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Doug Brunk is a San Diego-based award-winning reporter who began covering health care in 1991. Before joining the company, he wrote for the health sciences division of Columbia University and was an associate editor at Contemporary Long Term Care magazine when it won a Jesse H. Neal Award. His work has been syndicated by the Los Angeles Times and he is the author of two books related to the University of Kentucky Wildcats men's basketball program. Doug has a master’s degree in magazine journalism from the S.I. Newhouse School of Public Communications at Syracuse University. Follow him on Twitter @dougbrunk.
Two factors associated with vocal cord dysfunction in study
LOS ANGELES – Female sex and the absence of wheezing were the only factors significantly associated with vocal cord dysfunction in patients with high pretest probability of disease, a retrospective analysis showed.
The findings differ from those of the Pittsburgh Vocal Cord Index, which identified symptoms of throat tightness, dysphonia, absence of wheezing, and the presence of odors as key features predictive of vocal cord dysfunction (VCD). “This proves the point that VCD is an elusive diagnosis,” lead study author Phalgoon Shah, MD, said, in an interview, at the annual meeting of the American College of Chest Physicians.
The researchers found that a history of depression or anxiety, throat tightness, dysphonia, odor symptom trigger, lack of response to bronchodilator or truncation, and flattening of the inspiratory volume curve did not predict VCD.
The patients were active duty military personnel and veterans who were referred to the pulmonary function lab at Tripler Army Medical Center, Honolulu, for suspected VCD between 2010 and 2014. The researchers identified patients by laryngoscopy procedure code and collected numerous variables, including demographic information, past medical history, pulmonary function test data, and clinical variables such as ED visits for dyspnea.
Dr. Shah of the division of pulmonary and critical care at Tripler said that direct laryngoscopic visualization is used to diagnose VCD in military personnel because the diagnosis is grounds for dismissal, but in other practice settings, the technique is not readily available, even though it is considered the gold standard. “You might still have a very high clinical suspicion of VCD in spite of a negative laryngoscopy, and you send these patients to speech therapy and they get better,” he said. “By logic, you can assume that these patients had VCD, you just didn’t catch it right in the lab. For the first time, we are saying that exercise laryngoscopy is not the gold standard.”
He emphasized that more research is required to develop a validated scoring system to predict a diagnosis of VCD and to distinguish it from asthma. He reported having no financial disclosures.
LOS ANGELES – Female sex and the absence of wheezing were the only factors significantly associated with vocal cord dysfunction in patients with high pretest probability of disease, a retrospective analysis showed.
The findings differ from those of the Pittsburgh Vocal Cord Index, which identified symptoms of throat tightness, dysphonia, absence of wheezing, and the presence of odors as key features predictive of vocal cord dysfunction (VCD). “This proves the point that VCD is an elusive diagnosis,” lead study author Phalgoon Shah, MD, said, in an interview, at the annual meeting of the American College of Chest Physicians.
The researchers found that a history of depression or anxiety, throat tightness, dysphonia, odor symptom trigger, lack of response to bronchodilator or truncation, and flattening of the inspiratory volume curve did not predict VCD.
The patients were active duty military personnel and veterans who were referred to the pulmonary function lab at Tripler Army Medical Center, Honolulu, for suspected VCD between 2010 and 2014. The researchers identified patients by laryngoscopy procedure code and collected numerous variables, including demographic information, past medical history, pulmonary function test data, and clinical variables such as ED visits for dyspnea.
Dr. Shah of the division of pulmonary and critical care at Tripler said that direct laryngoscopic visualization is used to diagnose VCD in military personnel because the diagnosis is grounds for dismissal, but in other practice settings, the technique is not readily available, even though it is considered the gold standard. “You might still have a very high clinical suspicion of VCD in spite of a negative laryngoscopy, and you send these patients to speech therapy and they get better,” he said. “By logic, you can assume that these patients had VCD, you just didn’t catch it right in the lab. For the first time, we are saying that exercise laryngoscopy is not the gold standard.”
He emphasized that more research is required to develop a validated scoring system to predict a diagnosis of VCD and to distinguish it from asthma. He reported having no financial disclosures.
LOS ANGELES – Female sex and the absence of wheezing were the only factors significantly associated with vocal cord dysfunction in patients with high pretest probability of disease, a retrospective analysis showed.
The findings differ from those of the Pittsburgh Vocal Cord Index, which identified symptoms of throat tightness, dysphonia, absence of wheezing, and the presence of odors as key features predictive of vocal cord dysfunction (VCD). “This proves the point that VCD is an elusive diagnosis,” lead study author Phalgoon Shah, MD, said, in an interview, at the annual meeting of the American College of Chest Physicians.
The researchers found that a history of depression or anxiety, throat tightness, dysphonia, odor symptom trigger, lack of response to bronchodilator or truncation, and flattening of the inspiratory volume curve did not predict VCD.
The patients were active duty military personnel and veterans who were referred to the pulmonary function lab at Tripler Army Medical Center, Honolulu, for suspected VCD between 2010 and 2014. The researchers identified patients by laryngoscopy procedure code and collected numerous variables, including demographic information, past medical history, pulmonary function test data, and clinical variables such as ED visits for dyspnea.
Dr. Shah of the division of pulmonary and critical care at Tripler said that direct laryngoscopic visualization is used to diagnose VCD in military personnel because the diagnosis is grounds for dismissal, but in other practice settings, the technique is not readily available, even though it is considered the gold standard. “You might still have a very high clinical suspicion of VCD in spite of a negative laryngoscopy, and you send these patients to speech therapy and they get better,” he said. “By logic, you can assume that these patients had VCD, you just didn’t catch it right in the lab. For the first time, we are saying that exercise laryngoscopy is not the gold standard.”
He emphasized that more research is required to develop a validated scoring system to predict a diagnosis of VCD and to distinguish it from asthma. He reported having no financial disclosures.
AT CHEST 2016
Key clinical point:
Major finding: The only variables significantly associated with VCD were female sex (P = .006) and the absence of wheezing (P = .037).
Data source: A retrospective analysis of 244 patients referred to a pulmonary function lab for suspected VCD.
Disclosures: Dr. Shah reported having no financial disclosures.
Optimal management of GERD in IPF unknown
EXPERT ANALYSIS FROM CHEST 2016
LOS ANGELES – The optimal management of gastroesophageal reflux disease in patients with idiopathic pulmonary fibrosis has yet to be determined, according to Joyce S. Lee, MD.
“We need strong randomized clinical trial data to tell us whether or not medical or surgical treatment of GERD in IPF is indicated,” she said at the annual meeting of the American College of Chest Physicians.
Two proposed hypotheses explain the relationship between reflux and IPF. The first holds that reflux and microaspiration are involved in the pathogenesis of IPF. The second, favored by Dr. Lee, proposes that reflux and microaspiration impact the natural history, either through acute exacerbation, disease progression, or survival. Patients with IPF “have weakening of the lower esophageal sphincter, whether that’s due to the presence of a hiatal hernia, medications, or just aging of the tissue there,” she said. “We know how to diagnose reflux disease, but we don’t know how to diagnose microaspiration, which is defined as subclinical aspiration of small droplets of gastric contents. Reflux is a risk factor for the condition of microaspiration, but it is not a perfect surrogate. Not everybody with reflux will aspirate. There is a potential role for bronchoalveolar lavage pepsin and/or bile salt as a biomarker of microaspiration, but it is not validated or standardized in IPF yet.”
Reflux becomes pathologic when reflux of stomach contents causes troublesome symptoms and/or complications. “Troublesome” is defined as mild symptoms 2 or more days a week or moderate to severe symptoms more than 1 day a week. Dr. Lee said that chest physicians can diagnose GERD in their IPF patients the same way that gastroenterologists and primary care doctors do: with symptoms, barium swallow, 24-hour pH monitoring, impedance testing, and sometimes endoscopy. The 2015 IPF guidelines recommend that clinicians “use regular antacid treatment for patients with IPF (conditional recommendation, very low confidence in estimates of effect).” It does not extend to surgical treatment with fundoplication. (Am J Resp Crit Care Med. 2015 Jul 15;192[2]: e3-19).
In an effort to measure the relationship between antacid therapy and change in forced vital capacity, Dr. Lee and her associates evaluated IPF patients from placebo arms of the three Idiopathic Pulmonary Fibrosis Clinical Research Network randomized controlled trials. They found that, compared with patients who did not take antacid therapy at baseline, those who did experienced a slower decline in their forced vital capacity over time (Lancet Resp Med. 2013 Jul;1[5]:369-76). However, a more-recent analysis conducted by different investigators examined the placebo arms of three pirfenidone studies and found no significant effect of antacid therapy in IPF patients (Lancet Resp Med. 2016 May;4[5]:381-9). Dr. Lee said that both evaluations differed because they were secondary analyses of previously captured data. “There were also differences in the ways the trials obtained GERD history, medication indication, and dosing of the antacid therapy,” she said. “There were also differences in outcomes and different populations studied.”
Dr. Lee’s current approach to counseling IPF patients with GERD includes discussing lifestyle modifications and PPI therapy – either daily or twice a day dosing, depending on their symptoms. “Lifestyle modifications include weight loss, smoking cessation, raising the head of the bed 6-8 inches, and avoiding foods that cause acid reflux, including chocolate, alcohol, peppermint, and fatty or spicy foods, and avoiding large and late meals,” she said. “In terms of acid suppression therapy with H2 blockers and PPIs [proton pump inhibitors], symptom relief and healing of the esophagus occurs in 85%-90% of patients taking them correctly. This does not alter their risk of having microaspiration.” Laparoscopic antireflux therapy (fundoplication) is indicated only after the failure of medical therapy. “The goal is to correct any hernia and tighten the lower esophageal sphincter,” she said. “Efficacy and symptom relief is reported to be around 95%.”
An NIH-funded trial called Weighing Risks and Benefits of Laparoscopic Anti-Reflux Surgery in Patients with Idiopathic Fibrosis, is ongoing at six centers. Dr. Lee said that some results are expected within the next year. She reported having no financial disclosures.
EXPERT ANALYSIS FROM CHEST 2016
LOS ANGELES – The optimal management of gastroesophageal reflux disease in patients with idiopathic pulmonary fibrosis has yet to be determined, according to Joyce S. Lee, MD.
“We need strong randomized clinical trial data to tell us whether or not medical or surgical treatment of GERD in IPF is indicated,” she said at the annual meeting of the American College of Chest Physicians.
Two proposed hypotheses explain the relationship between reflux and IPF. The first holds that reflux and microaspiration are involved in the pathogenesis of IPF. The second, favored by Dr. Lee, proposes that reflux and microaspiration impact the natural history, either through acute exacerbation, disease progression, or survival. Patients with IPF “have weakening of the lower esophageal sphincter, whether that’s due to the presence of a hiatal hernia, medications, or just aging of the tissue there,” she said. “We know how to diagnose reflux disease, but we don’t know how to diagnose microaspiration, which is defined as subclinical aspiration of small droplets of gastric contents. Reflux is a risk factor for the condition of microaspiration, but it is not a perfect surrogate. Not everybody with reflux will aspirate. There is a potential role for bronchoalveolar lavage pepsin and/or bile salt as a biomarker of microaspiration, but it is not validated or standardized in IPF yet.”
Reflux becomes pathologic when reflux of stomach contents causes troublesome symptoms and/or complications. “Troublesome” is defined as mild symptoms 2 or more days a week or moderate to severe symptoms more than 1 day a week. Dr. Lee said that chest physicians can diagnose GERD in their IPF patients the same way that gastroenterologists and primary care doctors do: with symptoms, barium swallow, 24-hour pH monitoring, impedance testing, and sometimes endoscopy. The 2015 IPF guidelines recommend that clinicians “use regular antacid treatment for patients with IPF (conditional recommendation, very low confidence in estimates of effect).” It does not extend to surgical treatment with fundoplication. (Am J Resp Crit Care Med. 2015 Jul 15;192[2]: e3-19).
In an effort to measure the relationship between antacid therapy and change in forced vital capacity, Dr. Lee and her associates evaluated IPF patients from placebo arms of the three Idiopathic Pulmonary Fibrosis Clinical Research Network randomized controlled trials. They found that, compared with patients who did not take antacid therapy at baseline, those who did experienced a slower decline in their forced vital capacity over time (Lancet Resp Med. 2013 Jul;1[5]:369-76). However, a more-recent analysis conducted by different investigators examined the placebo arms of three pirfenidone studies and found no significant effect of antacid therapy in IPF patients (Lancet Resp Med. 2016 May;4[5]:381-9). Dr. Lee said that both evaluations differed because they were secondary analyses of previously captured data. “There were also differences in the ways the trials obtained GERD history, medication indication, and dosing of the antacid therapy,” she said. “There were also differences in outcomes and different populations studied.”
Dr. Lee’s current approach to counseling IPF patients with GERD includes discussing lifestyle modifications and PPI therapy – either daily or twice a day dosing, depending on their symptoms. “Lifestyle modifications include weight loss, smoking cessation, raising the head of the bed 6-8 inches, and avoiding foods that cause acid reflux, including chocolate, alcohol, peppermint, and fatty or spicy foods, and avoiding large and late meals,” she said. “In terms of acid suppression therapy with H2 blockers and PPIs [proton pump inhibitors], symptom relief and healing of the esophagus occurs in 85%-90% of patients taking them correctly. This does not alter their risk of having microaspiration.” Laparoscopic antireflux therapy (fundoplication) is indicated only after the failure of medical therapy. “The goal is to correct any hernia and tighten the lower esophageal sphincter,” she said. “Efficacy and symptom relief is reported to be around 95%.”
An NIH-funded trial called Weighing Risks and Benefits of Laparoscopic Anti-Reflux Surgery in Patients with Idiopathic Fibrosis, is ongoing at six centers. Dr. Lee said that some results are expected within the next year. She reported having no financial disclosures.
EXPERT ANALYSIS FROM CHEST 2016
LOS ANGELES – The optimal management of gastroesophageal reflux disease in patients with idiopathic pulmonary fibrosis has yet to be determined, according to Joyce S. Lee, MD.
“We need strong randomized clinical trial data to tell us whether or not medical or surgical treatment of GERD in IPF is indicated,” she said at the annual meeting of the American College of Chest Physicians.
Two proposed hypotheses explain the relationship between reflux and IPF. The first holds that reflux and microaspiration are involved in the pathogenesis of IPF. The second, favored by Dr. Lee, proposes that reflux and microaspiration impact the natural history, either through acute exacerbation, disease progression, or survival. Patients with IPF “have weakening of the lower esophageal sphincter, whether that’s due to the presence of a hiatal hernia, medications, or just aging of the tissue there,” she said. “We know how to diagnose reflux disease, but we don’t know how to diagnose microaspiration, which is defined as subclinical aspiration of small droplets of gastric contents. Reflux is a risk factor for the condition of microaspiration, but it is not a perfect surrogate. Not everybody with reflux will aspirate. There is a potential role for bronchoalveolar lavage pepsin and/or bile salt as a biomarker of microaspiration, but it is not validated or standardized in IPF yet.”
Reflux becomes pathologic when reflux of stomach contents causes troublesome symptoms and/or complications. “Troublesome” is defined as mild symptoms 2 or more days a week or moderate to severe symptoms more than 1 day a week. Dr. Lee said that chest physicians can diagnose GERD in their IPF patients the same way that gastroenterologists and primary care doctors do: with symptoms, barium swallow, 24-hour pH monitoring, impedance testing, and sometimes endoscopy. The 2015 IPF guidelines recommend that clinicians “use regular antacid treatment for patients with IPF (conditional recommendation, very low confidence in estimates of effect).” It does not extend to surgical treatment with fundoplication. (Am J Resp Crit Care Med. 2015 Jul 15;192[2]: e3-19).
In an effort to measure the relationship between antacid therapy and change in forced vital capacity, Dr. Lee and her associates evaluated IPF patients from placebo arms of the three Idiopathic Pulmonary Fibrosis Clinical Research Network randomized controlled trials. They found that, compared with patients who did not take antacid therapy at baseline, those who did experienced a slower decline in their forced vital capacity over time (Lancet Resp Med. 2013 Jul;1[5]:369-76). However, a more-recent analysis conducted by different investigators examined the placebo arms of three pirfenidone studies and found no significant effect of antacid therapy in IPF patients (Lancet Resp Med. 2016 May;4[5]:381-9). Dr. Lee said that both evaluations differed because they were secondary analyses of previously captured data. “There were also differences in the ways the trials obtained GERD history, medication indication, and dosing of the antacid therapy,” she said. “There were also differences in outcomes and different populations studied.”
Dr. Lee’s current approach to counseling IPF patients with GERD includes discussing lifestyle modifications and PPI therapy – either daily or twice a day dosing, depending on their symptoms. “Lifestyle modifications include weight loss, smoking cessation, raising the head of the bed 6-8 inches, and avoiding foods that cause acid reflux, including chocolate, alcohol, peppermint, and fatty or spicy foods, and avoiding large and late meals,” she said. “In terms of acid suppression therapy with H2 blockers and PPIs [proton pump inhibitors], symptom relief and healing of the esophagus occurs in 85%-90% of patients taking them correctly. This does not alter their risk of having microaspiration.” Laparoscopic antireflux therapy (fundoplication) is indicated only after the failure of medical therapy. “The goal is to correct any hernia and tighten the lower esophageal sphincter,” she said. “Efficacy and symptom relief is reported to be around 95%.”
An NIH-funded trial called Weighing Risks and Benefits of Laparoscopic Anti-Reflux Surgery in Patients with Idiopathic Fibrosis, is ongoing at six centers. Dr. Lee said that some results are expected within the next year. She reported having no financial disclosures.
Few non-ICU patients receive palliative care consults
LOS ANGELES – A significant percentage of patients who meet criteria for palliative care consultations do not receive a consult during their hospital stay, results from a single-center retrospective analysis showed.
“Physicians need to recognize the palliative care needs of patients with chronic illnesses other than malignancy before they get admitted to the ICU, especially when these patients are admitted repeatedly for the same problem [and] have a significant decline in functional status with a large symptom burden,” Mohleen Kang, MD, said in an interview in advance of the annual meeting of the American College of Chest Physicians. “There is a potential missed opportunity for these conversations to occur with the patients and their family prior to their decompensation and crisis.”
Twenty-nine percent (132) of the patients studied met an indication for a palliative care consult (PCC), with only 35 (27%) of such patients having received a PCC. Patients with metastatic cancer were significantly more likely to have received a PCC, compared with non-cancer patients (64% vs. 21%, respectively; P less than .001), while patients with New York Heart Association Class III or IV congestive heart failure were less likely to receive a PCC, compared with those who did not have congestive heart failure (5.6% vs. 29.8%; P = .014).
Criteria for PCC on admission include a life-limiting diagnosis and more than one admission in the past 3 months, decline in function, or complex care requirements. Criteria for PCC during hospitalization include life-limiting diagnosis and uncertainty about decisions, an ICU stay greater than 7 days, or lack of goals of care.
Dr. Kang, chief resident in the department of medicine at New Jersey Medical School, Newark, presented the results, which were of patients admitted to the department of medicine at University Hospital in Newark in 2015. Those admitted to the ICU within 24 hours of admission were excluded from the analysis, leaving 461 patient charts that were screened for PCC needs based on the consensus report from the Center to Advance Palliative Care.
The patients who met an indication for PCC had a mean age of 60 years and an average length of stay of 7 days. The percentages of these patients who were female, African American, and Hispanic were 45%, 40%, and 21%, respectively.
On multivariate analysis, patients who had a PCC within 72 hours of admission were eight times more likely to have a hospital length of stay less than 7 days (P = .019), while those who had a PCC within 48 hours of admission were 20 times more likely to have a hospital length of stay less than 7 days (P = .017). “So if we intervened early, we were able to decrease their length of stay to less than 7 days,” Dr. Kang said at the meeting.
She acknowledged certain limitations of the study, including its small sample size, retrospective design, and lack of follow-up. “This study also has a lot of confounding socioeconomic factors that do not make it applicable to every hospital across the country,” she said. “This is not a homogeneous patient population.”
The study’s principal investigator was Anne Sutherland, MD, medical intensive care unit director at University Hospital. Dr. Kang reported having no financial disclosures.
LOS ANGELES – A significant percentage of patients who meet criteria for palliative care consultations do not receive a consult during their hospital stay, results from a single-center retrospective analysis showed.
“Physicians need to recognize the palliative care needs of patients with chronic illnesses other than malignancy before they get admitted to the ICU, especially when these patients are admitted repeatedly for the same problem [and] have a significant decline in functional status with a large symptom burden,” Mohleen Kang, MD, said in an interview in advance of the annual meeting of the American College of Chest Physicians. “There is a potential missed opportunity for these conversations to occur with the patients and their family prior to their decompensation and crisis.”
Twenty-nine percent (132) of the patients studied met an indication for a palliative care consult (PCC), with only 35 (27%) of such patients having received a PCC. Patients with metastatic cancer were significantly more likely to have received a PCC, compared with non-cancer patients (64% vs. 21%, respectively; P less than .001), while patients with New York Heart Association Class III or IV congestive heart failure were less likely to receive a PCC, compared with those who did not have congestive heart failure (5.6% vs. 29.8%; P = .014).
Criteria for PCC on admission include a life-limiting diagnosis and more than one admission in the past 3 months, decline in function, or complex care requirements. Criteria for PCC during hospitalization include life-limiting diagnosis and uncertainty about decisions, an ICU stay greater than 7 days, or lack of goals of care.
Dr. Kang, chief resident in the department of medicine at New Jersey Medical School, Newark, presented the results, which were of patients admitted to the department of medicine at University Hospital in Newark in 2015. Those admitted to the ICU within 24 hours of admission were excluded from the analysis, leaving 461 patient charts that were screened for PCC needs based on the consensus report from the Center to Advance Palliative Care.
The patients who met an indication for PCC had a mean age of 60 years and an average length of stay of 7 days. The percentages of these patients who were female, African American, and Hispanic were 45%, 40%, and 21%, respectively.
On multivariate analysis, patients who had a PCC within 72 hours of admission were eight times more likely to have a hospital length of stay less than 7 days (P = .019), while those who had a PCC within 48 hours of admission were 20 times more likely to have a hospital length of stay less than 7 days (P = .017). “So if we intervened early, we were able to decrease their length of stay to less than 7 days,” Dr. Kang said at the meeting.
She acknowledged certain limitations of the study, including its small sample size, retrospective design, and lack of follow-up. “This study also has a lot of confounding socioeconomic factors that do not make it applicable to every hospital across the country,” she said. “This is not a homogeneous patient population.”
The study’s principal investigator was Anne Sutherland, MD, medical intensive care unit director at University Hospital. Dr. Kang reported having no financial disclosures.
LOS ANGELES – A significant percentage of patients who meet criteria for palliative care consultations do not receive a consult during their hospital stay, results from a single-center retrospective analysis showed.
“Physicians need to recognize the palliative care needs of patients with chronic illnesses other than malignancy before they get admitted to the ICU, especially when these patients are admitted repeatedly for the same problem [and] have a significant decline in functional status with a large symptom burden,” Mohleen Kang, MD, said in an interview in advance of the annual meeting of the American College of Chest Physicians. “There is a potential missed opportunity for these conversations to occur with the patients and their family prior to their decompensation and crisis.”
Twenty-nine percent (132) of the patients studied met an indication for a palliative care consult (PCC), with only 35 (27%) of such patients having received a PCC. Patients with metastatic cancer were significantly more likely to have received a PCC, compared with non-cancer patients (64% vs. 21%, respectively; P less than .001), while patients with New York Heart Association Class III or IV congestive heart failure were less likely to receive a PCC, compared with those who did not have congestive heart failure (5.6% vs. 29.8%; P = .014).
Criteria for PCC on admission include a life-limiting diagnosis and more than one admission in the past 3 months, decline in function, or complex care requirements. Criteria for PCC during hospitalization include life-limiting diagnosis and uncertainty about decisions, an ICU stay greater than 7 days, or lack of goals of care.
Dr. Kang, chief resident in the department of medicine at New Jersey Medical School, Newark, presented the results, which were of patients admitted to the department of medicine at University Hospital in Newark in 2015. Those admitted to the ICU within 24 hours of admission were excluded from the analysis, leaving 461 patient charts that were screened for PCC needs based on the consensus report from the Center to Advance Palliative Care.
The patients who met an indication for PCC had a mean age of 60 years and an average length of stay of 7 days. The percentages of these patients who were female, African American, and Hispanic were 45%, 40%, and 21%, respectively.
On multivariate analysis, patients who had a PCC within 72 hours of admission were eight times more likely to have a hospital length of stay less than 7 days (P = .019), while those who had a PCC within 48 hours of admission were 20 times more likely to have a hospital length of stay less than 7 days (P = .017). “So if we intervened early, we were able to decrease their length of stay to less than 7 days,” Dr. Kang said at the meeting.
She acknowledged certain limitations of the study, including its small sample size, retrospective design, and lack of follow-up. “This study also has a lot of confounding socioeconomic factors that do not make it applicable to every hospital across the country,” she said. “This is not a homogeneous patient population.”
The study’s principal investigator was Anne Sutherland, MD, medical intensive care unit director at University Hospital. Dr. Kang reported having no financial disclosures.
AT CHEST 2016
Key clinical point:
Major finding: Patients with metastatic cancer were significantly more likely to have received a PCC, compared with non-cancer patients (64% vs. 21%, respectively; P less than .001).
Data source: A retrospective study of 132 patients admitted to the department of medicine at University Hospital in Newark, N.J., in 2015.
Disclosures: Dr. Kang reported having no financial disclosures.
New mechanical ventilation guidelines unveiled
LOS ANGELES – Acutely hospitalized patients who have been on mechanical ventilation for more than 24 hours, are at high risk for extubation failure, and have passed a spontaneous breathing trial should be extubated to noninvasive ventilation.
The recommendation comes from new clinical practice guidelines from the American College of Chest Physicians and the American Thoracic Society. Moderate-quality evidence suggests that early extubation and a switch to noninvasive ventilation reduces ventilator-related and ICU-related complications, including infections and injury to the lungs and other organs. Extubation also cuts costs by reducing ICU stays.
At the annual meeting of the American College of Chest Physicians, one of the six project cochairs, Daniel R. Ouellette, MD, said that the guidelines were intended to address “new territory” from the evidence-based guidelines for weaning and discontinuing ventilator support that were published in 2001. That effort, chaired by Neil R. MacIntyre, MD, “was a landmark article that helped us learn about the steps that we needed to take to liberate patients from mechanical ventilation,” said Dr. Ouellette of the Henry Ford Hospital Department of Pulmonary and Critical Care Medicine, Detroit. “We hope that this guideline lives up to the importance of that one. We wanted to look over new information and give new recommendations about things that haven’t been addressed in the past.”
Six recommendations from the guideline panel include:
We suggest that the initial spontaneous breathing trial be conducted with inspiratory pressure augmentation rather than T-piece or continuous positive airway pressure. The committee wrote that conducting the initial spontaneous breathing trial with pressure augmentation was more likely to be successful, produced a higher rate of extubation success, and was associated with a trend towards lower intensive care unit mortality.
We suggest protocols attempting to minimize sedation. The committee found that sedation protocols reduced ICU length of stay. However, the protocols did not appear to decrease time on the ventilator or reduce short-term mortality. The authors could not recommend one protocol over another but said the burden of providing sedation by any of the protocols was “very low.”
We suggest protocolized rehabilitation directed toward early mobilization. The committee wrote that patients receiving the intervention spent less time on the ventilator and were more likely to be able to walk when they left the hospital. However, their mortality rate appeared unchanged. The authors noted the exercises created additional work for ICU staff that might have come at the expense of other care priorities.
We suggest managing patients with a ventilator liberation protocol. The committee said that patients managed by protocol spent on average 25 fewer hours on mechanical ventilation and were discharged from the ICU a day early. However, their mortality rate appeared unchanged.
We suggest performing a cuff leak test in patients who meet extubation criteria and are deemed at high risk for postextubation stridor. The committee suggested that the test should be used only in patients with a high risk of stridor (abnormal breathing caused by blockage of windpipe) after extubation. Although patients passing the test had lower stridor and reintubation rates, the authors wrote that a high percentage of patients who failed the test could be successfully extubated.
For patients who failed the cuff leak test but are otherwise ready for extubation, we suggest administering systemic steroids at least 4 hours before extubation. The committee said that clinical judgment should take priority over test results, and systemic steroids should be administered to these patients at least 4 hours before extubation. The authors added that the short duration of the steroid therapy was likely to improve success rates without resulting in adverse events.
In a prepared statement, Timothy Girard, MD, of the department of medicine at the University of Pittsburgh and a lead author of the guidelines said the committee hoped the guidelines would help reduce variations in practice that do not benefit patients. “We are not prescribing a specific approach to care for every patient every time,” he said. “But we are trying to summarize the available evidence in as clear and succinct a way as possible so that clinicians know how it applies to most patients.”
Dr. Ouellette disclosed that he has received a research grant from Cardeas Pharma for health care–associated pneumonia.
Daniel R. Ouellette, MD, FCCP, comments: Liberation from mechanical ventilation is one of the most important goals in taking care of critically ill patients receiving mechanical ventilation in the ICU. Patients who have a prolonged ventilator course are at risk for many complications and so physicians who work in the intensive care unit must work carefully to liberate patients from the ventilator at the earliest possible moment. That has to be done in a safe fashion so criteria to ensure that this can be done safely are important as well.
Patients often have medical illness that requires sedation, and it is often necessary to sedate patients so that they can tolerate being on mechanical ventilation; however, we know that oversedation can lead to failure to liberate patients from mechanical ventilation expeditiously. Therefore, one of our recommendations’ suggestions is to design protocols for sedation that focus on minimizing sedation so that patients can be extubated expeditiously.
All of the recommendations ultimately focused on a team approach to liberation from mechanical ventilation, because involvement of team members is always important. However, there are a couple of our recommendations that are particularly important in terms of their implications for the team approach and those include recommendations about using protocols to liberate patients from ventilators, in general, and also to use sedation protocols to minimize sedations.
We began to look at developing this topic, because we had initially published guidelines on [liberation from mechanical ventilation] in 2001. We knew that there was much new information that had emerged since the 2001 guidelines. For that reason we began to think about an update. With the initial inception of this project, we reached out to the American Thoracic Society so as to develop a collaborative effort since this was a topic that interested both societies. This collaboration was at all levels at CHEST and it involved not only the guidelines organization, but also the leadership of both societies and, of course, the panel that was ultimately constructed to address these issues was made up of members from both societies. The entire process [of developing the new guideline] took nearly 3 years.
When one develops a guideline, one makes an effort to make a guideline as comprehensive and globally applicable as possible. I think the practices in Europe are very similar to practices in North America in terms of mechanical ventilation. Several of our panelists are European and some of the important work that we reviewed came from centers in Europe. It’s my opinion that our guideline will be broadly applicable in both North America and Europe, but there may be regional or local differences. Nevertheless, we recognize in different regions in the world, there are different resource allocations for medical treatment, there are different cultural precepts, and there are other factors that implicate medical problems.
Certainly the European Respiratory Society and other European organizations developed guidelines on related topics ... one of the important caveats when CHEST decides to develop a guideline is that we are not reproducing the work that has been done elsewhere and so this guideline represents a project that fills a gap that previously had not been filled.
All guidelines that CHEST develops are living guidelines … it’s hard to envision exactly how often a guideline will be updated. We know that there will be certain areas of our guideline that will stand the test of time, but there will be other areas that will need to be updated, some sooner than others.
The original CHEST guideline on liberation from mechanical ventilation was a very important document that appeared in 2001 and changed the practice of medicine and the practice of managing patients on mechanical ventilation. Nevertheless, the guideline was somewhat limited in scope, because there was only so much information available. … Our goal in developing this guideline was to address some of practitioners’ questions that had emerged in the last decade by looking at newly available data.
[In formulating these guidelines], we purposely chose six new questions that were not directly related to any of the questions [that has been answered] in the previous guideline.
Daniel R. Ouellette, MD, FCCP, comments: Liberation from mechanical ventilation is one of the most important goals in taking care of critically ill patients receiving mechanical ventilation in the ICU. Patients who have a prolonged ventilator course are at risk for many complications and so physicians who work in the intensive care unit must work carefully to liberate patients from the ventilator at the earliest possible moment. That has to be done in a safe fashion so criteria to ensure that this can be done safely are important as well.
Patients often have medical illness that requires sedation, and it is often necessary to sedate patients so that they can tolerate being on mechanical ventilation; however, we know that oversedation can lead to failure to liberate patients from mechanical ventilation expeditiously. Therefore, one of our recommendations’ suggestions is to design protocols for sedation that focus on minimizing sedation so that patients can be extubated expeditiously.
All of the recommendations ultimately focused on a team approach to liberation from mechanical ventilation, because involvement of team members is always important. However, there are a couple of our recommendations that are particularly important in terms of their implications for the team approach and those include recommendations about using protocols to liberate patients from ventilators, in general, and also to use sedation protocols to minimize sedations.
We began to look at developing this topic, because we had initially published guidelines on [liberation from mechanical ventilation] in 2001. We knew that there was much new information that had emerged since the 2001 guidelines. For that reason we began to think about an update. With the initial inception of this project, we reached out to the American Thoracic Society so as to develop a collaborative effort since this was a topic that interested both societies. This collaboration was at all levels at CHEST and it involved not only the guidelines organization, but also the leadership of both societies and, of course, the panel that was ultimately constructed to address these issues was made up of members from both societies. The entire process [of developing the new guideline] took nearly 3 years.
When one develops a guideline, one makes an effort to make a guideline as comprehensive and globally applicable as possible. I think the practices in Europe are very similar to practices in North America in terms of mechanical ventilation. Several of our panelists are European and some of the important work that we reviewed came from centers in Europe. It’s my opinion that our guideline will be broadly applicable in both North America and Europe, but there may be regional or local differences. Nevertheless, we recognize in different regions in the world, there are different resource allocations for medical treatment, there are different cultural precepts, and there are other factors that implicate medical problems.
Certainly the European Respiratory Society and other European organizations developed guidelines on related topics ... one of the important caveats when CHEST decides to develop a guideline is that we are not reproducing the work that has been done elsewhere and so this guideline represents a project that fills a gap that previously had not been filled.
All guidelines that CHEST develops are living guidelines … it’s hard to envision exactly how often a guideline will be updated. We know that there will be certain areas of our guideline that will stand the test of time, but there will be other areas that will need to be updated, some sooner than others.
The original CHEST guideline on liberation from mechanical ventilation was a very important document that appeared in 2001 and changed the practice of medicine and the practice of managing patients on mechanical ventilation. Nevertheless, the guideline was somewhat limited in scope, because there was only so much information available. … Our goal in developing this guideline was to address some of practitioners’ questions that had emerged in the last decade by looking at newly available data.
[In formulating these guidelines], we purposely chose six new questions that were not directly related to any of the questions [that has been answered] in the previous guideline.
Daniel R. Ouellette, MD, FCCP, comments: Liberation from mechanical ventilation is one of the most important goals in taking care of critically ill patients receiving mechanical ventilation in the ICU. Patients who have a prolonged ventilator course are at risk for many complications and so physicians who work in the intensive care unit must work carefully to liberate patients from the ventilator at the earliest possible moment. That has to be done in a safe fashion so criteria to ensure that this can be done safely are important as well.
Patients often have medical illness that requires sedation, and it is often necessary to sedate patients so that they can tolerate being on mechanical ventilation; however, we know that oversedation can lead to failure to liberate patients from mechanical ventilation expeditiously. Therefore, one of our recommendations’ suggestions is to design protocols for sedation that focus on minimizing sedation so that patients can be extubated expeditiously.
All of the recommendations ultimately focused on a team approach to liberation from mechanical ventilation, because involvement of team members is always important. However, there are a couple of our recommendations that are particularly important in terms of their implications for the team approach and those include recommendations about using protocols to liberate patients from ventilators, in general, and also to use sedation protocols to minimize sedations.
We began to look at developing this topic, because we had initially published guidelines on [liberation from mechanical ventilation] in 2001. We knew that there was much new information that had emerged since the 2001 guidelines. For that reason we began to think about an update. With the initial inception of this project, we reached out to the American Thoracic Society so as to develop a collaborative effort since this was a topic that interested both societies. This collaboration was at all levels at CHEST and it involved not only the guidelines organization, but also the leadership of both societies and, of course, the panel that was ultimately constructed to address these issues was made up of members from both societies. The entire process [of developing the new guideline] took nearly 3 years.
When one develops a guideline, one makes an effort to make a guideline as comprehensive and globally applicable as possible. I think the practices in Europe are very similar to practices in North America in terms of mechanical ventilation. Several of our panelists are European and some of the important work that we reviewed came from centers in Europe. It’s my opinion that our guideline will be broadly applicable in both North America and Europe, but there may be regional or local differences. Nevertheless, we recognize in different regions in the world, there are different resource allocations for medical treatment, there are different cultural precepts, and there are other factors that implicate medical problems.
Certainly the European Respiratory Society and other European organizations developed guidelines on related topics ... one of the important caveats when CHEST decides to develop a guideline is that we are not reproducing the work that has been done elsewhere and so this guideline represents a project that fills a gap that previously had not been filled.
All guidelines that CHEST develops are living guidelines … it’s hard to envision exactly how often a guideline will be updated. We know that there will be certain areas of our guideline that will stand the test of time, but there will be other areas that will need to be updated, some sooner than others.
The original CHEST guideline on liberation from mechanical ventilation was a very important document that appeared in 2001 and changed the practice of medicine and the practice of managing patients on mechanical ventilation. Nevertheless, the guideline was somewhat limited in scope, because there was only so much information available. … Our goal in developing this guideline was to address some of practitioners’ questions that had emerged in the last decade by looking at newly available data.
[In formulating these guidelines], we purposely chose six new questions that were not directly related to any of the questions [that has been answered] in the previous guideline.
LOS ANGELES – Acutely hospitalized patients who have been on mechanical ventilation for more than 24 hours, are at high risk for extubation failure, and have passed a spontaneous breathing trial should be extubated to noninvasive ventilation.
The recommendation comes from new clinical practice guidelines from the American College of Chest Physicians and the American Thoracic Society. Moderate-quality evidence suggests that early extubation and a switch to noninvasive ventilation reduces ventilator-related and ICU-related complications, including infections and injury to the lungs and other organs. Extubation also cuts costs by reducing ICU stays.
At the annual meeting of the American College of Chest Physicians, one of the six project cochairs, Daniel R. Ouellette, MD, said that the guidelines were intended to address “new territory” from the evidence-based guidelines for weaning and discontinuing ventilator support that were published in 2001. That effort, chaired by Neil R. MacIntyre, MD, “was a landmark article that helped us learn about the steps that we needed to take to liberate patients from mechanical ventilation,” said Dr. Ouellette of the Henry Ford Hospital Department of Pulmonary and Critical Care Medicine, Detroit. “We hope that this guideline lives up to the importance of that one. We wanted to look over new information and give new recommendations about things that haven’t been addressed in the past.”
Six recommendations from the guideline panel include:
We suggest that the initial spontaneous breathing trial be conducted with inspiratory pressure augmentation rather than T-piece or continuous positive airway pressure. The committee wrote that conducting the initial spontaneous breathing trial with pressure augmentation was more likely to be successful, produced a higher rate of extubation success, and was associated with a trend towards lower intensive care unit mortality.
We suggest protocols attempting to minimize sedation. The committee found that sedation protocols reduced ICU length of stay. However, the protocols did not appear to decrease time on the ventilator or reduce short-term mortality. The authors could not recommend one protocol over another but said the burden of providing sedation by any of the protocols was “very low.”
We suggest protocolized rehabilitation directed toward early mobilization. The committee wrote that patients receiving the intervention spent less time on the ventilator and were more likely to be able to walk when they left the hospital. However, their mortality rate appeared unchanged. The authors noted the exercises created additional work for ICU staff that might have come at the expense of other care priorities.
We suggest managing patients with a ventilator liberation protocol. The committee said that patients managed by protocol spent on average 25 fewer hours on mechanical ventilation and were discharged from the ICU a day early. However, their mortality rate appeared unchanged.
We suggest performing a cuff leak test in patients who meet extubation criteria and are deemed at high risk for postextubation stridor. The committee suggested that the test should be used only in patients with a high risk of stridor (abnormal breathing caused by blockage of windpipe) after extubation. Although patients passing the test had lower stridor and reintubation rates, the authors wrote that a high percentage of patients who failed the test could be successfully extubated.
For patients who failed the cuff leak test but are otherwise ready for extubation, we suggest administering systemic steroids at least 4 hours before extubation. The committee said that clinical judgment should take priority over test results, and systemic steroids should be administered to these patients at least 4 hours before extubation. The authors added that the short duration of the steroid therapy was likely to improve success rates without resulting in adverse events.
In a prepared statement, Timothy Girard, MD, of the department of medicine at the University of Pittsburgh and a lead author of the guidelines said the committee hoped the guidelines would help reduce variations in practice that do not benefit patients. “We are not prescribing a specific approach to care for every patient every time,” he said. “But we are trying to summarize the available evidence in as clear and succinct a way as possible so that clinicians know how it applies to most patients.”
Dr. Ouellette disclosed that he has received a research grant from Cardeas Pharma for health care–associated pneumonia.
LOS ANGELES – Acutely hospitalized patients who have been on mechanical ventilation for more than 24 hours, are at high risk for extubation failure, and have passed a spontaneous breathing trial should be extubated to noninvasive ventilation.
The recommendation comes from new clinical practice guidelines from the American College of Chest Physicians and the American Thoracic Society. Moderate-quality evidence suggests that early extubation and a switch to noninvasive ventilation reduces ventilator-related and ICU-related complications, including infections and injury to the lungs and other organs. Extubation also cuts costs by reducing ICU stays.
At the annual meeting of the American College of Chest Physicians, one of the six project cochairs, Daniel R. Ouellette, MD, said that the guidelines were intended to address “new territory” from the evidence-based guidelines for weaning and discontinuing ventilator support that were published in 2001. That effort, chaired by Neil R. MacIntyre, MD, “was a landmark article that helped us learn about the steps that we needed to take to liberate patients from mechanical ventilation,” said Dr. Ouellette of the Henry Ford Hospital Department of Pulmonary and Critical Care Medicine, Detroit. “We hope that this guideline lives up to the importance of that one. We wanted to look over new information and give new recommendations about things that haven’t been addressed in the past.”
Six recommendations from the guideline panel include:
We suggest that the initial spontaneous breathing trial be conducted with inspiratory pressure augmentation rather than T-piece or continuous positive airway pressure. The committee wrote that conducting the initial spontaneous breathing trial with pressure augmentation was more likely to be successful, produced a higher rate of extubation success, and was associated with a trend towards lower intensive care unit mortality.
We suggest protocols attempting to minimize sedation. The committee found that sedation protocols reduced ICU length of stay. However, the protocols did not appear to decrease time on the ventilator or reduce short-term mortality. The authors could not recommend one protocol over another but said the burden of providing sedation by any of the protocols was “very low.”
We suggest protocolized rehabilitation directed toward early mobilization. The committee wrote that patients receiving the intervention spent less time on the ventilator and were more likely to be able to walk when they left the hospital. However, their mortality rate appeared unchanged. The authors noted the exercises created additional work for ICU staff that might have come at the expense of other care priorities.
We suggest managing patients with a ventilator liberation protocol. The committee said that patients managed by protocol spent on average 25 fewer hours on mechanical ventilation and were discharged from the ICU a day early. However, their mortality rate appeared unchanged.
We suggest performing a cuff leak test in patients who meet extubation criteria and are deemed at high risk for postextubation stridor. The committee suggested that the test should be used only in patients with a high risk of stridor (abnormal breathing caused by blockage of windpipe) after extubation. Although patients passing the test had lower stridor and reintubation rates, the authors wrote that a high percentage of patients who failed the test could be successfully extubated.
For patients who failed the cuff leak test but are otherwise ready for extubation, we suggest administering systemic steroids at least 4 hours before extubation. The committee said that clinical judgment should take priority over test results, and systemic steroids should be administered to these patients at least 4 hours before extubation. The authors added that the short duration of the steroid therapy was likely to improve success rates without resulting in adverse events.
In a prepared statement, Timothy Girard, MD, of the department of medicine at the University of Pittsburgh and a lead author of the guidelines said the committee hoped the guidelines would help reduce variations in practice that do not benefit patients. “We are not prescribing a specific approach to care for every patient every time,” he said. “But we are trying to summarize the available evidence in as clear and succinct a way as possible so that clinicians know how it applies to most patients.”
Dr. Ouellette disclosed that he has received a research grant from Cardeas Pharma for health care–associated pneumonia.
AT CHEST 2016
Study finds nonoperative management of blunt splenic injuries in elderly safe
WAIKOLOA, HAWAII – Nonoperative management of blunt splenic injuries in the geriatric population is safe, based on results from a study of national data.
Although the efficacy and safety of nonoperative management of blunt splenic injuries in adults is well established, “early recommendations stated that advanced age was a contraindication to nonoperative management of blunt splenic injuries due to high reported failure rates,” researchers led by Marc Trust, MD, wrote in an abstract presented at the annual meeting of the American Association for the Surgery of Trauma. “Although more recent literature has shown lower and acceptable failure rates, this population continues to fail more often compared to younger patients. Published data suffers from low patient numbers and is conflicting regarding future rate and safety.”
In an effort to obtain well powered, nationwide data to evaluate the recent failure rates and effect on morality among geriatric patients, Dr. Trust of the University of Texas at Austin and his associates retrospectively reviewed the 2014 National Trauma Databank to identify patients with blunt splenic injury. Those who did not receive splenectomy within 6 hours of admission were considered to have undergone nonoperative management. Failure of nonoperative management was defined as requiring splenectomy during the same hospitalization. The primary endpoints were failure of nonoperative management and mortality.
Of the 18,917 total patients identified with a blunt splenic injury 2,240 (12%) were aged 65 years and older. Geriatric patients failed nonoperative management more often than did younger patients (6% vs. 4%; P less than .0001). Having an Injury Severity Score of 16 or greater was the only independent risk factor associated with failure of nonoperative management in geriatric patients (odds ratio, 2.8; P less than .0001). No difference in mortality was observed in geriatric patients who had successful versus failed nonoperative management (11% vs. 15%; P = .22). Independent risk factors for mortality in geriatric patients who underwent nonoperative management included admission hypotension (OR, 1.5; P = .048), high ISS (OR, 3.8; P less than .0001), low Glasgow Coma Scale (OR, 5.0; P less than .0001), and preexisting cardiac disease (OR, 3.6; P less than .0001). However, failure of nonoperative management was not independently associated with mortality (OR, 1.4; P = .3).
In their abstract, the researchers characterized the increased failure rates of nonoperative blunt splenic injuries in geriatric patients, compared with their counterparts as “acceptable” and noted that they were lower than previously reported in published literature. They reported having no financial disclosures.
WAIKOLOA, HAWAII – Nonoperative management of blunt splenic injuries in the geriatric population is safe, based on results from a study of national data.
Although the efficacy and safety of nonoperative management of blunt splenic injuries in adults is well established, “early recommendations stated that advanced age was a contraindication to nonoperative management of blunt splenic injuries due to high reported failure rates,” researchers led by Marc Trust, MD, wrote in an abstract presented at the annual meeting of the American Association for the Surgery of Trauma. “Although more recent literature has shown lower and acceptable failure rates, this population continues to fail more often compared to younger patients. Published data suffers from low patient numbers and is conflicting regarding future rate and safety.”
In an effort to obtain well powered, nationwide data to evaluate the recent failure rates and effect on morality among geriatric patients, Dr. Trust of the University of Texas at Austin and his associates retrospectively reviewed the 2014 National Trauma Databank to identify patients with blunt splenic injury. Those who did not receive splenectomy within 6 hours of admission were considered to have undergone nonoperative management. Failure of nonoperative management was defined as requiring splenectomy during the same hospitalization. The primary endpoints were failure of nonoperative management and mortality.
Of the 18,917 total patients identified with a blunt splenic injury 2,240 (12%) were aged 65 years and older. Geriatric patients failed nonoperative management more often than did younger patients (6% vs. 4%; P less than .0001). Having an Injury Severity Score of 16 or greater was the only independent risk factor associated with failure of nonoperative management in geriatric patients (odds ratio, 2.8; P less than .0001). No difference in mortality was observed in geriatric patients who had successful versus failed nonoperative management (11% vs. 15%; P = .22). Independent risk factors for mortality in geriatric patients who underwent nonoperative management included admission hypotension (OR, 1.5; P = .048), high ISS (OR, 3.8; P less than .0001), low Glasgow Coma Scale (OR, 5.0; P less than .0001), and preexisting cardiac disease (OR, 3.6; P less than .0001). However, failure of nonoperative management was not independently associated with mortality (OR, 1.4; P = .3).
In their abstract, the researchers characterized the increased failure rates of nonoperative blunt splenic injuries in geriatric patients, compared with their counterparts as “acceptable” and noted that they were lower than previously reported in published literature. They reported having no financial disclosures.
WAIKOLOA, HAWAII – Nonoperative management of blunt splenic injuries in the geriatric population is safe, based on results from a study of national data.
Although the efficacy and safety of nonoperative management of blunt splenic injuries in adults is well established, “early recommendations stated that advanced age was a contraindication to nonoperative management of blunt splenic injuries due to high reported failure rates,” researchers led by Marc Trust, MD, wrote in an abstract presented at the annual meeting of the American Association for the Surgery of Trauma. “Although more recent literature has shown lower and acceptable failure rates, this population continues to fail more often compared to younger patients. Published data suffers from low patient numbers and is conflicting regarding future rate and safety.”
In an effort to obtain well powered, nationwide data to evaluate the recent failure rates and effect on morality among geriatric patients, Dr. Trust of the University of Texas at Austin and his associates retrospectively reviewed the 2014 National Trauma Databank to identify patients with blunt splenic injury. Those who did not receive splenectomy within 6 hours of admission were considered to have undergone nonoperative management. Failure of nonoperative management was defined as requiring splenectomy during the same hospitalization. The primary endpoints were failure of nonoperative management and mortality.
Of the 18,917 total patients identified with a blunt splenic injury 2,240 (12%) were aged 65 years and older. Geriatric patients failed nonoperative management more often than did younger patients (6% vs. 4%; P less than .0001). Having an Injury Severity Score of 16 or greater was the only independent risk factor associated with failure of nonoperative management in geriatric patients (odds ratio, 2.8; P less than .0001). No difference in mortality was observed in geriatric patients who had successful versus failed nonoperative management (11% vs. 15%; P = .22). Independent risk factors for mortality in geriatric patients who underwent nonoperative management included admission hypotension (OR, 1.5; P = .048), high ISS (OR, 3.8; P less than .0001), low Glasgow Coma Scale (OR, 5.0; P less than .0001), and preexisting cardiac disease (OR, 3.6; P less than .0001). However, failure of nonoperative management was not independently associated with mortality (OR, 1.4; P = .3).
In their abstract, the researchers characterized the increased failure rates of nonoperative blunt splenic injuries in geriatric patients, compared with their counterparts as “acceptable” and noted that they were lower than previously reported in published literature. They reported having no financial disclosures.
AT THE AAST ANNUAL MEETING
Inhaled antibiotic for bronchiectasis shows promise
AT CHEST 2016
LOS ANGELES – Long-term inhaled ciprofloxacin therapy appears to be a safe and effective treatment option in patients with bronchiectasis, results from an international phase III trial showed.
“This is really exciting; it’s the first large study of an inhaled antibiotic to show a benefit in this population,” study investigator Kevin Winthrop, MD, said in an interview prior to the annual meeting of the American College of Chest Physicians. “There’s a tremendous unmet need and a lot of these patients have daily struggles and their quality of life is low. To have something that would improve that would be a benefit for patients and physicians alike.”
Compared with patients in the placebo arm, those in the ciprofloxacin dry powder for inhalation (DPI) 14-day on/off arm experienced a significantly prolonged time to first exacerbation (a mean of 336 days versus 186 days, respectively; adjusted hazard ratio, 0.53; P = .0005) and a significantly reduced exacerbation frequency over 48 weeks (a mean of 0.78 vs. 1.42; adjusted incident rate of 0.61; P = .0061). A nonsignificant trend in favor of ciprofloxacin DPI was observed for both primary endpoints among patients in the 28-day on/off arm (time to first exacerbation: HR, 0.73; P = .065; frequency of exacerbations: adjusted incidence rate ratio, 0.98; P = .89).
Treatment-emergent adverse events and adverse events leading to discontinuation were similar across treatment groups (82% in the ciprofloxacin DPI 14-day on/off arm, 83% in the ciprofloxacin DPI 28-day on/off arm, and 83% in the pooled placebo arm. The rates of serious adverse events were also similar in the three treatment groups (17%, 20%, and 23%, respectively). “Tolerability markers like hoarseness, bronchospasm, shortness of breath, or increased cough were similar between the treatment arms,” said Dr. Winthrop, who is an infectious diseases specialist at Oregon Health and Science University, Portland.“The safety profile looks really good. There were no typical fluoroquinolone types of problems such as tendinopathy reported.”
A follow-up trial known as RESPIRE 2 is ongoing. RESPIRE 1 was funded by Bayer. Dr. Winthrop disclosed that he is a consultant for the company.
This article was updated on 10/25/2016 at 9:51 AM Est
AT CHEST 2016
LOS ANGELES – Long-term inhaled ciprofloxacin therapy appears to be a safe and effective treatment option in patients with bronchiectasis, results from an international phase III trial showed.
“This is really exciting; it’s the first large study of an inhaled antibiotic to show a benefit in this population,” study investigator Kevin Winthrop, MD, said in an interview prior to the annual meeting of the American College of Chest Physicians. “There’s a tremendous unmet need and a lot of these patients have daily struggles and their quality of life is low. To have something that would improve that would be a benefit for patients and physicians alike.”
Compared with patients in the placebo arm, those in the ciprofloxacin dry powder for inhalation (DPI) 14-day on/off arm experienced a significantly prolonged time to first exacerbation (a mean of 336 days versus 186 days, respectively; adjusted hazard ratio, 0.53; P = .0005) and a significantly reduced exacerbation frequency over 48 weeks (a mean of 0.78 vs. 1.42; adjusted incident rate of 0.61; P = .0061). A nonsignificant trend in favor of ciprofloxacin DPI was observed for both primary endpoints among patients in the 28-day on/off arm (time to first exacerbation: HR, 0.73; P = .065; frequency of exacerbations: adjusted incidence rate ratio, 0.98; P = .89).
Treatment-emergent adverse events and adverse events leading to discontinuation were similar across treatment groups (82% in the ciprofloxacin DPI 14-day on/off arm, 83% in the ciprofloxacin DPI 28-day on/off arm, and 83% in the pooled placebo arm. The rates of serious adverse events were also similar in the three treatment groups (17%, 20%, and 23%, respectively). “Tolerability markers like hoarseness, bronchospasm, shortness of breath, or increased cough were similar between the treatment arms,” said Dr. Winthrop, who is an infectious diseases specialist at Oregon Health and Science University, Portland.“The safety profile looks really good. There were no typical fluoroquinolone types of problems such as tendinopathy reported.”
A follow-up trial known as RESPIRE 2 is ongoing. RESPIRE 1 was funded by Bayer. Dr. Winthrop disclosed that he is a consultant for the company.
This article was updated on 10/25/2016 at 9:51 AM Est
AT CHEST 2016
LOS ANGELES – Long-term inhaled ciprofloxacin therapy appears to be a safe and effective treatment option in patients with bronchiectasis, results from an international phase III trial showed.
“This is really exciting; it’s the first large study of an inhaled antibiotic to show a benefit in this population,” study investigator Kevin Winthrop, MD, said in an interview prior to the annual meeting of the American College of Chest Physicians. “There’s a tremendous unmet need and a lot of these patients have daily struggles and their quality of life is low. To have something that would improve that would be a benefit for patients and physicians alike.”
Compared with patients in the placebo arm, those in the ciprofloxacin dry powder for inhalation (DPI) 14-day on/off arm experienced a significantly prolonged time to first exacerbation (a mean of 336 days versus 186 days, respectively; adjusted hazard ratio, 0.53; P = .0005) and a significantly reduced exacerbation frequency over 48 weeks (a mean of 0.78 vs. 1.42; adjusted incident rate of 0.61; P = .0061). A nonsignificant trend in favor of ciprofloxacin DPI was observed for both primary endpoints among patients in the 28-day on/off arm (time to first exacerbation: HR, 0.73; P = .065; frequency of exacerbations: adjusted incidence rate ratio, 0.98; P = .89).
Treatment-emergent adverse events and adverse events leading to discontinuation were similar across treatment groups (82% in the ciprofloxacin DPI 14-day on/off arm, 83% in the ciprofloxacin DPI 28-day on/off arm, and 83% in the pooled placebo arm. The rates of serious adverse events were also similar in the three treatment groups (17%, 20%, and 23%, respectively). “Tolerability markers like hoarseness, bronchospasm, shortness of breath, or increased cough were similar between the treatment arms,” said Dr. Winthrop, who is an infectious diseases specialist at Oregon Health and Science University, Portland.“The safety profile looks really good. There were no typical fluoroquinolone types of problems such as tendinopathy reported.”
A follow-up trial known as RESPIRE 2 is ongoing. RESPIRE 1 was funded by Bayer. Dr. Winthrop disclosed that he is a consultant for the company.
This article was updated on 10/25/2016 at 9:51 AM Est
Key clinical point:
Major finding: Compared with patients in the placebo arm, those in the ciprofloxacin 14-day on/off arm experienced a significantly prolonged time to first exacerbation (a mean of 336 days vs. 186 days, respectively; adjusted hazard ratio, 0.53; P = .0005).
Data source: A multicenter study of 416 patients who were randomized 2:1 to ciprofloxacin 32.5 mg or placebo administered twice per day using a pocket-sized inhaler as a cyclical regimen of either 14 days on/off drug or 28 days on/off drug, for 48 weeks.
Disclosures: RESPIRE 1 was funded by Bayer. Dr. Winthrop disclosed that he is a consultant for the company.
Lung cancer screening found effective in a community hospital
LOS ANGELES – Lung cancer screening with low-dose CT scans in a community hospital setting replicates results from international and multicenter trials when it comes to diagnosing early-stage lung cancer, findings from a single-center study showed.
“It’s too early in our experience to say that we’re saving lives, but the fact that we’re detecting early lung cancers in the predicted percentages is good for community hospitals that are wondering, ‘Is it worth it to screen for lung cancer? Can we do it?’ ” Richard P. Salzano Jr., MD, said in an interview in advance of the annual meeting of the American College of Chest Physicians.
In July 2013, the 130-bed Griffin Hospital launched a lung cancer screening program codirected by a pulmonologist and a cardiothoracic surgeon. All low-dose CT scans were read by two designated radiologists. Dr. Salzano reported results from 514 patients enrolled in the program between July 2013 and December 2015. A total of nine lung cancers were detected. Seven (78%) were stage I or II lung cancers, and the remaining two (22%) were stage II or IV, results that are in line with data from the I-ELCAP and NLST trials.
In another component of the study, the researchers randomly selected 101 patients from the lung cancer screening program to answer questions by telephone intended to quantify their anxiety about lung cancer before and after participating in the program, attitudes about smoking behaviors, and general impressions of the screening process. On a scale of 0-10, with 10 being “very anxious,” Dr. Salzano reported that the mean anxiety level about lung cancer fell from a level of 4.69 before screening to 3.87 afterward, a difference that reached statistical significance, with a P value of .014. “None of the patients reported negative impacts of the program,” he added. “They reported a general improvement in their well-being as a result of participating in the program.” In addition, of the 53 respondents who were current smokers upon enrolling in the screening program, five quit after intake, and the remaining 48 indicated that they were “more likely to quit” as a result of being enrolled.
“Community hospitals need to embrace lung screening,” Dr. Salzano concluded. “The findings from the large studies are transferable. It’s helping your patients in terms of their attitudes about lung cancer, about smoking cessation, and about improving their wellness.”
He reported having no relevant financial disclosures.
LOS ANGELES – Lung cancer screening with low-dose CT scans in a community hospital setting replicates results from international and multicenter trials when it comes to diagnosing early-stage lung cancer, findings from a single-center study showed.
“It’s too early in our experience to say that we’re saving lives, but the fact that we’re detecting early lung cancers in the predicted percentages is good for community hospitals that are wondering, ‘Is it worth it to screen for lung cancer? Can we do it?’ ” Richard P. Salzano Jr., MD, said in an interview in advance of the annual meeting of the American College of Chest Physicians.
In July 2013, the 130-bed Griffin Hospital launched a lung cancer screening program codirected by a pulmonologist and a cardiothoracic surgeon. All low-dose CT scans were read by two designated radiologists. Dr. Salzano reported results from 514 patients enrolled in the program between July 2013 and December 2015. A total of nine lung cancers were detected. Seven (78%) were stage I or II lung cancers, and the remaining two (22%) were stage II or IV, results that are in line with data from the I-ELCAP and NLST trials.
In another component of the study, the researchers randomly selected 101 patients from the lung cancer screening program to answer questions by telephone intended to quantify their anxiety about lung cancer before and after participating in the program, attitudes about smoking behaviors, and general impressions of the screening process. On a scale of 0-10, with 10 being “very anxious,” Dr. Salzano reported that the mean anxiety level about lung cancer fell from a level of 4.69 before screening to 3.87 afterward, a difference that reached statistical significance, with a P value of .014. “None of the patients reported negative impacts of the program,” he added. “They reported a general improvement in their well-being as a result of participating in the program.” In addition, of the 53 respondents who were current smokers upon enrolling in the screening program, five quit after intake, and the remaining 48 indicated that they were “more likely to quit” as a result of being enrolled.
“Community hospitals need to embrace lung screening,” Dr. Salzano concluded. “The findings from the large studies are transferable. It’s helping your patients in terms of their attitudes about lung cancer, about smoking cessation, and about improving their wellness.”
He reported having no relevant financial disclosures.
LOS ANGELES – Lung cancer screening with low-dose CT scans in a community hospital setting replicates results from international and multicenter trials when it comes to diagnosing early-stage lung cancer, findings from a single-center study showed.
“It’s too early in our experience to say that we’re saving lives, but the fact that we’re detecting early lung cancers in the predicted percentages is good for community hospitals that are wondering, ‘Is it worth it to screen for lung cancer? Can we do it?’ ” Richard P. Salzano Jr., MD, said in an interview in advance of the annual meeting of the American College of Chest Physicians.
In July 2013, the 130-bed Griffin Hospital launched a lung cancer screening program codirected by a pulmonologist and a cardiothoracic surgeon. All low-dose CT scans were read by two designated radiologists. Dr. Salzano reported results from 514 patients enrolled in the program between July 2013 and December 2015. A total of nine lung cancers were detected. Seven (78%) were stage I or II lung cancers, and the remaining two (22%) were stage II or IV, results that are in line with data from the I-ELCAP and NLST trials.
In another component of the study, the researchers randomly selected 101 patients from the lung cancer screening program to answer questions by telephone intended to quantify their anxiety about lung cancer before and after participating in the program, attitudes about smoking behaviors, and general impressions of the screening process. On a scale of 0-10, with 10 being “very anxious,” Dr. Salzano reported that the mean anxiety level about lung cancer fell from a level of 4.69 before screening to 3.87 afterward, a difference that reached statistical significance, with a P value of .014. “None of the patients reported negative impacts of the program,” he added. “They reported a general improvement in their well-being as a result of participating in the program.” In addition, of the 53 respondents who were current smokers upon enrolling in the screening program, five quit after intake, and the remaining 48 indicated that they were “more likely to quit” as a result of being enrolled.
“Community hospitals need to embrace lung screening,” Dr. Salzano concluded. “The findings from the large studies are transferable. It’s helping your patients in terms of their attitudes about lung cancer, about smoking cessation, and about improving their wellness.”
He reported having no relevant financial disclosures.
AT CHEST 2016
Key clinical point:
Major finding: Of nine lung cancers detected, seven (78%) were stage I or II lung cancers and the remaining two (22%) were stage II or IV.
Data source: Results from 514 patients enrolled in a community hospital–based lung cancer screening program between July 2013 and December 2015.
Disclosures: Dr. Salzano reported having no relevant financial disclosures.
Sepsis mortality linked to concentration of critical care fellowships
LOS ANGELES – Compared with other parts of the United States, survival rates for sepsis were highest in the Northeast and in metropolitan areas in the Western regions of the United States, which mirrors the concentration of critical care fellowship programs, results from a descriptive analysis found.
“There must be consideration to redistribute the critical care work force based on the spread of the malady that they are trained to deal with,” lead study author Aditya Shah, MD, said in an interview in advance of the annual meeting of the American College of Chest Physicians. “This could be linked to better reimbursements in the underserved areas.”
Dr. Shah has conducted similar projects in patient populations with HIV and hepatitis, but to his knowledge, this is the first such analysis using NCHS data. “What is unique about this is that we can make real time presentations to see how the work force and the pathology is evolving with regards to an epidemiological stand point with real time data, which can be easily accessed,” he explained. “Depending on what we see, interventions and redistributions could be made with regards to better distributing providers based on where they are needed the most.”
Of 150 critical care fellowship programs identified in the analysis, the majority were concentrated in the Northeast and metropolitan areas in the Western regions of the United States, which parallel similar patterns noted in other specialties. Survival rates for sepsis were also higher in these locations. Dr. Shah said that the findings support previous studies, which indicated that physicians often tend to practice in geographic areas close to their training sites. However, the fact that such variation existed in mortality from sepsis – one of the most common diagnoses in the medical and surgical intensive care units – surprised him. “You would have thought that there would be a work force to deal with this malady,” he said.
He acknowledged certain limitations of the study, including the fact that the NCHS data do not enable researchers to break down mortality from particular causes of sepsis. “Also, the most current data will always lag behind as it is entered retrospectively and needs time to be uploaded online,” he said. “I am still in search of a more real-time database. However, that would require much more intensive time, money, and resources.”
Dr. Shah reported having no financial disclosures.
LOS ANGELES – Compared with other parts of the United States, survival rates for sepsis were highest in the Northeast and in metropolitan areas in the Western regions of the United States, which mirrors the concentration of critical care fellowship programs, results from a descriptive analysis found.
“There must be consideration to redistribute the critical care work force based on the spread of the malady that they are trained to deal with,” lead study author Aditya Shah, MD, said in an interview in advance of the annual meeting of the American College of Chest Physicians. “This could be linked to better reimbursements in the underserved areas.”
Dr. Shah has conducted similar projects in patient populations with HIV and hepatitis, but to his knowledge, this is the first such analysis using NCHS data. “What is unique about this is that we can make real time presentations to see how the work force and the pathology is evolving with regards to an epidemiological stand point with real time data, which can be easily accessed,” he explained. “Depending on what we see, interventions and redistributions could be made with regards to better distributing providers based on where they are needed the most.”
Of 150 critical care fellowship programs identified in the analysis, the majority were concentrated in the Northeast and metropolitan areas in the Western regions of the United States, which parallel similar patterns noted in other specialties. Survival rates for sepsis were also higher in these locations. Dr. Shah said that the findings support previous studies, which indicated that physicians often tend to practice in geographic areas close to their training sites. However, the fact that such variation existed in mortality from sepsis – one of the most common diagnoses in the medical and surgical intensive care units – surprised him. “You would have thought that there would be a work force to deal with this malady,” he said.
He acknowledged certain limitations of the study, including the fact that the NCHS data do not enable researchers to break down mortality from particular causes of sepsis. “Also, the most current data will always lag behind as it is entered retrospectively and needs time to be uploaded online,” he said. “I am still in search of a more real-time database. However, that would require much more intensive time, money, and resources.”
Dr. Shah reported having no financial disclosures.
LOS ANGELES – Compared with other parts of the United States, survival rates for sepsis were highest in the Northeast and in metropolitan areas in the Western regions of the United States, which mirrors the concentration of critical care fellowship programs, results from a descriptive analysis found.
“There must be consideration to redistribute the critical care work force based on the spread of the malady that they are trained to deal with,” lead study author Aditya Shah, MD, said in an interview in advance of the annual meeting of the American College of Chest Physicians. “This could be linked to better reimbursements in the underserved areas.”
Dr. Shah has conducted similar projects in patient populations with HIV and hepatitis, but to his knowledge, this is the first such analysis using NCHS data. “What is unique about this is that we can make real time presentations to see how the work force and the pathology is evolving with regards to an epidemiological stand point with real time data, which can be easily accessed,” he explained. “Depending on what we see, interventions and redistributions could be made with regards to better distributing providers based on where they are needed the most.”
Of 150 critical care fellowship programs identified in the analysis, the majority were concentrated in the Northeast and metropolitan areas in the Western regions of the United States, which parallel similar patterns noted in other specialties. Survival rates for sepsis were also higher in these locations. Dr. Shah said that the findings support previous studies, which indicated that physicians often tend to practice in geographic areas close to their training sites. However, the fact that such variation existed in mortality from sepsis – one of the most common diagnoses in the medical and surgical intensive care units – surprised him. “You would have thought that there would be a work force to deal with this malady,” he said.
He acknowledged certain limitations of the study, including the fact that the NCHS data do not enable researchers to break down mortality from particular causes of sepsis. “Also, the most current data will always lag behind as it is entered retrospectively and needs time to be uploaded online,” he said. “I am still in search of a more real-time database. However, that would require much more intensive time, money, and resources.”
Dr. Shah reported having no financial disclosures.
AT CHEST 2016
Key clinical point:
Major finding: Higher survival rates for sepsis were more concentrated in the Northeast and metropolitan areas in the Western regions of the United States, compared with other areas of the country.
Data source: A descriptive analysis that evaluated sepsis mortality data linked to 150 critical care fellowship programs in the United States.
Disclosures: Dr. Shah reported having no financial disclosures.
Smokers’ hand grip strength predicts risk for respiratory events
LOS ANGELES – Hand grip strength is independently predictive of risk for respiratory events in smokers who have or are at risk for chronic obstructive pulmonary disease, results from a single-center study showed.
“Measures of lung function, including spirometry, are used as the main descriptors of COPD severity and prognosis,” Carlos H. Martinez, MD, MPH, said in an interview in advance of the annual meeting of the American College of Chest Physicians. “These measurements, as important as they are, need to be improved, in order to develop better risk and prognostic models of the disease, to identify subgroups at higher risk of poor outcomes ... With our work, we have proved that simple physical tests could be part of future prognostic models.”
Interest has grown in developing multidimensional models to predict respiratory prognosis. Such models include BODE (body mass index, airflow obstruction, dyspnea and exercise capacity), ADO (age, dyspnea and airflow obstruction), and DOSE (dyspnea, airflow obstruction, smoking status, and exacerbation frequency).
In patients with or at risk for COPD, Dr. Martinez, of the University of Michigan Health System, Ann Arbor, and his colleagues tested the associations of hand grip strength with measures of body composition such as pectoralis muscle area and extent of subcutaneous fat, imaging phenotypes, and lung function.
The researchers obtained demographic, clinical, lung function, hand grip strength, and imaging data from 441 smokers with and without COPD participating in the Genetic Epidemiology of COPD Study (COPDGene) at the National Jewish Health in Denver. Imaging methods used in the study were developed by George R. Washko, MD, and his associates at Brigham and Women’s Hospital, Boston, to evaluate patients’ body composition, including chest CTs to obtain measures of airway thickness, emphysema percentage, pectoralis muscle area, and subcutaneous adipose tissue area.
Correlations between measures of lung function, imaging phenotypes, body composition, and hand grip strength were analyzed in univariate analysis and in multivariate linear models. The association between hand grip strength and exacerbations was analyzed at enrollment and during an average follow-up of 2.6 years.
Hand grip strength was similar across groups categorized by spirometry severity and was not associated with emphysema severity.
After adjustment for demographics, smoking history, smoking intensity, comorbidities and lung imaging phenotypes, however, grip strength was associated with pectoralis muscle area (increase of 3.9 kg per one standard deviation of pectoral muscle area) and subcutaneous adipose tissue (a decrement of 5.1 kg per one standard deviation of subcutaneous adipose tissue). These associations were independent of body mass index and the presence of emphysema.
During follow-up, hand grip strength was associated with exacerbations (risk ratio 0.94 per one kg increment on grip strength) and incident exacerbations (incident risk ratio 0.92 per one kg increment on grip strength) in models adjusted for other factors known to be associated with exacerbations.
Research in body composition has mostly relied on dual absorptiometry and bioelectrical impedance, tools not routinely used in clinical practice, Dr. Martinez said. “We were surprised by the ability to show similar results using imaging data that are available from regular chest CTs.”
“We have confirmed prior hypotheses that it is not just weight or BMI that matters (to risk of exacerbations), but how much muscle and how much fat are contributing to our patient’s high or low BMI,” Dr. Martinez said.
Hand grip testing can be challenging in this patient population, he said. Still, “asking relevant questions about (patients’) physical fitness will help us to understand better our patients’ needs. We can also give more attention to the extrapulmonary structures included in the numerous chest CT scans that we order for our patients. These imaging studies, besides the information that they provide about parenchymal and mediastinal structures, include important and easy to discover clues to identify patients at higher risk of exacerbations – those with low muscle and low hand grip could benefit from close follow-up.”
Dr. Martinez acknowledged certain limitations of the study, including the selection of the measures of body composition. “We used analysis of chest CTs, instead of the gold standard of dual absorptiometry (DXA) or other methods such as bioelectrical impedance,” he said. “A final limitation is that we tested a selected group of participants in a cohort study, not a representative sample of the population, [with a] low burden of emphysema and fewer African American participants.”
Dr. Martinez disclosed that his work is supported by the National Institutes of Health and that COPDGene also receives NIH funding. He acknowledged the support and effort of all COPDGene investigators and participants.
LOS ANGELES – Hand grip strength is independently predictive of risk for respiratory events in smokers who have or are at risk for chronic obstructive pulmonary disease, results from a single-center study showed.
“Measures of lung function, including spirometry, are used as the main descriptors of COPD severity and prognosis,” Carlos H. Martinez, MD, MPH, said in an interview in advance of the annual meeting of the American College of Chest Physicians. “These measurements, as important as they are, need to be improved, in order to develop better risk and prognostic models of the disease, to identify subgroups at higher risk of poor outcomes ... With our work, we have proved that simple physical tests could be part of future prognostic models.”
Interest has grown in developing multidimensional models to predict respiratory prognosis. Such models include BODE (body mass index, airflow obstruction, dyspnea and exercise capacity), ADO (age, dyspnea and airflow obstruction), and DOSE (dyspnea, airflow obstruction, smoking status, and exacerbation frequency).
In patients with or at risk for COPD, Dr. Martinez, of the University of Michigan Health System, Ann Arbor, and his colleagues tested the associations of hand grip strength with measures of body composition such as pectoralis muscle area and extent of subcutaneous fat, imaging phenotypes, and lung function.
The researchers obtained demographic, clinical, lung function, hand grip strength, and imaging data from 441 smokers with and without COPD participating in the Genetic Epidemiology of COPD Study (COPDGene) at the National Jewish Health in Denver. Imaging methods used in the study were developed by George R. Washko, MD, and his associates at Brigham and Women’s Hospital, Boston, to evaluate patients’ body composition, including chest CTs to obtain measures of airway thickness, emphysema percentage, pectoralis muscle area, and subcutaneous adipose tissue area.
Correlations between measures of lung function, imaging phenotypes, body composition, and hand grip strength were analyzed in univariate analysis and in multivariate linear models. The association between hand grip strength and exacerbations was analyzed at enrollment and during an average follow-up of 2.6 years.
Hand grip strength was similar across groups categorized by spirometry severity and was not associated with emphysema severity.
After adjustment for demographics, smoking history, smoking intensity, comorbidities and lung imaging phenotypes, however, grip strength was associated with pectoralis muscle area (increase of 3.9 kg per one standard deviation of pectoral muscle area) and subcutaneous adipose tissue (a decrement of 5.1 kg per one standard deviation of subcutaneous adipose tissue). These associations were independent of body mass index and the presence of emphysema.
During follow-up, hand grip strength was associated with exacerbations (risk ratio 0.94 per one kg increment on grip strength) and incident exacerbations (incident risk ratio 0.92 per one kg increment on grip strength) in models adjusted for other factors known to be associated with exacerbations.
Research in body composition has mostly relied on dual absorptiometry and bioelectrical impedance, tools not routinely used in clinical practice, Dr. Martinez said. “We were surprised by the ability to show similar results using imaging data that are available from regular chest CTs.”
“We have confirmed prior hypotheses that it is not just weight or BMI that matters (to risk of exacerbations), but how much muscle and how much fat are contributing to our patient’s high or low BMI,” Dr. Martinez said.
Hand grip testing can be challenging in this patient population, he said. Still, “asking relevant questions about (patients’) physical fitness will help us to understand better our patients’ needs. We can also give more attention to the extrapulmonary structures included in the numerous chest CT scans that we order for our patients. These imaging studies, besides the information that they provide about parenchymal and mediastinal structures, include important and easy to discover clues to identify patients at higher risk of exacerbations – those with low muscle and low hand grip could benefit from close follow-up.”
Dr. Martinez acknowledged certain limitations of the study, including the selection of the measures of body composition. “We used analysis of chest CTs, instead of the gold standard of dual absorptiometry (DXA) or other methods such as bioelectrical impedance,” he said. “A final limitation is that we tested a selected group of participants in a cohort study, not a representative sample of the population, [with a] low burden of emphysema and fewer African American participants.”
Dr. Martinez disclosed that his work is supported by the National Institutes of Health and that COPDGene also receives NIH funding. He acknowledged the support and effort of all COPDGene investigators and participants.
LOS ANGELES – Hand grip strength is independently predictive of risk for respiratory events in smokers who have or are at risk for chronic obstructive pulmonary disease, results from a single-center study showed.
“Measures of lung function, including spirometry, are used as the main descriptors of COPD severity and prognosis,” Carlos H. Martinez, MD, MPH, said in an interview in advance of the annual meeting of the American College of Chest Physicians. “These measurements, as important as they are, need to be improved, in order to develop better risk and prognostic models of the disease, to identify subgroups at higher risk of poor outcomes ... With our work, we have proved that simple physical tests could be part of future prognostic models.”
Interest has grown in developing multidimensional models to predict respiratory prognosis. Such models include BODE (body mass index, airflow obstruction, dyspnea and exercise capacity), ADO (age, dyspnea and airflow obstruction), and DOSE (dyspnea, airflow obstruction, smoking status, and exacerbation frequency).
In patients with or at risk for COPD, Dr. Martinez, of the University of Michigan Health System, Ann Arbor, and his colleagues tested the associations of hand grip strength with measures of body composition such as pectoralis muscle area and extent of subcutaneous fat, imaging phenotypes, and lung function.
The researchers obtained demographic, clinical, lung function, hand grip strength, and imaging data from 441 smokers with and without COPD participating in the Genetic Epidemiology of COPD Study (COPDGene) at the National Jewish Health in Denver. Imaging methods used in the study were developed by George R. Washko, MD, and his associates at Brigham and Women’s Hospital, Boston, to evaluate patients’ body composition, including chest CTs to obtain measures of airway thickness, emphysema percentage, pectoralis muscle area, and subcutaneous adipose tissue area.
Correlations between measures of lung function, imaging phenotypes, body composition, and hand grip strength were analyzed in univariate analysis and in multivariate linear models. The association between hand grip strength and exacerbations was analyzed at enrollment and during an average follow-up of 2.6 years.
Hand grip strength was similar across groups categorized by spirometry severity and was not associated with emphysema severity.
After adjustment for demographics, smoking history, smoking intensity, comorbidities and lung imaging phenotypes, however, grip strength was associated with pectoralis muscle area (increase of 3.9 kg per one standard deviation of pectoral muscle area) and subcutaneous adipose tissue (a decrement of 5.1 kg per one standard deviation of subcutaneous adipose tissue). These associations were independent of body mass index and the presence of emphysema.
During follow-up, hand grip strength was associated with exacerbations (risk ratio 0.94 per one kg increment on grip strength) and incident exacerbations (incident risk ratio 0.92 per one kg increment on grip strength) in models adjusted for other factors known to be associated with exacerbations.
Research in body composition has mostly relied on dual absorptiometry and bioelectrical impedance, tools not routinely used in clinical practice, Dr. Martinez said. “We were surprised by the ability to show similar results using imaging data that are available from regular chest CTs.”
“We have confirmed prior hypotheses that it is not just weight or BMI that matters (to risk of exacerbations), but how much muscle and how much fat are contributing to our patient’s high or low BMI,” Dr. Martinez said.
Hand grip testing can be challenging in this patient population, he said. Still, “asking relevant questions about (patients’) physical fitness will help us to understand better our patients’ needs. We can also give more attention to the extrapulmonary structures included in the numerous chest CT scans that we order for our patients. These imaging studies, besides the information that they provide about parenchymal and mediastinal structures, include important and easy to discover clues to identify patients at higher risk of exacerbations – those with low muscle and low hand grip could benefit from close follow-up.”
Dr. Martinez acknowledged certain limitations of the study, including the selection of the measures of body composition. “We used analysis of chest CTs, instead of the gold standard of dual absorptiometry (DXA) or other methods such as bioelectrical impedance,” he said. “A final limitation is that we tested a selected group of participants in a cohort study, not a representative sample of the population, [with a] low burden of emphysema and fewer African American participants.”
Dr. Martinez disclosed that his work is supported by the National Institutes of Health and that COPDGene also receives NIH funding. He acknowledged the support and effort of all COPDGene investigators and participants.
AT CHEST 2016
Key clinical point:
Major finding: During an average follow-up of 2.6 years, hand grip strength was associated with cross-sectional exacerbations (risk ratio 0.94 per one kg increment on grip strength) and incident exacerbations (incident risk ratio 0.92 per one kg increment on grip strength).
Data source: Data from 441 smokers with and without COPD participating in the Genetic Epidemiology of COPD Study (COPDGene) at National Jewish Health in Denver.
Disclosures: Dr. Martinez disclosed that his work is supported by the National Institutes of Health and that COPDGene also receives NIH funding.
LMWH best for preventing PE in patients with major trauma
WAIKOLOA, HAWAII – Venous thromboembolism prophylaxis with low molecular weight heparin (LMWH), instead of unfractionated heparin (UH), is associated with lower risk of pulmonary embolism (PE) in patients with major trauma, results from a large study have shown.
The results of the study, based on data from the American College of Surgeons (ACS) Trauma Quality Improvement Program, suggest that LMWH-based strategies for thromboprophylaxis should be preferred after major trauma.
Dr. Byrne, a general surgery resident at Sunnybrook Health Science Center, Toronto, Ontario, Canada, went on to note that LMWH is often favored because of a randomized controlled trial which showed that LMWH was associated with fewer deep vein thromboses (N Engl. J. Med. 1996;335[10]:701-7). However, significant practice variability continues to exist.
“Practitioners might favor the shorter half-life of unfractionated heparin in patients where they perceive the risk for hemorrhagic complications is high,” he said. “There’s also recent evidence to suggest that dosing may be all important and that unfractionated heparin dosed three times daily may be equivalent to low molecular weight heparin. If this is true, it might suggest that the historically higher cost of low molecular weight heparin could favor the use of unfractionated heparin.”
Furthermore, there is a is a lack of evidence comparing either agent to prevent PE, he added. “This is an important gap in our knowledge, because PE frequently occurs in the absence of an identified DVT and carries a significant risk of death. At present, it is not known how practice patterns with respect to choice of prophylaxis type influence risk of PE at the patient or hospital levels.”
Due to a lack of evidence comparing agents to prevent PE, the researchers set out to compare the effectiveness of LMWH versus UH to prevent PE in patients with major trauma who were treated at trauma centers participating in the ACS Trauma Quality Improvement Program from 2012 to 2015. They included all adults with severe injury who received LMWH or UH and excluded those who died or were discharged within five days, and those with a bleeding disorder or chronic anticoagulation. The exposure was defined as thromboprophylaxis with LMWH versus UH, and the primary outcome was PE confirmed on radiologic imaging. Potential confounders were considered, including patient baseline characteristics, anatomic and global injury severity, presenting characteristics in the emergency department, acute intracranial injuries, orthopedic injuries, early surgical interventions, and timing of prophylaxis initiation.
Dr. Byrne and his associates then used three analytic approaches in the study: a propensity score matching methodology, a multivariable logistic regression model for PE, and a center-level analysis examining the influence of LMWH utilization on hospital rates of PE.
They identified 153,474 trauma patients from 217 trauma centers. Their median age was 50 years and 67% were male. Blunt trauma was most common (89%), with a mean Injury Severity Score score of 20. LMWH was the most common type of thromboprophylaxis used (74%), and PE was diagnosed in 2,722 patients (1.8%).
Compared with patients who received LMWH, those who received UH were older and were significantly more likely to have been injured by falling (42% vs. 28%), with higher rates of severe head injuries (43% vs. 24%) and intracranial hemorrhage (38% vs. 19%). Conversely, LMWH was most favored in patients with orthopedic injuries.
After propensity score matching, patients on LMWH suffered significantly fewer PEs (1.4% vs. 2.4%; odds ratio, 0.56). This result was consistent within propensity-matched subgroups, including for patients with blunt multisystem injuries (OR, 0.60), penetrating truncal injuries (OR, 0.65), shock in the ED (OR, 0.68), isolated severe traumatic brain injury (OR, 0.49), and isolated orthopedic injuries (OR, 0.28).
Results of a sensitivity analysis in which each propensity-matched pair was matched within the same trauma center yielded similar results. Specifically, patients who received LMWH were at significantly lower risk for developing PE (OR, 0.64). “Importantly, this analysis minimized residual confounding due to differences in hospital-level processes of care, such as prophylaxis dosing or frequency, mechanical prophylaxis use, and thromboembolism screening practices,” Dr. Byrne noted.
Multivariable logistic regression also showed that patients who received LMWH had lower odds of PE (OR, 0.59). Other significant predictors of PE included obesity (OR, 1.54), severe chest injury (OR, 1.31), femoral shaft fracture (OR, 1.60), and spinal cord injury (OR, 1.60). Delays in prophylaxis initiation beyond the first day in the hospital were associated with significantly higher rates of PE, with an 80% increased risk of PE for patients who had their prophylaxis initiated after the fourth day.
The researchers conducted a center-level analysis in an effort to answer the question whether practice patterns with respect to choice of prophylaxis type influence hospital rates of PE. Across all 217 trauma centers in the study, the median rate of LMWH use was 80%, while the mean rate of PE was 1.6%. When trauma centers were grouped into quartiles based on their unique rate of LMWH use, trauma centers in the highest quartile (median LMWH use: 95%) were 50 times more likely to use LMWH, compared to those in the lowest quartile (median LMWH use: 39%) after adjusting for patient case mix. Compared with the lowest quartile, trauma centers that used the greatest proportion of LMWH had significantly lower rates of PE (1.2% vs. 2.0%). After adjusting for patient baseline and injury characteristics, patients who were treated at trauma centers in the highest quartile had significantly lower odds of PE (OR, 0.59).
Dr. Byrne acknowledged certain limitations of the study, including the potential for residual confounding and the inability to account for the dosing and frequency of prophylaxis that was given. “We were only able to measure the type and timing of prophylaxis initiation. We don’t know what doses of prophylaxis were used, and it is possible that the trauma centers included in this study favored use of UH twice daily,” he said.
Therefore, it is possible that the results might have been different if they had been able to directly compare LMWH to UH administered three times a day. “We also couldn’t measure interruptions in dosing due to surgery or patient refusal,” he said. “However, if it the case that UH is more likely to be refused based on the need for more frequent dosing, perhaps that is another feather in the cap of low molecular weight heparin-based thromboprophylaxis strategies. Larger prospective studies are needed, that take into account prophylaxis type and dosing, and are powered to detect a difference with respect to PE.”
Dr. Byrne reported having no financial disclosures.
WAIKOLOA, HAWAII – Venous thromboembolism prophylaxis with low molecular weight heparin (LMWH), instead of unfractionated heparin (UH), is associated with lower risk of pulmonary embolism (PE) in patients with major trauma, results from a large study have shown.
The results of the study, based on data from the American College of Surgeons (ACS) Trauma Quality Improvement Program, suggest that LMWH-based strategies for thromboprophylaxis should be preferred after major trauma.
Dr. Byrne, a general surgery resident at Sunnybrook Health Science Center, Toronto, Ontario, Canada, went on to note that LMWH is often favored because of a randomized controlled trial which showed that LMWH was associated with fewer deep vein thromboses (N Engl. J. Med. 1996;335[10]:701-7). However, significant practice variability continues to exist.
“Practitioners might favor the shorter half-life of unfractionated heparin in patients where they perceive the risk for hemorrhagic complications is high,” he said. “There’s also recent evidence to suggest that dosing may be all important and that unfractionated heparin dosed three times daily may be equivalent to low molecular weight heparin. If this is true, it might suggest that the historically higher cost of low molecular weight heparin could favor the use of unfractionated heparin.”
Furthermore, there is a is a lack of evidence comparing either agent to prevent PE, he added. “This is an important gap in our knowledge, because PE frequently occurs in the absence of an identified DVT and carries a significant risk of death. At present, it is not known how practice patterns with respect to choice of prophylaxis type influence risk of PE at the patient or hospital levels.”
Due to a lack of evidence comparing agents to prevent PE, the researchers set out to compare the effectiveness of LMWH versus UH to prevent PE in patients with major trauma who were treated at trauma centers participating in the ACS Trauma Quality Improvement Program from 2012 to 2015. They included all adults with severe injury who received LMWH or UH and excluded those who died or were discharged within five days, and those with a bleeding disorder or chronic anticoagulation. The exposure was defined as thromboprophylaxis with LMWH versus UH, and the primary outcome was PE confirmed on radiologic imaging. Potential confounders were considered, including patient baseline characteristics, anatomic and global injury severity, presenting characteristics in the emergency department, acute intracranial injuries, orthopedic injuries, early surgical interventions, and timing of prophylaxis initiation.
Dr. Byrne and his associates then used three analytic approaches in the study: a propensity score matching methodology, a multivariable logistic regression model for PE, and a center-level analysis examining the influence of LMWH utilization on hospital rates of PE.
They identified 153,474 trauma patients from 217 trauma centers. Their median age was 50 years and 67% were male. Blunt trauma was most common (89%), with a mean Injury Severity Score score of 20. LMWH was the most common type of thromboprophylaxis used (74%), and PE was diagnosed in 2,722 patients (1.8%).
Compared with patients who received LMWH, those who received UH were older and were significantly more likely to have been injured by falling (42% vs. 28%), with higher rates of severe head injuries (43% vs. 24%) and intracranial hemorrhage (38% vs. 19%). Conversely, LMWH was most favored in patients with orthopedic injuries.
After propensity score matching, patients on LMWH suffered significantly fewer PEs (1.4% vs. 2.4%; odds ratio, 0.56). This result was consistent within propensity-matched subgroups, including for patients with blunt multisystem injuries (OR, 0.60), penetrating truncal injuries (OR, 0.65), shock in the ED (OR, 0.68), isolated severe traumatic brain injury (OR, 0.49), and isolated orthopedic injuries (OR, 0.28).
Results of a sensitivity analysis in which each propensity-matched pair was matched within the same trauma center yielded similar results. Specifically, patients who received LMWH were at significantly lower risk for developing PE (OR, 0.64). “Importantly, this analysis minimized residual confounding due to differences in hospital-level processes of care, such as prophylaxis dosing or frequency, mechanical prophylaxis use, and thromboembolism screening practices,” Dr. Byrne noted.
Multivariable logistic regression also showed that patients who received LMWH had lower odds of PE (OR, 0.59). Other significant predictors of PE included obesity (OR, 1.54), severe chest injury (OR, 1.31), femoral shaft fracture (OR, 1.60), and spinal cord injury (OR, 1.60). Delays in prophylaxis initiation beyond the first day in the hospital were associated with significantly higher rates of PE, with an 80% increased risk of PE for patients who had their prophylaxis initiated after the fourth day.
The researchers conducted a center-level analysis in an effort to answer the question whether practice patterns with respect to choice of prophylaxis type influence hospital rates of PE. Across all 217 trauma centers in the study, the median rate of LMWH use was 80%, while the mean rate of PE was 1.6%. When trauma centers were grouped into quartiles based on their unique rate of LMWH use, trauma centers in the highest quartile (median LMWH use: 95%) were 50 times more likely to use LMWH, compared to those in the lowest quartile (median LMWH use: 39%) after adjusting for patient case mix. Compared with the lowest quartile, trauma centers that used the greatest proportion of LMWH had significantly lower rates of PE (1.2% vs. 2.0%). After adjusting for patient baseline and injury characteristics, patients who were treated at trauma centers in the highest quartile had significantly lower odds of PE (OR, 0.59).
Dr. Byrne acknowledged certain limitations of the study, including the potential for residual confounding and the inability to account for the dosing and frequency of prophylaxis that was given. “We were only able to measure the type and timing of prophylaxis initiation. We don’t know what doses of prophylaxis were used, and it is possible that the trauma centers included in this study favored use of UH twice daily,” he said.
Therefore, it is possible that the results might have been different if they had been able to directly compare LMWH to UH administered three times a day. “We also couldn’t measure interruptions in dosing due to surgery or patient refusal,” he said. “However, if it the case that UH is more likely to be refused based on the need for more frequent dosing, perhaps that is another feather in the cap of low molecular weight heparin-based thromboprophylaxis strategies. Larger prospective studies are needed, that take into account prophylaxis type and dosing, and are powered to detect a difference with respect to PE.”
Dr. Byrne reported having no financial disclosures.
WAIKOLOA, HAWAII – Venous thromboembolism prophylaxis with low molecular weight heparin (LMWH), instead of unfractionated heparin (UH), is associated with lower risk of pulmonary embolism (PE) in patients with major trauma, results from a large study have shown.
The results of the study, based on data from the American College of Surgeons (ACS) Trauma Quality Improvement Program, suggest that LMWH-based strategies for thromboprophylaxis should be preferred after major trauma.
Dr. Byrne, a general surgery resident at Sunnybrook Health Science Center, Toronto, Ontario, Canada, went on to note that LMWH is often favored because of a randomized controlled trial which showed that LMWH was associated with fewer deep vein thromboses (N Engl. J. Med. 1996;335[10]:701-7). However, significant practice variability continues to exist.
“Practitioners might favor the shorter half-life of unfractionated heparin in patients where they perceive the risk for hemorrhagic complications is high,” he said. “There’s also recent evidence to suggest that dosing may be all important and that unfractionated heparin dosed three times daily may be equivalent to low molecular weight heparin. If this is true, it might suggest that the historically higher cost of low molecular weight heparin could favor the use of unfractionated heparin.”
Furthermore, there is a is a lack of evidence comparing either agent to prevent PE, he added. “This is an important gap in our knowledge, because PE frequently occurs in the absence of an identified DVT and carries a significant risk of death. At present, it is not known how practice patterns with respect to choice of prophylaxis type influence risk of PE at the patient or hospital levels.”
Due to a lack of evidence comparing agents to prevent PE, the researchers set out to compare the effectiveness of LMWH versus UH to prevent PE in patients with major trauma who were treated at trauma centers participating in the ACS Trauma Quality Improvement Program from 2012 to 2015. They included all adults with severe injury who received LMWH or UH and excluded those who died or were discharged within five days, and those with a bleeding disorder or chronic anticoagulation. The exposure was defined as thromboprophylaxis with LMWH versus UH, and the primary outcome was PE confirmed on radiologic imaging. Potential confounders were considered, including patient baseline characteristics, anatomic and global injury severity, presenting characteristics in the emergency department, acute intracranial injuries, orthopedic injuries, early surgical interventions, and timing of prophylaxis initiation.
Dr. Byrne and his associates then used three analytic approaches in the study: a propensity score matching methodology, a multivariable logistic regression model for PE, and a center-level analysis examining the influence of LMWH utilization on hospital rates of PE.
They identified 153,474 trauma patients from 217 trauma centers. Their median age was 50 years and 67% were male. Blunt trauma was most common (89%), with a mean Injury Severity Score score of 20. LMWH was the most common type of thromboprophylaxis used (74%), and PE was diagnosed in 2,722 patients (1.8%).
Compared with patients who received LMWH, those who received UH were older and were significantly more likely to have been injured by falling (42% vs. 28%), with higher rates of severe head injuries (43% vs. 24%) and intracranial hemorrhage (38% vs. 19%). Conversely, LMWH was most favored in patients with orthopedic injuries.
After propensity score matching, patients on LMWH suffered significantly fewer PEs (1.4% vs. 2.4%; odds ratio, 0.56). This result was consistent within propensity-matched subgroups, including for patients with blunt multisystem injuries (OR, 0.60), penetrating truncal injuries (OR, 0.65), shock in the ED (OR, 0.68), isolated severe traumatic brain injury (OR, 0.49), and isolated orthopedic injuries (OR, 0.28).
Results of a sensitivity analysis in which each propensity-matched pair was matched within the same trauma center yielded similar results. Specifically, patients who received LMWH were at significantly lower risk for developing PE (OR, 0.64). “Importantly, this analysis minimized residual confounding due to differences in hospital-level processes of care, such as prophylaxis dosing or frequency, mechanical prophylaxis use, and thromboembolism screening practices,” Dr. Byrne noted.
Multivariable logistic regression also showed that patients who received LMWH had lower odds of PE (OR, 0.59). Other significant predictors of PE included obesity (OR, 1.54), severe chest injury (OR, 1.31), femoral shaft fracture (OR, 1.60), and spinal cord injury (OR, 1.60). Delays in prophylaxis initiation beyond the first day in the hospital were associated with significantly higher rates of PE, with an 80% increased risk of PE for patients who had their prophylaxis initiated after the fourth day.
The researchers conducted a center-level analysis in an effort to answer the question whether practice patterns with respect to choice of prophylaxis type influence hospital rates of PE. Across all 217 trauma centers in the study, the median rate of LMWH use was 80%, while the mean rate of PE was 1.6%. When trauma centers were grouped into quartiles based on their unique rate of LMWH use, trauma centers in the highest quartile (median LMWH use: 95%) were 50 times more likely to use LMWH, compared to those in the lowest quartile (median LMWH use: 39%) after adjusting for patient case mix. Compared with the lowest quartile, trauma centers that used the greatest proportion of LMWH had significantly lower rates of PE (1.2% vs. 2.0%). After adjusting for patient baseline and injury characteristics, patients who were treated at trauma centers in the highest quartile had significantly lower odds of PE (OR, 0.59).
Dr. Byrne acknowledged certain limitations of the study, including the potential for residual confounding and the inability to account for the dosing and frequency of prophylaxis that was given. “We were only able to measure the type and timing of prophylaxis initiation. We don’t know what doses of prophylaxis were used, and it is possible that the trauma centers included in this study favored use of UH twice daily,” he said.
Therefore, it is possible that the results might have been different if they had been able to directly compare LMWH to UH administered three times a day. “We also couldn’t measure interruptions in dosing due to surgery or patient refusal,” he said. “However, if it the case that UH is more likely to be refused based on the need for more frequent dosing, perhaps that is another feather in the cap of low molecular weight heparin-based thromboprophylaxis strategies. Larger prospective studies are needed, that take into account prophylaxis type and dosing, and are powered to detect a difference with respect to PE.”
Dr. Byrne reported having no financial disclosures.
AT THE AAST ANNUAL MEETING
Key clinical point:
Major finding: After propensity score matching, patients on LMWH had significantly fewer PEs, compared with those on unfractionated heparin (1.4% vs. 2.4%; odds ratio, 0.56). Data source: A multicenter analysis of 2,722 trauma patients who were diagnosed with pulmonary embolism.
Disclosures: Dr. Byrne reported having no financial disclosures.