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Supportive parenting program reduced African American teen smoking
Particularly in high-risk populations, participation in a family-centered parenting intervention can reduce adolescent and early adult smoking, according to results of a randomized controlled trial of the Strong African American Families (SAAF) program published in Pediatrics June 14.
African Americans have the “highest mortality rates for coronary heart disease and stroke,” compared with other racial groups, and the high rate of smoking among young adult African Americans is of concern, wrote Yi-fu Chen, PhD, of National Taipei University, New Taipei City, Taiwan, and his coinvestigators.
In a study of 424 African American adolescents from small towns in nine rural counties of southern Georgia, the 257 who were randomized to SAAF at age 11 years overall displayed significantly lower cotinine scores a
The SAAF families each attended seven meetings that consisted of both a separate session for the youth and the parent, and a joint session in which they practiced the skills they learned separately. The parents focused on “consistent provision of instrumental and emotional support, along with high levels of monitoring, consistent discipline that is not harsh, predictable family routines, and the establishment of clear norms and expectations for the use of drugs,” while the youth focused on “the importance of having and abiding by household rules, adaptive behaviors to use when encountering racism, and the importance of forming goals for the future and making plans to attain them,” the researchers explained.
These results “may provide a strategy for reducing health vulnerabilities associated with smoking among African American youth who grow up in challenging rural contexts,” the authors wrote.
Read more in Pediatrics (doi: 10.1542/peds.2016-4162).
Particularly in high-risk populations, participation in a family-centered parenting intervention can reduce adolescent and early adult smoking, according to results of a randomized controlled trial of the Strong African American Families (SAAF) program published in Pediatrics June 14.
African Americans have the “highest mortality rates for coronary heart disease and stroke,” compared with other racial groups, and the high rate of smoking among young adult African Americans is of concern, wrote Yi-fu Chen, PhD, of National Taipei University, New Taipei City, Taiwan, and his coinvestigators.
In a study of 424 African American adolescents from small towns in nine rural counties of southern Georgia, the 257 who were randomized to SAAF at age 11 years overall displayed significantly lower cotinine scores a
The SAAF families each attended seven meetings that consisted of both a separate session for the youth and the parent, and a joint session in which they practiced the skills they learned separately. The parents focused on “consistent provision of instrumental and emotional support, along with high levels of monitoring, consistent discipline that is not harsh, predictable family routines, and the establishment of clear norms and expectations for the use of drugs,” while the youth focused on “the importance of having and abiding by household rules, adaptive behaviors to use when encountering racism, and the importance of forming goals for the future and making plans to attain them,” the researchers explained.
These results “may provide a strategy for reducing health vulnerabilities associated with smoking among African American youth who grow up in challenging rural contexts,” the authors wrote.
Read more in Pediatrics (doi: 10.1542/peds.2016-4162).
Particularly in high-risk populations, participation in a family-centered parenting intervention can reduce adolescent and early adult smoking, according to results of a randomized controlled trial of the Strong African American Families (SAAF) program published in Pediatrics June 14.
African Americans have the “highest mortality rates for coronary heart disease and stroke,” compared with other racial groups, and the high rate of smoking among young adult African Americans is of concern, wrote Yi-fu Chen, PhD, of National Taipei University, New Taipei City, Taiwan, and his coinvestigators.
In a study of 424 African American adolescents from small towns in nine rural counties of southern Georgia, the 257 who were randomized to SAAF at age 11 years overall displayed significantly lower cotinine scores a
The SAAF families each attended seven meetings that consisted of both a separate session for the youth and the parent, and a joint session in which they practiced the skills they learned separately. The parents focused on “consistent provision of instrumental and emotional support, along with high levels of monitoring, consistent discipline that is not harsh, predictable family routines, and the establishment of clear norms and expectations for the use of drugs,” while the youth focused on “the importance of having and abiding by household rules, adaptive behaviors to use when encountering racism, and the importance of forming goals for the future and making plans to attain them,” the researchers explained.
These results “may provide a strategy for reducing health vulnerabilities associated with smoking among African American youth who grow up in challenging rural contexts,” the authors wrote.
Read more in Pediatrics (doi: 10.1542/peds.2016-4162).
FROM PEDIATRICS
Personalized snoring video boosts CPAP adherence
BOSTON – Showing patients videos of themselves having apneic episodes may convince them to use continuous positive airway pressure (CPAP), suggests the first results of an ongoing randomized clinical trial.
The investigators based their research project design on a previous pilot study that showed improved adherence to CPAP in patients who were shown videos of themselves sleeping while participating in a sleep study, Mark S. Aloia, PhD, said in a presentation at the annual meeting of the Associated Professional Sleep Societies.
In the new study, patients who had been recently diagnosed with sleep apnea were randomly assigned to participate in one of the three treatment groups. All three groups received sleep apnea and CPAP education prior to the use of CPAP. One group also watched videos of themselves sleeping, snoring, and gasping for air, and another group watched videos of a stranger sleeping and having apneic events.
After adjustment for age, educational level, and baseline sleep apnea severity, those who watched videos of themselves still used their CPAP devices more than 2 hours per night longer than did patients in each of the groups receiving the other two interventions (P = .02).
Both video interventions involved watching 30 minutes of sleep footage shown to each patient once before starting CPAP therapy. CPAP adherence was measured by downloaded data from PAP devices over the first 90 days of use.
The average age of the patients was 50 years, and they had moderate or severe sleep apnea, with mean apnea hypopnea indices ranging from 26.5 to 33.3 in the three study arms. The majority of patients had body mass indexes over 30.
Adherence to CPAP treatment is often poor, with many patients failing to use the device for even 4 hours per night, said Dr. Aloia, a psychologist at National Jewish Health in Denver. Many patients prescribed CPAP for OSA will undergo an educational component that may include watching a video of someone with OSA sleeping and having apneic events, he added. They often have “dramatic responses” to these videos, but then fail to positively change their own behavior.
“Many times we think that if our patient just knew what we know, he or she would use CPAP more, but there is evidence that doctors don’t take their medications any more than patients do, so it is not just a matter of education, it is a little bit deeper than that and it has to be personalized,” he said.
“The use of a personalized video is promising … we hope to present more data next year,” said Dr. Aloia, who has board certification in behavioral sleep medicine,
He noted that the video technique used may be jeopardized as more and more patients partake in home-based rather than lab-based sleep studies. That said, he also reported that the research team had to exclude several patients from the study because they had already viewed videos of themselves sleeping and snoring that had been recorded by their partners.
If the intervention proves effective, Dr. Aloia said he thinks it can be modified for use in home testing.
The study is supported by a grant from the National Heart, Lung, and Blood Institute. Dr. Aloia disclosed that he is a paid employee of Phillips, but that the study used both Phillips and ResMed CPAP devices.
BOSTON – Showing patients videos of themselves having apneic episodes may convince them to use continuous positive airway pressure (CPAP), suggests the first results of an ongoing randomized clinical trial.
The investigators based their research project design on a previous pilot study that showed improved adherence to CPAP in patients who were shown videos of themselves sleeping while participating in a sleep study, Mark S. Aloia, PhD, said in a presentation at the annual meeting of the Associated Professional Sleep Societies.
In the new study, patients who had been recently diagnosed with sleep apnea were randomly assigned to participate in one of the three treatment groups. All three groups received sleep apnea and CPAP education prior to the use of CPAP. One group also watched videos of themselves sleeping, snoring, and gasping for air, and another group watched videos of a stranger sleeping and having apneic events.
After adjustment for age, educational level, and baseline sleep apnea severity, those who watched videos of themselves still used their CPAP devices more than 2 hours per night longer than did patients in each of the groups receiving the other two interventions (P = .02).
Both video interventions involved watching 30 minutes of sleep footage shown to each patient once before starting CPAP therapy. CPAP adherence was measured by downloaded data from PAP devices over the first 90 days of use.
The average age of the patients was 50 years, and they had moderate or severe sleep apnea, with mean apnea hypopnea indices ranging from 26.5 to 33.3 in the three study arms. The majority of patients had body mass indexes over 30.
Adherence to CPAP treatment is often poor, with many patients failing to use the device for even 4 hours per night, said Dr. Aloia, a psychologist at National Jewish Health in Denver. Many patients prescribed CPAP for OSA will undergo an educational component that may include watching a video of someone with OSA sleeping and having apneic events, he added. They often have “dramatic responses” to these videos, but then fail to positively change their own behavior.
“Many times we think that if our patient just knew what we know, he or she would use CPAP more, but there is evidence that doctors don’t take their medications any more than patients do, so it is not just a matter of education, it is a little bit deeper than that and it has to be personalized,” he said.
“The use of a personalized video is promising … we hope to present more data next year,” said Dr. Aloia, who has board certification in behavioral sleep medicine,
He noted that the video technique used may be jeopardized as more and more patients partake in home-based rather than lab-based sleep studies. That said, he also reported that the research team had to exclude several patients from the study because they had already viewed videos of themselves sleeping and snoring that had been recorded by their partners.
If the intervention proves effective, Dr. Aloia said he thinks it can be modified for use in home testing.
The study is supported by a grant from the National Heart, Lung, and Blood Institute. Dr. Aloia disclosed that he is a paid employee of Phillips, but that the study used both Phillips and ResMed CPAP devices.
BOSTON – Showing patients videos of themselves having apneic episodes may convince them to use continuous positive airway pressure (CPAP), suggests the first results of an ongoing randomized clinical trial.
The investigators based their research project design on a previous pilot study that showed improved adherence to CPAP in patients who were shown videos of themselves sleeping while participating in a sleep study, Mark S. Aloia, PhD, said in a presentation at the annual meeting of the Associated Professional Sleep Societies.
In the new study, patients who had been recently diagnosed with sleep apnea were randomly assigned to participate in one of the three treatment groups. All three groups received sleep apnea and CPAP education prior to the use of CPAP. One group also watched videos of themselves sleeping, snoring, and gasping for air, and another group watched videos of a stranger sleeping and having apneic events.
After adjustment for age, educational level, and baseline sleep apnea severity, those who watched videos of themselves still used their CPAP devices more than 2 hours per night longer than did patients in each of the groups receiving the other two interventions (P = .02).
Both video interventions involved watching 30 minutes of sleep footage shown to each patient once before starting CPAP therapy. CPAP adherence was measured by downloaded data from PAP devices over the first 90 days of use.
The average age of the patients was 50 years, and they had moderate or severe sleep apnea, with mean apnea hypopnea indices ranging from 26.5 to 33.3 in the three study arms. The majority of patients had body mass indexes over 30.
Adherence to CPAP treatment is often poor, with many patients failing to use the device for even 4 hours per night, said Dr. Aloia, a psychologist at National Jewish Health in Denver. Many patients prescribed CPAP for OSA will undergo an educational component that may include watching a video of someone with OSA sleeping and having apneic events, he added. They often have “dramatic responses” to these videos, but then fail to positively change their own behavior.
“Many times we think that if our patient just knew what we know, he or she would use CPAP more, but there is evidence that doctors don’t take their medications any more than patients do, so it is not just a matter of education, it is a little bit deeper than that and it has to be personalized,” he said.
“The use of a personalized video is promising … we hope to present more data next year,” said Dr. Aloia, who has board certification in behavioral sleep medicine,
He noted that the video technique used may be jeopardized as more and more patients partake in home-based rather than lab-based sleep studies. That said, he also reported that the research team had to exclude several patients from the study because they had already viewed videos of themselves sleeping and snoring that had been recorded by their partners.
If the intervention proves effective, Dr. Aloia said he thinks it can be modified for use in home testing.
The study is supported by a grant from the National Heart, Lung, and Blood Institute. Dr. Aloia disclosed that he is a paid employee of Phillips, but that the study used both Phillips and ResMed CPAP devices.
AT SLEEP 2017
Key clinical point: Showing patients videos of themselves having an apneic event during CPAP initiation resulted in greater treatment adherence over 3 months, compared to standard ways of initiating CPAP therapy.
Major finding: Patients who watched personalized sleep videos used their CPAP devices more than 2 hours per night longer, compared with those who were not shown a personalized video.
Data source: Randomized controlled trial with 3-month data on 24 individuals out of a planned enrollment of 300 patients.
Disclosures: This ongoing study is supported by a grant from the National Heart, Lung, and Blood Institute. Dr. Aloia disclosed that he is a paid employee of Phillips, but that the study used both Phillips and ResMed CPAP devices.
Mild OSA linked to hypertension
BOSTON – Sleep apnea doesn’t have to be severe or even symptomatic to increase the risk of hypertension and diabetes, according to a pair of new studies.
“We found that even mild sleep apnea was strongly associated with increased risk of developing hypertension by four times, compared to individuals without sleep apnea,” said principal investigator and top sleep researcher Alexandros N. Vgontzas, MD, of Pennsylvania State University College of Medicine in a SLEEP press release. “Similarly, moderate sleep apnea was associated with increased risk of developing diabetes by almost three times, compared to individuals without sleep apnea.”
Dr. Vgontzas presented his team’s results on the link between mild to moderate OSA and hypertension at the annual meeting of the American Academy of Sleep Medicine. In a separate session, his colleague at Penn State, Yun Li, MD, presented the diabetes-related findings of the same study.
After multivariate adjustment, including controlling for change in body mass index over time, both mild and moderate OSA were significantly associated with increased odds for developing hypertension, compared with controls without OSA (odds ratios, 4.36 and 3.46, respectively.).
The researchers found their test for an age interaction was also significant, indicating that younger adults with nonsevere OSA were at increased risk of hypertension, while those over 60 years of age were not.
[polldaddy:9792720]
“In young and middle-aged adults, our findings suggest that early detection and treatment of mild to moderate sleep apnea is warranted in order to prevent future cardiometabolic disease,” said Dr. Li in a press release. “Given the stronger association of sleep apnea with metabolic abnormalities in this age group, emphasis should be placed on yearly monitoring of indices of metabolic symptoms and lifestyle interventions, such as weight control, healthy diet, regular exercise, and stress management.”
For diabetes, moderate OSA was significantly associated with an almost threefold increased odds for developing diabetes after adjusting for a range of baseline and follow-up variables (OR, 2.78), but mild OSA was not associated with incident diabetes (OR, 0.47).
Both studies utilized data from the Penn State Adult Cohort, a random general population sample of 1,741 adults who underwent an overnight polysomnography sleep study and had a detailed medical history interview at baseline. Mild and moderate OSA were defined as an apnea hypopnea index from 5 to 14.9 and from 15 to 29.9, respectively. The presence of hypertension or diabetes at baseline and follow-up was defined by a self-report of receiving treatment for or having a physician diagnosis of either condition.
The age range of the studied population was wide (20-84 years), with a mean age of about 47 years. The incidence of diabetes was 10.2% at follow-up, while hypertension was found in 34.2% of patients. Dr. Vgontzas said the percentage of patients with hypertension was roughly what he had expected for this population.
“Our conclusion is that, the younger a person is, the stronger is the need for detection and treatment of sleep apnea,” said Dr. Vgontzas, though he acknowledged that putting these millions of people on continuous positive airway pressure therapy is not an easy proposition.
The study was supported by National Institutes of Health grants. Dr. Vgontzas reported no conflicts of interest.
BOSTON – Sleep apnea doesn’t have to be severe or even symptomatic to increase the risk of hypertension and diabetes, according to a pair of new studies.
“We found that even mild sleep apnea was strongly associated with increased risk of developing hypertension by four times, compared to individuals without sleep apnea,” said principal investigator and top sleep researcher Alexandros N. Vgontzas, MD, of Pennsylvania State University College of Medicine in a SLEEP press release. “Similarly, moderate sleep apnea was associated with increased risk of developing diabetes by almost three times, compared to individuals without sleep apnea.”
Dr. Vgontzas presented his team’s results on the link between mild to moderate OSA and hypertension at the annual meeting of the American Academy of Sleep Medicine. In a separate session, his colleague at Penn State, Yun Li, MD, presented the diabetes-related findings of the same study.
After multivariate adjustment, including controlling for change in body mass index over time, both mild and moderate OSA were significantly associated with increased odds for developing hypertension, compared with controls without OSA (odds ratios, 4.36 and 3.46, respectively.).
The researchers found their test for an age interaction was also significant, indicating that younger adults with nonsevere OSA were at increased risk of hypertension, while those over 60 years of age were not.
[polldaddy:9792720]
“In young and middle-aged adults, our findings suggest that early detection and treatment of mild to moderate sleep apnea is warranted in order to prevent future cardiometabolic disease,” said Dr. Li in a press release. “Given the stronger association of sleep apnea with metabolic abnormalities in this age group, emphasis should be placed on yearly monitoring of indices of metabolic symptoms and lifestyle interventions, such as weight control, healthy diet, regular exercise, and stress management.”
For diabetes, moderate OSA was significantly associated with an almost threefold increased odds for developing diabetes after adjusting for a range of baseline and follow-up variables (OR, 2.78), but mild OSA was not associated with incident diabetes (OR, 0.47).
Both studies utilized data from the Penn State Adult Cohort, a random general population sample of 1,741 adults who underwent an overnight polysomnography sleep study and had a detailed medical history interview at baseline. Mild and moderate OSA were defined as an apnea hypopnea index from 5 to 14.9 and from 15 to 29.9, respectively. The presence of hypertension or diabetes at baseline and follow-up was defined by a self-report of receiving treatment for or having a physician diagnosis of either condition.
The age range of the studied population was wide (20-84 years), with a mean age of about 47 years. The incidence of diabetes was 10.2% at follow-up, while hypertension was found in 34.2% of patients. Dr. Vgontzas said the percentage of patients with hypertension was roughly what he had expected for this population.
“Our conclusion is that, the younger a person is, the stronger is the need for detection and treatment of sleep apnea,” said Dr. Vgontzas, though he acknowledged that putting these millions of people on continuous positive airway pressure therapy is not an easy proposition.
The study was supported by National Institutes of Health grants. Dr. Vgontzas reported no conflicts of interest.
BOSTON – Sleep apnea doesn’t have to be severe or even symptomatic to increase the risk of hypertension and diabetes, according to a pair of new studies.
“We found that even mild sleep apnea was strongly associated with increased risk of developing hypertension by four times, compared to individuals without sleep apnea,” said principal investigator and top sleep researcher Alexandros N. Vgontzas, MD, of Pennsylvania State University College of Medicine in a SLEEP press release. “Similarly, moderate sleep apnea was associated with increased risk of developing diabetes by almost three times, compared to individuals without sleep apnea.”
Dr. Vgontzas presented his team’s results on the link between mild to moderate OSA and hypertension at the annual meeting of the American Academy of Sleep Medicine. In a separate session, his colleague at Penn State, Yun Li, MD, presented the diabetes-related findings of the same study.
After multivariate adjustment, including controlling for change in body mass index over time, both mild and moderate OSA were significantly associated with increased odds for developing hypertension, compared with controls without OSA (odds ratios, 4.36 and 3.46, respectively.).
The researchers found their test for an age interaction was also significant, indicating that younger adults with nonsevere OSA were at increased risk of hypertension, while those over 60 years of age were not.
[polldaddy:9792720]
“In young and middle-aged adults, our findings suggest that early detection and treatment of mild to moderate sleep apnea is warranted in order to prevent future cardiometabolic disease,” said Dr. Li in a press release. “Given the stronger association of sleep apnea with metabolic abnormalities in this age group, emphasis should be placed on yearly monitoring of indices of metabolic symptoms and lifestyle interventions, such as weight control, healthy diet, regular exercise, and stress management.”
For diabetes, moderate OSA was significantly associated with an almost threefold increased odds for developing diabetes after adjusting for a range of baseline and follow-up variables (OR, 2.78), but mild OSA was not associated with incident diabetes (OR, 0.47).
Both studies utilized data from the Penn State Adult Cohort, a random general population sample of 1,741 adults who underwent an overnight polysomnography sleep study and had a detailed medical history interview at baseline. Mild and moderate OSA were defined as an apnea hypopnea index from 5 to 14.9 and from 15 to 29.9, respectively. The presence of hypertension or diabetes at baseline and follow-up was defined by a self-report of receiving treatment for or having a physician diagnosis of either condition.
The age range of the studied population was wide (20-84 years), with a mean age of about 47 years. The incidence of diabetes was 10.2% at follow-up, while hypertension was found in 34.2% of patients. Dr. Vgontzas said the percentage of patients with hypertension was roughly what he had expected for this population.
“Our conclusion is that, the younger a person is, the stronger is the need for detection and treatment of sleep apnea,” said Dr. Vgontzas, though he acknowledged that putting these millions of people on continuous positive airway pressure therapy is not an easy proposition.
The study was supported by National Institutes of Health grants. Dr. Vgontzas reported no conflicts of interest.
AT SLEEP 2017
Key clinical point: In a random sample of adults, the presence of mild to moderate OSA was associated with a significantly higher risk of hypertension and diabetes.
Major finding: Individuals with mild to moderate OSA had more than a fourfold increased risk of hypertension over 10 years of follow-up (OR, 4.36). Moderate OSA was significantly associated with incident diabetes risk (OR, 2.78), but mild OSA was not.
Data source: An observational study including a random sample of 1,741 adults between the ages of 20 and 84 years.
Disclosures: The study was supported by National Institutes of Health grants. Dr. Vgontzas reported no conflicts of interest.
Loud, frequent snoring increases preterm delivery risk
BOSTON – Women who were prepregnancy, frequent, and loud snorers during pregnancy had a significantly higher risk of preterm or early term delivery, in a study presented at the annual meeting of the Associated Professional Sleep Societies.
“The fact that there is an association between snoring and time to delivery in a cohort which is not hypertensive is alarming, and I think that treatment for snoring earlier on in pregnancy may alleviate some of these outcomes,” reported Galit Levi Dunietz, PhD, MPH, of the University of Michigan in a session at the meeting.
Compared with nonsnorers, frequently loud snorers had about a 60% increased risk of preterm delivery even after adjusting for baseline body mass index, smoking, education, race, and parity. Pregnancy-onset snoring and infrequent or quiet snoring were not associated with preterm birth.
A limitation on the findings was that only a small number of women (4% of the sample) fell into the chronic, frequent, and loud snoring category. These women, however, had significantly lower mean gestational age, mean baseline BMI, and were more likely to be smokers, as compared with nonsnorers and quiet frequent or infrequent snorers.
“I think this is excellent work because it’s a big question,” said Dr. Omavi Gbodossou Bailey, MD, MPH from the University of Arizona, Pheonix, in a Q&A session at the conference. “As a primary care physician, I deliver babies and I also deal with sleep and when I ask the ob.gyns. about sleep apnea in this patient population, they’re not usually interested.”
Dr. Bailey noted in an interview that, often, women who had uncomplicated first pregnancies return with later pregnancies heavier, more sleep deprived, and snoring. “Then, they have higher risk for complications in the second or third pregnancy,” he said.
Snoring is common in pregnancy, affecting about 35% of women, and pregnancy itself is a risk factor for snoring. Previous studies have associated snoring with key pregnancy morbidities including hypertension, preeclampsia, and gestational diabetes, but, prior to this research, the few studies that had looked at snoring and preterm delivery had shown inconsistent results.
The researchers recruited 904 pregnant women in their third trimester and without hypertension or diabetes from prenatal clinics at the University of Michigan cared for between 2008 and 2011. The women were queried on the frequency of their snoring (from never to three or more times per week) along with its intensity (from nonsnoring to loud or very loud snoring). They were also categorized, based on self-report, as either chronic/prepregnancy snorers or incident/pregnancy-onset snorers.
In this low-risk cohort, 25% of the women reported incident snoring and 9% reported chronic prepregnancy snoring.
“The combination of snoring frequency and intensity may be a clinically useful marker to identify otherwise low-risk women who are likely to deliver earlier,” said Dr. Dunietz.
This study was funded by the Gilmore Fund for Sleep Research, the University of Michigan Institute for Clinical and Health Research, and the National Heart, Lung, and Blood Institute. Dr. Dunietz reported having no financial disclosures.
BOSTON – Women who were prepregnancy, frequent, and loud snorers during pregnancy had a significantly higher risk of preterm or early term delivery, in a study presented at the annual meeting of the Associated Professional Sleep Societies.
“The fact that there is an association between snoring and time to delivery in a cohort which is not hypertensive is alarming, and I think that treatment for snoring earlier on in pregnancy may alleviate some of these outcomes,” reported Galit Levi Dunietz, PhD, MPH, of the University of Michigan in a session at the meeting.
Compared with nonsnorers, frequently loud snorers had about a 60% increased risk of preterm delivery even after adjusting for baseline body mass index, smoking, education, race, and parity. Pregnancy-onset snoring and infrequent or quiet snoring were not associated with preterm birth.
A limitation on the findings was that only a small number of women (4% of the sample) fell into the chronic, frequent, and loud snoring category. These women, however, had significantly lower mean gestational age, mean baseline BMI, and were more likely to be smokers, as compared with nonsnorers and quiet frequent or infrequent snorers.
“I think this is excellent work because it’s a big question,” said Dr. Omavi Gbodossou Bailey, MD, MPH from the University of Arizona, Pheonix, in a Q&A session at the conference. “As a primary care physician, I deliver babies and I also deal with sleep and when I ask the ob.gyns. about sleep apnea in this patient population, they’re not usually interested.”
Dr. Bailey noted in an interview that, often, women who had uncomplicated first pregnancies return with later pregnancies heavier, more sleep deprived, and snoring. “Then, they have higher risk for complications in the second or third pregnancy,” he said.
Snoring is common in pregnancy, affecting about 35% of women, and pregnancy itself is a risk factor for snoring. Previous studies have associated snoring with key pregnancy morbidities including hypertension, preeclampsia, and gestational diabetes, but, prior to this research, the few studies that had looked at snoring and preterm delivery had shown inconsistent results.
The researchers recruited 904 pregnant women in their third trimester and without hypertension or diabetes from prenatal clinics at the University of Michigan cared for between 2008 and 2011. The women were queried on the frequency of their snoring (from never to three or more times per week) along with its intensity (from nonsnoring to loud or very loud snoring). They were also categorized, based on self-report, as either chronic/prepregnancy snorers or incident/pregnancy-onset snorers.
In this low-risk cohort, 25% of the women reported incident snoring and 9% reported chronic prepregnancy snoring.
“The combination of snoring frequency and intensity may be a clinically useful marker to identify otherwise low-risk women who are likely to deliver earlier,” said Dr. Dunietz.
This study was funded by the Gilmore Fund for Sleep Research, the University of Michigan Institute for Clinical and Health Research, and the National Heart, Lung, and Blood Institute. Dr. Dunietz reported having no financial disclosures.
BOSTON – Women who were prepregnancy, frequent, and loud snorers during pregnancy had a significantly higher risk of preterm or early term delivery, in a study presented at the annual meeting of the Associated Professional Sleep Societies.
“The fact that there is an association between snoring and time to delivery in a cohort which is not hypertensive is alarming, and I think that treatment for snoring earlier on in pregnancy may alleviate some of these outcomes,” reported Galit Levi Dunietz, PhD, MPH, of the University of Michigan in a session at the meeting.
Compared with nonsnorers, frequently loud snorers had about a 60% increased risk of preterm delivery even after adjusting for baseline body mass index, smoking, education, race, and parity. Pregnancy-onset snoring and infrequent or quiet snoring were not associated with preterm birth.
A limitation on the findings was that only a small number of women (4% of the sample) fell into the chronic, frequent, and loud snoring category. These women, however, had significantly lower mean gestational age, mean baseline BMI, and were more likely to be smokers, as compared with nonsnorers and quiet frequent or infrequent snorers.
“I think this is excellent work because it’s a big question,” said Dr. Omavi Gbodossou Bailey, MD, MPH from the University of Arizona, Pheonix, in a Q&A session at the conference. “As a primary care physician, I deliver babies and I also deal with sleep and when I ask the ob.gyns. about sleep apnea in this patient population, they’re not usually interested.”
Dr. Bailey noted in an interview that, often, women who had uncomplicated first pregnancies return with later pregnancies heavier, more sleep deprived, and snoring. “Then, they have higher risk for complications in the second or third pregnancy,” he said.
Snoring is common in pregnancy, affecting about 35% of women, and pregnancy itself is a risk factor for snoring. Previous studies have associated snoring with key pregnancy morbidities including hypertension, preeclampsia, and gestational diabetes, but, prior to this research, the few studies that had looked at snoring and preterm delivery had shown inconsistent results.
The researchers recruited 904 pregnant women in their third trimester and without hypertension or diabetes from prenatal clinics at the University of Michigan cared for between 2008 and 2011. The women were queried on the frequency of their snoring (from never to three or more times per week) along with its intensity (from nonsnoring to loud or very loud snoring). They were also categorized, based on self-report, as either chronic/prepregnancy snorers or incident/pregnancy-onset snorers.
In this low-risk cohort, 25% of the women reported incident snoring and 9% reported chronic prepregnancy snoring.
“The combination of snoring frequency and intensity may be a clinically useful marker to identify otherwise low-risk women who are likely to deliver earlier,” said Dr. Dunietz.
This study was funded by the Gilmore Fund for Sleep Research, the University of Michigan Institute for Clinical and Health Research, and the National Heart, Lung, and Blood Institute. Dr. Dunietz reported having no financial disclosures.
AT SLEEP 2017
Key clinical point: Compared with those who were nonloud, nonfrequent, or pregnancy-onset snorers, chronic, loud, and frequent snorers were at significantly greater risk for preterm delivery.
Major finding: Of women determined to be chronic, prepregnancy, frequent, and loud snorers, 25% had preterm delivery.
Data source: An observational study including 904 pregnant women in the third trimester.
Disclosures: This study was funded by the Gilmore Fund for Sleep Research, the University of Michigan Institute for Clinical and Health Research, and the National Heart, Lung, and Blood Institute. Dr. Dunietz reported having no financial disclosures.
Lung cancer linked to suicide
WASHINGTON – U.S. patients diagnosed with lung cancer have had the highest suicide rates among patients diagnosed with any of the other most common, non-skin cancers, and they also had a substantially higher suicide risk, compared with the general U.S. adult population, based on U.S. national data collected during 1973-2013.
Although U.S. lung cancer patients showed a “steep” decline in suicide rates starting in about 1985 that then accelerated beginning in the mid-1990s, as recently as 2010-2013 the rate was roughly twice as high in lung cancer patients when compared with the general U.S. adult population. The rate of lung cancer patients taking their lives was also significantly above the suicide rates among patients with breast, colorectal, or prostate cancer, Mohamed Rahouma, MD, reported at an international conference of the American Thoracic Society.
However, he also stressed that identification of lung cancer patients at especially high suicide risk was important to allow “proper psychological assessment, support, and counseling to reduce [suicide] rates.”
Lung cancer patients with the highest rates included men, widowed individuals, septuagenarians, and Asians, his analysis showed. Standardized mortality ratios (SMRs) for suicide of these highest-risk subgroups were near or exceeding 10 times fold higher than the suicide rates of comparable demographic groups among the general U.S. adult population, according to Dr. Rahouma and his associates.
The overall SMR for all lung cancer patients during the entire four decades studied, compared with the overall U.S. adult population, was 4. Even during the period 2005-2013, when suicide among lung cancer patients had fallen to its lowest level, the SMR for this group was still more than 2.
The investigators used data collected by the U.S. Surveillance Epidemiology and End Results (SEER) Program cancer database maintained by the National Cancer Institute. For suicide rates among the general U.S. population they used data from the National Vital Statistics Reports produced by the Centers for Disease Control and Prevention. The SEER database included entries for more than 3.6 million U.S. cancer patients during 1973-2013, of whom 6,661 patents had committed suicide, an overall SMR of 1.6.
When the researchers drilled down the SMRs for individual cancer types they found that while the SMR for lung cancer patients throughout the period studied was just above 4, the SMRs for breast and colorectal cancer patients were both 1.4, and 1.2 for patients with prostate cancer. This analysis adjusted for patients’ age, sex, race, and year of diagnosis, Dr. Rahouma reported.
The time from diagnosis to suicide was also strikingly quicker among lung cancer patients, at an average of 8 months, compared with average delays from diagnosis to suicide of 40-60 months for patients with breast, colorectal, or prostate cancer. Dr. Rahouma’s time-trend analysis showed that the SMRs for these three other cancer types held more or less steady within the range of 1-2 throughout the 4 decades examined, and by 2010-2013 the three SMRs all were at or just above 1. Lung cancer was the only malignancy in this group that showed a wide range in SMR over time, with the peak some 30-40 years ago.
Among the lung cancer patient subgroups that showed the highest SMRs for suicide during the entire period studied, men had a SMR of 9, Asians had a SMR of nearly 14, those with a deceased spouse had a SMR for suicide of almost 12, and septuagenarians had a SMR of 12, said Dr. Rahouma. The impact of these risk factors was greatest during the first 8 months following lung cancer diagnosis. After 8 months, the strength of the risk factors diminished, with the SMRs within each risk category dropping by roughly half.
The highest-risk subgroups that the analysis identified should especially be referred for psychiatric support, Dr. Rahouma concluded. “These data will change our practice” at Cornell, he predicted.
Dr. Rahouma had no disclosures.
[email protected]
On Twitter @mitchelzoler
WASHINGTON – U.S. patients diagnosed with lung cancer have had the highest suicide rates among patients diagnosed with any of the other most common, non-skin cancers, and they also had a substantially higher suicide risk, compared with the general U.S. adult population, based on U.S. national data collected during 1973-2013.
Although U.S. lung cancer patients showed a “steep” decline in suicide rates starting in about 1985 that then accelerated beginning in the mid-1990s, as recently as 2010-2013 the rate was roughly twice as high in lung cancer patients when compared with the general U.S. adult population. The rate of lung cancer patients taking their lives was also significantly above the suicide rates among patients with breast, colorectal, or prostate cancer, Mohamed Rahouma, MD, reported at an international conference of the American Thoracic Society.
However, he also stressed that identification of lung cancer patients at especially high suicide risk was important to allow “proper psychological assessment, support, and counseling to reduce [suicide] rates.”
Lung cancer patients with the highest rates included men, widowed individuals, septuagenarians, and Asians, his analysis showed. Standardized mortality ratios (SMRs) for suicide of these highest-risk subgroups were near or exceeding 10 times fold higher than the suicide rates of comparable demographic groups among the general U.S. adult population, according to Dr. Rahouma and his associates.
The overall SMR for all lung cancer patients during the entire four decades studied, compared with the overall U.S. adult population, was 4. Even during the period 2005-2013, when suicide among lung cancer patients had fallen to its lowest level, the SMR for this group was still more than 2.
The investigators used data collected by the U.S. Surveillance Epidemiology and End Results (SEER) Program cancer database maintained by the National Cancer Institute. For suicide rates among the general U.S. population they used data from the National Vital Statistics Reports produced by the Centers for Disease Control and Prevention. The SEER database included entries for more than 3.6 million U.S. cancer patients during 1973-2013, of whom 6,661 patents had committed suicide, an overall SMR of 1.6.
When the researchers drilled down the SMRs for individual cancer types they found that while the SMR for lung cancer patients throughout the period studied was just above 4, the SMRs for breast and colorectal cancer patients were both 1.4, and 1.2 for patients with prostate cancer. This analysis adjusted for patients’ age, sex, race, and year of diagnosis, Dr. Rahouma reported.
The time from diagnosis to suicide was also strikingly quicker among lung cancer patients, at an average of 8 months, compared with average delays from diagnosis to suicide of 40-60 months for patients with breast, colorectal, or prostate cancer. Dr. Rahouma’s time-trend analysis showed that the SMRs for these three other cancer types held more or less steady within the range of 1-2 throughout the 4 decades examined, and by 2010-2013 the three SMRs all were at or just above 1. Lung cancer was the only malignancy in this group that showed a wide range in SMR over time, with the peak some 30-40 years ago.
Among the lung cancer patient subgroups that showed the highest SMRs for suicide during the entire period studied, men had a SMR of 9, Asians had a SMR of nearly 14, those with a deceased spouse had a SMR for suicide of almost 12, and septuagenarians had a SMR of 12, said Dr. Rahouma. The impact of these risk factors was greatest during the first 8 months following lung cancer diagnosis. After 8 months, the strength of the risk factors diminished, with the SMRs within each risk category dropping by roughly half.
The highest-risk subgroups that the analysis identified should especially be referred for psychiatric support, Dr. Rahouma concluded. “These data will change our practice” at Cornell, he predicted.
Dr. Rahouma had no disclosures.
[email protected]
On Twitter @mitchelzoler
WASHINGTON – U.S. patients diagnosed with lung cancer have had the highest suicide rates among patients diagnosed with any of the other most common, non-skin cancers, and they also had a substantially higher suicide risk, compared with the general U.S. adult population, based on U.S. national data collected during 1973-2013.
Although U.S. lung cancer patients showed a “steep” decline in suicide rates starting in about 1985 that then accelerated beginning in the mid-1990s, as recently as 2010-2013 the rate was roughly twice as high in lung cancer patients when compared with the general U.S. adult population. The rate of lung cancer patients taking their lives was also significantly above the suicide rates among patients with breast, colorectal, or prostate cancer, Mohamed Rahouma, MD, reported at an international conference of the American Thoracic Society.
However, he also stressed that identification of lung cancer patients at especially high suicide risk was important to allow “proper psychological assessment, support, and counseling to reduce [suicide] rates.”
Lung cancer patients with the highest rates included men, widowed individuals, septuagenarians, and Asians, his analysis showed. Standardized mortality ratios (SMRs) for suicide of these highest-risk subgroups were near or exceeding 10 times fold higher than the suicide rates of comparable demographic groups among the general U.S. adult population, according to Dr. Rahouma and his associates.
The overall SMR for all lung cancer patients during the entire four decades studied, compared with the overall U.S. adult population, was 4. Even during the period 2005-2013, when suicide among lung cancer patients had fallen to its lowest level, the SMR for this group was still more than 2.
The investigators used data collected by the U.S. Surveillance Epidemiology and End Results (SEER) Program cancer database maintained by the National Cancer Institute. For suicide rates among the general U.S. population they used data from the National Vital Statistics Reports produced by the Centers for Disease Control and Prevention. The SEER database included entries for more than 3.6 million U.S. cancer patients during 1973-2013, of whom 6,661 patents had committed suicide, an overall SMR of 1.6.
When the researchers drilled down the SMRs for individual cancer types they found that while the SMR for lung cancer patients throughout the period studied was just above 4, the SMRs for breast and colorectal cancer patients were both 1.4, and 1.2 for patients with prostate cancer. This analysis adjusted for patients’ age, sex, race, and year of diagnosis, Dr. Rahouma reported.
The time from diagnosis to suicide was also strikingly quicker among lung cancer patients, at an average of 8 months, compared with average delays from diagnosis to suicide of 40-60 months for patients with breast, colorectal, or prostate cancer. Dr. Rahouma’s time-trend analysis showed that the SMRs for these three other cancer types held more or less steady within the range of 1-2 throughout the 4 decades examined, and by 2010-2013 the three SMRs all were at or just above 1. Lung cancer was the only malignancy in this group that showed a wide range in SMR over time, with the peak some 30-40 years ago.
Among the lung cancer patient subgroups that showed the highest SMRs for suicide during the entire period studied, men had a SMR of 9, Asians had a SMR of nearly 14, those with a deceased spouse had a SMR for suicide of almost 12, and septuagenarians had a SMR of 12, said Dr. Rahouma. The impact of these risk factors was greatest during the first 8 months following lung cancer diagnosis. After 8 months, the strength of the risk factors diminished, with the SMRs within each risk category dropping by roughly half.
The highest-risk subgroups that the analysis identified should especially be referred for psychiatric support, Dr. Rahouma concluded. “These data will change our practice” at Cornell, he predicted.
Dr. Rahouma had no disclosures.
[email protected]
On Twitter @mitchelzoler
AT ATS 2017
Key clinical point:
Major finding: During 1973-2013, suicide among U.S. lung cancer patients was four times higher than the general adult U.S. population.
Data source: Statistics on more than 3.6 million U.S. cancer patients in the SEER Program.
Disclosures: Dr. Rahouma had no disclosures.
Noninvasive therapy cut COPD readmissions
WASHINGTON – The addition of noninvasive ventilation to home oxygen therapy regimens correlated with increased time to readmission or death among patients with exacerbated chronic obstructive pulmonary diseases (COPD), according to a study presented at an international conference of the American Thoracic Society.
Among 116 patients observed with COPD, the 57 patients given home oxygen and noninvasive ventilation reported an average time to readmission of 4.3 months, compared with 1.4 months among the 59 patients given only home oxygen, according to Patrick B. Murphy, PhD, of St. Thomas’ Hospital, London (JAMA. 2017 May 21. doi: 10.1001/jama.2017.4451), who presented this research on the same day it was published in JAMA. 
Dr. Murphy said the findings are encouraging for patients with COPD suffering from exacerbations from the disease.
“Patients with established chronic respiratory failure secondary to COPD have poor outcomes with limited treatment options available,” the investigators noted. “The results of the current trial are reassuring, suggesting that home noninvasive ventilation added to home oxygen therapy in this population improved the overall clinical outcome without adding to the health burden of the patient.”
In this 12-month, phase III, multicenter, randomized clinical trial, the average age of the patients was 67 years, and the average body mass index was 21.6 mg/k2. The patients had an average partial pressure of carbon dioxide (PaCo2) level of 59, indicating persistent hypercapnia.
The investigators gave those in the intervention group one of three noninvasive home ventilators – nasal, oronasal, or total face mask – to use for a minimum of 6 hours nightly. Patients in both groups received 15 hours of oxygen therapy daily.
Doctors gathered data from patients after 6 weeks, 3 months, 6 months, and 12 months.
After 12 months, risk of readmission or death in the intervention group was 63.4%, while those in the oxygen-only group reported a risk of 80.4%. Despite a 17% risk reduction, a similar number of patients died during the experiment in both groups: five in the noninvasive intervention group and four in the control group, according to the investigators.
At the end of the trial, 16 patients (28%) in the intervention group and 19 (32%) in the control group died.
Dr. Murphy and his peers asserted that these deaths do not take away from the success of the treatment, as the focus of the study was to find a way to reduce readmissions, not necessarily mortality.
“The driver of the clinical improvement in the home oxygen therapy plus home noninvasive ventilation group was readmission avoidance with no significant difference in mortality,” they wrote. “This study has major clinical relevance because readmission avoidance is beneficial to the patient in terms of preservation of lung function and health-related quality of life, as well as providing a direct and indirect cost saving.”
The study was limited by the lack of a double-blind design; however, investigators said that a sham device may have made patients’ respiratory failure worse.
Some patients in the control group were later given ventilation treatment for safety reasons. Eighteen patients were given noninvasive ventilation, although reportedly after the primary endpoint was reached.
Philips Respironics, ResMed, the ResMed Foundation, and the Guy’s and St. Thomas’ Charity funded the study. Dr. Murphy and his coinvestigators reported receiving some manner of financial support from ResMed, Philips Respironics, and B&D Electromedical.
[email protected]
On Twitter @eaztweets
Vera A. De Palo, MD, FCCP, MBA, comments: A goal for any patient with a chronic disease is the best possible quality of life. Increasing hospital-free and exacerbation-free days helps to improve that quality of life. The authors report that the addition of noninvasive ventilation therapy increased the time to readmission due to COPD exacerbation. This adds another tool to the armamentarium to help improve outcomes for our COPD patients.
Vera A. De Palo, MD, FCCP, MBA, comments: A goal for any patient with a chronic disease is the best possible quality of life. Increasing hospital-free and exacerbation-free days helps to improve that quality of life. The authors report that the addition of noninvasive ventilation therapy increased the time to readmission due to COPD exacerbation. This adds another tool to the armamentarium to help improve outcomes for our COPD patients.
Vera A. De Palo, MD, FCCP, MBA, comments: A goal for any patient with a chronic disease is the best possible quality of life. Increasing hospital-free and exacerbation-free days helps to improve that quality of life. The authors report that the addition of noninvasive ventilation therapy increased the time to readmission due to COPD exacerbation. This adds another tool to the armamentarium to help improve outcomes for our COPD patients.
WASHINGTON – The addition of noninvasive ventilation to home oxygen therapy regimens correlated with increased time to readmission or death among patients with exacerbated chronic obstructive pulmonary diseases (COPD), according to a study presented at an international conference of the American Thoracic Society.
Among 116 patients observed with COPD, the 57 patients given home oxygen and noninvasive ventilation reported an average time to readmission of 4.3 months, compared with 1.4 months among the 59 patients given only home oxygen, according to Patrick B. Murphy, PhD, of St. Thomas’ Hospital, London (JAMA. 2017 May 21. doi: 10.1001/jama.2017.4451), who presented this research on the same day it was published in JAMA.
Dr. Murphy said the findings are encouraging for patients with COPD suffering from exacerbations from the disease.
“Patients with established chronic respiratory failure secondary to COPD have poor outcomes with limited treatment options available,” the investigators noted. “The results of the current trial are reassuring, suggesting that home noninvasive ventilation added to home oxygen therapy in this population improved the overall clinical outcome without adding to the health burden of the patient.”
In this 12-month, phase III, multicenter, randomized clinical trial, the average age of the patients was 67 years, and the average body mass index was 21.6 mg/k2. The patients had an average partial pressure of carbon dioxide (PaCo2) level of 59, indicating persistent hypercapnia.
The investigators gave those in the intervention group one of three noninvasive home ventilators – nasal, oronasal, or total face mask – to use for a minimum of 6 hours nightly. Patients in both groups received 15 hours of oxygen therapy daily.
Doctors gathered data from patients after 6 weeks, 3 months, 6 months, and 12 months.
After 12 months, risk of readmission or death in the intervention group was 63.4%, while those in the oxygen-only group reported a risk of 80.4%. Despite a 17% risk reduction, a similar number of patients died during the experiment in both groups: five in the noninvasive intervention group and four in the control group, according to the investigators.
At the end of the trial, 16 patients (28%) in the intervention group and 19 (32%) in the control group died.
Dr. Murphy and his peers asserted that these deaths do not take away from the success of the treatment, as the focus of the study was to find a way to reduce readmissions, not necessarily mortality.
“The driver of the clinical improvement in the home oxygen therapy plus home noninvasive ventilation group was readmission avoidance with no significant difference in mortality,” they wrote. “This study has major clinical relevance because readmission avoidance is beneficial to the patient in terms of preservation of lung function and health-related quality of life, as well as providing a direct and indirect cost saving.”
The study was limited by the lack of a double-blind design; however, investigators said that a sham device may have made patients’ respiratory failure worse.
Some patients in the control group were later given ventilation treatment for safety reasons. Eighteen patients were given noninvasive ventilation, although reportedly after the primary endpoint was reached.
Philips Respironics, ResMed, the ResMed Foundation, and the Guy’s and St. Thomas’ Charity funded the study. Dr. Murphy and his coinvestigators reported receiving some manner of financial support from ResMed, Philips Respironics, and B&D Electromedical.
[email protected]
On Twitter @eaztweets
WASHINGTON – The addition of noninvasive ventilation to home oxygen therapy regimens correlated with increased time to readmission or death among patients with exacerbated chronic obstructive pulmonary diseases (COPD), according to a study presented at an international conference of the American Thoracic Society.
Among 116 patients observed with COPD, the 57 patients given home oxygen and noninvasive ventilation reported an average time to readmission of 4.3 months, compared with 1.4 months among the 59 patients given only home oxygen, according to Patrick B. Murphy, PhD, of St. Thomas’ Hospital, London (JAMA. 2017 May 21. doi: 10.1001/jama.2017.4451), who presented this research on the same day it was published in JAMA.
Dr. Murphy said the findings are encouraging for patients with COPD suffering from exacerbations from the disease.
“Patients with established chronic respiratory failure secondary to COPD have poor outcomes with limited treatment options available,” the investigators noted. “The results of the current trial are reassuring, suggesting that home noninvasive ventilation added to home oxygen therapy in this population improved the overall clinical outcome without adding to the health burden of the patient.”
In this 12-month, phase III, multicenter, randomized clinical trial, the average age of the patients was 67 years, and the average body mass index was 21.6 mg/k2. The patients had an average partial pressure of carbon dioxide (PaCo2) level of 59, indicating persistent hypercapnia.
The investigators gave those in the intervention group one of three noninvasive home ventilators – nasal, oronasal, or total face mask – to use for a minimum of 6 hours nightly. Patients in both groups received 15 hours of oxygen therapy daily.
Doctors gathered data from patients after 6 weeks, 3 months, 6 months, and 12 months.
After 12 months, risk of readmission or death in the intervention group was 63.4%, while those in the oxygen-only group reported a risk of 80.4%. Despite a 17% risk reduction, a similar number of patients died during the experiment in both groups: five in the noninvasive intervention group and four in the control group, according to the investigators.
At the end of the trial, 16 patients (28%) in the intervention group and 19 (32%) in the control group died.
Dr. Murphy and his peers asserted that these deaths do not take away from the success of the treatment, as the focus of the study was to find a way to reduce readmissions, not necessarily mortality.
“The driver of the clinical improvement in the home oxygen therapy plus home noninvasive ventilation group was readmission avoidance with no significant difference in mortality,” they wrote. “This study has major clinical relevance because readmission avoidance is beneficial to the patient in terms of preservation of lung function and health-related quality of life, as well as providing a direct and indirect cost saving.”
The study was limited by the lack of a double-blind design; however, investigators said that a sham device may have made patients’ respiratory failure worse.
Some patients in the control group were later given ventilation treatment for safety reasons. Eighteen patients were given noninvasive ventilation, although reportedly after the primary endpoint was reached.
Philips Respironics, ResMed, the ResMed Foundation, and the Guy’s and St. Thomas’ Charity funded the study. Dr. Murphy and his coinvestigators reported receiving some manner of financial support from ResMed, Philips Respironics, and B&D Electromedical.
[email protected]
On Twitter @eaztweets
FROM ATS 2017
Key clinical point:
Major finding: The average time until readmission or death was 4.3 months for patients using both oxygen therapy and ventilation, compared with an average of 1.4 months for patients using only oxygen therapy.
Data source: Phase III, multicenter, randomized clinical trial of 116 COPD patients gathered from 13 U.K. medical centers between February, 2010, and April, 2015.
Disclosures: Philips Respironics, ResMed, the ResMed Foundation, and the Guy’s and St. Thomas’ Charity funded the study. Dr. Patrick B. Murphy and his coinvestigators reported receiving some manner of financial support from ResMed, Philips Respironics, and B&D Electromedical.
New chest x-ray assessment reflects ARDS severity
WASHINGTON – A new way to semiquantitatively score chest x-rays that takes into account lung density and consolidation may be a useful adjunct to current methods for assessing severity of acute respiratory distress syndrome.
The score, know as the Radiographic Assessment of Lung Edema (RALE) score, showed good correlations with lung edema, the severity of acute respiratory distress syndrome (ARDS), and response to fluid management resulting in reduced pulmonary edema, Melissa A. Warren, MD, said at an international conference of the American Thoracic Society.
The RALE score that Dr. Warren and her associates devised rates a patient’s chest x-ray for two parameters: consolidation, which is based on the extent of alveolar opacity in each of the four lung quadrants (left upper, left lower, right upper, and right lower), and a density score that is based on the density of alveolar opacity in each quadrant.
The consolidation score for each quadrant is rated on a 0-4 scale with 0 corresponding to no opacity, 1 for 1%-24% opacity, 2 for 25%-49% opacity, 3 for 50%-75% opacity, and 4 for more than 75%. The density score is rated on a scale of 1-3 with 1 for hazy opacity, 2 for moderate opacity, and 3 for dense opacity. The score for each quadrant is obtained by multiplying the extent score by the density score. A patient’s total RALE score sums the scores from all four quadrants.
The researchers ran three tests of the clinical relevance of this scoring system. First, they used it to score chest x-rays of 72 preprocurement lungs donated for transplant but unable to be used for that purpose, and compared the scores with the extent of lung edema measured by the actual weight of each explanted lung. This showed high correlation between the scores and the amount of edema, Dr. Warren reported.
Next they assessed the RALE score as a marker of ARDS by retrospectively calculating the scores of 174 patients with baseline chest x-rays enrolled in the Fluids and Catheters Treatment Trial (FACTT) (N Engl J Med. 2006;354[24]:2564-75). This analysis showed that patients with the highest RALE scores had significantly worse survival during 90-day follow-up, compared with the patients with the lowest scores.
Finally, the researchers assessed how the RALE score changed in response to either the liberal or conservative fluid management approaches tested in FACTT. This showed that at baseline the average RALE scores were similar among 92 patients randomized to the liberal fluid management treatment arm and 82 patients assigned to the conservative fluid management arm. But after 3 days of treatment, patients in the conservative arm showed a roughly one third reduction in their average RALE score, while patients in the liberal fluid arm showed virtually no change in their score.
“A conservative fluid management strategy favorably impacted the RALE score, reflecting a decrease in pulmonary edema,” Dr. Warren concluded.
[email protected]
On Twitter @mitchelzoler
Eric Gartman, MD, FCCP, comments: The results obtained from the use of this scoring system could be important in the prognostication of patients with ARDS, although it is unclear how the score would be used to alter clinical decision making. Further, issues may arise in its implementation given the somewhat subjective nature of the scoring (e.g., hazy vs. moderate vs. dense opacity), changing factors in the ICU that may affect the lung density on x-ray (e.g., different levels of positive end-expiratory pressure), and the variable quality of chest x-rays in the ICU. 
Eric Gartman, MD, FCCP, comments: The results obtained from the use of this scoring system could be important in the prognostication of patients with ARDS, although it is unclear how the score would be used to alter clinical decision making. Further, issues may arise in its implementation given the somewhat subjective nature of the scoring (e.g., hazy vs. moderate vs. dense opacity), changing factors in the ICU that may affect the lung density on x-ray (e.g., different levels of positive end-expiratory pressure), and the variable quality of chest x-rays in the ICU.
Eric Gartman, MD, FCCP, comments: The results obtained from the use of this scoring system could be important in the prognostication of patients with ARDS, although it is unclear how the score would be used to alter clinical decision making. Further, issues may arise in its implementation given the somewhat subjective nature of the scoring (e.g., hazy vs. moderate vs. dense opacity), changing factors in the ICU that may affect the lung density on x-ray (e.g., different levels of positive end-expiratory pressure), and the variable quality of chest x-rays in the ICU.
WASHINGTON – A new way to semiquantitatively score chest x-rays that takes into account lung density and consolidation may be a useful adjunct to current methods for assessing severity of acute respiratory distress syndrome.
The score, know as the Radiographic Assessment of Lung Edema (RALE) score, showed good correlations with lung edema, the severity of acute respiratory distress syndrome (ARDS), and response to fluid management resulting in reduced pulmonary edema, Melissa A. Warren, MD, said at an international conference of the American Thoracic Society.
The RALE score that Dr. Warren and her associates devised rates a patient’s chest x-ray for two parameters: consolidation, which is based on the extent of alveolar opacity in each of the four lung quadrants (left upper, left lower, right upper, and right lower), and a density score that is based on the density of alveolar opacity in each quadrant.
The consolidation score for each quadrant is rated on a 0-4 scale with 0 corresponding to no opacity, 1 for 1%-24% opacity, 2 for 25%-49% opacity, 3 for 50%-75% opacity, and 4 for more than 75%. The density score is rated on a scale of 1-3 with 1 for hazy opacity, 2 for moderate opacity, and 3 for dense opacity. The score for each quadrant is obtained by multiplying the extent score by the density score. A patient’s total RALE score sums the scores from all four quadrants.
The researchers ran three tests of the clinical relevance of this scoring system. First, they used it to score chest x-rays of 72 preprocurement lungs donated for transplant but unable to be used for that purpose, and compared the scores with the extent of lung edema measured by the actual weight of each explanted lung. This showed high correlation between the scores and the amount of edema, Dr. Warren reported.
Next they assessed the RALE score as a marker of ARDS by retrospectively calculating the scores of 174 patients with baseline chest x-rays enrolled in the Fluids and Catheters Treatment Trial (FACTT) (N Engl J Med. 2006;354[24]:2564-75). This analysis showed that patients with the highest RALE scores had significantly worse survival during 90-day follow-up, compared with the patients with the lowest scores.
Finally, the researchers assessed how the RALE score changed in response to either the liberal or conservative fluid management approaches tested in FACTT. This showed that at baseline the average RALE scores were similar among 92 patients randomized to the liberal fluid management treatment arm and 82 patients assigned to the conservative fluid management arm. But after 3 days of treatment, patients in the conservative arm showed a roughly one third reduction in their average RALE score, while patients in the liberal fluid arm showed virtually no change in their score.
“A conservative fluid management strategy favorably impacted the RALE score, reflecting a decrease in pulmonary edema,” Dr. Warren concluded.
[email protected]
On Twitter @mitchelzoler
WASHINGTON – A new way to semiquantitatively score chest x-rays that takes into account lung density and consolidation may be a useful adjunct to current methods for assessing severity of acute respiratory distress syndrome.
The score, know as the Radiographic Assessment of Lung Edema (RALE) score, showed good correlations with lung edema, the severity of acute respiratory distress syndrome (ARDS), and response to fluid management resulting in reduced pulmonary edema, Melissa A. Warren, MD, said at an international conference of the American Thoracic Society.
The RALE score that Dr. Warren and her associates devised rates a patient’s chest x-ray for two parameters: consolidation, which is based on the extent of alveolar opacity in each of the four lung quadrants (left upper, left lower, right upper, and right lower), and a density score that is based on the density of alveolar opacity in each quadrant.
The consolidation score for each quadrant is rated on a 0-4 scale with 0 corresponding to no opacity, 1 for 1%-24% opacity, 2 for 25%-49% opacity, 3 for 50%-75% opacity, and 4 for more than 75%. The density score is rated on a scale of 1-3 with 1 for hazy opacity, 2 for moderate opacity, and 3 for dense opacity. The score for each quadrant is obtained by multiplying the extent score by the density score. A patient’s total RALE score sums the scores from all four quadrants.
The researchers ran three tests of the clinical relevance of this scoring system. First, they used it to score chest x-rays of 72 preprocurement lungs donated for transplant but unable to be used for that purpose, and compared the scores with the extent of lung edema measured by the actual weight of each explanted lung. This showed high correlation between the scores and the amount of edema, Dr. Warren reported.
Next they assessed the RALE score as a marker of ARDS by retrospectively calculating the scores of 174 patients with baseline chest x-rays enrolled in the Fluids and Catheters Treatment Trial (FACTT) (N Engl J Med. 2006;354[24]:2564-75). This analysis showed that patients with the highest RALE scores had significantly worse survival during 90-day follow-up, compared with the patients with the lowest scores.
Finally, the researchers assessed how the RALE score changed in response to either the liberal or conservative fluid management approaches tested in FACTT. This showed that at baseline the average RALE scores were similar among 92 patients randomized to the liberal fluid management treatment arm and 82 patients assigned to the conservative fluid management arm. But after 3 days of treatment, patients in the conservative arm showed a roughly one third reduction in their average RALE score, while patients in the liberal fluid arm showed virtually no change in their score.
“A conservative fluid management strategy favorably impacted the RALE score, reflecting a decrease in pulmonary edema,” Dr. Warren concluded.
[email protected]
On Twitter @mitchelzoler
AT ATS 2017
Key clinical point:
Major finding: The RALE score correlated with lung edema and ARDS severity, and changed in response to conservative fluid management.
Data source: A subgroup of 174 patients with ARDS enrolled in the FACTT trial, and also 72 donor lungs not available for transplantation.
Disclosures: Dr. Warren had no disclosures.
Rapid lab test predicts pediatric pneumococcal pneumonia severity
MADRID – Thomsen-Friedenreich antigen activation is useful as a novel early predictor of empyema in pediatric community-acquired pneumonia, Chi-Jung Chang, MD, reported at the annual meeting of the European Society for Paediatric Infectious Diseases.
In her retrospective study of 142 Taiwanese children and adolescents hospitalized for community-acquired pneumonia (CAP), Thomsen-Friedenreich antigen (TA) activation had 100% specificity, 100% positive predictive value, and 31% sensitivity for Streptococcus pneumoniae as the causative microorganism.
Moreover, the higher the TA activation titer, the more severe the pneumonia complications that followed, according to Dr. Chang of MacKay Children’s Hospital in Taipei, Taiwan.
The value of this lab test lies in its speed and accuracy for detection of S. pneumoniae CAP. Conventional culture methods are relatively slow and have poor sensitivity, because a child often already has been on empiric antimicrobial therapy and the culture specimen is unwittingly obtained from a sterile site, she explained.
Twenty-two of the 142 children and adolescents hospitalized for lobar CAP were TA activation positive at admission. They were considerably sicker than were the 120 patients who were TA activation negative. Their initial C-reactive protein level was 31.9 mg/dL, twice that of the negative group. Their peak CRP during the hospital stay was significantly higher as well, as was their peak WBC.
Hospital lengths of stay were longer in the TA activation–positive group. Eighteen of 22 TA activation–positive patients (82%) were admitted to the ICU for an average of 8 days, compared with 9% of the negative group.
All TA activation–positive patients had complicated pneumonia with parapneumonic effusions, empyema, necrotizing pneumonia, and/or lung abscesses, as did 36% of the negative group.
S. pneumoniae was the most common pathogen in this study of CAP. It was the responsible microbe in all 22 of the TA activation–positive patients and in 29% of the TA activation–negative ones. The most common serotype in the TA activation group was 19A, which accounted for 12 of the 22 cases. This also was the predominant serotype found in CAP across all Taiwan during the first half of this decade, when the study took place.
In a multivariate logistic regression analysis, TA activation was far and away the strongest independent predictor of empyema, with an associated 15.8-fold increased risk. The other two independent predictors – longer fever duration prior to hospitalization and a higher initial CRP level – were far less robust, according to Dr. Chang.
How TA activation works as a predictor
TA is present on the surface of erythrocytes, platelets, and glomeruli, but ordinarily it is covered by a layer of N-acetylneuraminic acid. Streptococcus pneumoniae produces circulating neuraminidases, which cleave the N-acetylneuraminic acid and expose the underlying TA. The TA then quickly becomes activated through interaction with the anti-TA antibodies, which are normally present in plasma. Once activated, the TA stays so for weeks to months.
Other neuraminidase-producing microorganisms include Clostridium perfringens, Escherichia coli, and Bacteroides.
Dr. Chang and her colleagues used the peanut lectin agglutination method in their TA activation testing.
She reported having no financial conflicts regarding her study.
MADRID – Thomsen-Friedenreich antigen activation is useful as a novel early predictor of empyema in pediatric community-acquired pneumonia, Chi-Jung Chang, MD, reported at the annual meeting of the European Society for Paediatric Infectious Diseases.
In her retrospective study of 142 Taiwanese children and adolescents hospitalized for community-acquired pneumonia (CAP), Thomsen-Friedenreich antigen (TA) activation had 100% specificity, 100% positive predictive value, and 31% sensitivity for Streptococcus pneumoniae as the causative microorganism.
Moreover, the higher the TA activation titer, the more severe the pneumonia complications that followed, according to Dr. Chang of MacKay Children’s Hospital in Taipei, Taiwan.
The value of this lab test lies in its speed and accuracy for detection of S. pneumoniae CAP. Conventional culture methods are relatively slow and have poor sensitivity, because a child often already has been on empiric antimicrobial therapy and the culture specimen is unwittingly obtained from a sterile site, she explained.
Twenty-two of the 142 children and adolescents hospitalized for lobar CAP were TA activation positive at admission. They were considerably sicker than were the 120 patients who were TA activation negative. Their initial C-reactive protein level was 31.9 mg/dL, twice that of the negative group. Their peak CRP during the hospital stay was significantly higher as well, as was their peak WBC.
Hospital lengths of stay were longer in the TA activation–positive group. Eighteen of 22 TA activation–positive patients (82%) were admitted to the ICU for an average of 8 days, compared with 9% of the negative group.
All TA activation–positive patients had complicated pneumonia with parapneumonic effusions, empyema, necrotizing pneumonia, and/or lung abscesses, as did 36% of the negative group.
S. pneumoniae was the most common pathogen in this study of CAP. It was the responsible microbe in all 22 of the TA activation–positive patients and in 29% of the TA activation–negative ones. The most common serotype in the TA activation group was 19A, which accounted for 12 of the 22 cases. This also was the predominant serotype found in CAP across all Taiwan during the first half of this decade, when the study took place.
In a multivariate logistic regression analysis, TA activation was far and away the strongest independent predictor of empyema, with an associated 15.8-fold increased risk. The other two independent predictors – longer fever duration prior to hospitalization and a higher initial CRP level – were far less robust, according to Dr. Chang.
How TA activation works as a predictor
TA is present on the surface of erythrocytes, platelets, and glomeruli, but ordinarily it is covered by a layer of N-acetylneuraminic acid. Streptococcus pneumoniae produces circulating neuraminidases, which cleave the N-acetylneuraminic acid and expose the underlying TA. The TA then quickly becomes activated through interaction with the anti-TA antibodies, which are normally present in plasma. Once activated, the TA stays so for weeks to months.
Other neuraminidase-producing microorganisms include Clostridium perfringens, Escherichia coli, and Bacteroides.
Dr. Chang and her colleagues used the peanut lectin agglutination method in their TA activation testing.
She reported having no financial conflicts regarding her study.
MADRID – Thomsen-Friedenreich antigen activation is useful as a novel early predictor of empyema in pediatric community-acquired pneumonia, Chi-Jung Chang, MD, reported at the annual meeting of the European Society for Paediatric Infectious Diseases.
In her retrospective study of 142 Taiwanese children and adolescents hospitalized for community-acquired pneumonia (CAP), Thomsen-Friedenreich antigen (TA) activation had 100% specificity, 100% positive predictive value, and 31% sensitivity for Streptococcus pneumoniae as the causative microorganism.
Moreover, the higher the TA activation titer, the more severe the pneumonia complications that followed, according to Dr. Chang of MacKay Children’s Hospital in Taipei, Taiwan.
The value of this lab test lies in its speed and accuracy for detection of S. pneumoniae CAP. Conventional culture methods are relatively slow and have poor sensitivity, because a child often already has been on empiric antimicrobial therapy and the culture specimen is unwittingly obtained from a sterile site, she explained.
Twenty-two of the 142 children and adolescents hospitalized for lobar CAP were TA activation positive at admission. They were considerably sicker than were the 120 patients who were TA activation negative. Their initial C-reactive protein level was 31.9 mg/dL, twice that of the negative group. Their peak CRP during the hospital stay was significantly higher as well, as was their peak WBC.
Hospital lengths of stay were longer in the TA activation–positive group. Eighteen of 22 TA activation–positive patients (82%) were admitted to the ICU for an average of 8 days, compared with 9% of the negative group.
All TA activation–positive patients had complicated pneumonia with parapneumonic effusions, empyema, necrotizing pneumonia, and/or lung abscesses, as did 36% of the negative group.
S. pneumoniae was the most common pathogen in this study of CAP. It was the responsible microbe in all 22 of the TA activation–positive patients and in 29% of the TA activation–negative ones. The most common serotype in the TA activation group was 19A, which accounted for 12 of the 22 cases. This also was the predominant serotype found in CAP across all Taiwan during the first half of this decade, when the study took place.
In a multivariate logistic regression analysis, TA activation was far and away the strongest independent predictor of empyema, with an associated 15.8-fold increased risk. The other two independent predictors – longer fever duration prior to hospitalization and a higher initial CRP level – were far less robust, according to Dr. Chang.
How TA activation works as a predictor
TA is present on the surface of erythrocytes, platelets, and glomeruli, but ordinarily it is covered by a layer of N-acetylneuraminic acid. Streptococcus pneumoniae produces circulating neuraminidases, which cleave the N-acetylneuraminic acid and expose the underlying TA. The TA then quickly becomes activated through interaction with the anti-TA antibodies, which are normally present in plasma. Once activated, the TA stays so for weeks to months.
Other neuraminidase-producing microorganisms include Clostridium perfringens, Escherichia coli, and Bacteroides.
Dr. Chang and her colleagues used the peanut lectin agglutination method in their TA activation testing.
She reported having no financial conflicts regarding her study.
AT ESPID 2017
Key clinical point:
Major finding: A positive Thomsen-Friedenreich antigen activation test in pediatric community-acquired pneumonia had 100% specificity, 100% positive predictive value, and 31% sensitivity for S. pneumoniae as the causative microorganism.
Data source: A retrospective study of 142 Taiwanese children and teens hospitalized for lobular community-acquired pneumonia.
Disclosures: The study presenter reported having no financial conflicts of interest.
VIDEO: Hyperinflammatory ARDS responds to simvastatin
WASHINGTON – Acute respiratory distress syndrome (ARDS) appears to exist in at least two major forms, and one of these, the hyperinflammatory form, seemed responsive to simvastatin in a post-hoc analysis of trial data.
The other version of ARDs is a hypoinflammatory form, which occurred in 70% of ARDS patients in most of the analyses that have been done.
Researchers classified the 540 ARDS patients enrolled in a 2014 study of simvastatin as either hyperinflammatory or hypoinflammatory. Separating out the hyperinflammatory patients created a subclass that responded to simvastatin, with a 13% absolute reduction in mortality during follow-up, compared with no response among patients in the hypoinflammatory group, Carolyn S. Calfee, MD, said at an international conference of the American Thoracic Society.
“Hyperinflammatory patients treated with simvastatin may have improved outcomes, compared with hypoinflammatory* patients treated with placebo,” said Dr. Calfee, a pulmonologist at the University of California, San Francisco.
The finding raises the possibility that simvastatin, as well as other statins, may be an effective treatment for selected patients with ARDS, but proving this requires new prospective, randomized trials in hyperinflammatory patients, Dr. Calfee said in a video interview.
Currently, the tests Dr. Calfee uses to distinguish hyperinflammatory and hypoinflammatory ARDS patients take about 6-8 hours to complete. A “point of care test to stratify patients in real time,” is needed to further study the various forms of ARDs, Dr. Calfee noted. A critical next step would be the development of a “practical, rapid, bedside assay” to ease identification of hyperinflammatory ARDS patients. “The work we’ve done prior seems to indicate that we are going to definitely need to measure biomarkers in order to identity these subgroups,” she noted.
Hypoinflammatory patients also merit study, she added. Although hyperinflammatory patients have significant worse mortality rates, the hypoinflammatory subclass includes about 70% of ARDS patients, “so we need to better understand how to potentially treat this group.”
Dr. Calfee and her associates first reported finding the two ARDS subclasses, what they also call subphenotypes or endotypes, in two separate cohorts of ARDS patients in a 2014 report (Lancet Resp Med. 2014 Aug;2[8]:611-20). Then, they confirmed the finding in a third ARDS cohort in a 2017 report (Amer J Resp Crit Care Med. 2017 Feb 1;195[3]:331-8). These reports have documented other characteristics of the hyperinflammatory ARDS subclass: hypotension, metabolic acidosis, more frequent treatment with vasopressors, and a higher prevalence of sepsis and shock. Concurrent with the 2017 report, an editorial hailed the finding as “the dawn of personalized medicine for ARDS” (Amer J resp Crit Care Med. 2017 Feb 1;195[3]: 280-1).
To build on this, Dr. Calfee and her associates applied their method for identifying ARDS subclasses to a different cohort of 540 patients enrolled in the The HARP (Hydroxymethylglutaryl-CoA Reductase Inhibition with Simvastatin in Acute Lung Injury to Reduce Pulmonary Dysfunction)–2 study, a multicenter UK and Irish study designed to test the efficacy of daily simvastatin treatment in a heterogeneous group of ARDS patients. A 2014 report of the study’s primary results showed no significant effect from simvastatin for increasing the number of ventilator-free days nor did the drug improve any other measured efficacy endpoints (New Engl J Med. 2014 Oct 30;371[18]:1695-703).
Applying a statistical analysis called “latent class analysis,” which is designed to recognize subclass groupings that might not be readily apparent, Dr. Calfee and her team first confirmed that, in this fourth cohort, the ARDS patients again split into a hyperinflammatory subclass, in this case including 188 (35%) of the cohort, and a hypoinflammatory subclass with 352 (65%) patients. The next step was to see what impact simvastatin treatment had in each of the two patient subclasses. They focused the analysis on a secondary outcome in HARP-2, 28-day survival.
They found that simvastatin produced no significant difference in 28-day survival, compared with placebo among the hypoinflammatory patients, but, in the hyperinflammatory subclass, 28-day survival was 68% for patients on simvastatin and 55% for those on placebo, a statistically significant difference, Dr. Calfee reported (Am J Resp Crit Care Med. 2017;195:A6749).
“I’m excited that we are seeing, for the first time, a different response to pharmacotherapy” after dividing ARDS patients into these two subclasses, she said. But, the work remains in an early stage, she cautioned. “We need to test treatments [like statins] prospectively.” The new finding for simvastatin “is not the same as showing benefit in a prospective, randomized trial.”
In the meantime, Dr. Calfee plans to apply the same analytic approach to data collected in another failed statin trial in ARDS patients, the SAILS trial. That study failed to show benefit from rosuvastatin treatment in an unselected population of patients with sepsis-associated ARDS (New Engl J Med. 2014 June 5;370[23]:2191-200).
Dr. Calfee is a consultant to Bayer, Boehringer Ingelheim, and GlaxoSmithKline. She received research funding from GlaxoSmithKline.
[email protected]
On Twitter @mitchelzoler
*An earlier version of this article misquoted Dr. Calfee.
WASHINGTON – Acute respiratory distress syndrome (ARDS) appears to exist in at least two major forms, and one of these, the hyperinflammatory form, seemed responsive to simvastatin in a post-hoc analysis of trial data.
The other version of ARDs is a hypoinflammatory form, which occurred in 70% of ARDS patients in most of the analyses that have been done.
Researchers classified the 540 ARDS patients enrolled in a 2014 study of simvastatin as either hyperinflammatory or hypoinflammatory. Separating out the hyperinflammatory patients created a subclass that responded to simvastatin, with a 13% absolute reduction in mortality during follow-up, compared with no response among patients in the hypoinflammatory group, Carolyn S. Calfee, MD, said at an international conference of the American Thoracic Society.
“Hyperinflammatory patients treated with simvastatin may have improved outcomes, compared with hypoinflammatory* patients treated with placebo,” said Dr. Calfee, a pulmonologist at the University of California, San Francisco.
The finding raises the possibility that simvastatin, as well as other statins, may be an effective treatment for selected patients with ARDS, but proving this requires new prospective, randomized trials in hyperinflammatory patients, Dr. Calfee said in a video interview.
Currently, the tests Dr. Calfee uses to distinguish hyperinflammatory and hypoinflammatory ARDS patients take about 6-8 hours to complete. A “point of care test to stratify patients in real time,” is needed to further study the various forms of ARDs, Dr. Calfee noted. A critical next step would be the development of a “practical, rapid, bedside assay” to ease identification of hyperinflammatory ARDS patients. “The work we’ve done prior seems to indicate that we are going to definitely need to measure biomarkers in order to identity these subgroups,” she noted.
Hypoinflammatory patients also merit study, she added. Although hyperinflammatory patients have significant worse mortality rates, the hypoinflammatory subclass includes about 70% of ARDS patients, “so we need to better understand how to potentially treat this group.”
Dr. Calfee and her associates first reported finding the two ARDS subclasses, what they also call subphenotypes or endotypes, in two separate cohorts of ARDS patients in a 2014 report (Lancet Resp Med. 2014 Aug;2[8]:611-20). Then, they confirmed the finding in a third ARDS cohort in a 2017 report (Amer J Resp Crit Care Med. 2017 Feb 1;195[3]:331-8). These reports have documented other characteristics of the hyperinflammatory ARDS subclass: hypotension, metabolic acidosis, more frequent treatment with vasopressors, and a higher prevalence of sepsis and shock. Concurrent with the 2017 report, an editorial hailed the finding as “the dawn of personalized medicine for ARDS” (Amer J resp Crit Care Med. 2017 Feb 1;195[3]: 280-1).
To build on this, Dr. Calfee and her associates applied their method for identifying ARDS subclasses to a different cohort of 540 patients enrolled in the The HARP (Hydroxymethylglutaryl-CoA Reductase Inhibition with Simvastatin in Acute Lung Injury to Reduce Pulmonary Dysfunction)–2 study, a multicenter UK and Irish study designed to test the efficacy of daily simvastatin treatment in a heterogeneous group of ARDS patients. A 2014 report of the study’s primary results showed no significant effect from simvastatin for increasing the number of ventilator-free days nor did the drug improve any other measured efficacy endpoints (New Engl J Med. 2014 Oct 30;371[18]:1695-703).
Applying a statistical analysis called “latent class analysis,” which is designed to recognize subclass groupings that might not be readily apparent, Dr. Calfee and her team first confirmed that, in this fourth cohort, the ARDS patients again split into a hyperinflammatory subclass, in this case including 188 (35%) of the cohort, and a hypoinflammatory subclass with 352 (65%) patients. The next step was to see what impact simvastatin treatment had in each of the two patient subclasses. They focused the analysis on a secondary outcome in HARP-2, 28-day survival.
They found that simvastatin produced no significant difference in 28-day survival, compared with placebo among the hypoinflammatory patients, but, in the hyperinflammatory subclass, 28-day survival was 68% for patients on simvastatin and 55% for those on placebo, a statistically significant difference, Dr. Calfee reported (Am J Resp Crit Care Med. 2017;195:A6749).
“I’m excited that we are seeing, for the first time, a different response to pharmacotherapy” after dividing ARDS patients into these two subclasses, she said. But, the work remains in an early stage, she cautioned. “We need to test treatments [like statins] prospectively.” The new finding for simvastatin “is not the same as showing benefit in a prospective, randomized trial.”
In the meantime, Dr. Calfee plans to apply the same analytic approach to data collected in another failed statin trial in ARDS patients, the SAILS trial. That study failed to show benefit from rosuvastatin treatment in an unselected population of patients with sepsis-associated ARDS (New Engl J Med. 2014 June 5;370[23]:2191-200).
Dr. Calfee is a consultant to Bayer, Boehringer Ingelheim, and GlaxoSmithKline. She received research funding from GlaxoSmithKline.
[email protected]
On Twitter @mitchelzoler
*An earlier version of this article misquoted Dr. Calfee.
WASHINGTON – Acute respiratory distress syndrome (ARDS) appears to exist in at least two major forms, and one of these, the hyperinflammatory form, seemed responsive to simvastatin in a post-hoc analysis of trial data.
The other version of ARDs is a hypoinflammatory form, which occurred in 70% of ARDS patients in most of the analyses that have been done.
Researchers classified the 540 ARDS patients enrolled in a 2014 study of simvastatin as either hyperinflammatory or hypoinflammatory. Separating out the hyperinflammatory patients created a subclass that responded to simvastatin, with a 13% absolute reduction in mortality during follow-up, compared with no response among patients in the hypoinflammatory group, Carolyn S. Calfee, MD, said at an international conference of the American Thoracic Society.
“Hyperinflammatory patients treated with simvastatin may have improved outcomes, compared with hypoinflammatory* patients treated with placebo,” said Dr. Calfee, a pulmonologist at the University of California, San Francisco.
The finding raises the possibility that simvastatin, as well as other statins, may be an effective treatment for selected patients with ARDS, but proving this requires new prospective, randomized trials in hyperinflammatory patients, Dr. Calfee said in a video interview.
Currently, the tests Dr. Calfee uses to distinguish hyperinflammatory and hypoinflammatory ARDS patients take about 6-8 hours to complete. A “point of care test to stratify patients in real time,” is needed to further study the various forms of ARDs, Dr. Calfee noted. A critical next step would be the development of a “practical, rapid, bedside assay” to ease identification of hyperinflammatory ARDS patients. “The work we’ve done prior seems to indicate that we are going to definitely need to measure biomarkers in order to identity these subgroups,” she noted.
Hypoinflammatory patients also merit study, she added. Although hyperinflammatory patients have significant worse mortality rates, the hypoinflammatory subclass includes about 70% of ARDS patients, “so we need to better understand how to potentially treat this group.”
Dr. Calfee and her associates first reported finding the two ARDS subclasses, what they also call subphenotypes or endotypes, in two separate cohorts of ARDS patients in a 2014 report (Lancet Resp Med. 2014 Aug;2[8]:611-20). Then, they confirmed the finding in a third ARDS cohort in a 2017 report (Amer J Resp Crit Care Med. 2017 Feb 1;195[3]:331-8). These reports have documented other characteristics of the hyperinflammatory ARDS subclass: hypotension, metabolic acidosis, more frequent treatment with vasopressors, and a higher prevalence of sepsis and shock. Concurrent with the 2017 report, an editorial hailed the finding as “the dawn of personalized medicine for ARDS” (Amer J resp Crit Care Med. 2017 Feb 1;195[3]: 280-1).
To build on this, Dr. Calfee and her associates applied their method for identifying ARDS subclasses to a different cohort of 540 patients enrolled in the The HARP (Hydroxymethylglutaryl-CoA Reductase Inhibition with Simvastatin in Acute Lung Injury to Reduce Pulmonary Dysfunction)–2 study, a multicenter UK and Irish study designed to test the efficacy of daily simvastatin treatment in a heterogeneous group of ARDS patients. A 2014 report of the study’s primary results showed no significant effect from simvastatin for increasing the number of ventilator-free days nor did the drug improve any other measured efficacy endpoints (New Engl J Med. 2014 Oct 30;371[18]:1695-703).
Applying a statistical analysis called “latent class analysis,” which is designed to recognize subclass groupings that might not be readily apparent, Dr. Calfee and her team first confirmed that, in this fourth cohort, the ARDS patients again split into a hyperinflammatory subclass, in this case including 188 (35%) of the cohort, and a hypoinflammatory subclass with 352 (65%) patients. The next step was to see what impact simvastatin treatment had in each of the two patient subclasses. They focused the analysis on a secondary outcome in HARP-2, 28-day survival.
They found that simvastatin produced no significant difference in 28-day survival, compared with placebo among the hypoinflammatory patients, but, in the hyperinflammatory subclass, 28-day survival was 68% for patients on simvastatin and 55% for those on placebo, a statistically significant difference, Dr. Calfee reported (Am J Resp Crit Care Med. 2017;195:A6749).
“I’m excited that we are seeing, for the first time, a different response to pharmacotherapy” after dividing ARDS patients into these two subclasses, she said. But, the work remains in an early stage, she cautioned. “We need to test treatments [like statins] prospectively.” The new finding for simvastatin “is not the same as showing benefit in a prospective, randomized trial.”
In the meantime, Dr. Calfee plans to apply the same analytic approach to data collected in another failed statin trial in ARDS patients, the SAILS trial. That study failed to show benefit from rosuvastatin treatment in an unselected population of patients with sepsis-associated ARDS (New Engl J Med. 2014 June 5;370[23]:2191-200).
Dr. Calfee is a consultant to Bayer, Boehringer Ingelheim, and GlaxoSmithKline. She received research funding from GlaxoSmithKline.
[email protected]
On Twitter @mitchelzoler
*An earlier version of this article misquoted Dr. Calfee.
AT ATS 2017
Key clinical point:
Major finding: Among hyperinflammatory ARDS patients, 28-day survival was 68% with simvastatin and 55% with placebo, a statistically significant difference.
Data source: A post-hoc analysis of a multicenter randomized trial of 540 patients.
Disclosures: Dr. Calfee is a consultant to Bayer, Boehringer Ingelheim, and GlaxoSmithKline. She received research funding from GlaxoSmithKline.
GI disorders more prevalent in children with poorly controlled asthma
SAN FRANCISCO – Pediatric patients who have asthma that is poorly controlled may be more likely to have functional gastrointestinal (GI) disorders, which feature chronic GI distress that has several causes, according to a study of patients treated at one hospital.
Female sex and increased anxiety were influential factors.
“This study suggests a high prevalence of functional GI disorders among patients with persistent asthma. Moreover, patients with functional GI disorders had poor asthma control and increased anxiety. Clinicians should consider functional GI disorders in patients with poor asthma control and assess for anxiety as indicated,” Ruben J. Colman, MD, a pediatric resident at SBH Health System, Bronx, N.Y., said at the Pediatric Academic Societies meeting.
Functional GI disorders including functional abdominal pain, irritable bowel syndrome, and functional dyspepsia were evaluated. The study was prompted by the knowledge that these conditions are a common cause of chronic GI symptoms in children, and from the findings of a retrospective study of 30,000 patients in Europe that reported a higher prevalence of asthma in those with functional GI disorders, compared with those without chronic GI distress (Aliment Pharmacol Ther. 2014 Aug;40[40]:382-91). Data are scarce in North America concerning asthma control and functional GI disorders in both pediatric and adult populations.
The validated Questionnaire on Pediatric Gastrointestinal Symptoms–Rome III version was used to assess functional GI disorders. Asthma control was assessed using the childhood Asthma Control Test (ACT) questionnaire, with scores exceeding 30, less than 19, and less than 14 indicating well-controlled, not well-controlled, and poorly controlled asthma, respectively. Anxiety was assessed using the Beck Anxiety Inventory, with increasing scores indicating increasing anxiety.
The 110 enrolled patients had a mean age of 10 years. Age was similar between the 18 patients with functional GI disorders – representing a prevalence rate of 16% – and the 92 without such disorders at 12 and 10 years, respectively. Those with functional GI disorders were predominantly female, compared with the patients without a functional GI disorder (72% vs 45%; P less than .03). The GI distress in the 18 patients comprised 10 cases of abdominal pain disorders and 13 cases of upper GI tract disorders, with 3 patients having an overlap of 2 to 3 functional GI disorders.
Patients with functional GI disorders had a lower mean ACT score, compared with those without (12 vs. 15; P = .03). Functional GI disorders also were associated with higher anxiety scores (34 vs. 14; P less than .01).
Asthma control significantly predicted the presence of functional GI disorders in univariate analysis (odds ratio, 0.9; 95% confidence interval, 0.80-0.99; P = .03). However, this significance was lost in a multivariate analysis that adjusted for asthma control, anxiety, and sex. The multivariate analysis revealed continued significant associations between functional GI disorders and anxiety (OR, 1.1; 95% CI, 1.01-1.10; P less than .01) and female sex (OR, 3.3; 95% CI, 1.00-10.56; P less than .05).
Dr. Colman speculated that the apparent association of asthma with chronic GI distress could reflect asthma-related inflammation that exacerbates the GI disorders. Future research should examine if improving the control of asthma and lessening anxiety can decrease symptoms of functional GI disorders.
SAN FRANCISCO – Pediatric patients who have asthma that is poorly controlled may be more likely to have functional gastrointestinal (GI) disorders, which feature chronic GI distress that has several causes, according to a study of patients treated at one hospital.
Female sex and increased anxiety were influential factors.
“This study suggests a high prevalence of functional GI disorders among patients with persistent asthma. Moreover, patients with functional GI disorders had poor asthma control and increased anxiety. Clinicians should consider functional GI disorders in patients with poor asthma control and assess for anxiety as indicated,” Ruben J. Colman, MD, a pediatric resident at SBH Health System, Bronx, N.Y., said at the Pediatric Academic Societies meeting.
Functional GI disorders including functional abdominal pain, irritable bowel syndrome, and functional dyspepsia were evaluated. The study was prompted by the knowledge that these conditions are a common cause of chronic GI symptoms in children, and from the findings of a retrospective study of 30,000 patients in Europe that reported a higher prevalence of asthma in those with functional GI disorders, compared with those without chronic GI distress (Aliment Pharmacol Ther. 2014 Aug;40[40]:382-91). Data are scarce in North America concerning asthma control and functional GI disorders in both pediatric and adult populations.
The validated Questionnaire on Pediatric Gastrointestinal Symptoms–Rome III version was used to assess functional GI disorders. Asthma control was assessed using the childhood Asthma Control Test (ACT) questionnaire, with scores exceeding 30, less than 19, and less than 14 indicating well-controlled, not well-controlled, and poorly controlled asthma, respectively. Anxiety was assessed using the Beck Anxiety Inventory, with increasing scores indicating increasing anxiety.
The 110 enrolled patients had a mean age of 10 years. Age was similar between the 18 patients with functional GI disorders – representing a prevalence rate of 16% – and the 92 without such disorders at 12 and 10 years, respectively. Those with functional GI disorders were predominantly female, compared with the patients without a functional GI disorder (72% vs 45%; P less than .03). The GI distress in the 18 patients comprised 10 cases of abdominal pain disorders and 13 cases of upper GI tract disorders, with 3 patients having an overlap of 2 to 3 functional GI disorders.
Patients with functional GI disorders had a lower mean ACT score, compared with those without (12 vs. 15; P = .03). Functional GI disorders also were associated with higher anxiety scores (34 vs. 14; P less than .01).
Asthma control significantly predicted the presence of functional GI disorders in univariate analysis (odds ratio, 0.9; 95% confidence interval, 0.80-0.99; P = .03). However, this significance was lost in a multivariate analysis that adjusted for asthma control, anxiety, and sex. The multivariate analysis revealed continued significant associations between functional GI disorders and anxiety (OR, 1.1; 95% CI, 1.01-1.10; P less than .01) and female sex (OR, 3.3; 95% CI, 1.00-10.56; P less than .05).
Dr. Colman speculated that the apparent association of asthma with chronic GI distress could reflect asthma-related inflammation that exacerbates the GI disorders. Future research should examine if improving the control of asthma and lessening anxiety can decrease symptoms of functional GI disorders.
SAN FRANCISCO – Pediatric patients who have asthma that is poorly controlled may be more likely to have functional gastrointestinal (GI) disorders, which feature chronic GI distress that has several causes, according to a study of patients treated at one hospital.
Female sex and increased anxiety were influential factors.
“This study suggests a high prevalence of functional GI disorders among patients with persistent asthma. Moreover, patients with functional GI disorders had poor asthma control and increased anxiety. Clinicians should consider functional GI disorders in patients with poor asthma control and assess for anxiety as indicated,” Ruben J. Colman, MD, a pediatric resident at SBH Health System, Bronx, N.Y., said at the Pediatric Academic Societies meeting.
Functional GI disorders including functional abdominal pain, irritable bowel syndrome, and functional dyspepsia were evaluated. The study was prompted by the knowledge that these conditions are a common cause of chronic GI symptoms in children, and from the findings of a retrospective study of 30,000 patients in Europe that reported a higher prevalence of asthma in those with functional GI disorders, compared with those without chronic GI distress (Aliment Pharmacol Ther. 2014 Aug;40[40]:382-91). Data are scarce in North America concerning asthma control and functional GI disorders in both pediatric and adult populations.
The validated Questionnaire on Pediatric Gastrointestinal Symptoms–Rome III version was used to assess functional GI disorders. Asthma control was assessed using the childhood Asthma Control Test (ACT) questionnaire, with scores exceeding 30, less than 19, and less than 14 indicating well-controlled, not well-controlled, and poorly controlled asthma, respectively. Anxiety was assessed using the Beck Anxiety Inventory, with increasing scores indicating increasing anxiety.
The 110 enrolled patients had a mean age of 10 years. Age was similar between the 18 patients with functional GI disorders – representing a prevalence rate of 16% – and the 92 without such disorders at 12 and 10 years, respectively. Those with functional GI disorders were predominantly female, compared with the patients without a functional GI disorder (72% vs 45%; P less than .03). The GI distress in the 18 patients comprised 10 cases of abdominal pain disorders and 13 cases of upper GI tract disorders, with 3 patients having an overlap of 2 to 3 functional GI disorders.
Patients with functional GI disorders had a lower mean ACT score, compared with those without (12 vs. 15; P = .03). Functional GI disorders also were associated with higher anxiety scores (34 vs. 14; P less than .01).
Asthma control significantly predicted the presence of functional GI disorders in univariate analysis (odds ratio, 0.9; 95% confidence interval, 0.80-0.99; P = .03). However, this significance was lost in a multivariate analysis that adjusted for asthma control, anxiety, and sex. The multivariate analysis revealed continued significant associations between functional GI disorders and anxiety (OR, 1.1; 95% CI, 1.01-1.10; P less than .01) and female sex (OR, 3.3; 95% CI, 1.00-10.56; P less than .05).
Dr. Colman speculated that the apparent association of asthma with chronic GI distress could reflect asthma-related inflammation that exacerbates the GI disorders. Future research should examine if improving the control of asthma and lessening anxiety can decrease symptoms of functional GI disorders.
AT PAS 17
Key clinical point: The prevalence of functional gastrointestinal disorders is high in pediatric patients with poorly controlled asthma.
Major finding:
Data source: Prospective cross-sectional study at one institution.
Disclosures: The sponsor of the study was SBH Health System. The study was not funded. Dr. Colman had no conflicts to report.