and the Center for Outcomes Research (J.T.S.), Houston Methodist, and the Pulmonary, Critical Care and Sleep Medicine Section, Ben Taub Hospital, Baylor College of Medicine (K.K.G.), Houston; the Division of Pulmonary/Critical Care Medicine, University of Texas Health, and the South Texas Veterans Health Care System, San Antonio (A.A.); and Texas Health Harris Methodist Hospital Fort Worth, Fort Worth (A.S.) - all in Texas; the University of Sydney, and the Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, and the Department of Anesthesiology, University of Wisconsin, Madison (R.D.S.); Pulmonary and Critical Care Medicine, Baton Rouge General Medical Center and Our Lady of the Lake Regional Medical Center, Baton Rouge, LA (H.R.O.); the Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco (M.A.G.); Pulmonary and Critical Care, Mission Hospital, Asheville, NC (G.J.S.); the Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus (N.E.B.); and Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh (T.D.G.)
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Halpin DMG, Criner GJ, Papi A, Singh D, Anzueto A, Martinez FJ, Agusti AA. Global Initiative for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease. The 2020 GOLD Science Committee Report on COVID-19 and Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med 2021; 203:24-36. [PMID: 33146552 PMCID: PMC7781116 DOI: 10.1164/rccm.202009-3533so] [Citation(s) in RCA: 351] [Impact Index Per Article: 117.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 11/04/2020] [Indexed: 02/07/2023] Open
Abstract
The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has raised many questions about the management of patients with chronic obstructive pulmonary disease (COPD) and whether modifications of their therapy are required. It has raised questions about recognizing and differentiating coronavirus disease (COVID-19) from COPD given the similarity of the symptoms. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) Science Committee used established methods for literature review to present an overview of the management of patients with COPD during the COVID-19 pandemic. It is unclear whether patients with COPD are at increased risk of becoming infected with SARS-CoV-2. During periods of high community prevalence of COVID-19, spirometry should only be used when it is essential for COPD diagnosis and/or to assess lung function status for interventional procedures or surgery. Patients with COPD should follow basic infection control measures, including social distancing, hand washing, and wearing a mask or face covering. Patients should remain up to date with appropriate vaccinations, particularly annual influenza vaccination. Although data are limited, inhaled corticosteroids, long-acting bronchodilators, roflumilast, or chronic macrolides should continue to be used as indicated for stable COPD management. Systemic steroids and antibiotics should be used in COPD exacerbations according to the usual indications. Differentiating symptoms of COVID-19 infection from chronic underlying symptoms or those of an acute COPD exacerbation may be challenging. If there is suspicion for COVID-19, testing for SARS-CoV-2 should be considered. Patients who developed moderate-to-severe COVID-19, including hospitalization and pneumonia, should be treated with evolving pharmacotherapeutic approaches as appropriate, including remdesivir, dexamethasone, and anticoagulation. Managing acute respiratory failure should include appropriate oxygen supplementation, prone positioning, noninvasive ventilation, and protective lung strategy in patients with COPD and severe acute respiratory distress syndrome. Patients who developed asymptomatic or mild COVID-19 should be followed with the usual COPD protocols. Patients who developed moderate or worse COVID-19 should be monitored more frequently and accurately than the usual patients with COPD, with particular attention to the need for oxygen therapy.
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Affiliation(s)
- David M. G. Halpin
- College of Medicine and Health, University of Exeter Medical School, University of Exeter, Exeter, United Kingdom
| | - Gerard J. Criner
- Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania
| | - Alberto Papi
- Department of Medical Sciences, Cardiorespiratory and Internal Medicine Unit, University of Ferrara, Ferrara, Italy
| | - Dave Singh
- Manchester University NHS Foundation Trust, University of Manchester, Manchester, United Kingdom
| | - Antonio Anzueto
- Division of Pulmonary/Critical Care Medicine, South Texas Veterans Health Care System, University of Texas Health, University of Texas, San Antonio, Texas
| | - Fernando J. Martinez
- Division of Pulmonary and Critical Care Medicine, Weill Cornell Medical College, New York, New York
| | - Alvar A. Agusti
- Hospital Clinic, IDIBAPS, University of Barcelona, CIBERES, Barcelona, Spain; and
| | - on behalf of the GOLD Science Committee
- College of Medicine and Health, University of Exeter Medical School, University of Exeter, Exeter, United Kingdom
- Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania
- Department of Medical Sciences, Cardiorespiratory and Internal Medicine Unit, University of Ferrara, Ferrara, Italy
- Manchester University NHS Foundation Trust, University of Manchester, Manchester, United Kingdom
- Division of Pulmonary/Critical Care Medicine, South Texas Veterans Health Care System, University of Texas Health, University of Texas, San Antonio, Texas
- Division of Pulmonary and Critical Care Medicine, Weill Cornell Medical College, New York, New York
- Hospital Clinic, IDIBAPS, University of Barcelona, CIBERES, Barcelona, Spain; and
- Department of Medicine, Pulmonary, and Critical Care Medicine, the German Center for Lung Research, University Medical Center Giessen and Marburg, Philipps-University Marburg, Marburg, Germany
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Protti A, Greco M, Filippini M, Vilardo AM, Langer T, Villa M, Frutos-Vivar F, Santini A, Caruso PF, Spano S, Anzueto A, Citerio G, Bellani G, Foti G, Fumagalli R, Pesenti A, Grasselli G, Cecconi M. Barotrauma in mechanically ventilated patients with Coronavirus disease 2019: a survey of 38 hospitals in Lombardy, Italy. Minerva Anestesiol 2020; 87:193-198. [PMID: 33325217 DOI: 10.23736/s0375-9393.20.15002-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND The aim was to describe the incidence and risk factors of barotrauma in patients with the Coronavirus disease 2019 (COVID-19) on invasive mechanical ventilation, during the outbreak in our region (Lombardy, Italy). METHODS The study was an electronic survey open from March 27th to May 2nd, 2020. Patients with COVID-19 who developed barotrauma while on invasive mechanical ventilation from 61 hospitals of the COVID-19 Lombardy Intensive Care Unit network were involved. RESULTS The response rate was 38/61 (62%). The incidence of barotrauma was 145/2041 (7.1%; 95%-CI: 6.1-8.3%). Only a few cases occurred with ventilatory settings that may be considered non-protective such as a plateau airway pressure >35 cmH<inf>2</inf>O (2/113 [2%]), a driving airway pressure >15 cmH<inf>2</inf>O (30/113 [27%]), or a tidal volume >8 mL/kg of ideal body weight and a plateau airway pressure >30 cmH<inf>2</inf>O (12/134 [9%]). CONCLUSIONS Within the limits of a survey, patients with COVID-19 might be at high risk for barotrauma during invasive (and allegedly lung-protective) mechanical ventilation.
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Affiliation(s)
- Alessandro Protti
- Department of Anesthesiology and Intensive Care Units, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy.,Humanitas University, Pieve Emanuele, Milan, Italy
| | - Massimiliano Greco
- Department of Anesthesiology and Intensive Care Units, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy - .,Humanitas University, Pieve Emanuele, Milan, Italy
| | | | - Anna M Vilardo
- ASST Pavia, Ospedale Civile di Voghera, Voghera, Pavia, Italy
| | - Thomas Langer
- ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy.,University of Milano-Bicocca, Milan, Italy
| | | | | | - Alessandro Santini
- Department of Anesthesiology and Intensive Care Units, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Pier F Caruso
- Department of Anesthesiology and Intensive Care Units, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy.,Humanitas University, Pieve Emanuele, Milan, Italy
| | - Sofia Spano
- Department of Anesthesiology and Intensive Care Units, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy.,Humanitas University, Pieve Emanuele, Milan, Italy
| | - Antonio Anzueto
- University of Texas Health, and South Texas Veterans Health Care System, San Antonio, TX, USA
| | - Giuseppe Citerio
- University of Milano-Bicocca, Milan, Italy.,ASST Monza, Hospital of Desio, Monza, Monza-Brianza, Italy
| | - Giacomo Bellani
- University of Milano-Bicocca, Milan, Italy.,ASST Monza, San Gerardo Hospital, Monza, Monza-Brianza, Italy
| | - Giuseppe Foti
- University of Milano-Bicocca, Milan, Italy.,ASST Monza, San Gerardo Hospital, Monza, Monza-Brianza, Italy
| | - Roberto Fumagalli
- ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy.,University of Milano-Bicocca, Milan, Italy
| | - Antonio Pesenti
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,University of Milan, Milan, Italy
| | - Giacomo Grasselli
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,University of Milan, Milan, Italy
| | - Maurizio Cecconi
- Department of Anesthesiology and Intensive Care Units, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy.,Humanitas University, Pieve Emanuele, Milan, Italy
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Anzueto A, Smyth HDC. Letter to the Editor in response to the article: "Nebulization: a potential source of SARS-CoV-2 transmission". Respir Med Res 2020; 79:100802. [PMID: 33618077 PMCID: PMC7670916 DOI: 10.1016/j.resmer.2020.100802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 11/09/2020] [Indexed: 10/27/2022]
Affiliation(s)
- A Anzueto
- UT Health, and South Texas Health Care System, San Antonio, TX, USA.
| | - H D C Smyth
- College of Pharmacy, The University of Texas at Austin, Austin, TX, USA
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Soriano JB, Anzueto A, Bosnic Anticevich S, Kaplan A, Miravitlles M, Usmani O, Papadopoulos NG, Puggioni F, Canonica GW, Roche N. Face masks, respiratory patients and COVID-19. Eur Respir J 2020; 56:13993003.03325-2020. [PMID: 32994197 PMCID: PMC7525001 DOI: 10.1183/13993003.03325-2020] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 09/07/2020] [Indexed: 11/05/2022]
Affiliation(s)
- Joan B Soriano
- Servicio de Neumología, Hospital Universitario La Princesa, Madrid, Spain .,Centro de Investigación en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Antonio Anzueto
- Division of Pulmonary Diseases and Critical Care Medicine, The University of Texas Health, San Antonio, TX, USA.,Pulmonary Diseases Section, Audie L. Murphy Memorial VA Hospital, South Texas Veterans Health Care System, San Antonio, TX, USA
| | - Sinthia Bosnic Anticevich
- Woolcock Institute of Medical Research, The University of Sydney, Sydney Local Health District, Sydney, Australia
| | - Alan Kaplan
- Dept of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Marc Miravitlles
- Centro de Investigación en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III (ISCIII), Madrid, Spain.,Pneumology Dept, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Omar Usmani
- National Heart and Lung Institute, Imperial College London and Royal Brompton Hospital, Airways Disease Section, London, UK
| | - Nikolaos G Papadopoulos
- Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester, UK.,Allergy Dept, 2nd Pediatric Clinic, National and Kapodistrian University of Athens, Athens, Greece
| | - Francesca Puggioni
- Personalized Medicine, Asthma and Allergy, Humanitas Clinical and Research Center, IRCCS, Rozzano, Italy.,Dept of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - G Walter Canonica
- Personalized Medicine, Asthma and Allergy, Humanitas Clinical and Research Center, IRCCS, Rozzano, Italy.,Dept of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Nicolas Roche
- Respiratory Medicine, Hôpital Cochin, APHP Centre, Université de Paris (UMR1016, Institut Cochin), Paris, France
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Anzueto A, Kaplan A. Dual bronchodilators in chronic obstructive pulmonary disease: Evidence from randomized controlled trials and real-world studies. Respiratory Medicine: X 2020. [DOI: 10.1016/j.yrmex.2020.100016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Surani S, Anzueto A, Rodriguez M, Chitra S, Gunter K. TREATMENT OF LEGIONELLA PNEUMOPHILA USING OMADACYCLINE VS MOXIFLOXACIN: SUBANALYSIS RESULTS FROM A PHASE 3 RANDOMIZED, DOUBLE-BLIND, MULTICENTER STUDY (OPTIC). Chest 2020. [DOI: 10.1016/j.chest.2020.08.306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Wedzicha JA, Buhl R, Singh D, Vogelmeier CF, de la Hoz A, Xue W, Anzueto A, Calverley PMA. Tiotropium/Olodaterol Decreases Exacerbation Rates Compared with Tiotropium in a Range of Patients with COPD: Pooled Analysis of the TONADO ®/DYNAGITO ® Trials. Adv Ther 2020; 37:4266-4279. [PMID: 32776202 DOI: 10.1007/s12325-020-01438-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Indexed: 01/30/2023]
Abstract
INTRODUCTION Previous studies demonstrated that tiotropium/olodaterol reduced rates of exacerbations in patients with chronic obstructive pulmonary disease (COPD). However, this should be examined in a wider population. METHODS This post hoc analysis pooled data from TONADO® 1 + 2 and DYNAGITO®, three 52-week, parallel-group, randomised, double-blind, phase III trials investigating patients with moderate-to-very severe COPD, with and without previous exacerbations, who received tiotropium/olodaterol 5/5 µg or tiotropium 5 µg. Subgroup analyses were conducted on patients stratified by exacerbation history, Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage 2-4 disease severity and baseline inhaled corticosteroid (ICS) use. RESULTS In 9942 patients, tiotropium/olodaterol was associated with lower rates of moderate/severe exacerbations (0.68 vs. 0.77 per patient-year; rate ratio (RR) vs. tiotropium 0.89, 95% confidence interval (CI) 0.84, 0.95; P = 0.0003) and exacerbations requiring hospitalisation (0.11 vs. 0.13 per patient-year; RR 0.86, 95% CI 0.75, 0.99; P = 0.0380) versus tiotropium. Lower rates of moderate/severe exacerbations with tiotropium/olodaterol versus tiotropium were evident in patients with 0-1 moderate exacerbation in the previous year (0.54 vs. 0.60 per patient-year; RR 0.90, 95% CI 0.82, 0.98; P = 0.0187) and at least two moderate or at least one severe exacerbation(s) in the previous year (0.97 vs. 1.09 per patient-year; RR 0.89, 95% CI 0.82, 0.97; P = 0.0096). In patients with GOLD 2 and GOLD 3 COPD, moderate/severe exacerbation rates were lower with tiotropium/olodaterol versus tiotropium; GOLD 4 patients showed negligible difference between treatments. When evaluating patients by baseline ICS use, there was a significantly lower rate of moderate/severe exacerbations with tiotropium/olodaterol versus tiotropium in patients receiving ICS. CONCLUSIONS Tiotropium/olodaterol decreased the rate of moderate/severe exacerbations and exacerbations leading to hospitalisation versus tiotropium. Results from this large, pooled, post hoc analysis support the use of dual bronchodilation with tiotropium/olodaterol in a broad range of patients, reflective of patients with COPD in clinical practice. TRIAL REGISTRATION TONADO® 1 (ClinicalTrials.gov: NCT01431274); TONADO® 2 (ClinicalTrials.gov: NCT01431287); DYNAGITO® (ClinicalTrials.gov: NCT02296138). People with chronic obstructive pulmonary disease (COPD) may have times when their symptoms worsen, known as exacerbations. This may mean that they need to take additional medications, such as antibiotics or oral steroids. Studies have shown that a combination of two types of inhaled medicine-tiotropium and olodaterol-can help to reduce exacerbations in some people. To see if this is also the case across a larger and more diverse range of people, we combined the results from three studies (TONADO® 1 + 2 and DYNAGITO®) that looked at people who were taking tiotropium and olodaterol together and people who were taking tiotropium alone. We showed that, across a wide range of people, treatment with tiotropium/olodaterol was generally better at reducing exacerbations than tiotropium. Tiotropium/olodaterol also decreased the number of exacerbations that led to hospitalisation compared with tiotropium. Overall, our results support the use of combined tiotropium/olodaterol in people at different stages of COPD.
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Affiliation(s)
- Jadwiga A Wedzicha
- Respiratory Division, National Heart and Lung Institute, Imperial College London, London, UK.
| | - Roland Buhl
- Johannes Gutenberg University Mainz, Mainz, Germany
| | - Dave Singh
- Medicines Evaluation Unit, University of Manchester, Manchester University NHS Foundation Trust, Manchester, UK
| | - Claus F Vogelmeier
- Department of Medicine, Pulmonary and Critical Care Medicine, University Medical Center Giessen and Marburg, Philipps University of Marburg, Member of the German Center for Lung Research (DZL), Marburg, Germany
| | - Alberto de la Hoz
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Wenqiong Xue
- Boehringer Ingelheim Pharmaceuticals Inc., Ridgefield, CT, USA
| | - Antonio Anzueto
- Department of Pulmonary Medicine and Critical Care, University of Texas Health Sciences Center and South Texas Veterans Health Care System, San Antonio, TX, USA
| | - Peter M A Calverley
- Clinical Science Centre, Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
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Abstract
Background Bronchodilators are the mainstay of pharmacological treatment in chronic obstructive pulmonary disease (COPD), and long-acting muscarinic antagonist (LAMA) monotherapy is recommended as initial treatment for Global Initiative for Chronic Obstructive Lung Disease (GOLD) groups B, C, and D. Main body Tiotropium bromide was the first LAMA available for COPD in clinical practice and, because of its long duration of action, is administered once daily. Tiotropium was initially available as an inhalation powder delivered via a dry-powder inhaler (DPI). Later, tiotropium also became available as an inhalation spray delivered via a soft mist inhaler (SMI). The SMI was designed to overcome or minimize some of the issues associated with other inhaler types (eg, the need for strong inspiratory airflow with DPIs). Results of short- and long-term randomized, controlled clinical trials of tiotropium in patients with COPD indicated tiotropium was safe and significantly improved lung function, health-related quality of life, and exercise endurance, and reduced dyspnea, lung hyperinflation, exacerbations, and use of rescue medication compared with placebo or active comparators. These positive efficacy findings triggered the evaluation of tiotropium in fixed-dose combination with olodaterol (a long-acting β2-agonist). In this review, we provide an overview of studies of tiotropium for the treatment of COPD, with a focus on pivotal studies. Conclusion Tiotropium is safe and efficacious as a long-term, once-daily LAMA for the maintenance treatment of COPD and for reducing COPD exacerbations. The SMI generates a low-velocity, long-duration aerosol spray with a high fine-particle fraction, which results in marked lung drug deposition. In addition, high inspiratory flow rates are not required.
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Affiliation(s)
- Antonio Anzueto
- Internal Medicine, Pulmonary Disease, University of Texas Health, and South Texas Veterans Health Care System, San Antonio, TX, USA.
| | - Marc Miravitlles
- Pneumology Department, Hospital Universitary Vall d'Hebron/Vall d'Hebron Research Institute (VHIR). CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
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Marin-Corral J, Pascual-Guardia S, Amati F, Aliberti S, Masclans JR, Soni N, Rodriguez A, Sibila O, Sanz F, Sotgiu G, Anzueto A, Dimakou K, Petrino R, van de Garde E, Restrepo MI. Aspiration Risk Factors, Microbiology, and Empiric Antibiotics for Patients Hospitalized With Community-Acquired Pneumonia. Chest 2020; 159:58-72. [PMID: 32687909 DOI: 10.1016/j.chest.2020.06.079] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 06/18/2020] [Accepted: 06/22/2020] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Aspiration community-acquired pneumonia (ACAP) and community-acquired pneumonia (CAP) in patients with aspiration risk factors (AspRFs) are infections associated with anaerobes, but limited evidence suggests their pathogenic role. RESEARCH QUESTION What are the aspiration risk factors, microbiology patterns, and empiric anti-anaerobic use in patients hospitalized with CAP? STUDY DESIGN AND METHODS This is a secondary analysis of GLIMP, an international, multicenter, point-prevalence study of adults hospitalized with CAP. Patients were stratified into three groups: (1) ACAP, (2) CAP/AspRF+ (CAP with AspRF), and (3) CAP/AspRF- (CAP without AspRF). Data on demographics, comorbidities, microbiological results, and anti-anaerobic antibiotics were analyzed in all groups. Patients were further stratified in severe and nonsevere CAP groups. RESULTS We enrolled 2,606 patients with CAP, of which 193 (7.4%) had ACAP. Risk factors independently associated with ACAP were male, bedridden, underweight, a nursing home resident, and having a history of stroke, dementia, mental illness, and enteral tube feeding. Among non-ACAP patients, 1,709 (70.8%) had CAP/AspRF+ and 704 (29.2%) had CAP/AspRF-. Microbiology patterns including anaerobes were similar between CAP/AspRF-, CAP/AspRF+ and ACAP (0.0% vs 1.03% vs 1.64%). Patients with severe ACAP had higher rates of total gram-negative bacteria (64.3% vs 44.3% vs 33.3%, P = .021) and lower rates of total gram-positive bacteria (7.1% vs 38.1% vs 50.0%, P < .001) when compared with patients with severe CAP/AspRF+ and severe CAP/AspRF-, respectively. Most patients (>50% in all groups) independent of AspRFs or ACAP received specific or broad-spectrum anti-anaerobic coverage antibiotics. INTERPRETATION Hospitalized patients with ACAP or CAP/AspRF+ had similar anaerobic flora compared with patients without aspiration risk factors. Gram-negative bacteria were more prevalent in patients with severe ACAP. Despite having similar microbiological flora between groups, a large proportion of CAP patients received anti-anaerobic antibiotic coverage.
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Affiliation(s)
- Judith Marin-Corral
- Critical Care Department, Hospital del Mar, Barcelona, Spain, and the Critical Illness Research Group (GREPAC), Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain; Division of Pulmonary Diseases & Critical Care Medicine, University of Texas Health San Antonio, San Antonio, TX
| | - Sergi Pascual-Guardia
- Division of Pulmonary Diseases & Critical Care Medicine, University of Texas Health San Antonio, San Antonio, TX; Respiratory Department, Hospital del Mar, IMIM, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Spain
| | - Francesco Amati
- Fondazione IRCCS Ca Granda Ospedale Maggiore Policlinico, Respiratory Unit and Cystic Fibrosis Adult Center, and University of Milan, Department of Pathophysiology and Transplantation, Milan, Italy
| | - Stefano Aliberti
- Fondazione IRCCS Ca Granda Ospedale Maggiore Policlinico, Respiratory Unit and Cystic Fibrosis Adult Center, and University of Milan, Department of Pathophysiology and Transplantation, Milan, Italy
| | - Joan R Masclans
- Critical Care Department, Hospital del Mar, Barcelona, Spain, and the Critical Illness Research Group (GREPAC), Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain; Department of Medicine, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Nilam Soni
- Division of Pulmonary Diseases & Critical Care Medicine, University of Texas Health San Antonio, San Antonio, TX; Section of Pulmonary & Critical Care Medicine, South Texas Veterans Health Care System, San Antonio, TX
| | - Alejandro Rodriguez
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Spain; Critical Care Medicine, Hospital Universitari Joan XXIII and Rovira & Virgili University, Tarragona, Spain
| | - Oriol Sibila
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Spain; Department of Pulmonary Medicine, Hospital Clínic-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) and University of Barcelona, Barcelona, Spain
| | - Francisco Sanz
- Pulmonology Department, Consorci Hospital General Universitari de Valencia, Valencia, Spain
| | - Giovanni Sotgiu
- Clinical Epidemiology and Medical Statistics Unit, Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
| | - Antonio Anzueto
- Division of Pulmonary Diseases & Critical Care Medicine, University of Texas Health San Antonio, San Antonio, TX; Section of Pulmonary & Critical Care Medicine, South Texas Veterans Health Care System, San Antonio, TX
| | - Katerina Dimakou
- 5th Department of Pulmonary Medicine, Sotiria Chest Diseases Hospital, Athens, Greece
| | | | - Ewoudt van de Garde
- Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Marcos I Restrepo
- Division of Pulmonary Diseases & Critical Care Medicine, University of Texas Health San Antonio, San Antonio, TX; Section of Pulmonary & Critical Care Medicine, South Texas Veterans Health Care System, San Antonio, TX.
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Ramirez JA, Musher DM, Evans SE, Dela Cruz C, Crothers KA, Hage CA, Aliberti S, Anzueto A, Arancibia F, Arnold F, Azoulay E, Blasi F, Bordon J, Burdette S, Cao B, Cavallazzi R, Chalmers J, Charles P, Chastre J, Claessens YE, Dean N, Duval X, Fartoukh M, Feldman C, File T, Froes F, Furmanek S, Gnoni M, Lopardo G, Luna C, Maruyama T, Menendez R, Metersky M, Mildvan D, Mortensen E, Niederman MS, Pletz M, Rello J, Restrepo MI, Shindo Y, Torres A, Waterer G, Webb B, Welte T, Witzenrath M, Wunderink R. Treatment of Community-Acquired Pneumonia in Immunocompromised Adults: A Consensus Statement Regarding Initial Strategies. Chest 2020; 158:1896-1911. [PMID: 32561442 PMCID: PMC7297164 DOI: 10.1016/j.chest.2020.05.598] [Citation(s) in RCA: 92] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 04/03/2020] [Accepted: 05/09/2020] [Indexed: 12/23/2022] Open
Abstract
Background Community-acquired pneumonia (CAP) guidelines have improved the treatment and outcomes of patients with CAP, primarily by standardization of initial empirical therapy. But current society-published guidelines exclude immunocompromised patients. Research Question There is no consensus regarding the initial treatment of immunocompromised patients with suspected CAP. Study Design and Methods This consensus document was created by a multidisciplinary panel of 45 physicians with experience in the treatment of CAP in immunocompromised patients. The Delphi survey methodology was used to reach consensus. Results The panel focused on 21 questions addressing initial management strategies. The panel achieved consensus in defining the population, site of care, likely pathogens, microbiologic workup, general principles of empirical therapy, and empirical therapy for specific pathogens. Interpretation This document offers general suggestions for the initial treatment of the immunocompromised patient who arrives at the hospital with pneumonia.
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Affiliation(s)
- Julio A Ramirez
- Division of Infectious Diseases, University of Louisville, Louisville, KY.
| | - Daniel M Musher
- Baylor College of Medicine and Michael E. DeBakey VA Medical Center, Houston, TX
| | - Scott E Evans
- Department of Pulmonary Medicine, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Charles Dela Cruz
- Pulmonary, Critical Care and Sleep Medicine, Yale University, New Haven, CT
| | - Kristina A Crothers
- Veterans Puget Sound Health Care System, University of Washington, Seattle WA
| | - Chadi A Hage
- Thoracic Transplant Program, Indiana University, Indianapolis, IN
| | - Stefano Aliberti
- Department of Pathophysiology and Transplantation, University of Milan, and Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Respiratory Unit and Cystic Fibrosis Adult Center, Milan, Italy
| | - Antonio Anzueto
- South Texas Veterans Health Care System, Audie L. Murphy Memorial Veterans Hospital, and University of Texas Health, San Antonio, TX
| | - Francisco Arancibia
- Pneumology Service, Instituto Nacional del Tórax and Clínica Santa María, Santiago de Chile, Chile
| | - Forest Arnold
- Division of Infectious Diseases, University of Louisville, Louisville, KY
| | - Elie Azoulay
- Medical ICU, Saint-Louis Teaching Hospital, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France
| | - Francesco Blasi
- Department of Pathophysiology and Transplantation, University of Milan, and Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Respiratory Unit and Cystic Fibrosis Adult Center, Milan, Italy
| | - Jose Bordon
- Section of Infectious Diseases, Providence Health Center, Washington, DC
| | - Steven Burdette
- Wright State University Boonshoft School of Medicine, Dayton, OH
| | - Bin Cao
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, National Clinical Research Center for Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China
| | - Rodrigo Cavallazzi
- Division of Pulmonary, Critical Care, and Sleep Disorders Medicine, University of Louisville, Louisville, KY
| | - James Chalmers
- Scottish Centre for Respiratory Research, School of Medicine, Ninewells Hospital and Medical School, Dundee, UK
| | - Patrick Charles
- Department of Infectious Diseases, Austin Health and Department of Medicine, University of Melbourne, Australia
| | - Jean Chastre
- Service de Médecine Intensive-Réanimation, Hôpital La Pitié-Salpêtrière, Sorbonne Université, APHP, Paris, France
| | | | - Nathan Dean
- Intermountain Medical Center and the University of Utah, Salt Lake City, UT
| | - Xavier Duval
- UMR 1137, IAME, INSERM, and CIC 1425, Hôpital Bichat-Claude Bernard, APHP, Paris, France
| | - Muriel Fartoukh
- Service de Médecine Intensive Réanimation, Hôpital Tenon, APHP, and APHP, Sorbonne Université, Faculté de Médecine Sorbonne Université, Paris, France
| | - Charles Feldman
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Thomas File
- Infectious Disease Section, Northeast Ohio Medical University and Infectious Disease Division, Summa Health, Akron, OH
| | - Filipe Froes
- ICU, Chest Department, Hospital Pulido Valente-Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
| | - Stephen Furmanek
- Division of Infectious Diseases, University of Louisville, Louisville, KY
| | - Martin Gnoni
- Division of Infectious Diseases, University of Louisville, Louisville, KY
| | - Gustavo Lopardo
- Fundación del Centro de Estudios Infectológicos, Buenos Aires, Argentina
| | - Carlos Luna
- Pulmonary Diseases Division, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Takaya Maruyama
- Department of Respiratory Medicine, National Hospital Organization Mie National Hospital, Tsu, Japan
| | - Rosario Menendez
- Pneumology Department, La Fe University and Polytechnic Hospital, La Fe Health Research Institute, Valencia, Spain
| | - Mark Metersky
- Division of Pulmonary, Critical Care and Sleep Medicine and Center for Bronchiectasis Care, University of Connecticut Health, Farmington, CT
| | - Donna Mildvan
- Icahn School of Medicine at Mount Sinai, New York, NY
| | - Eric Mortensen
- Department of Medicine, University of Connecticut Health Center, Farmington, CT
| | - Michael S Niederman
- Pulmonary and Critical Care, New York Presbyterian/Weill Cornell Medical Center and Weill Cornell Medical College, New York, NY
| | - Mathias Pletz
- Institute for Infectious Diseases and Infection Control, Jena University Hospital, Jena, Germany
| | - Jordi Rello
- Centro de Investigacion Biomedica en Red de Enfermedades Respiratorias, Instituto de Salud Carlos III, and Infections Area, Vall d'Hebron Institute of Research, Barcelona, Spain
| | - Marcos I Restrepo
- South Texas Veterans Health Care System, Audie L. Murphy Memorial Veterans Hospital, and University of Texas Health, San Antonio, TX
| | - Yuichiro Shindo
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Antoni Torres
- Servei de Pneumologia, Hospital Clinic, Universitat de Barcelona. Barcelona, CIBERES, Spain
| | - Grant Waterer
- School of Medicine, University of Western Australia, Perth, Australia
| | - Brandon Webb
- Division of Infectious Diseases and Clinical Epidemiology, Intermountain Healthcare, Salt Lake City, UT and Division of Infectious Diseases and Geographic Medicine, Stanford Medicine, Palo Alto, CA
| | - Tobias Welte
- German Center for Lung Research, Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH) Clinic of Pneumology, Hannover Medical School, Hannover, Germany
| | - Martin Witzenrath
- Division of Pulmonary Inflammation and Department of Infectious Diseases and Respiratory Medicine, Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Richard Wunderink
- Pulmonary and Critical Care, Northwestern University Feinberg School of Medicine, Chicago, IL
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Peñuelas O, Frutos-Vivar F, Muriel A, Mancebo J, García-Jiménez A, de Pablo R, Valledor M, Ferrer M, León M, Quiroga JM, Temprano S, Vallverdú I, Fernández R, Gordo F, Anzueto A, Esteban A. Mechanical ventilation in Spain, 1998-2016: Epidemiology and outcomes. Med Intensiva 2020; 45:3-13. [PMID: 32723483 DOI: 10.1016/j.medin.2020.04.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 03/03/2020] [Accepted: 04/15/2020] [Indexed: 12/14/2022]
Abstract
PURPOSE To evaluate changes in the epidemiology of mechanical ventilation in Spain from 1998 to 2016. DESIGN A post hoc analysis of four cohort studies was carried out. SETTING A total of 138 Spanish ICUs. PATIENTS A sample of 4293 patients requiring invasive mechanical ventilation for more than 12h or noninvasive ventilation for more than 1h. INTERVENTIONS None. VARIABLES OF INTEREST Demographic variables, reason for mechanical ventilation, variables related to ventilatory support (ventilation mode, tidal volume, PEEP, airway pressures), complications during mechanical ventilation, duration of mechanical ventilation, ICU stay and ICU mortality. RESULTS There was an increase in severity (SAPSII: 43 points in 1998 vs. 47 points in 2016), changes in the reason for mechanical ventilation (decrease in chronic obstructive pulmonary disease and acute respiratory failure secondary to trauma, and increase in neurological disease and post-cardiac arrest). There was an increase in noninvasive mechanical ventilation as the first mode of ventilatory support (p<0.001). Volume control ventilation was the most commonly used mode, with increased support pressure and pressure-regulated volume-controlled ventilation. A decrease in tidal volume was observed (9ml/kg actual b.w. in 1998 and 6.6ml/kg in 2016; p<0.001) as well as an increase in PEEP (3cmH2O in 1998 and 6cmH2O in 2016; p<0.001). In-ICU mortality decreased (34% in 1998 and 27% in 2016; p<0.001), without geographical variability (median OR 1.43; p=0.258). CONCLUSIONS A significant decrease in mortality was observed in patients ventilated in Spanish ICUs. These changes in mortality could be related to modifications in ventilation strategy to minimize ventilator-induced lung injury.
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Affiliation(s)
- O Peñuelas
- Hospital Universitario de Getafe y Centro de Investigación en Red de Enfermedades Respiratorias (CIBERES), Madrid, España
| | - F Frutos-Vivar
- Hospital Universitario de Getafe y Centro de Investigación en Red de Enfermedades Respiratorias (CIBERES), Madrid, España.
| | - A Muriel
- Unidad de Bioestadística Clínica Hospital Ramón y Cajal, Instituto Ramón y Cajal de Investigaciones Sanitarias (IRYCIS), Centro de Investigación en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, España
| | - J Mancebo
- Hospital Universitari de la Santa Creu i Sant Pau, Barcelona, España
| | | | | | | | - M Ferrer
- Hospital Clínic-IDIBAPS, Barcelona, España
| | - M León
- Hospital Arnau de Vilanova, Lleida, España
| | | | | | - I Vallverdú
- Hospital Universitari Sant Joan, Reus, España
| | - R Fernández
- Hospital Sant Joan de Déu, Fundació Althaia, Manresa, España
| | - F Gordo
- Grupo de Investigación en Patología Crítica, Universidad Francisco de Vitoria, Pozuelo de Alarcón. Hospital Universitario del Henares, Coslada, España
| | - A Anzueto
- South Texas Veterans Health Care System and University of Texas Health, San Antonio, Texas, Estados Unidos
| | - A Esteban
- Hospital Universitario de Getafe y Centro de Investigación en Red de Enfermedades Respiratorias (CIBERES), Madrid, España
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Hanania NA, Papi A, Anzueto A, Martinez FJ, Rossman KA, Cappelletti CS, Duncan EA, Nyberg JS, Dorinsky PM. Efficacy and safety of two doses of budesonide/formoterol fumarate metered dose inhaler in COPD. ERJ Open Res 2020; 6:00187-2019. [PMID: 32363206 PMCID: PMC7184113 DOI: 10.1183/23120541.00187-2019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 01/19/2020] [Indexed: 11/09/2022] Open
Abstract
Inhaled corticosteroid/long-acting β2-agonist combination therapy is a recommended treatment option for patients with chronic obstructive pulmonary disease (COPD) and increased exacerbation risk, particularly those with elevated blood eosinophil levels. SOPHOS (NCT02727660) evaluated the efficacy and safety of two doses of budesonide/formoterol fumarate dihydrate metered dose inhaler (BFF MDI) versus formoterol fumarate dihydrate (FF) MDI, each delivered using co-suspension delivery technology, in patients with moderate-to-very severe COPD and a history of exacerbations. In this phase 3, randomised, double-blind, parallel-group, 12–52-week, variable length study, patients received twice-daily BFF MDI 320/10 µg or 160/10 µg, or FF MDI 10 µg. The primary endpoint was change from baseline in morning pre-dose trough forced expiratory volume in 1 s (FEV1) at week 12. Secondary and other endpoints included assessments of moderate/severe COPD exacerbations and safety. The primary analysis (modified intent-to-treat) population included 1843 patients (BFF MDI 320/10 µg, n=619; BFF MDI 160/10 µg, n=617; and FF MDI, n=607). BFF MDI 320/10 µg and 160/10 µg improved morning pre-dose trough FEV1 at week 12 versus FF MDI (least squares mean differences 34 mL [p=0.0081] and 32 mL [p=0.0134], respectively), increased time to first exacerbation (hazard ratios 0.827 [p=0.0441] and 0.803 [p=0.0198], respectively) and reduced exacerbation rate (rate ratios 0.67 [p=0.0001] and 0.71 [p=0.0010], respectively). Lung function and exacerbation benefits were driven by patients with blood eosinophil counts ≥150 cells·mm−3. The incidence of adverse events was similar, and pneumonia rates were low (≤2.4%) across treatments. SOPHOS demonstrated the efficacy and tolerability of BFF MDI 320/10 µg and 160/10 µg in patients with moderate-to-very severe COPD at increased risk of exacerbations. Co-suspension delivery technology budesonide/formoterol fumarate metered dose inhaler improve lung function and reduce exacerbation risk versus LABA monotherapy in patients with moderate to very severe COPD and an exacerbation history in the prior yearhttp://bit.ly/3aDOvru
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Affiliation(s)
- Nicola A Hanania
- Section of Pulmonary and Critical Care Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Alberto Papi
- Research Centre on Asthma and COPD, Dept of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Antonio Anzueto
- Pulmonary Medicine and Critical Care, University of Texas Health Science Center and South Texas Veterans Health Care System, San Antonio, TX, USA
| | - Fernando J Martinez
- Joan and Sanford I. Weill Dept of Medicine, Weill Cornell Medicine, New York, NY, USA
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40
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Metlay JP, Waterer GW, Long AC, Anzueto A, Brozek J, Crothers K, Cooley LA, Dean NC, Fine MJ, Flanders SA, Griffin MR, Metersky ML, Musher DM, Restrepo MI, Whitney CG. Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med 2020; 200:e45-e67. [PMID: 31573350 PMCID: PMC6812437 DOI: 10.1164/rccm.201908-1581st] [Citation(s) in RCA: 1703] [Impact Index Per Article: 425.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background: This document provides evidence-based clinical practice guidelines on the management of adult patients with community-acquired pneumonia. Methods: A multidisciplinary panel conducted pragmatic systematic reviews of the relevant research and applied Grading of Recommendations, Assessment, Development, and Evaluation methodology for clinical recommendations. Results: The panel addressed 16 specific areas for recommendations spanning questions of diagnostic testing, determination of site of care, selection of initial empiric antibiotic therapy, and subsequent management decisions. Although some recommendations remain unchanged from the 2007 guideline, the availability of results from new therapeutic trials and epidemiological investigations led to revised recommendations for empiric treatment strategies and additional management decisions. Conclusions: The panel formulated and provided the rationale for recommendations on selected diagnostic and treatment strategies for adult patients with community-acquired pneumonia.
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MESH Headings
- Adult
- Ambulatory Care
- Anti-Bacterial Agents/therapeutic use
- Antigens, Bacterial/urine
- Blood Culture
- Chlamydophila Infections/diagnosis
- Chlamydophila Infections/drug therapy
- Chlamydophila Infections/metabolism
- Community-Acquired Infections/diagnosis
- Community-Acquired Infections/drug therapy
- Culture Techniques
- Drug Therapy, Combination
- Haemophilus Infections/diagnosis
- Haemophilus Infections/drug therapy
- Haemophilus Infections/metabolism
- Hospitalization
- Humans
- Legionellosis/diagnosis
- Legionellosis/drug therapy
- Legionellosis/metabolism
- Macrolides/therapeutic use
- Moraxellaceae Infections/diagnosis
- Moraxellaceae Infections/drug therapy
- Moraxellaceae Infections/metabolism
- Pneumonia, Bacterial/diagnosis
- Pneumonia, Bacterial/drug therapy
- Pneumonia, Mycoplasma/diagnosis
- Pneumonia, Mycoplasma/drug therapy
- Pneumonia, Mycoplasma/metabolism
- Pneumonia, Pneumococcal/diagnosis
- Pneumonia, Pneumococcal/drug therapy
- Pneumonia, Pneumococcal/metabolism
- Pneumonia, Staphylococcal/diagnosis
- Pneumonia, Staphylococcal/drug therapy
- Pneumonia, Staphylococcal/metabolism
- Radiography, Thoracic
- Severity of Illness Index
- Sputum
- United States
- beta-Lactams/therapeutic use
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41
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Hurst JR, Skolnik N, Hansen GJ, Anzueto A, Donaldson GC, Dransfield MT, Varghese P. Understanding the impact of chronic obstructive pulmonary disease exacerbations on patient health and quality of life. Eur J Intern Med 2020; 73:1-6. [PMID: 31954592 DOI: 10.1016/j.ejim.2019.12.014] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 12/10/2019] [Accepted: 12/18/2019] [Indexed: 01/14/2023]
Abstract
Exacerbations of chronic obstructive pulmonary disease (COPD) represent a significant clinical problem, and are associated with decreased lung function, worsening quality of life and decreased physical activity levels, with even a single exacerbation having detrimental effects. The occurrence of COPD exacerbations can also have a considerable impact on healthcare costs and mortality rates, with over one-fifth of patients hospitalized for a COPD exacerbation for the first time dying within one year of discharge. This highlights the need for COPD exacerbations to be a major focus in clinical practice. Furthermore, the substantial effect that COPD exacerbations can have on patient mental health should not be underestimated. Despite their clinical importance, COPD exacerbations are poorly recognized and reported by patients, and improving patient understanding and reporting of exacerbations to ensure prompt treatment may minimize their deleterious effects. Renewed focus on improving current clinical practice with support from evidence-based guidelines is required. This also raises a challenge to payors, healthcare systems and government policies to do more to tackle the considerable outstanding burden of COPD exacerbations.
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Affiliation(s)
- John R Hurst
- 114 UCL Respiratory, Rayne Building, University College London, London WC1E 6JF, UK.
| | - Neil Skolnik
- Sidney Kimmel Medical College, Thomas Jefferson University, Abington Jefferson Health, Abington, PA, USA; Abington Hospital - Jefferson Health, Abington, PA, USA
| | | | - Antonio Anzueto
- University of Texas Health Science Center and South Texas Veterans Health Care System, San Antonio, TX, USA
| | - Gavin C Donaldson
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Mark T Dransfield
- Lung Health Center and Division of Pulmonary, Allergy and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
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42
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Roche N, Anzueto A, Bosnic Anticevich S, Kaplan A, Miravitlles M, Ryan D, Soriano JB, Usmani O, Papadopoulos N, Canonica GW. Connected real-life research, a pillar of P4 medicine. Eur Respir J 2020; 55:55/1/1902287. [PMID: 31949104 DOI: 10.1183/13993003.02287-2019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 11/27/2019] [Indexed: 11/05/2022]
Affiliation(s)
- Nicolas Roche
- Respiratory Medicine, Hôpitaux Universitaires Paris Centre, Hôpital Cochin, AP-HP and Université de Paris (UMR1016), Paris, France .,Respiratory Effectiveness Group, Board of Directors, Ely, UK
| | - Antonio Anzueto
- Respiratory Effectiveness Group, Board of Directors, Ely, UK.,University of Texas Health and South Texas Veterans Health Care System, San Antonio, TX, USA
| | - Sinthia Bosnic Anticevich
- Respiratory Effectiveness Group, Board of Directors, Ely, UK.,Woolcock Institute of Medical Research, The University of Sydney, Sydney Local Health District, Sydney, Australia
| | - Alan Kaplan
- Respiratory Effectiveness Group, Board of Directors, Ely, UK.,Dept of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Marc Miravitlles
- Respiratory Effectiveness Group, Board of Directors, Ely, UK.,Pneumology Dept, University Hospital Vall d'Hebron, Ciber de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | - Dermot Ryan
- Respiratory Effectiveness Group, Board of Directors, Ely, UK.,Allergy and Respiratory Research Group, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Medical School, Edinburgh, UK
| | - Joan B Soriano
- Respiratory Effectiveness Group, Board of Directors, Ely, UK.,Hospital Universitario de la Princesa, Universidad Autónoma de Madrid and Centro de Investigación en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Omar Usmani
- Respiratory Effectiveness Group, Board of Directors, Ely, UK.,National Heart and Lung Institute, Imperial College London and Royal Brompton Hospital, Airways Disease Section, London, UK
| | - Nikos Papadopoulos
- Respiratory Effectiveness Group, Board of Directors, Ely, UK.,Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester, UK.,Allergy Dept, 2nd Pediatric Clinic, National and Kapodistrian University of Athens, Athens, Greece
| | - G Walter Canonica
- Respiratory Effectiveness Group, Board of Directors, Ely, UK.,Respiratory Disease and Allergy Clinic, IRCCS Humanitas Clinical and Research Center, Humanitas University, Milan, Italy
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43
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Peñuelas O, Muriel A, Abraira V, Frutos-Vivar F, Mancebo J, Raymondos K, Du B, Thille AW, Ríos F, González M, Del-Sorbo L, Ferguson ND, Del Carmen Marín M, Pinheiro BV, Soares MA, Nin N, Maggiore SM, Bersten A, Amin P, Cakar N, Suh GY, Abroug F, Jibaja M, Matamis D, Zeggwagh AA, Sutherasan Y, Anzueto A, Esteban A. Inter-country variability over time in the mortality of mechanically ventilated patients. Intensive Care Med 2020; 46:444-453. [PMID: 31912203 PMCID: PMC7222132 DOI: 10.1007/s00134-019-05867-9] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 11/12/2019] [Indexed: 01/09/2023]
Abstract
Purpose Variations in clinical characteristics and management and in the mortality of mechanically ventilated patients have not been sufficiently evaluated. We hypothesized that mortality shows a variability associated with country after adjustment for clinical characteristics and management. Methods Analysis of four studies carried out at 6-year intervals over an 18-year period. The studies included 26,024 patients (5183 in 1998, 4968 in 2004, 8108 in 2010, and 7765 in 2016) admitted to 1253 units from 38 countries. The primary outcome was 28-day mortality. We performed analyses using multilevel logistic modeling with mixed-random effects, including country as a random variable. To evaluate the effect of management strategies on mortality, a mediation analysis was performed. Results Adjusted 28-day mortality decreased significantly over time (first study as reference): 2004: odds ratio 0.82 (95% confidence interval [CI] 0.72–0.93); 2010: 0.63 (95% CI 0.53–0.75); 2016: 0.49 (95% CI 0.39–0.61). A protective ventilatory strategy and the use of continuous sedation mediated a moderate fraction of the effect of time on mortality in patients with moderate hypoxemia and without hypoxemia, respectively. Logistic multilevel modeling showed a significant effect of country on mortality: median odds ratio (MOR) in 1998: 2.02 (95% CI 1.57–2.48); in 2004: 1.76 (95% CI 1.47–2.06); in 2010: 1.55 (95% CI 1.37–1.74), and in 2016: 1.39 (95% CI 1.25–1.54). Conclusions These findings suggest that country could contribute, independently of confounder variables, to outcome. The magnitude of the effect of country decreased over time. Clinical trials registered with http://www.clinicaltrials.gov (NCT02731898). Electronic supplementary material The online version of this article (10.1007/s00134-019-05867-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Oscar Peñuelas
- Hospital Universitario de Getafe, Centro de Investigación en Red de Enfermedades Respiratorias (CIBERES), Carretera de Toledo km 12, 500 28905, Madrid, Spain
| | - Alfonso Muriel
- Unidad de Bioestadística, Clinica Hospital Ramón y Cajal, Instituto Ramón y Cajal de Investigaciones Sanitarias (IRYCIS), Centro de Investigación en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Victor Abraira
- Unidad de Bioestadística, Clinica Hospital Ramón y Cajal, Instituto Ramón y Cajal de Investigaciones Sanitarias (IRYCIS), Centro de Investigación en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Fernando Frutos-Vivar
- Hospital Universitario de Getafe, Centro de Investigación en Red de Enfermedades Respiratorias (CIBERES), Carretera de Toledo km 12, 500 28905, Madrid, Spain.
| | - Jordi Mancebo
- Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | | | - Bin Du
- Peking Union Medical College Hospital, Beijing, People's Republic of China
| | | | - Fernando Ríos
- Hospital Nacional Alejandro Posadas, Buenos Aires, Argentina
| | - Marco González
- Clínica Medellín and Universidad Pontificia Bolivariana, Medellín, Colombia
| | - Lorenzo Del-Sorbo
- Interdepartmental Division of Critical Care Medicine, Toronto, ON, Canada
| | - Niall D Ferguson
- Interdepartmental Division of Critical Care Medicine, Toronto, ON, Canada
| | - Maria Del Carmen Marín
- Hospital Regional 1° de Octubre, Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado (ISSSTE), Mexico, DF, Mexico
| | - Bruno Valle Pinheiro
- Pulmonary Research Laboratory, Federal University of Juiz de Fora, Juiz De Fora, Brazil
| | | | - Nicolas Nin
- Hospital Universitario de Montevideo, Montevideo, Uruguay
| | | | - Andrew Bersten
- Department of Critical Care Medicine, Flinders University, Adelaide, SA, Australia
| | - Pravin Amin
- Bombay Hospital Institute of Medical Sciences, Mumbai, India
| | - Nahit Cakar
- Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Gee Young Suh
- Center for Clinical Epidemiology of Samsung Medical Center, Seoul, South Korea
| | | | - Manuel Jibaja
- Hospital de Especialidades Eugenio Espejo, Quito, Ecuador
| | | | - Amine Ali Zeggwagh
- Centre Hospitalier Universitarie Ibn Sina, Mohammed V University, Rabat, Morocco
| | - Yuda Sutherasan
- Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Antonio Anzueto
- South Texas Veterans Health Care System, University of Texas Health Science Center, San Antonio, TX, USA
| | - Andrés Esteban
- Hospital Universitario de Getafe, Centro de Investigación en Red de Enfermedades Respiratorias (CIBERES), Carretera de Toledo km 12, 500 28905, Madrid, Spain
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44
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Wernly B, Frutos-Vivar F, Peñuelas O, Raymondos K, Muriel A, Du B, Thille AW, Ríos F, González M, Del-Sorbo L, Del Carmen Marín M, Pinheiro BV, Soares MA, Nin N, Maggiore SM, Bersten A, Kelm M, Amin P, Cakar N, Lichtenauer M, Suh GY, Abroug F, Jibaja M, Matamis D, Zeggwagh AA, Sutherasan Y, Anzueto A, Esteban A, Jung C. Easy prognostic assessment of concomitant organ failure in critically ill patients undergoing mechanical ventilation. Eur J Intern Med 2019; 70:18-23. [PMID: 31606309 DOI: 10.1016/j.ejim.2019.09.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 08/25/2019] [Accepted: 09/02/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND Acute respiratory distress syndrome (ARDS) is a life-threatening disease. We evaluated the prognostic utility of Model for End-stage Liver Disease excluding INR (MELD-XI) score for predicting mortality in a cohort of critically ill patients on mechanical ventilation. METHODS In total, 11,091 mechanically ventilated patients were included in our post-hoc retrospective analysis, a subgroup of the VENTILA study (NCT02731898). Evaluation of associations with mortality was done by logistic and Cox regression analysis, an optimal cut-off was calculated using the Youden Index. We divided the cohort in two sub-groups based on their MELD-XI score at the optimal cut-off (12 score points). RESULTS Peak-, plateau- and positive end-expiratory pressure were higher in patients with MELD-XI>12. Patients with MELD-XI>12 had higher driving pressures (14 ± 6 cmH2O versus 13 ± 6; p < 0.001). MELD-XI was associated with 28-day mortality after correction for relevant cofounders including SAPS II and ventilation pressures (HR 1.04 95%CI 1.03-1.05; p < 0.001. Patients with MELD-XI>12 evidenced both increased hospital (46% versus 27%; p < 0.001) and 28-day mortality (39% versus 22%). CONCLUSIONS MELD-XI is independently associated with mortality and constitutes a useful and easily applicable tool for risk stratification in critically ill patients receiving mechanical ventilation. TRIAL REGISTRATION NCT02731898, registered 4 April 2016.
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Affiliation(s)
- Bernhard Wernly
- Clinic of Internal Medicine II, Department of Cardiology, Paracelsus Medical University of Salzburg, Salzburg 5020, Austria.
| | - Fernando Frutos-Vivar
- Hospital Universitario de Getafe & Centro de Investigación en Red de Enfermedades Respiratorias (CIBERES), Spain.
| | - Oscar Peñuelas
- Hospital Universitario de Getafe & Centro de Investigación en Red de Enfermedades Respiratorias (CIBERES), Spain
| | | | - Alfonso Muriel
- Hospital Universitario de Getafe & Centro de Investigación en Red de Enfermedades Respiratorias (CIBERES), Spain; Unidad de Bioestadística Clinica Hospital Ramón y Cajal, Instituto Ramón y Cajal de Investigaciones Sanitarias (IRYCIS) & Centro de Investigación en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain.
| | - Bin Du
- Peking Union Medical College Hospital, Beijing, PR China
| | | | - Fernando Ríos
- Hospital Nacional Alejandro Posadas, Buenos Aires, Argentina
| | - Marco González
- Clínica Medellín & Universidad Pontificia Bolivariana, Medellín, Colombia
| | - Lorenzo Del-Sorbo
- Interdepartmental Division of Critical Care Medicine, Toronto, ON, Canada.
| | - Maria Del Carmen Marín
- Hospital Regional 1° de Octubre, Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado (ISSSTE), México, DF, Mexico
| | | | | | | | | | - Andrew Bersten
- Department of Critical Care Medicine, Flinders University, Adelaide, South Australia, Australia.
| | - Malte Kelm
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, University of Düsseldorf, Düsseldorf 40225, Germany.
| | - Pravin Amin
- Bombay Hospital Institute of Medical Sciences, Mumbai, India.
| | - Nahit Cakar
- Department of Anesthesiology and Reanimation, Koç University Faculty of Medicine, İstanbul-Turkey
| | - Michael Lichtenauer
- Clinic of Internal Medicine II, Department of Cardiology, Paracelsus Medical University of Salzburg, Salzburg 5020, Austria.
| | - Gee Young Suh
- Center for Clinical Epidemiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | | | - Manuel Jibaja
- Unidad de Cuidados Intensivos, Hospital Eugenio Espejo, Escuela de Medicina, Universidad Internacional del Ecuador, Quito
| | | | - Amine Ali Zeggwagh
- Centre Hospitalier Universitarie Ibn Sina, Mohammed V University, Rabat, Morocco.
| | - Yuda Sutherasan
- Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Antonio Anzueto
- Division of Pulmonary Diseases & Critical Care Medicine, The University of Texas Health Science Centre at San Antonio, San Antonio, TX, USA.
| | - Andrés Esteban
- Hospital Universitario de Getafe & Centro de Investigación en Red de Enfermedades Respiratorias (CIBERES), Spain.
| | - Christian Jung
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, University of Düsseldorf, Düsseldorf 40225, Germany.
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45
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Boivin Z, Perez MF, Atuegwu NC, Metersky M, Alvarez CA, Anzueto A, Mortensen EM. Association of atypical antipsychotics and mortality for patients hospitalised with pneumonia. ERJ Open Res 2019; 5:00223-2018. [PMID: 31720299 PMCID: PMC6826252 DOI: 10.1183/23120541.00223-2018] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Accepted: 06/11/2019] [Indexed: 12/26/2022] Open
Abstract
Introduction Atypical antipsychotics are commonly used in patients with psychiatric conditions and dementia. They are also frequently used in patients being admitted with pneumonia; however, there are few safety data. The purpose of this study was to examine whether atypical antipsychotic use prior to admission is associated with increased mortality in patients with pneumonia. Methods We conducted a retrospective cohort study of hospitalised patients with pneumonia over a 10-year period. We included patients 65 years or older and hospitalised with pneumonia. For our primary analysis, we used propensity score matching to balance confounders between atypical antipsychotic users and nonusers. Results There were 102 897 patients and 5977 were taking atypical antipsychotics. After matching there were 5513 users and 5513 nonusers. Atypical antipsychotic use was associated with increased odds of 30-day (OR 1.20, 95% CI 1.11–1.31) and 90-day mortality (1.19, 1.09–1.30). Conclusion In patients 65 years or older that are hospitalised with pneumonia, we found an association between atypical antipsychotic use and increased odds of mortality. This was particularly pronounced for patients with pre-existing psychiatric or cardiac conditions. We suggest closely monitoring patients who use these medications and minimising their use in older adult patients. When hospitalised with pneumonia, older patients who use atypical antipsychotics should be monitored closely and their use of these drugs should be minimised as much as possiblehttp://bit.ly/2JEevHV
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Affiliation(s)
- Zachary Boivin
- University of Connecticut Medical Center, Farmington, CT, USA
| | - Mario F Perez
- University of Connecticut Medical Center, Farmington, CT, USA
| | | | - Mark Metersky
- University of Connecticut Medical Center, Farmington, CT, USA
| | - Carlos A Alvarez
- VA North Texas Health Care System, Dallas, TX, USA.,Texas Tech University Health Sciences Center, Dallas, TX, USA
| | - Antonio Anzueto
- South Texas Veterans Health Care System, San Antonio, TX, USA.,University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Eric M Mortensen
- University of Connecticut Medical Center, Farmington, CT, USA.,VA North Texas Health Care System, Dallas, TX, USA
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Lowe KE, Regan EA, Anzueto A, Austin E, Austin JHM, Beaty TH, Benos PV, Benway CJ, Bhatt SP, Bleecker ER, Bodduluri S, Bon J, Boriek AM, Boueiz ARE, Bowler RP, Budoff M, Casaburi R, Castaldi PJ, Charbonnier JP, Cho MH, Comellas A, Conrad D, Costa Davis C, Criner GJ, Curran-Everett D, Curtis JL, DeMeo DL, Diaz AA, Dransfield MT, Dy JG, Fawzy A, Fleming M, Flenaugh EL, Foreman MG, Fortis S, Gebrekristos H, Grant S, Grenier PA, Gu T, Gupta A, Han MK, Hanania NA, Hansel NN, Hayden LP, Hersh CP, Hobbs BD, Hoffman EA, Hogg JC, Hokanson JE, Hoth KF, Hsiao A, Humphries S, Jacobs K, Jacobson FL, Kazerooni EA, Kim V, Kim WJ, Kinney GL, Koegler H, Lutz SM, Lynch DA, MacIntye Jr. NR, Make BJ, Marchetti N, Martinez FJ, Maselli DJ, Mathews AM, McCormack MC, McDonald MLN, McEvoy CE, Moll M, Molye SS, Murray S, Nath H, Newell Jr. JD, Occhipinti M, Paoletti M, Parekh T, Pistolesi M, Pratte KA, Putcha N, Ragland M, Reinhardt JM, Rennard SI, Rosiello RA, Ross JC, Rossiter HB, Ruczinski I, San Jose Estepar R, Sciurba FC, Sieren JC, Singh H, Soler X, Steiner RM, Strand MJ, Stringer WW, Tal-Singer R, Thomashow B, Vegas Sánchez-Ferrero G, Walsh JW, Wan ES, Washko GR, Michael Wells J, Wendt CH, Westney G, Wilson A, Wise RA, Yen A, Young K, Yun J, Silverman EK, Crapo JD. COPDGene ® 2019: Redefining the Diagnosis of Chronic Obstructive Pulmonary Disease. Chronic Obstr Pulm Dis 2019; 6:384-399. [PMID: 31710793 PMCID: PMC7020846 DOI: 10.15326/jcopdf.6.5.2019.0149] [Citation(s) in RCA: 83] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/11/2019] [Indexed: 12/27/2022]
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) remains a major cause of morbidity and mortality. Present-day diagnostic criteria are largely based solely on spirometric criteria. Accumulating evidence has identified a substantial number of individuals without spirometric evidence of COPD who suffer from respiratory symptoms and/or increased morbidity and mortality. There is a clear need for an expanded definition of COPD that is linked to physiologic, structural (computed tomography [CT]) and clinical evidence of disease. Using data from the COPD Genetic Epidemiology study (COPDGene®), we hypothesized that an integrated approach that includes environmental exposure, clinical symptoms, chest CT imaging and spirometry better defines disease and captures the likelihood of progression of respiratory obstruction and mortality. METHODS Four key disease characteristics - environmental exposure (cigarette smoking), clinical symptoms (dyspnea and/or chronic bronchitis), chest CT imaging abnormalities (emphysema, gas trapping and/or airway wall thickening), and abnormal spirometry - were evaluated in a group of 8784 current and former smokers who were participants in COPDGene® Phase 1. Using these 4 disease characteristics, 8 categories of participants were identified and evaluated for odds of spirometric disease progression (FEV1 > 350 ml loss over 5 years), and the hazard ratio for all-cause mortality was examined. RESULTS Using smokers without symptoms, CT imaging abnormalities or airflow obstruction as the reference population, individuals were classified as Possible COPD, Probable COPD and Definite COPD. Current Global initiative for obstructive Lung Disease (GOLD) criteria would diagnose 4062 (46%) of the 8784 study participants with COPD. The proposed COPDGene® 2019 diagnostic criteria would add an additional 3144 participants. Under the new criteria, 82% of the 8784 study participants would be diagnosed with Possible, Probable or Definite COPD. These COPD groups showed increased risk of disease progression and mortality. Mortality increased in patients as the number of their COPD characteristics increased, with a maximum hazard ratio for all cause-mortality of 5.18 (95% confidence interval [CI]: 4.15-6.48) in those with all 4 disease characteristics. CONCLUSIONS A substantial portion of smokers with respiratory symptoms and imaging abnormalities do not manifest spirometric obstruction as defined by population normals. These individuals are at significant risk of death and spirometric disease progression. We propose to redefine the diagnosis of COPD through an integrated approach using environmental exposure, clinical symptoms, CT imaging and spirometric criteria. These expanded criteria offer the potential to stimulate both current and future interventions that could slow or halt disease progression in patients before disability or irreversible lung structural changes develop.
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Affiliation(s)
- Katherine E. Lowe
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve School of Medicine, Cleveland, Ohio
| | | | | | | | | | | | | | | | | | | | | | - Jessica Bon
- University of Pittsburgh, Pittsburgh, Pennsylvania
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | | | | | | | - Matthew Budoff
- Los Angeles Biomedical Research Institute at Harbor- University of California Los Angeles Medical Center, Torrance
| | - Richard Casaburi
- Los Angeles Biomedical Research Institute at Harbor- University of California Los Angeles Medical Center, Torrance
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Margaret Fleming
- Novartis Institute for Biomedical Research, Cambridge, Massachusetts
| | | | | | | | | | - Sarah Grant
- Novartis Institute for Biomedical Research, Cambridge, Massachusetts
| | | | - Tian Gu
- University of Michigan, Ann Arbor
| | - Abhya Gupta
- Boehringer Ingelheim, Biberach an der Riss, Germany
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Victor Kim
- Temple University, Philadelphia, Pennsylvania
| | - Woo Jin Kim
- Kangwon National University, Chuncheon, Korea
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Matthew Moll
- Brigham and Women's Hospital, Boston, Massachusetts
| | | | | | | | | | | | | | | | | | | | | | | | | | - Stephen I. Rennard
- AstraZeneca, Cambridge, United Kingdom
- University of Nebraska Medical Center, Omaha
| | | | | | - Harry B. Rossiter
- Los Angeles Biomedical Research Institute at Harbor- University of California Los Angeles Medical Center, Torrance
- University of Leeds, Leeds, United Kingdom
| | | | | | | | | | | | - Xavier Soler
- University of California at San Diego
- GlaxoSmithKline, Research Triangle Park, North Carolina
| | | | | | - William W. Stringer
- Los Angeles Biomedical Research Institute at Harbor- University of California Los Angeles Medical Center, Torrance
| | | | | | | | | | - Emily S. Wan
- Brigham and Women's Hospital, Boston, Massachusetts
- VA Boston Healthcare System, Jamaica Plain, Massachusetts
| | | | | | | | | | | | | | | | - Kendra Young
- University of Colorado Anschutz Medical Campus, Aurora
| | - Jeong Yun
- Brigham and Women's Hospital, Boston, Massachusetts
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Miravitlles M, Llor C, Bjerrum L, Sethi S, Anzueto A. Is CRP-guided antibiotic treatment a safe way to reduce antibiotic use in severe hospitalised patients with exacerbations of COPD? Eur Respir J 2019; 54:54/4/1901405. [PMID: 31624129 DOI: 10.1183/13993003.01405-2019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 07/20/2019] [Indexed: 11/05/2022]
Affiliation(s)
- Marc Miravitlles
- Pneumology Dept, Hospital Universitari Vall d'Hebron/Vall d'Hebron Research Institute (VHIR), CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | - Carl Llor
- Research Unit for General Practice and Section of General Practice, Dept of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Lars Bjerrum
- Research Unit for General Practice and Section of General Practice, Dept of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Sanjay Sethi
- Division of Pulmonary, Critical Care and Sleep Medicine, Dept of Medicine, University at Buffalo, SUNY, Buffalo, NY, USA
| | - Antonio Anzueto
- Division of Pulmonary Diseases and Critical Care Medicine, School of Medicine, The University of Texas Health Science Center, San Antonio, TX, USA.,Audie L. Murphy Memorial VA Hospital, South Texas Veterans Health Care System, San Antonio, TX, USA
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Calverley P, Jenkins C, Wedzicha J, Hoz ADL, Voß F, Rabe K, Anzueto A. COPD EXACERBATION RATE BY BASELINE COPD ASSESSMENT TEST SCORE IN THE DYNAGITO STUDY. Chest 2019. [DOI: 10.1016/j.chest.2019.08.1533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Matsunaga K, Oishi K, Miravitlles M, Anzueto A. Time To Revise COPD Treatment Algorithm. Int J Chron Obstruct Pulmon Dis 2019; 14:2229-2234. [PMID: 31631994 PMCID: PMC6776289 DOI: 10.2147/copd.s219051] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 09/16/2019] [Indexed: 12/12/2022] Open
Abstract
In 2017, a new two-step algorithm for the treatment of COPD was proposed. This algorithm was based on the severity of symptoms and phenotypes or treatable traits, and patient-specialised assessment targeting eosinophilic inflammation, chronic bronchitis, and frequent infections is recommended after exacerbation occurs despite maximal bronchodilation therapy. However, recent studies have revealed the clinical characteristics of patients who should have second controllers added, such as ICS. We again realized that treatable traits should be assessed and intervened for as early as possible. Moreover, the treatment algorithm is necessary to be adapted to the situation of clinical practice, taking into account the characteristics of the patients. The time to revise COPD treatment algorithm has come and we propose a new 3-step parallel approach for initial COPD treatment. After the diagnosis of COPD, the first assessment is to divide into two categories based on the usual clinical characteristics for patients with COPD and the specific clinical characteristics for each patient with concomitant disease. In the former, the assessment should be based on the level of dyspnea and the frequency of exacerbations. After the assessment, mono- or dual bronchodilator should be selected. In the latter, the assessment should be based on asthma characteristics, chronic bronchitis, and chronic heart failure. After the assessment, patients with asthmatic characteristics may consider treatment with ICS, while patients with chronic bronchitis may consider treatment with roflumilast and/or macrolide, while patients with chronic heart failure may consider treatment with selective β1-blocker. The 3-step parallel approach is completed by adding an additional therapy for patients with concomitant disease to essential therapy for patients with COPD. In addition, it is important to review the response around 4 weeks after the initial therapy. This COPD management proposal might be considered as an approach based on patients’ clinical characteristics and on personalized therapy.
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Affiliation(s)
- Kazuto Matsunaga
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, Ube, Yamaguchi, Japan
| | - Keiji Oishi
- Department of Medicine and Clinical Science, Graduate School of Medicine, Yamaguchi University, Ube, Yamaguchi, Japan
| | - Marc Miravitlles
- Department of Pneumology, Hospital Universitari Vall d'Hebron/Vall d'Hebron Research Institute (VHIR), Centro de Investigación Biomédica en Red Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | - Antonio Anzueto
- Division of Pulmonary Diseases and Critical Care Medicine, School of Medicine, The University of Texas Health Science Center, San Antonio, TX, USA.,Pulmonary Diseases Section, Audie L. Murphy Memorial VA Hospital, South Texas Veterans Health Care System, San Antonio, TX, USA
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50
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Martinez FJ, Rabe KF, Calverley PMA, Fabbri LM, Sethi S, Pizzichini E, McIvor A, Anzueto A, Alagappan VKT, Siddiqui S, Reisner C, Zetterstrand S, Román J, Purkayastha D, Bagul N, Rennard SI. Determinants of Response to Roflumilast in Severe Chronic Obstructive Pulmonary Disease. Pooled Analysis of Two Randomized Trials. Am J Respir Crit Care Med 2019; 198:1268-1278. [PMID: 29763572 DOI: 10.1164/rccm.201712-2493oc] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Roflumilast reduces exacerbations in patients with severe chronic obstructive pulmonary disease associated with chronic bronchitis and a history of exacerbations. Further characterization of patients most likely to benefit is warranted. OBJECTIVES Define characteristics that most robustly identify patients who derive greatest exacerbation risk reduction with roflumilast. METHODS Predefined, pooled analyses of REACT (Roflumilast in the Prevention of COPD Exacerbations While Taking Appropriate Combination Treatment; NCT01329029) and RE2SPOND (Roflumilast Effect on Exacerbations in Patients on Dual [LABA/ICS] Therapy; NCT01443845) multicenter, randomized, double-blind, placebo-controlled studies. The primary endpoint was rate of moderate or severe exacerbations per patient per year. MEASUREMENTS AND MAIN RESULTS In the overall intention-to-treat population (n = 4,287), roflumilast reduced moderate or severe exacerbations by 12.3% (rate ratio, 0.88, 95% confidence interval, 0.80-0.97; P = 0.0086) and severe exacerbations by 16.1% (0.84; 0.71-0.99; P = 0.0409) versus placebo. The reduction in moderate or severe exacerbations with roflumilast was most pronounced in patients who had been hospitalized for an exacerbation in the prior year (0.74; 0.63-0.88; P = 0.0005); had more than two exacerbations in the prior year (0.79; 0.65-0.96; P = 0.0160); or had baseline eosinophils ≥150 cells/μl (0.81; 0.71-0.93; P = 0.0020), ≥150 to <300 cells/μl (0.84; 0.71-0.98; P = 0.0282), or ≥300 cells/μl (0.77; 0.61-0.97; P = 0.0264). Similar subgroup results were noted for severe exacerbations. In patients with prior hospitalization and higher baseline blood eosinophil concentrations, roflumilast reduced moderate or severe exacerbations by 34.5% at ≥150 cells/μl (0.65; 0.52-0.82; P = 0.0003) and 42.7% at ≥300 cells/μl (0.57; 0.37-0.88; P = 0.0111) versus placebo. CONCLUSIONS This prespecified, pooled analysis confirms the benefit of roflumilast in decreasing exacerbations in patients with prior hospitalization for exacerbation, greater exacerbation frequency, and higher (≥150 cells/μl, ≥150 to <300 cells/μl, or ≥300 cells/μl) baseline blood eosinophil count.
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Affiliation(s)
| | - Klaus F Rabe
- 2 LungenClinic Grosshansdorf, Airway Research Center North, German Center for Lung Research, Grosshansdorf, Germany
| | - Peter M A Calverley
- 3 Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, United Kingdom
| | - Leonardo M Fabbri
- 4 Department of Clinical Medicine, University of Ferrara, Ferrara, Italy.,5 COPD Center, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Sanjay Sethi
- 6 University at Buffalo, State University of New York, Buffalo, New York
| | | | - Andrew McIvor
- 8 McMaster University, Firestone Institute for Respiratory Health, St. Joseph's Healthcare, Hamilton, Ontario, Canada
| | - Antonio Anzueto
- 9 University of Texas Health Science Center and South Texas Veterans Health Care System, San Antonio, Texas
| | | | | | | | | | | | | | - Nitin Bagul
- 13 Takeda Development Centre Europe Ltd., London, United Kingdom
| | - Stephen I Rennard
- 14 University of Nebraska Medical Center, Omaha, Nebraska; and.,15 Early Clinical Development, IMED Biotech Unit, AstraZeneca, Cambridge, United Kingdom
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