Development of saliva-based cardiac troponin I point-of-care test using alpha-amylase depletion: a feasibility study

INTRODUCTION

Cardiac troponin (cTn) is the biomarker of choice for detection of myocardial injury. There is a great need for simple point-of-care (POC) troponin testing among patients with chest pain, mainly in the prehospital setting. The purpose of this study was to evaluate the presence of cardiac troponin I (cTnI) in saliva of patients with myocardial injury using alpha-amylase depletion technique.

METHODS

Saliva samples were collected from 40 patients with myocardial injury who were tested positive for conventional high-sensitivity cardiac troponin T (cTnT) blood tests, and from 66 healthy volunteers. Saliva samples were treated for the removal of salivary alpha-amylase. Treated and untreated samples were tested with blood cTnI Rapid Diagnostic Test. Salivary cTnI levels were compared to blood cTnT levels.

RESULTS

Thirty-six of 40 patients with positive blood cTnT had positive salivary samples for cTnI following alpha-amylase depletion treatment (90.00% sensitivity). Moreover, three of the four negative saliva samples were obtained from patients with relatively low blood cTnT levels of 100 ng/L or less (96.88% sensitivity for 100 ng/L and above). The negative predictive value was 93.65% and rose up to 98.33% considering the 100 ng/L cutoff. Positive predictive values were 83.72% and 81.58%, respectively. Among 66 healthy volunteers and 7 samples yielded positive results (89.39% specificity).

CONCLUSION

In this preliminary work, the presence of cTnI in saliva was demonstrated for the first time to be feasibly identified by a POC oriented assay. The specific salivary alpha-amylase depletion technique was shown to be crucial for the suggested assay.

National Weekly SARS-CoV-2 RT-PCR Screening of All Workers in Long-Term Care Facilities Associated with Decrease in Resident Mortality Rate

Introduction Outbreaks of COVID-19 in long-term care facilities (LTCFs) have resulted mainly from disease transmission by asymptomatic health care workers. This study examines whether routine screening tests carried out on health care workers can help in reducing COVID-19 outbreaks, morbidity, and mortality of LTCF residents. Methods The study followed a weekly, nationwide, government-funded screening program of LTCF personnel for SARS-CoV-2, by using reverse transcription polymerase chain reaction as the main testing technology. It included all residents and employees in Israeli LTCFs who were screened weekly during the second wave of COVID-19, during the time period between July 13, 2020, and November 21, 2020. Results During the study period, 1,107 LTCFs were screened on a weekly basis, including 62,159 HCWs and 100,046 residents. The program screened a median of 55,282 (Range 16,249, min 45,910, max 62,159) employees per week, 0.05-1.5% of which were positive for SARS-CoV-2. LTCF mortality in the first wave accounted for 45.3% of all COVID-19 deaths recorded nationally (252 of 556), and in the second wave this ratio was reduced to 30.3% (709 of 2,337) representing a reduction of 33.8% in expected mortality (P<0.001). A significant reduction was detected also in hospitalization rate (13.59% vs. 11.41%, p<0.001) and elder (≥75 years-old) mortality rate (52.89% vs. 41.42%, p<0.001). 214 outbreaks in the second wave were avoided by early identification of SARS-CoV-2 positive HCWs and successful prevention of subsequent infections in the facility. Conclusions and relevance Routine weekly SARS-CoV-2 RT-PCR testing of LTCF employees was associated with reduced national LTCF residents' hospitalizations and mortality rate.

BNT162b2 mRNA COVID-19 (Comirnaty) Vaccine Effectiveness in Elderly Patients Who Live in Long-Term Care Facilities: A Nationwide Cohort

INTRODUCTION

In early 2020, the novel SARS-CoV-2 virus began to spread around the world and claim victims. Initially, in the Western world, COVID-19-related mortality was due to illness in long-term care facilities (LTCFs). To manage the COVID-19 crisis in LTCFs in Israel, the Ministry of Health established a task force named "Senior Shield." The task force executed a screening program of weekly polymerase chain reaction (PCR) SARS-CoV-2 tests for LTCF residents and caregivers, and at a later stage, the task force led the Ministry of Health vaccination program at LTCFs. This study aimed to estimate the effectiveness of the BNT162b2 mRNA COVID-19 (Comirnaty) vaccine in reducing COVID-19 morbidity and mortality in LTCF residents.

METHODS

We designed a nationwide cohort study utilizing data from the Senior Shield task force. Residents had received the vaccines starting December 2020. The study follow-up period was 5 months (ending May 2021). We defined four outcomes: (a) documented SARS-CoV-2 infection, defined by a positive PCR test, (b) COVID-19 death, defined by a positive PCR test followed by death, (c) all-cause mortality, defined as death regardless of the result of a PCR test, and (d) a composite endpoint which included documented SARS-CoV-2 infection or death, the earliest of both. We used Kaplan-Meier curves with a log-rank comparison and Cox regression with a time-dependent covariate model to estimate adjusted hazard ratios for vaccine effectiveness (VE). The index date was the date of the first vaccine dose. In unvaccinated residents, the index date was the first date of vaccination in their LTCF.

RESULTS

A total of 43,596 residents with a mean age of 83 years living in 454 LTCFs were found eligible for this study. Ninety-one percent of the study population received the first vaccine dose (39,482) and 86% received the second vaccine dose (37,656). Estimated VE 28 days after the first vaccine dose (approximately 7 days after the second vaccine dose) was 81.2% for SARS-CoV-2 infection, 85.3% for COVID-related death, 63.7% for all-cause mortality, and 71.1% for the composite endpoint (SARS-CoV-2 infection or death).

CONCLUSION

This study shows that the BNT162b2 mRNA COVID-19 vaccine effectively prevents SARS-CoV-2 infection, COVID-19-related death, and all-cause mortality in LTCF residents. Further research is warranted on the effect of the third vaccine (booster) in this population.

Comparison of Rate Control Efficacy between beta-blockers and Calcium Channel Blockers in Patients Hospitalized with Atrial Fibrillation

BACKGROUND

Atrial fibrillation (AF) is the most prevalent cardiac arrhythmia. Previous studies showed that rhythm and rate control strategies are associated with similar rates of mortality and serious morbidity. Beta blockers (BB) and calcium channel blockers (CCB) are commonly used and the selection between these two medications depends on personal preference.

OBJECTIVES

To compare real-time capability of BB and CCB for the treatment of rapid AF and to estimate their efficacy in reducing hospitalization duration.

METHODS

We conducted a retrospective cohort study of 306 patients hospitalized at Soroka Hospital during a 5-year period with new onset AF who were treated by a rate control strategy.

RESULTS

A significant difference between the two groups regarding the time (in hours) until reaching a target heart rate below 100 beats/min was observed. BB were found to decrease the heart rate after 5 hours (range 4-14) vs. 8 hours (range 4-18) for CCB (P = 0.009). Patients diagnosed with new-onset AF exhibited shorter duration of hospitalization after therapy with BB compared to CCB (median 72 vs. 96 hours, P = 0.012) in the subgroup of patients discharged with persistent AF. There was no significant difference between CCB and BB regarding the duration of hospitalization (P = 0.4) in the total patient population.

CONCLUSIONS

BB therapy is more potent for rapid reduction of the heart rate compared to CCB and demonstrated better efficiency in shortening the duration of hospitalization in a subgroup of patients. This finding should be reevaluated in subsequent research.

Association of Receipt of the Fourth BNT162b2 Dose With Omicron Infection and COVID-19 Hospitalizations Among Residents of Long-term Care Facilities

IMPORTANCE

The administration of a fourth BNT162b2 COVID-19 vaccine dose was approved in Israel in December 2021 for individuals 60 years or older who were vaccinated with a third dose 4 months previously or earlier to control the substantial surge of the SARS-CoV-2 Omicron variant. Nonetheless, the association between receipt of the fourth dose and protection against infection remains elusive.

OBJECTIVE

To determine the association of the fourth BNT162b2 dose with protection against SARS-CoV-2-related infections, hospitalizations, and deaths during the Omicron surge in long-term care facility (LTCF) residents.

DESIGN, SETTING, AND PARTICIPANTS

This prospective cohort study was conducted in Israel between January 10 and March 31, 2022 and included LTCF residents 60 years or older.

EXPOSURES

Vaccination with the fourth dose of BNT162b2 vs 3 doses that were administered 4 months previously or earlier.

MAIN OUTCOMES AND MEASURES

Cumulative incidences of SARS-CoV-2 infections, hospitalizations, and deaths during the Omicron surge. The follow-up was initiated more than 7 days after receipt of the fourth dose, which was matched to the follow-up initiation date of those who had received 3 doses of vaccine in each facility. We obtained hazard ratios and 95% confidence intervals from multivariable Cox regression models.

RESULTS

The data of 43 775 residents (mean [SD] age, 80.1 [9.4] years; 29 679 women [67.8%]) were analyzed, of whom 24 088 (55.0%) and 19 687 (45.0%) received the fourth and third dose (4 months previously or earlier), respectively. The median follow-up time was 73 days (4-dose group: IQR, 6 days; 3-dose group: IQR, 56 days). More than 7 days postvaccination with the fourth dose, SARS-CoV-2 infection was detected among 4058 fourth-dose vs 4370 third-dose recipients (cumulative incidence, 17.6% vs 24.9%). The corresponding incidences of hospitalizations for mild-to-moderate COVID-19, severe illness, and mortality were 0.9% and 2.8%, 0.5% and 1.5%, and 0.2% and 0.5%, respectively. The adjusted protections were 34% (95% CI, 30%-37%), 64% (95% CI, 56%-71%), and 67% (95% CI, 57%-75%) against overall infection, hospitalizations for mild-to-moderate illness, and severe illness, respectively, and 72% (95% CI, 57%-83%) against related deaths.

CONCLUSIONS AND RELEVANCE

The results of this cohort study suggest that receipt of a fourth BNT162b2 dose conferred high protection against COVID-19 hospitalizations and deaths among LTCF residents during a substantial Omicron variant surge, but protection was modest against infection. These findings are relevant to the control of COVID-19 pandemic globally, especially among the population of LTCFs.

Association of BNT162b2 Vaccine Third Dose Receipt With Incidence of SARS-CoV-2 Infection, COVID-19-Related Hospitalization, and Death Among Residents of Long-term Care Facilities, August to October 2021

IMPORTANCE

COVID-19 vaccine might be less immunogenic and effective among residents of long-term care facilities (LTCFs).

OBJECTIVE

To examine the association of BNT162b2 third dose (first booster dose) with overall SARS-CoV-2 infection, COVID-19 hospitalizations, and mortality among LTCF residents during a nationwide surge of the Delta variant in Israel.

DESIGN, SETTING, AND PARTICIPANTS

This observational cohort study conducted nationwide COVID-19 surveillance in LTCFs in Israel between August and October 2021. Participants were residents of LTCFs aged 60 years or older.

EXPOSURES

Vaccination with the third dose of BNT162b2 vaccine vs receipt of 2 doses at least 5 months earlier, based on self-preference and choice.

MAIN OUTCOMES AND MEASURES

The cumulative incidences of reverse transcription-polymerase chain reaction (RT-PCR)-confirmed SARS-CoV-2 infection, COVID-19 hospitalizations, and COVID-19-related deaths more than 7 days after vaccination with the third dose were compared between the groups using Kaplan-Meier curves. Hazard ratios (HRs) and 95% CIs were obtained using multivariable Cox regression models.

RESULTS

Among 18 611 residents included in the analysis, 12 715 (68.3%) were female, 463 (2.5%) were from the Arab population, 16 976 (91.2%) were from the general Jewish population, and 618 (3.3%) were from the ultraorthodox Jewish population; the mean (SD) age was 81.1 (9.2) years; 16 082 residents received their first booster dose (third dose) and 2529 were vaccinated with 2 doses at least 5 months earlier. The median (IQR) follow-up durations were 66 (60-70) days among 3-dose recipients and 56 (53-62) days among 2-dose-only recipients; 107 residents had SARS-CoV-2 infection after 7 days following vaccination with the booster dose compared with 185 among the 2-dose only group (cumulative incidence: 0.7% vs 7.5%; adjusted HR, 0.11 [95% CI, 0.07-0.15]). The respective adjusted HRs were 0.07 (95% CI, 0.03-0.14) and 0.10 (95% CI, 0.04-0.24) for the associations of vaccination with the third dose with hospitalization for mild-to-moderate COVID-19 and severe illness. Five COVID-19-related deaths occurred among the third dose vaccinees during the follow-up period compared with 22 among the 2-dose-only vaccinees (cumulative rate: 0.04% vs 0.9%; adjusted HR, 0.04 [95% CI, 0.009-0.16]).

CONCLUSIONS AND RELEVANCE

This cohort study found significant inverse associations between vaccination with the third dose of the BNT162b2 vaccine with overall SARS-CoV-2 infection, COVID-19 hospitalizations, severe disease, and COVID-19-related deaths among LTCF residents during a massive surge caused by the Delta variant in Israel.

Effectiveness of BNT162b2 mRNA Coronavirus Disease 2019 (COVID-19) Vaccine Against Acquisition of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Among Healthcare Workers in Long-Term Care Facilities: A Prospective Cohort Study

BACKGROUND

We assessed vaccine effectiveness (VE) of BNT162b2 mRNA coronavirus disease 2019 (COVID-19) vaccine against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) acquisition among healthcare workers (HCWs) of long-term care facilities (LTCFs).

METHODS

This prospective study, in the framework of the "Senior Shield" program in Israel, included routine weekly nasopharyngeal SARS-CoV-2 RT-PCR testing from all LTCF HCWs since July 2020. All residents and 75% of HCWs were immunized between December 2020 and January 2021. The analysis was limited to HCWs adhering to routine testing. Fully vaccinated (14+ days after second dose; n = 6960) and unvaccinated (n = 2202) HCWs were simultaneously followed until SARS-CoV-2 acquisition or end of follow-up, 11 April 2021. Hazard ratios (HRs) for vaccination versus no vaccination were calculated (Cox proportional hazards regression models, adjusting for sociodemographics and residential-area COVID-19 incidence). VE was calculated as (1- HR) × 100. RT-PCR cycle threshold (Ct) values were compared between vaccinated and unvaccinated HCWs.

RESULTS

At >14 days post-second dose, 40 vaccinated HCWs acquired SARS-CoV-2 (median follow-up, 66 days; cumulative incidence, 0.6%) versus 84 unvaccinated HCWs (median follow-up, 43 days; cumulative incidence, 5.1%) (HR, .11; 95% CI, .07-.17; unadjusted VE, 89%; 95% CI, 83-93%). Adjusted VE >7 and >14 days post-second dose were similar. The median PCR Ct targeting the ORF1ab gene among 20 vaccinated and 40 unvaccinated HCWs was 32.0 versus 26.7, respectively (P value  = .008).

CONCLUSIONS

VE following 2 doses of BNT162b2 against SARS-CoV-2 acquisition in LTCF HCWs was high. The lower viral loads among SARS-CoV-2-positive HCWs suggest further reduction in transmission.

Overuse of reliever inhalers and associated healthcare utilization of asthma patients

Global Initiative for Asthma 2019 guidelines recommend to avoid strengthening patients’ reliance on relievers since they increase exacerbation risk. Our aim was to examine the association between reliever inhalers overuse and all-cause healthcare utilization (HCU). A retrospective study among Clalit Health Services (CHS) adult enrollees (n = 977) for 2012–2017. Reliever inhalers overuse was defined as consistent prescription refills of ≥ 3 canisters annually. Adherence to controllers was calculated using the proportion of days covered. HCU included: hospitalizations, diagnostic and surgical procedures, medications, emergency room (ER) visits, and clinic visits. 27% of the study population (n = 264) consistently refilled ≥ 3 relievers prescriptions annually, and had higher adherence to controllers (0.38 vs. 0.24, p < 0.001). Their total 6-year HCU costs were not higher than that of others ($5,550 vs. $5,562, p = 0.107). Most HCU components [including hospitalization (p = 0.405) and ER visits (p = 0.884)] were comparable; however, medication costs were higher ($1734 vs. $1504, p < 0.001). A multivariable ordered-logit model revealed that frequent and regular use of relievers was not associated with higher HCU costs (OR = 0.82, 95% CI 0.62–1.09, p = 0.175). Higher adherence to maintenance and reliever therapy (OR = 2.18, 95% CI 1.44–3.28, p < 0.001), other controllers (OR = 3.30, 95% CI 2.11–5.16, p < 0.001), and nebulized SABAs and SAMAs (OR = 1.08, 95% CI 1.02–1.14, p = 0.007) was associated with higher costs. Overuse of reliever inhalers was prevalent and associated with higher adherence to controllers, yet not associated with higher all-cause HCU. This highlights the need to examine the sources of elevated usage in order to develop intervention strategies to optimize pharmaceutical therapy of asthma patients.

The Presence of Snoring as Well as its Intensity Is Underreported by Women

STUDY OBJECTIVES

Women are underrepresented and thus sleep conditions are underdiagnosed at sleep clinics that evaluate sleep-disordered breathing. The most common sign of obstructive sleep apnea (OSA) is snoring; therefore, it is one of the main red flags for suspected OSA. The aim of this study is to determine whether self-reported snoring and snoring intensity by women and men correlates with snoring volume measured objectively during sleep laboratory study.

METHODS

Consecutive patients who were referred to a polysomnography (PSG) study in a university hospital over a 2-year period had their snoring volume quantified by means of a calibrated digital sound survey meter. Participants were given a questionnaire in which they were asked to rate the severity of their snoring. The correlation between objective snoring intensity as measured during PSG and the self-reported snoring intensity was evaluated.

RESULTS

A total of 1,913 patients were enrolled in the study. A positive correlation was found between objectively measured snoring intensity and the intensity listed by each participant in the questionnaire. Measurement of the volume of snoring revealed that women snored as loudly as men; however, 28% of the females (189/675) considered themselves to be nonsnorers compared to only 6.9% of men (P < .05). Furthermore, 36.5% of women (69/189) who reported themselves as nonsnorers turned out to have severe or very severe snoring intensity, whereas, in contrast, only 11.7% of men (10/85) of men had this discrepancy. These findings are in concordance with the finding that fewer women quantified their snoring as very severe or severe (38.4%), significantly less than men of whom 61.5% reported their snoring to be severe or very severe.

CONCLUSIONS

In a population of individuals referred to a PSG study, although no difference in snoring intensity was found between sexes, women tend to underreport the fact that they snore and to underestimate the loudness of their snoring. Improved awareness of this discrepancy may increase women's access to sleep laboratories, and improve diagnostic rates of sleep apnea in females.

[THE ASSOCIATION BETWEEN OBESITY AND CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)]

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a preventable and treatable disease, with major respiratory and systemic expressions. Obesity is defined as a BMI>30 kg/ m2 and its prevalence has doubled in recent decades. The possible relationship of obesity to COPD, and its influence on respiratory pathophysiology, is considered a mystery. Studies show obesity to be a survival advantage among COPD patients, unlike in the general population, in which obesity correlates to decreased life expectancy. This study aims to assess the differences between obese and non-obese COPD patients. The main clinical aspect assessed is the number of COPDexacerbation related hospital admissions.

METHODS

We conducted a retrospective cohort study of 323 COPD patients (95 obese, 228 non-obese), who had been followed from 2003-2010 by the Pulmonology Institute at the Soroka Medical Center. We collected demographics, medical history, BMI, lung function tests, information about hospital admissions and mortality.

RESULTS

Non-obese COPD patients are 1.6 times more likely to be hospitalized due to COPD exacerbation. Additionally, women are 1.8 times more likely to be hospitalized due to COPD exacerbation. The FEV1 and FEV1/FVC ratios, which were measured latest during the study period, were higher among obese COPD patients. There was no significant difference in mortality.

CONCLUSIONS

Obesity and male gender act as protective factors against COPD exacerbations requiring hospitalization. Lung function test values are higher among obese patients. Despite this, obesity has no influence on COPD patient survival. Subsequent studies are required, in order to define nutrition recommendations and target weights for COPD patients.

[THE UTILITY OF BRONCHOSCOPY IN INTENSIVE CARE UNIT PATIENTS WITH VENTILATOR ASSOCIATED PNEUMONIA]

BACKGROUND

Ventilator associated pneumonia (VAPI is a common complication leading to lengthier hospitalizations and higher mortality. Prompt adequate initial antibiotic coverage is the crucial issue affecting survival. Currently, there is no gold standard diagnostic test. No conclusive data regarding the benefit of bronchoscopy exists in the literature reviewed.

AIM

This study aims to evaluate the change of prognosis for patients who developed VAP, following a positive culture from bronchoalveolar lavage (BAL).

DESIGN

This is a retrospective cohort study.

SETTING

General intensive care unit in a tertiary university healthcare center.

PARTICIPANTS

All patients who were admitted to Surgical ICU and developed VAP and who then underwent diagnostic bronchoscopy with BAL between the period 01/02/2007 - 31/02/2011.

MEASUREMENTS AND RESULTS

A total of 66 patients who were admitted to the ICU, developed VAP and underwent bronchoscopy while ventilated; 30 patients were excluded. The positive BAL culture group was compared to the negative BAL culture group; there was no difference between demographic and clinical characteristics, mortality rates (for 30 days) or therapy change between the two groups. No complications were reported regarding the bronchoscopy procedure.

CONCLUSIONS

Our findings demonstrate that performing y a diagnostic bronchoscopy with BAL does not improve the prognosis of patients with VAP. Furthermore, expanded prospective studies will be needed to conclude regarding its benefit in diagnosis and subsequent rectifying of therapy.

[THE ROLE OF CLOSED PLEURAL BIOPSY IN THE DIAGNOSIS OF TUBERCULOUS PLEURISY IN A POPULATION AT-RISK]

BACKGROUND

Tuberculous pleurisy is the most common form of extrapulmonary tuberculosis, and a common cause of exudative pleural effusion. Closed pleural biopsy can be used for diagnosis. In recent years, more invasive methods are used for the diagnostic process in the western world. Contrary to the global trend, physicians at the Pulmonary Institute of the Soroka University Medical Center still perform a closed pleural biopsy as the first diagnostic step. In this article, we report our experience in the diagnosis of tuberculous pleurisy by closed pleural biopsy.

METHODS

A retrospective cohort analysis, conducted among patients, who were admitted for investigation of pleural effusion between 2008 and 2013, and underwent closed pleural biopsy with an Abrams needle in the evaluation of tuberculous pleurisy (n=25). Histopathological evidence of tuberculosis bacterium infection included a positive staining for acid-fast bacteria, identification of Langerhans giant cells, demonstration of chronic granulomatous inflammation or demonstration of granulomas with central necrosis in samples of pleural fluid or pleural biopsy.

RESULTS

Closed pleural biopsy was performed in 22/25 (88%) of patients. In 15/22 subjects (68%) histopathotogical evidence of tuberculous pleurisy was found. No significant complications were evident after the procedure. In addition, it was found that acid-fast bacteria in sputum samples, gastric fluid and pleural fluid is of very low diagnostic yield for the diagnosis of tuberculous pleurisy, while in cultures of sputum, gastric fluid or pleural fluid infection it was diagnosed in 27, 28 and 28% of subjects respectively.

CONCLUSIONS

In subjects with a high probability for tuberculous pleurisy, closed pleural biopsy using Abrams needle is available, inexpensive and has a good diagnostic yield and low complication rate. We believe that there is great importance in preserving the ability to perform a closed pleural biopsy in all. medical centers in Israel.

Two-year follow-up in patients treated with emphysematous lung sealant for advanced emphysema

Endoscopic lung volume-reduction therapy for emphysema has been associated with therapeutic responses smaller in magnitude and less durable than surgical volume reduction (LVRS). Bronchoscopic emphysematous lung sealant (ELS) therapy has been shown to produce improvements in pulmonary function similar to surgery at 1 year. This case series summarizes safety and efficacy data of all patients from the initial ELS study out to 2 years. Between 1 and 2 years, there were three all-cause adverse events requiring hospitalization. One patient went on to successful lung transplant. Improvements relative to baseline in spirometry (change in FEV1: + 14.3 ± 33.1%; change in FVC: + 5.8 ± 23.2%) and diffusing capacity (change in diffusing capacity of the lung for carbon monoxide: + 10.6 ± 20.6%) were observed at 2 years. An exponential model fit to FEV₁ data at 6, 12, 18, and 24 months predicted improvements from a baseline of > 5% out to 4.1 years, similar to what has been reported following surgery. This report confirms long-term safety and efficacy following ELS therapy in advanced emphysema. Studies in a larger cohort are needed to define the role of ELS therapy in the treatment algorithm of patients with this condition.

Sarcoidosis-associated pulmonary hypertension in patients with near-normal lung function

SETTING

Tertiary care medical centre in Israel.

BACKGROUND

Pulmonary hypertension (PH) is a predictor of poor outcome in patients with sarcoidosis. Early diagnosis may improve outcome.

OBJECTIVE

To determine factors that might contribute to the early diagnosis of PH in sarcoidosis patients with near normal lung function tests.

DESIGN

Retrospective patient review.

METHODS

Data from 127 patients with sarcoidosis and near normal lung function tests (forced vital capacity > 70%, forced expiratory volume in 1 second > 70% and diffusion capacity of carbon monoxide [D(LCO)] > 60%), who underwent high resolution computed tomography (HRCT) scan, the 6-minute walk distance (6MWD) test and echocardiogram were analysed. Demographic, clinical and HRCT findings were compared between patients with and those without PH.

RESULTS

Thirty-six patients (28.3%) had PH. Patients with PH tended to have lower D(LCO) (68% ± 8 vs. 75% ± 17, P = 0.038), 6MWD (308 m ± 106 vs. 486 m ± 99, P = 0.009) and exercise saturation (91 ± 4 vs. 95 ± 3, P = 0.0001) compared to those without PH. HRCT patterns in PH showed higher frequencies of interstitial thickening (P = 0.004), ground glass appearance (P = 0.01) and fibrosis (P = 0.032). In logistic regression, only 6MWD was predictive of PH (P = 0.005, 95%CI 0.970-0.995).

CONCLUSION

Physiological and radiographic characteristics appeared to differentiate patients with PH from those without. Physicians should be aware of PH in patients with sarcoidosis, even in those with near normal lung function.

Major respiratory adverse events after laparascopic gastric banding surgery for morbid obesity

BACKGROUND

Laparoscopic adjustable gastric banding surgery has become one of the most common restrictive surgical procedures for treatment of morbid obesity worldwide. Although short-term respiratory complications are well known, long-term data is scarce. We investigated the manifestations of major pulmonary complications showed at least six months after the procedure.

METHODS

A retrospective cohort study was conducted at a tertiary university medical center in the five years period of 2006-2010. We included every patient who had had major respiratory complication who needed hospitalization, at least 6 months after laparoscopic adjustable gastric banding procedure. Demographic, pre-operative and post-operative clinical data were collected. We documented respiratory symptoms, results of physical examination, pulmonary function tests, and imaging as well as therapies given and outcome.

RESULTS

Out of 2100 patients who underwent LAGB, thirty subjects, mean age of 45.7 (range 29-64) with an equal number of males and females were included. Mean interval between operation and onset of respiratory symptoms was 51.5 months (range 10-150 months). All had dyspeptic complaints which included: regurgitation, fullness after meals, dysphagia and food aspiration with esophageal dilatation. Major respiratory complications included aspiration pneumonia (19) including pulmonary abscess (4) and empyema (2), exacerbation of asthma (3) and hemoptysis (1). Additionally we documented the emergence of chronic diseases such as interstitial lung disease (5) and bronchiectasis (3). One patient developed acute respiratory distress syndrome due to aspiration pneumonia and eventually died in the intensive care unit. The main mode of therapy was deflation of the gastric band. Those who refused to deflate or remove the gastric banding continued to suffer from dyspeptic and respiratory symptoms including recurrent pulmonary abscess.

CONCLUSION

Although laparoscopic adjustable gastric banding surgery has few short-term risks and is highly effective at achieving weight reduction, we found an increased risk for major respiratory complications in the long-term period. The obesity epidemic and the increased use of surgical techniques to treat obesity will most likely lead to an increase in the incidence of long-term post-operative respiratory complications. This entity is probably under-reported and needs further research into how to reduce its incidence and morbidity.

[Incidence of hospitalizations among chronic obstructive pulmonary disease (COPD) patients with anemia]

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is characterized by progressive exertional and resting dyspnea and is associated with major co-morbidities. Hemoglobin level disorders (anemia and polycythemia) prevalence among patients and the relationship between them and the clinical expression are still not characterized unequivocally. The main purpose of this work is to test the association between anemia and hospitalizations. The presence of such a link may promote the diagnosis and treatment aimed at the patient's hemoglobin levels.

HYPOTHESIS

Anemia in patients with COPD is associated with an increased number of hospitalizations.

METHODS

A retrospective cohort study analysis, conducted on a group of COPD patients (n = 333) followed in the Pulmonology Institute of the Soroka University Medical Center in the years 2003-2009. Demographic physiological and clinical characteristics were compared between anemic, polycythemic and normal hemoglobin patients. Using statistical models, we examined the relationship between the presence of anemia and clinical outcome.

RESULTS

Anemia was found in 79 patients (24%) and polycythemia among seven patients (2%). No difference was found between the groups in terms of number of hospitalizations, number of hospitalization days and ventilator events. There was a higher rate of co-morbidities (such as heart failure, chronic kidney disease) among anemic patients. There were also lower values of BMI and lung function and a higher proportion of men among anemic patients.

CONCLUSIONS

Anemia in patients with COPD was not associated with an increase in the number of severe exacerbations. More studies are needed to clarify the threshold of a hemoglobin level below which there is an increase in the rate of hospitalizations.

A 47-year-old female with shortness of breath and "reversed halo sign"

A 47-yr-old female was referred to a tertiary centre for further evaluation of chronic cough, fever, progressive exertional dyspnoea and fatigue. From a respiratory point of view she had been well until 7&emsp14;months previously when she had started to experience systemic fatigue, low-grade fever and chronic dry cough. A computed tomography scan of the chest demonstrated diffuse bilateral ground-glass, ill-defined pulmonary opacities affecting all lobes. Some had central ground-glass hazy density with peripheral areas of increased opacity, which is consistent with "reversed halo sign". Cryptogenic organising pneumonia (COP) is a clinical, radiological and pathological diagnosis which is made when no definite cause, such as infection or connective tissue disease, is found. It is characterised histopathologically by the presence of patchy distribution of granulation tissue, which consists of fibroblasts and myofibroblasts embedded in a loose connective matrix, present in the lumen of the distal airspaces including alveoli, alveolar ducts and bronchioles. This case report illustrates the association of the reversed halo sign with COP. Although only seen in one fifth of patients with the disease, it appears to suggest the diagnosis of COP and, with proper clinical correlation, it may be another diagnostic adjunct.

Determinants of elevated healthcare utilization in patients with COPD

BACKGROUND

Chronic obstructive pulmonary disease (COPD) imparts a substantial economic burden on western health systems. Our objective was to analyze the determinants of elevated healthcare utilization among patients with COPD in a single-payer health system.

METHODS

Three-hundred eighty-nine adults with COPD were matched 1:3 to controls by age, gender and area of residency. Total healthcare cost 5 years prior recruitment and presence of comorbidities were obtained from a computerized database. Health related quality of life (HRQoL) indices were obtained using validated questionnaires among a subsample of 177 patients.

RESULTS

Healthcare utilization was 3.4-fold higher among COPD patients compared with controls (p < 0.001). The "most-costly" upper 25% of COPD patients (n = 98) consumed 63% of all costs. Multivariate analysis revealed that independent determinants of being in the "most costly" group were (OR; 95% CI): age-adjusted Charlson Comorbidity Index (1.09; 1.01-1.2), history of: myocardial infarct (2.87; 1.5-5.5), congestive heart failure (3.52; 1.9-6.4), mild liver disease (3.83; 1.3-11.2) and diabetes (2.02; 1.1-3.6). Bivariate analysis revealed that cost increased as HRQoL declined and severity of airflow obstruction increased but these were not independent determinants in a multivariate analysis.

CONCLUSION

Comorbidity burden determines elevated utilization for COPD patients. Decision makers should prioritize scarce health care resources to a better care management of the "most costly" patients.

Sleep quality predicts quality of life in chronic obstructive pulmonary disease

Purpose

Chronic obstructive pulmonary disease (COPD) patients may suffer from poor sleep and health-related quality of life. We hypothesized that disturbed sleep in COPD is correlated with quality of life.

Methods

In 180 patients with COPD (forced expired volume in 1 second [FEV₁] 47.6 ± 15.2% predicted, 77.8% male, aged 65.9 ± 11.7 years), we administered general (Health Utilities Index 3) and disease-specific (St George’s Respiratory) questionnaires and an index of disturbed sleep (Pittsburgh Sleep Quality Index).

Results

Overall scores indicated poor general (Health Utilities Index 3: 0.52 ± 0.38), disease- specific (St George’s: 57.0 ± 21.3) quality of life and poor sleep quality (Pittsburgh 11.0 ± 5.4). Sleep time correlated with the number of respiratory and anxiety symptoms reported at night. Seventy-seven percent of the patients had Pittsburg scores >5, and the median Pittsburgh score was 12. On multivariate regression, the Pittsburgh Sleep Quality Index was an independent predictor of both the Health Utilities Index 3 and the St George’s scores, accounting for 3% and 5%, respectively, of the scores. Only approximately 25% of the patients demonstrated excessive sleepiness (Epworth Sleepiness Scale >9).

Conclusions

Most patients with COPD suffer disturbed sleep. Sleep quality was correlated with general and disease-specific quality of life. Only a minority of COPD patients complain of being sleepy.

Does snoring intensity correlate with the severity of obstructive sleep apnea?

STUDY OBJECTIVES

It is commonly believed that louder snoring is associated with more severe obstructive sleep apnea (OSA). We evaluated the association between snoring intensity and the severity of OSA to better understand this clinical correlation. We also investigated the relationships between body mass index (BMI), neck size, sleep stage, and body position with the intensity of snoring.

METHODS

Overnight polysomnography, including objective measurement of snoring intensity, in 1643 habitual snorers referred for evaluation of sleep apnea.

RESULTS

Sixty-five percent of patients were male; the cohort had a mean age of 48.7 +/- 13.7 y and BMI of 30.9 +/- 8.8 kg/m2. The mean apnea-hypopnea index (AHI) was 28.2 +/- 26. The severity of OSA was graded as no OSA (AHI < 5), mild (AHI 5 to 15), moderate (AHI 15 to 30), severe (AHI 30 to 50), and very severe OSA (AHI > 50). Snoring intensity increased progressively across all 5 categories of AHI frequency and ranged from 46.3 +/- 3.6 db in patients with AHI < 5 to 60.5 +/- 6.4 db in those with AHI > 50. Furthermore, there was a positive correlation between the intensity of snoring and the AHI (r = 0.66, p < 0.01).

CONCLUSIONS

The intensity of snoring increases as OSA becomes more severe.

Lung cancer screening--are we there yet?

BACKGROUND

Lung cancer is the most lethal cancer and most cases are the result of cigarette smoking. Although a high risk target population for screening can be defined, and although early stage lung cancer has a much better prognosis than advanced disease, there is still no clear evidence that lung cancer screening decreases mortality. Accordingly, current guidelines suggest that there is no evidence to support routine screening. Although randomized studies in the 1970('s) which used chest x-ray and sputum for screening were clearly negative in the last 20 years more sensitive screening tools such as chest computed tomography have revolutionized the field. However, randomized controlled trials of computed tomography have only recently been launched. AIMS OF THIS REVIEW: Our objectives are to provide the reader with the rationale for screening for lung cancer, to review the older screening studies and their limitations, and to summarize the current knowledge and ongoing trials of lung cancer screening.

LITERATURE SEARCH

A literature search using Medline was conducted from 1966 onwards searching for articles with relevant key words such as lung cancer screening chest X - ray low dose computerized tomography cancer screening guideline. When appropriate additional references were found from the bibliographies of identified papers of interest.

CONCLUSIONS

Recent uncontrolled multicenter studies of chest computed tomography scans show encouraging results. However, until data from, large properly designed and appropriately analyzed randomized controlled trials which may overcome research biases is available, the benefit of lung cancer screening, if any is still unknown.

Low-grade systemic inflammation in patients with amyotrophic lateral sclerosis

OBJECTIVE

To prospectively determine the intensity of systemic low-grade inflammation in patients with amyotrophic lateral sclerosis (ALS).

PATIENTS AND METHODS

Patients with ALS and matched healthy controls underwent blood tests for inflammation-sensitive biomarkers: erythrocyte sedimentation rate (ESR), quantitative fibrinogen, wide-range C-reactive protein (wrCRP) concentrations, leukocyte count and neutrophil-to-lymphocyte ratio (NLR). The correlation between these inflammatory biomarkers and disability status of the patients, expressed by the ALS Functional Rating Scale (ALSFRS-R), was evaluated.

RESULTS

Eighty patients with ALS and 80 matched controls were included. wrCRP, fibrinogen, ESR and NLR values were significantly elevated in patients compared with controls. There was a significant correlation between the ALSFRS-R score and wrCRP, ESR and fibrinogen levels. This correlation persisted on sequential examinations.

CONCLUSIONS

A systemic low-grade inflammation was detected in patients with ALS and correlated with their degree of disability. A heightened systemic inflammatory state is apparently associated with a negative prognosis in ALS.

An animal model for chemotherapy-associated steatohepatitis (CASH) and its prevention by the oral administration of fatty acid bile acid conjugate (FABAC)

4098

Background: Preoperative chemotherapy (irinotecan and oxaliplatin), used in patients undergoing hepatic resection of colorectal liver metastases, is associated with the development of CASH. This hepatic injury increases the risk of perioperative morbidity and mortality. An animal model for CASH has not yet been described. Fatty acid bile acid conjugates (FABACs) are novel synthetic lipid molecules that were shown to prevent the formation of diet induced fatty liver. The present study was designed to establish an animal model of CASH and to use it to study the effect of FABAC on its occurrence. Methods: C57B1/6 mice were given different doses of intraperitoneally injected oxaliplatin and irinotecan. Once weekly administered oxaliplatin at a dose of 6mg/m2 for a total dose of 24mg/ m2, was best tolerated and most consistently associated with CASH in comparison to higher doses of oxaliplatin or different irinotecan regimens. Thus it was chosen as the induction model for CASH. Subsequently, 32 mice were divided into a control group (no treatment, n=6), oxaliplatin group (n=14), and a CASH prevention group (n=12) treated by oxaliplatin and C20-FABAC (arachidyl-amido-cholanoic acid) at a dose of 150 mg/kg/day administered by gavage. The animals were sacrificed after 28 days. Their livers were homogenized and analyzed for fat content (measured as mg lipid/g liver tissue). Results: There were no significant differences in animal or liver weights between the groups. Liver fat content, was significantly lower (P<0.0001) among the control (51.63 mg/g) and prevention (62.13 mg/g) groups versus the oxaliplatin group (95.35 mg/g). The difference between the control and prevention groups was not significant. To the best of our knowledge this is the first description of a model and a potential preventive treatment for CASH. Conclusions: C57B1/6 mice treated by intraperitoneal injection of weekly oxaliplatin at a dose of 6mg/m2 for a total of 24mg/m2, can be used as a model for CASH. Oral FABAC therapy reduces the development of chemotherapy associated steatohepatitis in animals treated with oxaliplatin.

No significant financial relationships to disclose.