Mary Ann Moon

Overall survival was 81.5% for the 27 patients with Ebola virus infection who were treated in the United States or Europe during the recent outbreak, according to a report published online Feb. 18 in the New England Journal of Medicine.

This is markedly higher than the 37%-74% survival reported for the almost 29,000 cases treated in West Africa, where treatment centers were challenged by overwhelming numbers of critically ill patients; limited medical supplies; insufficient numbers of caregivers; limited water, electricity, refrigeration, and other basic resources; and hot, humid working conditions that reduced the time health care personnel could attend to patients while wearing the required protective gear, said Dr. Timothy M. Uyeki of the Centers for Disease Control and Prevention, Atlanta, and his associates.

Courtesy Wikimedia Commons/Thomas W. Geisbert/Creative Commons License

The investigators performed a retrospective analysis of the medical records of these 27 patients in a descriptive study of their clinical care. The patients were treated from August 2014 through December 2015 at 15 hospitals in 9 countries. Twenty (74%) were medically evacuated from West Africa, three (11%) were Western health care personnel who acquired the disease while caring for patients, and four were “imported” patients who contracted the virus while in West Africa but didn’t become ill until after they traveled to the United States or Europe. Overall, 22 of the patients (81%) were health care personnel, of whom 17 (77%) contracted the virus in West Africa.

Overall mortality was 11.1% after 2 weeks of illness and 18.5% after 4 weeks. The five patients who died were all aged 42 years or older and were significantly older than those who survived. Being 40-45 years old or older has been identified as a risk factor in West Africa as well. Those who died also were hospitalized significantly later after the onset of illness. At least six more patients would have died if they hadn’t received advanced organ support: two required noninvasive ventilation, two required invasive mechanical ventilation, and two required both invasive mechanical ventilation and continuous renal-replacement therapy.

Routine therapies included oral or intravenous fluid replacement, total parenteral nutrition, antiemetics, empiric treatment with multiple antibiotics, nonconvalescent blood products, and respiratory supportive care. Most patients also received investigative therapies such as monoclonal antibody cocktails, antivirals, and treatments aimed at counteracting vascular leakage.

A wide range of possible adverse effects were reported – including systemic inflammatory response syndrome, hypotension, elevated aminotransferase levels, and transfusion-associated acute lung injury – but couldn’t be distinguished from the effects of supportive treatments or even of the virus itself “because of their uncontrolled administration and because most patients received multiple, overlapping investigational therapies,” the researchers said (N Engl J Med. 2016 Feb 18;374:636-46. doi: 10.1056/NEJMoa1504874).

“A key feature” of the lifesaving clinical care was laboratory testing to closely monitor electrolyte levels and hematologic factors. “Our experience suggests that early presentation and receipt of supportive care, IV fluid resuscitation, careful fluid management and electrolyte replacement to correct metabolic abnormalities, nutritional support, and critical care support may reduce mortality among patients with Ebola virus disease,” Dr. Uyeki and his associates said.

They noted that, until now, the infection was not thought to involve a clinically significant respiratory component; however, eight of these patients (30%) presented with cough and nine required ventilatory assistance, and difficulty breathing raised the risk of death.

“The pathophysiological mechanism of pulmonary disease in patients with Ebola virus infection is unknown, but there could be multiple contributing factors, including vascular leak from endothelial infection or cytokine dysregulation or direct damage to Ebola-infected [pulmonary] cells,” they wrote. Aggressive fluid repletion and lung injury from investigational treatments also may have contributed to respiratory involvement.

This study was supported by the working group of the U.S.–European Clinical Network on Clinical Management of Ebola Virus Disease Patients in the U.S. and Europe. Dr. Uyeki reported having no relevant financial disclosures; two of his associates reported ties to Epiguard and Pfizer.

Overall survival was 81.5% for the 27 patients with Ebola virus infection who were treated in the United States or Europe during the recent outbreak, according to a report published online Feb. 18 in the New England Journal of Medicine.

This is markedly higher than the 37%-74% survival reported for the almost 29,000 cases treated in West Africa, where treatment centers were challenged by overwhelming numbers of critically ill patients; limited medical supplies; insufficient numbers of caregivers; limited water, electricity, refrigeration, and other basic resources; and hot, humid working conditions that reduced the time health care personnel could attend to patients while wearing the required protective gear, said Dr. Timothy M. Uyeki of the Centers for Disease Control and Prevention, Atlanta, and his associates.

Courtesy Wikimedia Commons/Thomas W. Geisbert/Creative Commons License

The investigators performed a retrospective analysis of the medical records of these 27 patients in a descriptive study of their clinical care. The patients were treated from August 2014 through December 2015 at 15 hospitals in 9 countries. Twenty (74%) were medically evacuated from West Africa, three (11%) were Western health care personnel who acquired the disease while caring for patients, and four were “imported” patients who contracted the virus while in West Africa but didn’t become ill until after they traveled to the United States or Europe. Overall, 22 of the patients (81%) were health care personnel, of whom 17 (77%) contracted the virus in West Africa.

Overall mortality was 11.1% after 2 weeks of illness and 18.5% after 4 weeks. The five patients who died were all aged 42 years or older and were significantly older than those who survived. Being 40-45 years old or older has been identified as a risk factor in West Africa as well. Those who died also were hospitalized significantly later after the onset of illness. At least six more patients would have died if they hadn’t received advanced organ support: two required noninvasive ventilation, two required invasive mechanical ventilation, and two required both invasive mechanical ventilation and continuous renal-replacement therapy.

Routine therapies included oral or intravenous fluid replacement, total parenteral nutrition, antiemetics, empiric treatment with multiple antibiotics, nonconvalescent blood products, and respiratory supportive care. Most patients also received investigative therapies such as monoclonal antibody cocktails, antivirals, and treatments aimed at counteracting vascular leakage.

A wide range of possible adverse effects were reported – including systemic inflammatory response syndrome, hypotension, elevated aminotransferase levels, and transfusion-associated acute lung injury – but couldn’t be distinguished from the effects of supportive treatments or even of the virus itself “because of their uncontrolled administration and because most patients received multiple, overlapping investigational therapies,” the researchers said (N Engl J Med. 2016 Feb 18;374:636-46. doi: 10.1056/NEJMoa1504874).

“A key feature” of the lifesaving clinical care was laboratory testing to closely monitor electrolyte levels and hematologic factors. “Our experience suggests that early presentation and receipt of supportive care, IV fluid resuscitation, careful fluid management and electrolyte replacement to correct metabolic abnormalities, nutritional support, and critical care support may reduce mortality among patients with Ebola virus disease,” Dr. Uyeki and his associates said.

They noted that, until now, the infection was not thought to involve a clinically significant respiratory component; however, eight of these patients (30%) presented with cough and nine required ventilatory assistance, and difficulty breathing raised the risk of death.

“The pathophysiological mechanism of pulmonary disease in patients with Ebola virus infection is unknown, but there could be multiple contributing factors, including vascular leak from endothelial infection or cytokine dysregulation or direct damage to Ebola-infected [pulmonary] cells,” they wrote. Aggressive fluid repletion and lung injury from investigational treatments also may have contributed to respiratory involvement.

This study was supported by the working group of the U.S.–European Clinical Network on Clinical Management of Ebola Virus Disease Patients in the U.S. and Europe. Dr. Uyeki reported having no relevant financial disclosures; two of his associates reported ties to Epiguard and Pfizer.

Overall survival was 81.5% for the 27 patients with Ebola virus infection who were treated in the United States or Europe during the recent outbreak, according to a report published online Feb. 18 in the New England Journal of Medicine.

This is markedly higher than the 37%-74% survival reported for the almost 29,000 cases treated in West Africa, where treatment centers were challenged by overwhelming numbers of critically ill patients; limited medical supplies; insufficient numbers of caregivers; limited water, electricity, refrigeration, and other basic resources; and hot, humid working conditions that reduced the time health care personnel could attend to patients while wearing the required protective gear, said Dr. Timothy M. Uyeki of the Centers for Disease Control and Prevention, Atlanta, and his associates.

Courtesy Wikimedia Commons/Thomas W. Geisbert/Creative Commons License

The investigators performed a retrospective analysis of the medical records of these 27 patients in a descriptive study of their clinical care. The patients were treated from August 2014 through December 2015 at 15 hospitals in 9 countries. Twenty (74%) were medically evacuated from West Africa, three (11%) were Western health care personnel who acquired the disease while caring for patients, and four were “imported” patients who contracted the virus while in West Africa but didn’t become ill until after they traveled to the United States or Europe. Overall, 22 of the patients (81%) were health care personnel, of whom 17 (77%) contracted the virus in West Africa.

Overall mortality was 11.1% after 2 weeks of illness and 18.5% after 4 weeks. The five patients who died were all aged 42 years or older and were significantly older than those who survived. Being 40-45 years old or older has been identified as a risk factor in West Africa as well. Those who died also were hospitalized significantly later after the onset of illness. At least six more patients would have died if they hadn’t received advanced organ support: two required noninvasive ventilation, two required invasive mechanical ventilation, and two required both invasive mechanical ventilation and continuous renal-replacement therapy.

Routine therapies included oral or intravenous fluid replacement, total parenteral nutrition, antiemetics, empiric treatment with multiple antibiotics, nonconvalescent blood products, and respiratory supportive care. Most patients also received investigative therapies such as monoclonal antibody cocktails, antivirals, and treatments aimed at counteracting vascular leakage.

A wide range of possible adverse effects were reported – including systemic inflammatory response syndrome, hypotension, elevated aminotransferase levels, and transfusion-associated acute lung injury – but couldn’t be distinguished from the effects of supportive treatments or even of the virus itself “because of their uncontrolled administration and because most patients received multiple, overlapping investigational therapies,” the researchers said (N Engl J Med. 2016 Feb 18;374:636-46. doi: 10.1056/NEJMoa1504874).

“A key feature” of the lifesaving clinical care was laboratory testing to closely monitor electrolyte levels and hematologic factors. “Our experience suggests that early presentation and receipt of supportive care, IV fluid resuscitation, careful fluid management and electrolyte replacement to correct metabolic abnormalities, nutritional support, and critical care support may reduce mortality among patients with Ebola virus disease,” Dr. Uyeki and his associates said.

They noted that, until now, the infection was not thought to involve a clinically significant respiratory component; however, eight of these patients (30%) presented with cough and nine required ventilatory assistance, and difficulty breathing raised the risk of death.

“The pathophysiological mechanism of pulmonary disease in patients with Ebola virus infection is unknown, but there could be multiple contributing factors, including vascular leak from endothelial infection or cytokine dysregulation or direct damage to Ebola-infected [pulmonary] cells,” they wrote. Aggressive fluid repletion and lung injury from investigational treatments also may have contributed to respiratory involvement.

This study was supported by the working group of the U.S.–European Clinical Network on Clinical Management of Ebola Virus Disease Patients in the U.S. and Europe. Dr. Uyeki reported having no relevant financial disclosures; two of his associates reported ties to Epiguard and Pfizer.

The risk of finding occult uterine sarcoma during hysterectomy for benign indications was lower than expected in a single-center retrospective cohort study, at 0.089%, or 1 in 1,124 hysterectomies, according to a recent analysis.

This is markedly lower than the estimated risks in previous studies, which ranged from 1 in 204 to 1 in 667 procedures for women with presumed myomas. The American College of Obstetricians and Gynecologists estimated the risk to be 1 in 500 hysterectomies, and the Food and Drug Administration pegged it at 1 in 352 based on a pooled analysis of nine studies of women undergoing hysterectomy or myomectomy for presumed myomas. The last estimate in particular has been criticized as inaccurate because of concerns about the quality of data and methodologic flaws of the nine studies, reported Dr. Kimberly A. Kho of the University of Texas Southwestern Medical Center, Dallas, and her associates (Obstet. Gynecol. 2016;127:468-73.).

©monkeybusinessimages/Thinkstock.com

The investigators analyzed information in a database for all 10,119 hysterectomies performed for benign indications at their medical center during a 14-year period, and correlated it with data concerning all cases of uterine sarcoma in their center’s tumor registry. A total of 59.4% of these procedures used an abdominal approach, 21.6% were laparoscopic or robot assisted, and 18.9% used a vaginal approach. The most common indications were leiomyomata (37%), abnormal uterine bleeding (28%), and pelvic organ prolapse (11%).

Nine women were found to have an occult uterine sarcoma, including five leiomyosarcomas, two endometrial stromal sarcomas, and two uterine adenocarcinomas.

“All patients had received up-to-date cervical cancer screening and, in the majority of cases, women had received preoperative evaluation with either endometrial sampling or imaging, which did not suggest malignancy. Of the suggested risk factors for sarcoma, it is notable that none of the women we identified were postmenopausal, exposed to pelvic radiation or tamoxifen, nor had a family history of cancer,” the researchers wrote.

Only one patient underwent manual morcellation of a large, bulky uterus before her sarcoma was discovered during total abdominal hysterectomy. The abdominal cavity was then thoroughly explored, and no suspicious lesions were found. This patient later received chemotherapy and had no evidence of disease 3 years later.

The study findings may be helpful for surgical planning and for counseling patients about management options. “It is important to stress that although low, the risk of encountering an occult sarcoma exists. Hence, ongoing efforts to identify potentially safer methods for tissue extraction are essential, as are efforts to improve preoperative identification of malignancies,” the researchers noted.

The study was supported by the University of Texas Southwestern Medical Center. Dr. Kho reported ties to Actamax Surgical Materials and Applied Medical; one of her associates reported ties to AstraZeneca and Genentech.

The risk of finding occult uterine sarcoma during hysterectomy for benign indications was lower than expected in a single-center retrospective cohort study, at 0.089%, or 1 in 1,124 hysterectomies, according to a recent analysis.

This is markedly lower than the estimated risks in previous studies, which ranged from 1 in 204 to 1 in 667 procedures for women with presumed myomas. The American College of Obstetricians and Gynecologists estimated the risk to be 1 in 500 hysterectomies, and the Food and Drug Administration pegged it at 1 in 352 based on a pooled analysis of nine studies of women undergoing hysterectomy or myomectomy for presumed myomas. The last estimate in particular has been criticized as inaccurate because of concerns about the quality of data and methodologic flaws of the nine studies, reported Dr. Kimberly A. Kho of the University of Texas Southwestern Medical Center, Dallas, and her associates (Obstet. Gynecol. 2016;127:468-73.).

©monkeybusinessimages/Thinkstock.com

The investigators analyzed information in a database for all 10,119 hysterectomies performed for benign indications at their medical center during a 14-year period, and correlated it with data concerning all cases of uterine sarcoma in their center’s tumor registry. A total of 59.4% of these procedures used an abdominal approach, 21.6% were laparoscopic or robot assisted, and 18.9% used a vaginal approach. The most common indications were leiomyomata (37%), abnormal uterine bleeding (28%), and pelvic organ prolapse (11%).

Nine women were found to have an occult uterine sarcoma, including five leiomyosarcomas, two endometrial stromal sarcomas, and two uterine adenocarcinomas.

“All patients had received up-to-date cervical cancer screening and, in the majority of cases, women had received preoperative evaluation with either endometrial sampling or imaging, which did not suggest malignancy. Of the suggested risk factors for sarcoma, it is notable that none of the women we identified were postmenopausal, exposed to pelvic radiation or tamoxifen, nor had a family history of cancer,” the researchers wrote.

Only one patient underwent manual morcellation of a large, bulky uterus before her sarcoma was discovered during total abdominal hysterectomy. The abdominal cavity was then thoroughly explored, and no suspicious lesions were found. This patient later received chemotherapy and had no evidence of disease 3 years later.

The study findings may be helpful for surgical planning and for counseling patients about management options. “It is important to stress that although low, the risk of encountering an occult sarcoma exists. Hence, ongoing efforts to identify potentially safer methods for tissue extraction are essential, as are efforts to improve preoperative identification of malignancies,” the researchers noted.

The study was supported by the University of Texas Southwestern Medical Center. Dr. Kho reported ties to Actamax Surgical Materials and Applied Medical; one of her associates reported ties to AstraZeneca and Genentech.

The risk of finding occult uterine sarcoma during hysterectomy for benign indications was lower than expected in a single-center retrospective cohort study, at 0.089%, or 1 in 1,124 hysterectomies, according to a recent analysis.

This is markedly lower than the estimated risks in previous studies, which ranged from 1 in 204 to 1 in 667 procedures for women with presumed myomas. The American College of Obstetricians and Gynecologists estimated the risk to be 1 in 500 hysterectomies, and the Food and Drug Administration pegged it at 1 in 352 based on a pooled analysis of nine studies of women undergoing hysterectomy or myomectomy for presumed myomas. The last estimate in particular has been criticized as inaccurate because of concerns about the quality of data and methodologic flaws of the nine studies, reported Dr. Kimberly A. Kho of the University of Texas Southwestern Medical Center, Dallas, and her associates (Obstet. Gynecol. 2016;127:468-73.).

©monkeybusinessimages/Thinkstock.com

The investigators analyzed information in a database for all 10,119 hysterectomies performed for benign indications at their medical center during a 14-year period, and correlated it with data concerning all cases of uterine sarcoma in their center’s tumor registry. A total of 59.4% of these procedures used an abdominal approach, 21.6% were laparoscopic or robot assisted, and 18.9% used a vaginal approach. The most common indications were leiomyomata (37%), abnormal uterine bleeding (28%), and pelvic organ prolapse (11%).

Nine women were found to have an occult uterine sarcoma, including five leiomyosarcomas, two endometrial stromal sarcomas, and two uterine adenocarcinomas.

“All patients had received up-to-date cervical cancer screening and, in the majority of cases, women had received preoperative evaluation with either endometrial sampling or imaging, which did not suggest malignancy. Of the suggested risk factors for sarcoma, it is notable that none of the women we identified were postmenopausal, exposed to pelvic radiation or tamoxifen, nor had a family history of cancer,” the researchers wrote.

Only one patient underwent manual morcellation of a large, bulky uterus before her sarcoma was discovered during total abdominal hysterectomy. The abdominal cavity was then thoroughly explored, and no suspicious lesions were found. This patient later received chemotherapy and had no evidence of disease 3 years later.

The study findings may be helpful for surgical planning and for counseling patients about management options. “It is important to stress that although low, the risk of encountering an occult sarcoma exists. Hence, ongoing efforts to identify potentially safer methods for tissue extraction are essential, as are efforts to improve preoperative identification of malignancies,” the researchers noted.

The study was supported by the University of Texas Southwestern Medical Center. Dr. Kho reported ties to Actamax Surgical Materials and Applied Medical; one of her associates reported ties to AstraZeneca and Genentech.

In four large, separate research cohorts in which middle-aged and older participants underwent lung CT, interstitial lung abnormalities were associated with a higher-than-average risk of death within 3-9 years, according to a report published online Feb. 16 in JAMA.

These imaging abnormalities were defined as specific patterns of increased lung density affecting more than 5% of any lung zone and included reticular or ground-glass abnormalities, diffuse centrilobular nodularity, nonemphysematous cysts, honeycombing, traction bronchiectasis, or pulmonary parenchymal architectural distortion diagnostic of fibrotic lung disease. They were identified in approximately 7% of the 11,691 study participants. The study findings, taken together with those of previous research, “demonstrate that despite often being undiagnosed and asymptomatic, interstitial lung abnormalities may be associated with lower survival rates among older persons,” said Dr. Rachel K. Putman of the pulmonary and critical care division at Brigham and Women’s Hospital and Harvard Medical School, Boston, and her associates.

Previously, interstitial lung abnormalities have been found in the same proportion, 7%, of the general population and have been associated with reduced lung capacity, exercise capacity, and gas exchange. They are more common in families affected by familial interstitial pneumonia and idiopathic pulmonary fibrosis. Given these correlations, “we hypothesized that the presence of interstitial lung abnormalities would be associated with an increased rate of mortality,” the investigators said.

To test this hypothesis, they analyzed data from four large study cohorts that included lung CT: 2,633 participants in the Framingham Heart Study (median follow-up of 4 years after CT), 5,320 in the Age Gene/Environment Susceptibility (AGES)-Reykjavik study (median follow-up, 8.9 years), 2,068 in the Genetic Epidemiology of COPD (COPDGene) study (median follow-up, 6.5 years), and 1,670 participants in the Evaluation of COPD Longitudinally to Identify Predictive Surrogate Endpoints (ECLIPSE) study (median follow-up, 2.9 years).

The absolute rates of all-cause mortality were significantly higher among participants who had interstitial lung abnormalities than among those who did not. Mortality rates were 7% vs. 1% in the FHS, 56% vs. 33% in AGES-Reykjavik, 16% vs. 11% in COPDGene, and 11% vs. 5% in ECLIPSE. After the data were adjusted to account for confounding factors such as age, sex, race, body-mass index, current smoking status, and pack-years of smoking, the lung abnormalities remained strongly associated with a higher risk of death in the FHS (hazard ratio, 2.7), AGES-Reykjavik (HR, 1.3), COPDGene (HR, 1.8), and ECLIPSE (HR, 1.4) studies.

The association remained robust in further analyses restricted only to nonsmoking participants, Dr. Putman and her associates said (JAMA. 2016 Feb 16;315[7]672-81. doi: 10.1001/jama.2016.0518).

The AGES-Reykjavik study was the only one to assess causes of death. In that cohort, participants who had interstitial lung abnormalities were more likely to die of a respiratory cause (13%) than were those who had no such abnormalities (4%) or those who had indeterminate findings on lung CT (6%). After the data were adjusted to account for confounding factors, participants with interstitial lung abnormalities were at much higher risk of dying from a respiratory cause (OR, 2.4) such as respiratory failure or pulmonary fibrosis. In contrast, there was no association between the lung abnormalities and deaths due to cardiovascular disease, cancer, or other causes.

The clinical implications of the association between interstitial lung abnormalities and mortality, particularly respiratory-related mortality, require further investigation, the investigators added.

This study was supported by the National Institutes of Health; the Icelandic Research Fund; the Lanspitali Scientific Fund; the National Cancer Institute; the National Heart, Lung, and Blood Institute; GlaxoSmithKline; the National Institute on Aging; the Icelandic Heart Association; and the Icelandic Parliament. Dr. Putman reported having no relevant financial disclosures; her associates reported numerous ties to industry sources.

[email protected]

In four large, separate research cohorts in which middle-aged and older participants underwent lung CT, interstitial lung abnormalities were associated with a higher-than-average risk of death within 3-9 years, according to a report published online Feb. 16 in JAMA.

These imaging abnormalities were defined as specific patterns of increased lung density affecting more than 5% of any lung zone and included reticular or ground-glass abnormalities, diffuse centrilobular nodularity, nonemphysematous cysts, honeycombing, traction bronchiectasis, or pulmonary parenchymal architectural distortion diagnostic of fibrotic lung disease. They were identified in approximately 7% of the 11,691 study participants. The study findings, taken together with those of previous research, “demonstrate that despite often being undiagnosed and asymptomatic, interstitial lung abnormalities may be associated with lower survival rates among older persons,” said Dr. Rachel K. Putman of the pulmonary and critical care division at Brigham and Women’s Hospital and Harvard Medical School, Boston, and her associates.

Previously, interstitial lung abnormalities have been found in the same proportion, 7%, of the general population and have been associated with reduced lung capacity, exercise capacity, and gas exchange. They are more common in families affected by familial interstitial pneumonia and idiopathic pulmonary fibrosis. Given these correlations, “we hypothesized that the presence of interstitial lung abnormalities would be associated with an increased rate of mortality,” the investigators said.

To test this hypothesis, they analyzed data from four large study cohorts that included lung CT: 2,633 participants in the Framingham Heart Study (median follow-up of 4 years after CT), 5,320 in the Age Gene/Environment Susceptibility (AGES)-Reykjavik study (median follow-up, 8.9 years), 2,068 in the Genetic Epidemiology of COPD (COPDGene) study (median follow-up, 6.5 years), and 1,670 participants in the Evaluation of COPD Longitudinally to Identify Predictive Surrogate Endpoints (ECLIPSE) study (median follow-up, 2.9 years).

The absolute rates of all-cause mortality were significantly higher among participants who had interstitial lung abnormalities than among those who did not. Mortality rates were 7% vs. 1% in the FHS, 56% vs. 33% in AGES-Reykjavik, 16% vs. 11% in COPDGene, and 11% vs. 5% in ECLIPSE. After the data were adjusted to account for confounding factors such as age, sex, race, body-mass index, current smoking status, and pack-years of smoking, the lung abnormalities remained strongly associated with a higher risk of death in the FHS (hazard ratio, 2.7), AGES-Reykjavik (HR, 1.3), COPDGene (HR, 1.8), and ECLIPSE (HR, 1.4) studies.

The association remained robust in further analyses restricted only to nonsmoking participants, Dr. Putman and her associates said (JAMA. 2016 Feb 16;315[7]672-81. doi: 10.1001/jama.2016.0518).

The AGES-Reykjavik study was the only one to assess causes of death. In that cohort, participants who had interstitial lung abnormalities were more likely to die of a respiratory cause (13%) than were those who had no such abnormalities (4%) or those who had indeterminate findings on lung CT (6%). After the data were adjusted to account for confounding factors, participants with interstitial lung abnormalities were at much higher risk of dying from a respiratory cause (OR, 2.4) such as respiratory failure or pulmonary fibrosis. In contrast, there was no association between the lung abnormalities and deaths due to cardiovascular disease, cancer, or other causes.

The clinical implications of the association between interstitial lung abnormalities and mortality, particularly respiratory-related mortality, require further investigation, the investigators added.

This study was supported by the National Institutes of Health; the Icelandic Research Fund; the Lanspitali Scientific Fund; the National Cancer Institute; the National Heart, Lung, and Blood Institute; GlaxoSmithKline; the National Institute on Aging; the Icelandic Heart Association; and the Icelandic Parliament. Dr. Putman reported having no relevant financial disclosures; her associates reported numerous ties to industry sources.

[email protected]

In four large, separate research cohorts in which middle-aged and older participants underwent lung CT, interstitial lung abnormalities were associated with a higher-than-average risk of death within 3-9 years, according to a report published online Feb. 16 in JAMA.

These imaging abnormalities were defined as specific patterns of increased lung density affecting more than 5% of any lung zone and included reticular or ground-glass abnormalities, diffuse centrilobular nodularity, nonemphysematous cysts, honeycombing, traction bronchiectasis, or pulmonary parenchymal architectural distortion diagnostic of fibrotic lung disease. They were identified in approximately 7% of the 11,691 study participants. The study findings, taken together with those of previous research, “demonstrate that despite often being undiagnosed and asymptomatic, interstitial lung abnormalities may be associated with lower survival rates among older persons,” said Dr. Rachel K. Putman of the pulmonary and critical care division at Brigham and Women’s Hospital and Harvard Medical School, Boston, and her associates.

Previously, interstitial lung abnormalities have been found in the same proportion, 7%, of the general population and have been associated with reduced lung capacity, exercise capacity, and gas exchange. They are more common in families affected by familial interstitial pneumonia and idiopathic pulmonary fibrosis. Given these correlations, “we hypothesized that the presence of interstitial lung abnormalities would be associated with an increased rate of mortality,” the investigators said.

To test this hypothesis, they analyzed data from four large study cohorts that included lung CT: 2,633 participants in the Framingham Heart Study (median follow-up of 4 years after CT), 5,320 in the Age Gene/Environment Susceptibility (AGES)-Reykjavik study (median follow-up, 8.9 years), 2,068 in the Genetic Epidemiology of COPD (COPDGene) study (median follow-up, 6.5 years), and 1,670 participants in the Evaluation of COPD Longitudinally to Identify Predictive Surrogate Endpoints (ECLIPSE) study (median follow-up, 2.9 years).

The absolute rates of all-cause mortality were significantly higher among participants who had interstitial lung abnormalities than among those who did not. Mortality rates were 7% vs. 1% in the FHS, 56% vs. 33% in AGES-Reykjavik, 16% vs. 11% in COPDGene, and 11% vs. 5% in ECLIPSE. After the data were adjusted to account for confounding factors such as age, sex, race, body-mass index, current smoking status, and pack-years of smoking, the lung abnormalities remained strongly associated with a higher risk of death in the FHS (hazard ratio, 2.7), AGES-Reykjavik (HR, 1.3), COPDGene (HR, 1.8), and ECLIPSE (HR, 1.4) studies.

The association remained robust in further analyses restricted only to nonsmoking participants, Dr. Putman and her associates said (JAMA. 2016 Feb 16;315[7]672-81. doi: 10.1001/jama.2016.0518).

The AGES-Reykjavik study was the only one to assess causes of death. In that cohort, participants who had interstitial lung abnormalities were more likely to die of a respiratory cause (13%) than were those who had no such abnormalities (4%) or those who had indeterminate findings on lung CT (6%). After the data were adjusted to account for confounding factors, participants with interstitial lung abnormalities were at much higher risk of dying from a respiratory cause (OR, 2.4) such as respiratory failure or pulmonary fibrosis. In contrast, there was no association between the lung abnormalities and deaths due to cardiovascular disease, cancer, or other causes.

The clinical implications of the association between interstitial lung abnormalities and mortality, particularly respiratory-related mortality, require further investigation, the investigators added.

This study was supported by the National Institutes of Health; the Icelandic Research Fund; the Lanspitali Scientific Fund; the National Cancer Institute; the National Heart, Lung, and Blood Institute; GlaxoSmithKline; the National Institute on Aging; the Icelandic Heart Association; and the Icelandic Parliament. Dr. Putman reported having no relevant financial disclosures; her associates reported numerous ties to industry sources.

[email protected]

Screening a high-prevalence population for acute HIV infection using an antigen/antibody combination assay instead of rapid HIV testing improved the diagnostic yield by 10%, according to a report published online Feb. 16 in JAMA.

Identifying HIV infection during the acute phase is important because that is the most highly infectious stage of the disease. HIV RNA testing using a pooled protocol is effective at this stage but hasn’t been widely adopted “because only 1 RNA assay is U.S. Food and Drug Administration–approved [for this indication], the pooling protocol is logistically complex and time intensive, and it may not be cost-effective,” said Dr. Philip J. Peters of the division of HIV/AIDS prevention, Centers for Disease Control and Prevention, Atlanta, and his associates.

©jarun011/Thinkstock

In contrast, combination assays that detect both the p24 antigen and anti-HIV antibodies are faster, are probably cost effective, and are currently recommended by the CDC and the Association of Public Health Laboratories to screen for acute infection. Nevertheless, these assays are not as sensitive as pooled HIV RNA testing, and their accuracy has not been fully established. Dr. Peters and his associates compared the performance of the HIV antigen/antibody combination assay against that of pooled HIV RNA testing (the reference standard) in a high-prevalence population: 86,836 patients treated at 12 centers in San Francisco, New York City, and North Carolina during a 2-year period, including STD clinics and community-based programs.

Just over half of the study population were men who had sex with men, and the median age was 29 years.

The antigen/antibody assay detected 134 of 168 acute infections that had been missed by the rapid HIV test, but it also produced false-positive results for 93 patients. The assay thus had a sensitivity of 79.8%, a specificity of 99.9%, and a positive predictive value of 59%. Relative to rapid HIV testing, the antigen/antibody assay increased the diagnostic yield by 10.4%, Dr. Peters and his associates reported (JAMA. 2016 Feb 16;315[7]:682-690. doi: 10.1001/jama.2016.0286).

As expected, pooled HIV RNA testing performed even better, detecting 164 of the 168 acute infections for a sensitivity of 97.6%, a specificity of 100%, and a positive predictive value of 96.5%. Relative to rapid HIV testing, pooled HIV RNA testing increased the diagnostic yield by 12.4%.

Pooled HIV RNA testing, however, is estimated to cost approximately $160.07 per test, while antigen/antibody combination assays cost only $4.23 each. In addition, antigen/antibody testing requires only 30 minutes (if results are negative) to 60 minutes (if results are positive), while pooled HIV RNA testing requires 6 hours, and the pooling process requires an additional 4-7 days, the investigators noted.

This study was supported by the Centers for Disease Control and Prevention, the San Francisco Department of Public Health, the New York City Department of Health and Mental Hygiene, and the University of North Carolina at Chapel Hill. Dr. Peters and his associates reported having no relevant financial disclosures.

Screening a high-prevalence population for acute HIV infection using an antigen/antibody combination assay instead of rapid HIV testing improved the diagnostic yield by 10%, according to a report published online Feb. 16 in JAMA.

Identifying HIV infection during the acute phase is important because that is the most highly infectious stage of the disease. HIV RNA testing using a pooled protocol is effective at this stage but hasn’t been widely adopted “because only 1 RNA assay is U.S. Food and Drug Administration–approved [for this indication], the pooling protocol is logistically complex and time intensive, and it may not be cost-effective,” said Dr. Philip J. Peters of the division of HIV/AIDS prevention, Centers for Disease Control and Prevention, Atlanta, and his associates.

©jarun011/Thinkstock

In contrast, combination assays that detect both the p24 antigen and anti-HIV antibodies are faster, are probably cost effective, and are currently recommended by the CDC and the Association of Public Health Laboratories to screen for acute infection. Nevertheless, these assays are not as sensitive as pooled HIV RNA testing, and their accuracy has not been fully established. Dr. Peters and his associates compared the performance of the HIV antigen/antibody combination assay against that of pooled HIV RNA testing (the reference standard) in a high-prevalence population: 86,836 patients treated at 12 centers in San Francisco, New York City, and North Carolina during a 2-year period, including STD clinics and community-based programs.

Just over half of the study population were men who had sex with men, and the median age was 29 years.

The antigen/antibody assay detected 134 of 168 acute infections that had been missed by the rapid HIV test, but it also produced false-positive results for 93 patients. The assay thus had a sensitivity of 79.8%, a specificity of 99.9%, and a positive predictive value of 59%. Relative to rapid HIV testing, the antigen/antibody assay increased the diagnostic yield by 10.4%, Dr. Peters and his associates reported (JAMA. 2016 Feb 16;315[7]:682-690. doi: 10.1001/jama.2016.0286).

As expected, pooled HIV RNA testing performed even better, detecting 164 of the 168 acute infections for a sensitivity of 97.6%, a specificity of 100%, and a positive predictive value of 96.5%. Relative to rapid HIV testing, pooled HIV RNA testing increased the diagnostic yield by 12.4%.

Pooled HIV RNA testing, however, is estimated to cost approximately $160.07 per test, while antigen/antibody combination assays cost only $4.23 each. In addition, antigen/antibody testing requires only 30 minutes (if results are negative) to 60 minutes (if results are positive), while pooled HIV RNA testing requires 6 hours, and the pooling process requires an additional 4-7 days, the investigators noted.

This study was supported by the Centers for Disease Control and Prevention, the San Francisco Department of Public Health, the New York City Department of Health and Mental Hygiene, and the University of North Carolina at Chapel Hill. Dr. Peters and his associates reported having no relevant financial disclosures.

Screening a high-prevalence population for acute HIV infection using an antigen/antibody combination assay instead of rapid HIV testing improved the diagnostic yield by 10%, according to a report published online Feb. 16 in JAMA.

Identifying HIV infection during the acute phase is important because that is the most highly infectious stage of the disease. HIV RNA testing using a pooled protocol is effective at this stage but hasn’t been widely adopted “because only 1 RNA assay is U.S. Food and Drug Administration–approved [for this indication], the pooling protocol is logistically complex and time intensive, and it may not be cost-effective,” said Dr. Philip J. Peters of the division of HIV/AIDS prevention, Centers for Disease Control and Prevention, Atlanta, and his associates.

©jarun011/Thinkstock

In contrast, combination assays that detect both the p24 antigen and anti-HIV antibodies are faster, are probably cost effective, and are currently recommended by the CDC and the Association of Public Health Laboratories to screen for acute infection. Nevertheless, these assays are not as sensitive as pooled HIV RNA testing, and their accuracy has not been fully established. Dr. Peters and his associates compared the performance of the HIV antigen/antibody combination assay against that of pooled HIV RNA testing (the reference standard) in a high-prevalence population: 86,836 patients treated at 12 centers in San Francisco, New York City, and North Carolina during a 2-year period, including STD clinics and community-based programs.

Just over half of the study population were men who had sex with men, and the median age was 29 years.

The antigen/antibody assay detected 134 of 168 acute infections that had been missed by the rapid HIV test, but it also produced false-positive results for 93 patients. The assay thus had a sensitivity of 79.8%, a specificity of 99.9%, and a positive predictive value of 59%. Relative to rapid HIV testing, the antigen/antibody assay increased the diagnostic yield by 10.4%, Dr. Peters and his associates reported (JAMA. 2016 Feb 16;315[7]:682-690. doi: 10.1001/jama.2016.0286).

As expected, pooled HIV RNA testing performed even better, detecting 164 of the 168 acute infections for a sensitivity of 97.6%, a specificity of 100%, and a positive predictive value of 96.5%. Relative to rapid HIV testing, pooled HIV RNA testing increased the diagnostic yield by 12.4%.

Pooled HIV RNA testing, however, is estimated to cost approximately $160.07 per test, while antigen/antibody combination assays cost only $4.23 each. In addition, antigen/antibody testing requires only 30 minutes (if results are negative) to 60 minutes (if results are positive), while pooled HIV RNA testing requires 6 hours, and the pooling process requires an additional 4-7 days, the investigators noted.

This study was supported by the Centers for Disease Control and Prevention, the San Francisco Department of Public Health, the New York City Department of Health and Mental Hygiene, and the University of North Carolina at Chapel Hill. Dr. Peters and his associates reported having no relevant financial disclosures.

Two behavioral interventions for primary care clinicians cut the rate of inappropriate antibiotic prescribing for acute respiratory tract infections significantly, according to a report published online Feb. 9 in JAMA.

Compared with a control condition that included clinician education, the two interventions reduced inappropriate prescribing by 5.2% and 7.0%, respectively.

oksix/thinkstock

“We believe these effect sizes are clinically significant, especially when measured against control clinicians who were motivated to join a trial, knew they were being monitored, and who had relatively low antibiotic prescribing rates at baseline,” said Daniella Meeker, Ph.D., of the Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, and her associates.

In a cluster-randomized trial involving 248 clinicians at 47 primary care practices in Boston and Los Angeles, the investigators designed three interventions and tested various combinations of them against a control condition during an 18-month period. The number of inappropriate antibiotic prescriptions given during this intervention period was then compared with that during a baseline period, the 18 months preceding the intervention.

The analysis included 14,753 patient visits for acute respiratory tract infections during the baseline period and 16,959 visits during the intervention period.

The first behavioral intervention, termed “accountable justification,” used an alert each time a clinician prescribed an antibiotic in a patient’s electronic health record – a prompt asking for an explicit justification for doing so. That approach was based on the hope that to preserve their reputations, clinicians would tailor their behavior to fall in line with norms followed by their peers and recommended in clinical guidelines.

The second intervention, “peer comparison,” used monthly e-mails to inform clinicians whether or not they were “top performers” (within the lowest decile) for inappropriate prescribing in their geographical region. The emails included the number and proportion of antibiotic prescriptions they wrote inappropriately for acute upper respiratory tract infections, compared with the proportion written by top performers.

The mean rate of antibiotic prescribing decreased during the intervention in all the study groups, including the control group, which showed an absolute decrease of 11% (from 24.1% to 13.1%). The absolute decrease was significantly greater, at 18.1%, in the accountable justification group (from 23.2% to 5.2%) and at 16.3% in the peer comparison group (from 19.9% to 3.7%), Dr. Meeker and her associates said (JAMA. 2016 Feb 9;315[6]:562-70). The rate of return visits for possible bacterial infections within 30 days of the index visit was used as a measure of safety for withholding antibiotic prescriptions. This rate was 0.4% in the control group. The only intervention group that showed a “modestly higher” rate of return visits was the one that used both the accountable justification and the peer comparison interventions together, for which the rate of return visits was 1.4%.

The study was supported by the American Recovery and Reinvestment Act of 2009, the National Institutes of Health, the National Institute on Aging, the Agency for Healthcare Research and Quality, the University of Southern California’s Medical Information Network for Experimental Research, and the Patient-Centered Outcomes Research Institute. Dr. Meeker and her associates reported having no relevant financial disclosures.

Two behavioral interventions for primary care clinicians cut the rate of inappropriate antibiotic prescribing for acute respiratory tract infections significantly, according to a report published online Feb. 9 in JAMA.

Compared with a control condition that included clinician education, the two interventions reduced inappropriate prescribing by 5.2% and 7.0%, respectively.

oksix/thinkstock

“We believe these effect sizes are clinically significant, especially when measured against control clinicians who were motivated to join a trial, knew they were being monitored, and who had relatively low antibiotic prescribing rates at baseline,” said Daniella Meeker, Ph.D., of the Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, and her associates.

In a cluster-randomized trial involving 248 clinicians at 47 primary care practices in Boston and Los Angeles, the investigators designed three interventions and tested various combinations of them against a control condition during an 18-month period. The number of inappropriate antibiotic prescriptions given during this intervention period was then compared with that during a baseline period, the 18 months preceding the intervention.

The analysis included 14,753 patient visits for acute respiratory tract infections during the baseline period and 16,959 visits during the intervention period.

The first behavioral intervention, termed “accountable justification,” used an alert each time a clinician prescribed an antibiotic in a patient’s electronic health record – a prompt asking for an explicit justification for doing so. That approach was based on the hope that to preserve their reputations, clinicians would tailor their behavior to fall in line with norms followed by their peers and recommended in clinical guidelines.

The second intervention, “peer comparison,” used monthly e-mails to inform clinicians whether or not they were “top performers” (within the lowest decile) for inappropriate prescribing in their geographical region. The emails included the number and proportion of antibiotic prescriptions they wrote inappropriately for acute upper respiratory tract infections, compared with the proportion written by top performers.

The mean rate of antibiotic prescribing decreased during the intervention in all the study groups, including the control group, which showed an absolute decrease of 11% (from 24.1% to 13.1%). The absolute decrease was significantly greater, at 18.1%, in the accountable justification group (from 23.2% to 5.2%) and at 16.3% in the peer comparison group (from 19.9% to 3.7%), Dr. Meeker and her associates said (JAMA. 2016 Feb 9;315[6]:562-70). The rate of return visits for possible bacterial infections within 30 days of the index visit was used as a measure of safety for withholding antibiotic prescriptions. This rate was 0.4% in the control group. The only intervention group that showed a “modestly higher” rate of return visits was the one that used both the accountable justification and the peer comparison interventions together, for which the rate of return visits was 1.4%.

The study was supported by the American Recovery and Reinvestment Act of 2009, the National Institutes of Health, the National Institute on Aging, the Agency for Healthcare Research and Quality, the University of Southern California’s Medical Information Network for Experimental Research, and the Patient-Centered Outcomes Research Institute. Dr. Meeker and her associates reported having no relevant financial disclosures.

Two behavioral interventions for primary care clinicians cut the rate of inappropriate antibiotic prescribing for acute respiratory tract infections significantly, according to a report published online Feb. 9 in JAMA.

Compared with a control condition that included clinician education, the two interventions reduced inappropriate prescribing by 5.2% and 7.0%, respectively.

oksix/thinkstock

“We believe these effect sizes are clinically significant, especially when measured against control clinicians who were motivated to join a trial, knew they were being monitored, and who had relatively low antibiotic prescribing rates at baseline,” said Daniella Meeker, Ph.D., of the Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, and her associates.

In a cluster-randomized trial involving 248 clinicians at 47 primary care practices in Boston and Los Angeles, the investigators designed three interventions and tested various combinations of them against a control condition during an 18-month period. The number of inappropriate antibiotic prescriptions given during this intervention period was then compared with that during a baseline period, the 18 months preceding the intervention.

The analysis included 14,753 patient visits for acute respiratory tract infections during the baseline period and 16,959 visits during the intervention period.

The first behavioral intervention, termed “accountable justification,” used an alert each time a clinician prescribed an antibiotic in a patient’s electronic health record – a prompt asking for an explicit justification for doing so. That approach was based on the hope that to preserve their reputations, clinicians would tailor their behavior to fall in line with norms followed by their peers and recommended in clinical guidelines.

The second intervention, “peer comparison,” used monthly e-mails to inform clinicians whether or not they were “top performers” (within the lowest decile) for inappropriate prescribing in their geographical region. The emails included the number and proportion of antibiotic prescriptions they wrote inappropriately for acute upper respiratory tract infections, compared with the proportion written by top performers.

The mean rate of antibiotic prescribing decreased during the intervention in all the study groups, including the control group, which showed an absolute decrease of 11% (from 24.1% to 13.1%). The absolute decrease was significantly greater, at 18.1%, in the accountable justification group (from 23.2% to 5.2%) and at 16.3% in the peer comparison group (from 19.9% to 3.7%), Dr. Meeker and her associates said (JAMA. 2016 Feb 9;315[6]:562-70). The rate of return visits for possible bacterial infections within 30 days of the index visit was used as a measure of safety for withholding antibiotic prescriptions. This rate was 0.4% in the control group. The only intervention group that showed a “modestly higher” rate of return visits was the one that used both the accountable justification and the peer comparison interventions together, for which the rate of return visits was 1.4%.

The study was supported by the American Recovery and Reinvestment Act of 2009, the National Institutes of Health, the National Institute on Aging, the Agency for Healthcare Research and Quality, the University of Southern California’s Medical Information Network for Experimental Research, and the Patient-Centered Outcomes Research Institute. Dr. Meeker and her associates reported having no relevant financial disclosures.

Cognitive behavioral therapy (CBT) and second-generation antidepressants have similar efficacy and are both viable choices for adult patients who have major depressive disorder, according to a new clinical practice guideline published online Feb. 8 in the Annals of Internal Medicine.

“Although second-generation antidepressants are often initially prescribed for patients with depression, CBT is a reasonable approach for initial treatment and should be strongly considered as an alternative,” said Amir Qaseem, M.D., Ph.D., of the American College of Physicians, Philadelphia, and his associates on the clinical guidelines committee (Ann Intern Med. 2016 Feb 9; doi: 10.7326/M15-2570).

Until now, the relative benefits and harms of antidepressant medications vs. other therapies were unclear. The guideline was intended “to summarize and grade the evidence on the comparative effectiveness and safety of nonpharmacologic treatments and [antidepressants], alone or in combination.”

It is based on a systematic review and meta-analysis of 45 English-, German-, and Italian-language randomized, controlled trials of at least 6 weeks’ duration published from 1990 to September 2015, as well as relevant unpublished research. The Evidence-Based Practice Center of the federal Agency for Healthcare Research and Quality and the University of North Carolina at Chapel Hill conducted the review.

The nonpharmacologic treatments that were assessed included:

• Cognitive therapy, which aims to correct negative thoughts and false self-beliefs.

• CBT, which includes a behavioral component such as activity scheduling and homework.

• Acceptance and commitment therapy, which uses mindfulness techniques to help patients accept problems and counter negative thoughts;

• Interpersonal therapy, which focuses on relationships.

• Psychodynamic therapy, which targets past experiences and conscious and unconscious feelings.

• Third-wave CBT, which focuses on thought processes to help patients achieve awareness and acceptance.

The complementary and alternative treatments that were examined included acupuncture, meditation, yoga, and the use of omega-3 fatty acid supplements, SAMe, or St. John’s wort. Exercise as practiced individually, in informal groups, or in classes also was assessed.

The second-generation antidepressants that were assessed included selective serotonin reuptake inhibitors (such as fluoxetine, sertraline, and paroxetine), serotonin norepinephrine reuptake inhibitors (such as venlafaxine and duloxetine), selective serotonin norepinephrine reuptake inhibitors, and bupropion, mirtazapine, nefazodone, and trazodone.

The outcomes of interest with antidepressants were response rates, remission rates, speed of response, speed of remission, relapse rates, adverse events, quality of life, functional capacity, reduction of suicidality, and reduction of hospitalization.

Moderate-quality evidence showed no significant difference between antidepressants and CBT in either treatment response or discontinuation of treatment because of adverse effects.

Therefore, the guideline strongly recommends that “clinicians select between either CBT or second-generation antidepressants to treat patients with major depressive disorder after discussing treatment effects, adverse effect profiles, cost, accessibility, and preferences with the patient,” Dr. Qaseem and his associates said.

The guideline also states that most patients do not achieve remission after initial treatment with antidepressants, so “switching therapies or augmenting with additional interventions may be warranted.”

Regarding other treatments and other outcomes, the evidence was considered too sparse and of such low quality that it would not support any other recommendations at this time. Most of the reviewed studies were flawed by high dropout rates, dosing inequalities, small sample sizes, and poor evaluation of adverse events, according to Dr. Gerald Gartlehner and his associates at the Evidence-Based Practice Center, Chapel Hill, N.C. (Ann Intern Med. 2016 Feb 9; doi: 10.7326/M15-1813).

The guideline and the review/meta-analysis of the literature are available at www.annals.org. The guideline work was supported exclusively by the American College of Physicians. Dr. Qaseem disclosed no conflicts of interest. Complete disclosures for the members of the clinical guideline committee are available at www.acponline.org.

Cognitive behavioral therapy (CBT) and second-generation antidepressants have similar efficacy and are both viable choices for adult patients who have major depressive disorder, according to a new clinical practice guideline published online Feb. 8 in the Annals of Internal Medicine.

“Although second-generation antidepressants are often initially prescribed for patients with depression, CBT is a reasonable approach for initial treatment and should be strongly considered as an alternative,” said Amir Qaseem, M.D., Ph.D., of the American College of Physicians, Philadelphia, and his associates on the clinical guidelines committee (Ann Intern Med. 2016 Feb 9; doi: 10.7326/M15-2570).

Until now, the relative benefits and harms of antidepressant medications vs. other therapies were unclear. The guideline was intended “to summarize and grade the evidence on the comparative effectiveness and safety of nonpharmacologic treatments and [antidepressants], alone or in combination.”

It is based on a systematic review and meta-analysis of 45 English-, German-, and Italian-language randomized, controlled trials of at least 6 weeks’ duration published from 1990 to September 2015, as well as relevant unpublished research. The Evidence-Based Practice Center of the federal Agency for Healthcare Research and Quality and the University of North Carolina at Chapel Hill conducted the review.

The nonpharmacologic treatments that were assessed included:

• Cognitive therapy, which aims to correct negative thoughts and false self-beliefs.

• CBT, which includes a behavioral component such as activity scheduling and homework.

• Acceptance and commitment therapy, which uses mindfulness techniques to help patients accept problems and counter negative thoughts;

• Interpersonal therapy, which focuses on relationships.

• Psychodynamic therapy, which targets past experiences and conscious and unconscious feelings.

• Third-wave CBT, which focuses on thought processes to help patients achieve awareness and acceptance.

The complementary and alternative treatments that were examined included acupuncture, meditation, yoga, and the use of omega-3 fatty acid supplements, SAMe, or St. John’s wort. Exercise as practiced individually, in informal groups, or in classes also was assessed.

The second-generation antidepressants that were assessed included selective serotonin reuptake inhibitors (such as fluoxetine, sertraline, and paroxetine), serotonin norepinephrine reuptake inhibitors (such as venlafaxine and duloxetine), selective serotonin norepinephrine reuptake inhibitors, and bupropion, mirtazapine, nefazodone, and trazodone.

The outcomes of interest with antidepressants were response rates, remission rates, speed of response, speed of remission, relapse rates, adverse events, quality of life, functional capacity, reduction of suicidality, and reduction of hospitalization.

Moderate-quality evidence showed no significant difference between antidepressants and CBT in either treatment response or discontinuation of treatment because of adverse effects.

Therefore, the guideline strongly recommends that “clinicians select between either CBT or second-generation antidepressants to treat patients with major depressive disorder after discussing treatment effects, adverse effect profiles, cost, accessibility, and preferences with the patient,” Dr. Qaseem and his associates said.

The guideline also states that most patients do not achieve remission after initial treatment with antidepressants, so “switching therapies or augmenting with additional interventions may be warranted.”

Regarding other treatments and other outcomes, the evidence was considered too sparse and of such low quality that it would not support any other recommendations at this time. Most of the reviewed studies were flawed by high dropout rates, dosing inequalities, small sample sizes, and poor evaluation of adverse events, according to Dr. Gerald Gartlehner and his associates at the Evidence-Based Practice Center, Chapel Hill, N.C. (Ann Intern Med. 2016 Feb 9; doi: 10.7326/M15-1813).

The guideline and the review/meta-analysis of the literature are available at www.annals.org. The guideline work was supported exclusively by the American College of Physicians. Dr. Qaseem disclosed no conflicts of interest. Complete disclosures for the members of the clinical guideline committee are available at www.acponline.org.

Cognitive behavioral therapy (CBT) and second-generation antidepressants have similar efficacy and are both viable choices for adult patients who have major depressive disorder, according to a new clinical practice guideline published online Feb. 8 in the Annals of Internal Medicine.

“Although second-generation antidepressants are often initially prescribed for patients with depression, CBT is a reasonable approach for initial treatment and should be strongly considered as an alternative,” said Amir Qaseem, M.D., Ph.D., of the American College of Physicians, Philadelphia, and his associates on the clinical guidelines committee (Ann Intern Med. 2016 Feb 9; doi: 10.7326/M15-2570).

Until now, the relative benefits and harms of antidepressant medications vs. other therapies were unclear. The guideline was intended “to summarize and grade the evidence on the comparative effectiveness and safety of nonpharmacologic treatments and [antidepressants], alone or in combination.”

It is based on a systematic review and meta-analysis of 45 English-, German-, and Italian-language randomized, controlled trials of at least 6 weeks’ duration published from 1990 to September 2015, as well as relevant unpublished research. The Evidence-Based Practice Center of the federal Agency for Healthcare Research and Quality and the University of North Carolina at Chapel Hill conducted the review.

The nonpharmacologic treatments that were assessed included:

• Cognitive therapy, which aims to correct negative thoughts and false self-beliefs.

• CBT, which includes a behavioral component such as activity scheduling and homework.

• Acceptance and commitment therapy, which uses mindfulness techniques to help patients accept problems and counter negative thoughts;

• Interpersonal therapy, which focuses on relationships.

• Psychodynamic therapy, which targets past experiences and conscious and unconscious feelings.

• Third-wave CBT, which focuses on thought processes to help patients achieve awareness and acceptance.

The complementary and alternative treatments that were examined included acupuncture, meditation, yoga, and the use of omega-3 fatty acid supplements, SAMe, or St. John’s wort. Exercise as practiced individually, in informal groups, or in classes also was assessed.

The second-generation antidepressants that were assessed included selective serotonin reuptake inhibitors (such as fluoxetine, sertraline, and paroxetine), serotonin norepinephrine reuptake inhibitors (such as venlafaxine and duloxetine), selective serotonin norepinephrine reuptake inhibitors, and bupropion, mirtazapine, nefazodone, and trazodone.

The outcomes of interest with antidepressants were response rates, remission rates, speed of response, speed of remission, relapse rates, adverse events, quality of life, functional capacity, reduction of suicidality, and reduction of hospitalization.

Moderate-quality evidence showed no significant difference between antidepressants and CBT in either treatment response or discontinuation of treatment because of adverse effects.

Therefore, the guideline strongly recommends that “clinicians select between either CBT or second-generation antidepressants to treat patients with major depressive disorder after discussing treatment effects, adverse effect profiles, cost, accessibility, and preferences with the patient,” Dr. Qaseem and his associates said.

The guideline also states that most patients do not achieve remission after initial treatment with antidepressants, so “switching therapies or augmenting with additional interventions may be warranted.”

Regarding other treatments and other outcomes, the evidence was considered too sparse and of such low quality that it would not support any other recommendations at this time. Most of the reviewed studies were flawed by high dropout rates, dosing inequalities, small sample sizes, and poor evaluation of adverse events, according to Dr. Gerald Gartlehner and his associates at the Evidence-Based Practice Center, Chapel Hill, N.C. (Ann Intern Med. 2016 Feb 9; doi: 10.7326/M15-1813).

The guideline and the review/meta-analysis of the literature are available at www.annals.org. The guideline work was supported exclusively by the American College of Physicians. Dr. Qaseem disclosed no conflicts of interest. Complete disclosures for the members of the clinical guideline committee are available at www.acponline.org.

Among current and former smokers with or without chronic obstructive pulmonary disease (COPD), expiratory central airway collapse develops in approximately 5% and is associated with a worse respiratory-related quality of life, greater dyspnea, and an increased rate of total and severe exacerbations of pulmonary problems, according to a report published online Feb. 2 in JAMA.

Until recently, expiratory central airway collapse (ECAC) could only be studied using bronchoscopy, so it was not very well characterized. For example, the estimated prevalence among patients with known respiratory problems ranged from 1% to 53%. With the increasing use of noninvasive imaging techniques, the condition is being recognized more often, especially in association with smoking and COPD, but it still remains poorly understood, said Dr. Surya P. Bhatt of the division of pulmonary, allergy, and critical care medicine, University of Alabama at Birmingham, and his associates.

To assess the prevalence and clinical significance of ECAC, the investigators analyzed paired CT images of inspiratory and expiratory scans collected in the multicenter COPDGene study, focusing on scans for 8,820 current and former smokers aged 45-80 years (mean age, 59.7 years) who enrolled from local communities across the United States at 21 participating medical centers. Approximately 57% of the study participants were men, 66% were white and 34% were African American, 52% were active smokers, and 44% had COPD.

A total of 443 cases of ECAC were identified, for a prevalence of 5%.

ECAC was more common in participants with COPD (5.9%) than in those without COPD (4.3%), and the prevalence increased with increasing severity of COPD. Study subjects with ECAC were older than those without the condition, with a mean age of 65 years, compared with 59 years. ECAC also was more frequent among women than men (7.2% vs 3.1%), and among whites than blacks (6.2% vs 2.5%). Participants with ECAC had a higher body-mass index, a higher prevalence of chronic bronchitis, and more pack-years of smoking than those without ECAC.

In the primary data analysis, adults with ECAC had a worse respiratory-related quality of life than those without the condition, as measured using the St. George’s Respiratory Questionnaire. This association remained robust, and was independent of the degree of airflow obstruction and the severity of COPD, after the data were adjusted to account for patient demographics, structural lung disease, and forced expiratory volume in 1 second. “We speculate that ECAC might explain some cases of dyspnea disproportionate to apparent obstructive airways disease measured by CT, spirometry, or both,” Dr. Bhatt and his associates said.

Participants with ECAC also had more severe dyspnea as measured by the modified Medical Research Council score but did not have a shorter walking distance on the 6-minute walk test (JAMA 2016 Feb 2. doi: 10.1001/jama.2015.19431).A subset of 7,456 study participants were assessed at 3- to 6-month intervals for a median of 4.3 years. Compared with participants who did not have ECAC, those who did developed more total exacerbations of pulmonary problems (35 vs. 58 events per 100 person-years) and more severe exacerbations requiring hospitalization (10 vs. 17 events per 100 person-years). Mortality, however, was not significantly different between participants who had ECAC (9.9%) and those who did not (9.6%).

“Whether some of these [exacerbations] represent decompensated ECAC or whether ECAC is a marker for future respiratory events needs to be investigated. Our results suggest that ECAC might contribute to symptoms independent of underlying disease and also may serve as a CT-based biomarker of poor respiratory outcomes,” the investigators said.

This study was supported by the National Heart, Lung, and Blood Institute. Dr. Bhatt reported having no relevant financial disclosures; his associates reported ties to numerous industry sources.

Among current and former smokers with or without chronic obstructive pulmonary disease (COPD), expiratory central airway collapse develops in approximately 5% and is associated with a worse respiratory-related quality of life, greater dyspnea, and an increased rate of total and severe exacerbations of pulmonary problems, according to a report published online Feb. 2 in JAMA.

Until recently, expiratory central airway collapse (ECAC) could only be studied using bronchoscopy, so it was not very well characterized. For example, the estimated prevalence among patients with known respiratory problems ranged from 1% to 53%. With the increasing use of noninvasive imaging techniques, the condition is being recognized more often, especially in association with smoking and COPD, but it still remains poorly understood, said Dr. Surya P. Bhatt of the division of pulmonary, allergy, and critical care medicine, University of Alabama at Birmingham, and his associates.

To assess the prevalence and clinical significance of ECAC, the investigators analyzed paired CT images of inspiratory and expiratory scans collected in the multicenter COPDGene study, focusing on scans for 8,820 current and former smokers aged 45-80 years (mean age, 59.7 years) who enrolled from local communities across the United States at 21 participating medical centers. Approximately 57% of the study participants were men, 66% were white and 34% were African American, 52% were active smokers, and 44% had COPD.

A total of 443 cases of ECAC were identified, for a prevalence of 5%.

ECAC was more common in participants with COPD (5.9%) than in those without COPD (4.3%), and the prevalence increased with increasing severity of COPD. Study subjects with ECAC were older than those without the condition, with a mean age of 65 years, compared with 59 years. ECAC also was more frequent among women than men (7.2% vs 3.1%), and among whites than blacks (6.2% vs 2.5%). Participants with ECAC had a higher body-mass index, a higher prevalence of chronic bronchitis, and more pack-years of smoking than those without ECAC.

In the primary data analysis, adults with ECAC had a worse respiratory-related quality of life than those without the condition, as measured using the St. George’s Respiratory Questionnaire. This association remained robust, and was independent of the degree of airflow obstruction and the severity of COPD, after the data were adjusted to account for patient demographics, structural lung disease, and forced expiratory volume in 1 second. “We speculate that ECAC might explain some cases of dyspnea disproportionate to apparent obstructive airways disease measured by CT, spirometry, or both,” Dr. Bhatt and his associates said.

Participants with ECAC also had more severe dyspnea as measured by the modified Medical Research Council score but did not have a shorter walking distance on the 6-minute walk test (JAMA 2016 Feb 2. doi: 10.1001/jama.2015.19431).A subset of 7,456 study participants were assessed at 3- to 6-month intervals for a median of 4.3 years. Compared with participants who did not have ECAC, those who did developed more total exacerbations of pulmonary problems (35 vs. 58 events per 100 person-years) and more severe exacerbations requiring hospitalization (10 vs. 17 events per 100 person-years). Mortality, however, was not significantly different between participants who had ECAC (9.9%) and those who did not (9.6%).

“Whether some of these [exacerbations] represent decompensated ECAC or whether ECAC is a marker for future respiratory events needs to be investigated. Our results suggest that ECAC might contribute to symptoms independent of underlying disease and also may serve as a CT-based biomarker of poor respiratory outcomes,” the investigators said.

This study was supported by the National Heart, Lung, and Blood Institute. Dr. Bhatt reported having no relevant financial disclosures; his associates reported ties to numerous industry sources.

Among current and former smokers with or without chronic obstructive pulmonary disease (COPD), expiratory central airway collapse develops in approximately 5% and is associated with a worse respiratory-related quality of life, greater dyspnea, and an increased rate of total and severe exacerbations of pulmonary problems, according to a report published online Feb. 2 in JAMA.

Until recently, expiratory central airway collapse (ECAC) could only be studied using bronchoscopy, so it was not very well characterized. For example, the estimated prevalence among patients with known respiratory problems ranged from 1% to 53%. With the increasing use of noninvasive imaging techniques, the condition is being recognized more often, especially in association with smoking and COPD, but it still remains poorly understood, said Dr. Surya P. Bhatt of the division of pulmonary, allergy, and critical care medicine, University of Alabama at Birmingham, and his associates.

To assess the prevalence and clinical significance of ECAC, the investigators analyzed paired CT images of inspiratory and expiratory scans collected in the multicenter COPDGene study, focusing on scans for 8,820 current and former smokers aged 45-80 years (mean age, 59.7 years) who enrolled from local communities across the United States at 21 participating medical centers. Approximately 57% of the study participants were men, 66% were white and 34% were African American, 52% were active smokers, and 44% had COPD.

A total of 443 cases of ECAC were identified, for a prevalence of 5%.

ECAC was more common in participants with COPD (5.9%) than in those without COPD (4.3%), and the prevalence increased with increasing severity of COPD. Study subjects with ECAC were older than those without the condition, with a mean age of 65 years, compared with 59 years. ECAC also was more frequent among women than men (7.2% vs 3.1%), and among whites than blacks (6.2% vs 2.5%). Participants with ECAC had a higher body-mass index, a higher prevalence of chronic bronchitis, and more pack-years of smoking than those without ECAC.

In the primary data analysis, adults with ECAC had a worse respiratory-related quality of life than those without the condition, as measured using the St. George’s Respiratory Questionnaire. This association remained robust, and was independent of the degree of airflow obstruction and the severity of COPD, after the data were adjusted to account for patient demographics, structural lung disease, and forced expiratory volume in 1 second. “We speculate that ECAC might explain some cases of dyspnea disproportionate to apparent obstructive airways disease measured by CT, spirometry, or both,” Dr. Bhatt and his associates said.

Participants with ECAC also had more severe dyspnea as measured by the modified Medical Research Council score but did not have a shorter walking distance on the 6-minute walk test (JAMA 2016 Feb 2. doi: 10.1001/jama.2015.19431).A subset of 7,456 study participants were assessed at 3- to 6-month intervals for a median of 4.3 years. Compared with participants who did not have ECAC, those who did developed more total exacerbations of pulmonary problems (35 vs. 58 events per 100 person-years) and more severe exacerbations requiring hospitalization (10 vs. 17 events per 100 person-years). Mortality, however, was not significantly different between participants who had ECAC (9.9%) and those who did not (9.6%).

“Whether some of these [exacerbations] represent decompensated ECAC or whether ECAC is a marker for future respiratory events needs to be investigated. Our results suggest that ECAC might contribute to symptoms independent of underlying disease and also may serve as a CT-based biomarker of poor respiratory outcomes,” the investigators said.

This study was supported by the National Heart, Lung, and Blood Institute. Dr. Bhatt reported having no relevant financial disclosures; his associates reported ties to numerous industry sources.