A comprehensive care plan that reduces readmissions after acute exacerbations of COPD

BACKGROUND

"Transitions of care" have been the focus of readmission reduction strategies for acute exacerbations of Chronic Obstructive Pulmonary Disease (AECOPD). Wake Forest Baptist Medical Center (WFBMC) implemented a comprehensive care plan for AECOPD admissions in 2014 that also seeks to improve the diagnosis/treatment of COPD, strives for the optimal management of co-morbidities, and emphasizes hospice/palliative care in appropriate patients.

METHODS

A retrospective, electronic health record (EHR) based, observational cohort study was used to evaluate AECOPD admissions between 5/12/2014 to 6/28/2016. An existing AECOPD registry was used to determine care plan status, readmissions were identified from the EHR, and mortality information was obtained from the state of North Carolina. Propensity weighted, multiple logistic regression was used to compare the care plan (n = 597) versus usual care (n = 677) on readmission and mortality outcomes after covariate adjustment.

RESULTS

Enrollment in the care plan was associated with a reduced odds of 30-day all-cause readmission (OR 0.84, 95% CI 0.71-0.99), 30-day mortality (OR 0.63, 95% CI 0.44-0.88), and the composite endpoint of 30-day, all-cause readmissions and mortality (OR 0.78, 95% CI 0.67-0.92). The plan also reduced AECOPD-specific readmissions at 90 days (OR 0.78, 95% CI 0.63-0.96).

CONCLUSION

A comprehensive care plan for patients hospitalized for AECOPD reduced the odds of all-cause readmission, mortality, and AECOPD specific readmission risk. This exploratory study reinforces the use of the AECOPD Care Plan at WFBMC. Future research should focus on a randomized, pragmatic clinical trial to further evaluate the impact of this plan on clinical outcomes.

Prevention of venous thromboembolic disease following primary total knee arthroplasty. A randomized, multicenter, open-label, parallel-group comparison of enoxaparin and warfarin

BACKGROUND

Patients treated with total knee arthroplasty are at high risk for the development of venous thromboembolism postoperatively. This study compared the efficacy and safety of two common thromboprophylactic agents, enoxaparin (a low-molecular-weight heparin) and warfarin.

METHODS

Three hundred and forty-nine patients were included in a prospective, randomized, multicenter, open-label, parallel-group clinical trial. Treatment with enoxaparin (30 mg, administered subcutaneously twice daily) or warfarin (adjusted to an international normalized ratio of 2 to 3) was initiated during the immediate postoperative period, within eight hours after the surgery, and was continued for four to fourteen days. Venous thromboembolism was defined as deep-vein thrombosis documented by contrast venography, symptomatic deep-vein thrombosis documented by lower-extremity ultrasonography, or symptomatic pulmonary embolism confirmed by a positive lung scan or pulmonary angiography.

RESULTS

In the all-treated-patients group, eighty (45%) of the 176 warfarin-treated patients had venous thromboembolism: fifty-nine (34%) had distal deep-vein thrombosis; twenty (11%), proximal deep-vein thrombosis; and one (0.6%), pulmonary embolism. Venous thromboembolism developed in significantly fewer (p = 0.0001) enoxaparin-treated patients (forty-four of 173; 25%): forty-one (24%) had distal deep-vein thrombosis, three (2%) had proximal deep-vein thrombosis, and none had pulmonary embolism. The enoxaparin-treated patients also had a significantly lower prevalence of proximal deep-vein thrombosis (p = 0.002). The estimated odds for the development of venous thromboembolism were 2.52 times greater (95% confidence interval, 2.00 to 3.19) with warfarin than they were with enoxaparin. Major hemorrhage occurred in four warfarin-treated patients and nine enoxaparin-treated patients; with the numbers available, this difference was not significant (p = 0.17). Clinically important operative-site hemorrhage occurred in six (3%) of the warfarin-treated patients and twelve (7%) of the enoxaparin-treated patients (p = 0.15).

CONCLUSIONS

A fixed 30-mg subcutaneous dose of enoxaparin, administered twice daily, with the first dose administered within eight hours after the completion of surgery, was significantly more effective than adjusted-dose warfarin in reducing the occurrence of asymptomatic venous thromboembolism, including proximal deep-vein thrombosis, in patients undergoing total knee arthroplasty. With the numbers available, there was no significant difference between groups with regard to the occurrence of major hemorrhagic complications; however, the rate of overall hemorrhagic complications was higher in the enoxaparin group.

New combination therapies for asthma

Combination products often have useful clinical benefits in asthma. The scientific rationale for combination therapy includes the fact that different agents have complimentary modes of action. Long-acting beta(2)-agonists have effects on airway smooth muscle, and inhaled corticosteroids have potent topical antiinflammatory effect. This combination has been shown to effectively reduce exacerbations and improve symptoms. Substantial clinical trial data provide a rationale for dual-control therapy supported by basic scientific data. Another combined therapy is inhaled steroids plus leukotriene-receptor antagonists, which provides the patient with two effective therapies. Leukotriene-receptor antagonist can also be combined with antihistamines for improved asthma control. Older therapies including theophylline and controlled release albuterol have been effectively added to inhaled corticosteroids, enabling a reduction in the dose of the inhaled steroids. Many other combination therapies are presently being tested.

Computerized morphometry of the pulmonary vasculature over a range of intravascular pressures

Recent availability of computerized image analysis has fostered hope that barium injection and landmarking of pulmonary arteries would be unnecessary for morphometric assessment when using this technique. We reasoned that if barium injection altered morphometric variables, it would do so in a linear fashion correlating with incremental increases in injection pressure of the barium. The two goals of the present study were to determine whether barium injection into arteries affected morphometric measurements and to determine whether incremental increases in injection pressure correlated with alterations in morphometric measurements in a linear fashion. Computerized image analysis was used to measure the internal elastic lamina (IEL) and external elastic lamina (EEL). Medial area (MA), luminal area (LA), percentage of medial thickness, IEL square root of MA, and idealized LA were calculated. Barium injection did not alter morphometric variables in a linear fashion correlating with incremental increases in injection pressure of the barium except the percentage of arteries that filled with barium. Maximum recruitment for pre-acinar arteries occurred at 40 mmHg pressure and 60 mmHg distending pressure for intra-acinar arteries. Incremental increases in injection pressure did not affect IEL, EEL, or calculated morphometric variables. However, IEL, medial thickness, and MA were all smaller in injected vessels than in uninjected vessels. IEL square root of MA and the ratio of measured vs. idealized LA were both increased in injected lungs. We suspect that vascular injection selects for evaluation, a population of smaller, thin-walled vessels, which in the uninjected lungs are collapsed and hence excluded from analysis.

Increased gelatinolytic activity in bronchoalveolar lavage fluid in stable lung transplant recipients

Proteolytic enzymes have been proposed to play a role in the pathogenesis of various inflammatory pulmonary diseases accompanied by parenchymal remodeling. To assess the role of inflammatory cells and proteolytic enzymes in the development of chronic allograft rejection after lung transplantation, bronchoalveolar lavage fluid (BALF) samples from clinically stable lung transplant (LT) recipients (i.e., without evidence of active infection or rejection), heart transplant (HT) recipients, and healthy volunteers (NL) were analyzed for total white blood cell (WBC) count and differential cell count, along with gelatinolytic/type IV collagenolytic activity. The LT group displayed a significantly increased total WBC count, neutrophil count, and percent neutrophils compared with the NL group, confirming the presence of inflammation. Furthermore, gelatin zymography revealed a significant increase in activity of the 72 and 92 kD gelatinases in the LT group compared with the NL group. A positive correlation existed between neutrophil counts and the increase in proteolytic activity. Immunosuppressive therapy did not account for the findings, since no significant difference in cell counts or proteolytic activity existed between the NL and HT control groups. These findings, together with those of others that relate chronic lung allograft dysfunction to an increase in BALF neutrophils and collagen matrix remodeling, collectively indicate that up-regulated proteolytic activity may have a role in chronic rejection after lung transplantation.

Effects of aerosolized surfactant in patients with stable chronic bronchitis: a prospective randomized controlled trial

CONTEXT

Chronic bronchitis, estimated to affect more than 13 million adults in the United States, is characterized in part by retention of airway secretions, but no approved or effective therapy for airway mucus retention in patients with chronic bronchitis has been established. Surfactant reduces sputum adhesiveness, which contributes to difficulty in clearing secretions, but surfactant has not been tested in patients with chronic bronchitis.

OBJECTIVE

To examine the effects of exogenous surfactant on sputum clearance and pulmonary function in patients with stable chronic bronchitis.

DESIGN

A prospective, multicenter, randomized, double-blind, parallel-group, placebo-controlled comparison of the effects of 2 weeks of treatment with 3 doses of aerosolized surfactant (palmitoylphosphadidylcholine [DPPC]) or saline (placebo).

SETTING

Four US teaching hospitals.

PARTICIPANTS

A total of 87 adult patients with the diagnosis of stable chronic bronchitis.

MAIN OUTCOME MEASURES

Pulmonary function, respiratory symptoms, and sputum properties before treatment (day 0), after 2 weeks of treatment (day 14), and 7 days after stopping treatment (day 21).

RESULTS

A total of 66 patients were randomized to surfactant treatment and 21 to saline treatment. Patient demographic characteristics between groups were similar at baseline. In patients who received a DPPC dose of 607.5 mg/d for 2 weeks, prebronchodilator forced expiratory volume in 1 second (FEV1) increased from 1.22 L (SEM, 0.08 L) at day 0 to 1.33 L (SEM, 0.09 L) at day 21 (P=.05), an improvement of 11.4%; postbronchodilator FEV1 improved 10.4% by days 14 and 21 (P=.02); and the ratio of residual volume to total lung capacity, a measure of thoracic gas trapping, decreased 6.2% by day 21 (P=.009). In the surfactant groups, there was a dose-dependent increase in the ability of sputum to be transported by cilia in vitro.

CONCLUSION

Aerosolized surfactant improved pulmonary function and resulted in a dose-related improvement in sputum transport by cilia in patients with stable chronic bronchitis.

Flow cytometric analysis of lung lymphocytes in lung transplant recipients

Lung transplantation is an accepted therapeutic modality in end-stage lung disease. Presently, histologic examination of tissue by transbronchial biopsy remains as the definitive diagnostic procedure for determining rejection. To begin addressing the usefulness of flow cytometric analysis of bronchoalveolar lavage fluid (BALF) in acute lung rejection, we prospectively studied the expression of markers on lymphocytes from BALF samples removed from 10 lung and heart-lung transplant recipients and compared their pattern with that of BALF lymphs obtained from normal volunteers (Norm) and nonrejecting heart transplant recipients (HT) who were receiving similar immunosuppressive regimens. Compared with both Norm and HT subjects, CD4+ lymphocytes in the BALF of lung transplant recipients was significantly reduced. A greater percentage of the CD4+ lymphocytes in nonrejecting lung transplant subjects also expressed the interleukin-2 receptor, but only during the early post-transplant period, suggesting possible reactivity to persistent donor cells. However, the CD8+ lymphocytes were increased only in lung transplant recipients undergoing acute lung rejection. We conclude that the immunologic milieu is indeed altered in the transplanted lung. Further studies in lung transplant recipients are required to evaluate the role of flow cytometry in the early detection of acute lung rejection.

Iodinated glycerol has no effect on pulmonary function, symptom score, or sputum properties in patients with stable chronic bronchitis

STUDY OBJECTIVE

It has been reported that therapy with iodinated glycerol (IG) can improve the quality of life for patients with chronic bronchitis. The purpose of this study was to determine the effects of IG therapy on the quality of life, pulmonary function, and on the properties of sputum collected from adults with stable chronic bronchitis.

DESIGN

Thirty-two week, double-blind, randomized, placebo-controlled cross-over study.

SETTING

A university outpatient pulmonary clinic.

PARTICIPANTS

Twenty-six adults with stable chronic bronchitis completed the study; 28 completed the first treatment arm.

INTERVENTIONS

Sixteen weeks each of placebo or IG 60 mg qid.

MEASUREMENTS

First, pulmonary function by spirometry and plethysmography. Second, symptom score measured using a questionnaire. Third, sputum bulk and surface rheology, spinnability, mucociliary transportability and cough transportability.

RESULTS

There were no significant changes in pulmonary function, clinical scores, or sputum properties related to therapy with IG. There was a significant improvement in the Global Petty score after both IG (p = 0.01) and placebo (p < 0.01) when compared with baseline, but there was no difference between treatment periods. There was a positive correlation between changes in the Global score during therapy and changes in sputum spinnability (p < 0.01, r = 0.38).

CONCLUSIONS

This study clearly demonstrates that in chronic bronchitis, 16 weeks of therapy with IG does not produce any appreciable effect on pulmonary function, well being, or on sputum viscoelasticity or clearability.

Chronic platelet-activating factor induces a decrease in pulmonary vascular compliance, hydroxyproline, and loss of vascular matrix

We have previously demonstrated that chronic intravenous platelet-activating factor (PAF) induces morphologic remodeling of pulmonary arteries characterized by a decrease in internal and external elastic lamina circumference, pulmonary arterial contracture, and internal elastic lamina duplication. The mechanism of PAF-induced arterial contracture is unknown. In this study we determined whether PAF caused arterial contracture through cell loss by calculating the number of cell nuclei/total cross-sectional area of arteries. The nuclear ratio was increased in intra- and preacinar pulmonary arteries of PAF-treated rabbits. Hydroxyproline content of lungs stratified by anatomic region was significantly reduced in intra-acinar tissue of PAF-treated rabbits, indicating that PAF-induced vascular contracture was associated with loss of interstitial collagen. We next tested whether these morphologic alterations were associated with decreased pulmonary vascular compliance and increased resistance. Compliance and resistance were determined in isolated, perfused lungs from rabbits chronically treated with PAF. Compliance was calculated: (1) from the slope of the venous occlusion trace (CVO), (2) by increasing left atrial pressure (CLA), (3) by increasing flow (CHF), and (4) by the classic static technique (CAV) of adding volume (2 ml) to a passively drained lung. Vascular compliance was significantly reduced in PAF-treated lungs when measured by all four methods; however, pulmonary vascular resistance was unchanged. We conclude that structural changes that result from chronic intravenous PAF infusion affect the elastic modulus to a greater extent than factors that influence pulmonary vascular resistance.

IR-192, low dose rate endobronchial brachytherapy in the treatment of malignant airway obstruction

PURPOSE

To assess the value of low-dose-rate endobronchial brachytherapy in the treatment of malignant airway obstruction.

METHODS AND MATERIALS

Between September 1986 and April 1989, 39 patients with malignant airway obstruction had 49 catheter placements for an afterloading, low-dose-rate Ir-192 endobronchial brachytherapy. A flexible fiberoptic bronchoscope with fluoroscopic guidance was used for positioning. Thirty-eight of 39 (97%) patients completed the prescribed treatments. Ninety-seven percent had received previous external radiation in doses ranging from 36-60 Gy. One patient had metastatic renal cell carcinoma; the remainder had recurrent lung cancer. Endobronchial laser treatments were given to three patients 2-3 weeks prior to endobronchial brachytherapy. All patients were followed until death. The median dose delivered in 48 of the 49 placements was 20 Gy at 1 cm.

RESULTS

Follow-up bronchoscopy was performed in 28 (72%) of 39 patients. Of these, 13 (46%) had a complete response, 12 (43%) had a partial response, and 3 (17%) had a minor response. Dyspnea improved in 30 of 37 patients (82%); hemoptysis in 17 of 19 patients (89%); cough in 31 of 39 patients (79%); and postobstructive pneumonia in 21 of 23 patients (92%). The median survival for the entire group was 5 months (range 1-31 months).

CONCLUSION

This technique is simple, well-tolerated and offered significant palliation.

Platelet-activating factor induces selective pulmonary arterial hyperreactivity in isolated perfused rabbit lungs

The role of vasoreactivity in PAF-induced pulmonary hypertension (PHT) was assessed in isolated, perfused rabbit lungs. We evaluated the steady-state pulmonary vascular response to five vasoconstrictors: PGF2 alpha, norepinephrine, angiotensin II, PAF, and KCl. Pulmonary arterial pressure and pulmonary vascular resistance (PVR) were significantly greater in lungs of rabbits treated with PAF for 28 days than in control rabbits in response to PGF2 alpha and norepinephrine. When resistance was partitioned by the vascular occlusion method, at baseline the vascular resistance was equally distributed between arterial and venous segments in both experimental groups. Arterial resistance accounted for approximately 76% of PVR during norepinephrine injection and 60% of PVR during PGF2 alpha injection in PAF-treated lungs. Whereas arterial resistance accounted for approximately 63% of PVR during norepinephrine injection and 52% of PVR during PGF2 alpha injection in control lungs, there was no significant difference in the response to angiotensin II, acute PAF, and KCl in lungs from chronic PAF-treated rabbits compared with responses in control rabbit lungs, though the pressor response to acute PAF tended to be blunted in PAF-treated lungs. Chronic PAF treatment results in enhanced pulmonary arterial reactivity to selected autacoids in isolated perfused lungs.

Bronchoalveolar lavage cell count and differential are not reliable indicators of amiodarone-induced pneumonitis

Amiodarone-induced interstitial pneumonitis is a serious, frequently fatal untoward effect of a commonly used antiarrhythmic agent. Recent reports suggest that bronchoalveolar lavage (BAL) fluid cellular analysis might be used to diagnose amiodarone-induced pneumonitis. The purpose of this study was to determine if the diagnosis of amiodarone-induced pneumonitis could be made by patient history, pulmonary function evaluation, and examination of BAL fluid. We studied five groups of patients. Three of the five groups received amiodarone: patients receiving amiodarone without evident lung toxic reaction, patients with amiodarone-induced pneumonitis, and amiodarone-treated patients diagnosed as having other pathologic processes involving the lung. The two other groups examined were healthy volunteers and patients with interstitial lung disease from causes other than amiodarone. Pulmonary function tests included vital capacity (FVC), first second forced exhaled volume (FEV1), total lung capacity (TLC), and diffusing capacity for carbon monoxide (DCO). BAL fluid analysis included total and differential cell counts. We found that amiodarone-induced interstitial pneumonitis was not associated with an alteration in pulmonary function or BAL cellular composition which could permit its distinction from amiodarone-treated patients diagnosed as having an unrelated pulmonary process or patients with interstitial lung disease from other causes. The most frequent abnormality encountered in patients with amiodarone toxicity was a reduction in the percentage of macrophages in the differential cell count. The sensitivity, specificity, and predictive value of this finding was 82 percent, 69 percent, and 69 percent, respectively. The sensitivity, specificity, and predictive value of a > or = 15 percent reduction in DCO was 44 percent, 50 percent, and 36 percent, respectively. We conclude that amiodarone-induced interstitial pneumonitis remains a diagnosis of exclusion, and the role of BAL fluid analysis is to narrow the differential diagnosis through microbiologic culture and cytologic examination.

Administration of chronic intravenous platelet-activating factor induces pulmonary arterial atrophy and hypertension in rabbits

Platelet-activating factor (PAF), a lipid mediator of inflammation, was given by continuous intravenous infusion to rabbits for 2, 4, and 8 weeks, and morphologic and hemodynamic findings were correlated. Pulmonary arterial pressure (PAP), cardiac output, and right atrial pressure were measured, and total pulmonary resistance was calculated. In cross-sections of intraparenchymal pulmonary arteries, internal elastic lamina circumference and intimal and medial areas were measured. The ratio of the weight of the right ventricle to the weight of the left ventricle plus septum, and alveolar/artery ratios were also obtained. In bronchoalveolar lavage fluid, total and differential cell counts were determined. After 2 weeks of PAF treatment, PAP rose by 4 mm Hg. The increase in PAP became significant by 4 weeks and remained so at 8 weeks of treatment. Total pulmonary resistance nearly doubled by 2 weeks and continued to be elevated throughout 8 weeks of PAF treatment. Cardiac output fell significantly to 0.26 liters/minute at 2 weeks of PAF treatment and remained low at 4 weeks. By 8 weeks of treatment, it normalized. The significant rise in total pulmonary resistance at 2 and 4 weeks correlated with the rise in PAP and the fall in cardiac output. The alveolar/artery ratio was increased at 2 weeks of treatment and progressively increased at 4 and 8 weeks, reaching statistical significance at 8 weeks. In intra-acinar arteries, after 2 weeks of treatment, there was a reduction in total cross-sectional area (within the external elastic lamina), medial area, and internal elastic lamina circumference measured by computerized image analysis of 5-microns thick Verhoeff Van Gieson-stained sections. Changes in total area, medial area, and internal elastic lamina circumference persisted after 4 and 8 weeks of treatment. In preacinar arteries, similar changes occurred that were significant only after 8 weeks of treatment. Other findings apparent at 2 weeks of treatment included right ventricular hypertrophy and a marked decline in the number of macrophages and lymphocytes recovered from bronchoalveolar lavage fluid. We conclude that chronic intravenous infusion of PAF in rabbits induces remodeling of pulmonary arteries, specifically reduction of the internal elastic lamina, with consequent narrowing of arterial lumens producing increased pulmonary vascular resistance and pulmonary hypertension. We attribute the increase in alveolar/artery without evident vessel obliteration, to a shortening of arterial length, which is of insufficient magnitude to overcome the effect of vessel narrowing on vascular resistance.

A rabbit model of pulmonary hypertension induced by the synthetic platelet-activating factor acetylglyceryl ether phosphorylcholine

Development of effective treatment for human pulmonary hypertension (PHT) has been hampered by an incomplete understanding of its pathogenesis. We present a rabbit model of PHT based on platelet-activating factor (PAF), a potent phospholipid autacoid synthesized by a variety of mammalian cells. PAF was intravenously infused into rabbits for 4 wk. After the infusion, rabbits underwent pulmonary arterial catheterization for hemodynamic evaluation, and lung tissue was morphometrically analyzed for changes in cross-sectional areas of intima and media, and alteration in number of small pulmonary arteries. The heart was evaluated by the method of Fulton for right ventricular hypertrophy. Mean pulmonary arterial pressure was 20 +/- 2 mm Hg in PAF-treated rabbits compared with 12 +/- 1 mm Hg in vehicle-treated control rabbits. PAF induced a trend toward loss of small muscular pulmonary arteries, measuring 50 to 200 microns in diameter, and right ventricular hypertrophy. There was a decrease in circumference of the internal elastic lamina in vessels accompanying alveolar ducts and in alveolar walls, and a relative increase in the intimal cross-sectional area of these vessels. These lesions were associated with a trend toward medial hypertrophy. No increase in lung water was found. Pressure changes occurred in the absence of alterations in hematocrit and arterial partial pressure of oxygen. We conclude that chronic intravenous infusion of PAF, a naturally synthesized substance, into rabbits provides a potentially useful model for the study of vascular changes associated with PHT.

Usefulness of serial pulmonary function testing as an indicator of amiodarone toxicity

A prospective study was conducted of 189 patients treated with amiodarone, maintained at doses of 400 to 800 mg/day and followed for up to 6 years. Only patients who had life-threatening ventricular arrhythmias unresponsive to conventional therapy were enrolled, and they underwent baseline pretreatment pulmonary function tests, with follow-up testing every 6 months. Morbidity and mortality statistics were confirmed by chart review and patient telephone interview. Of the 189 enrolled patients, 101 are alive, 84 are dead and 4 are lost to follow-up. Amiodarone-induced toxicity to the neurologic system, lungs, thyroid or liver was the primary or complicating cause of death in 12 of the 84 patients who died. The overall prevalence of all these forms of toxicity was 15%. Sixty-nine percent of the patients with amiodarone toxicity had pulmonary toxicity alone or combined with other forms of toxicity. Pulmonary function test abnormalities were noted at baseline in 75% of patients who had amiodarone-induced toxicity. The proportion of abnormal baseline pulmonary function tests was not significantly different among all toxic patients, pulmonary toxic patients and nontoxic patients. An evaluation of the decrease in pulmonary function over time could not distinguish patients who developed toxicity from those who did not. The observed incidence of pulmonary toxicity is consistent with published values; however, contrary to the findings of others, no statistically significant differences in pulmonary function at baseline or in changes over time were found between toxic and nontoxic patients.(ABSTRACT TRUNCATED AT 250 WORDS)