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Medicolegal aspects of sleep apnea
Question: A patient who is a commercial truck driver has a long history of snoring and daytime sleepiness. His physical exam was remarkable for obesity, prominent extremities, a large tongue, and a prominent jaw. The treating doctor did not pursue additional work-up or treatment.
One day, the patient fell asleep while driving his truck and hit an oncoming vehicle, resulting in injuries to both patient and the other driver.
In this hypothetical scenario, which of the following statements is best?
A. The doctor may be found negligent for missing the diagnosis of acromegaly and accompanying sleep apnea, and for failing to treat and warn about driving risks.
B. The doctor may be liable to both his patient and the other injured driver.
C. The patient may be terminated from his job as a commercial truck driver, because he poses a danger to himself and the public.
D. Both A and B are correct.
E. All are correct.
Answer: D. Sleep apnea, an underdiagnosed and undertreated disabling condition, places the patient at substantial risk for injuries, chronic hypoxemia, and respiratory arrest. Excessive daytime sleepiness and fatigue may prove hazardous, particularly in those whose undivided attention is a requirement of their jobs, such as with truck drivers.
Diagnosis is established with a formal sleep study (polysomnography), and treatment with a continuous positive airway pressure (CPAP) device is usually effective. In severe or recalcitrant cases, surgical intervention (that is, uvulopalatopharyngoplasty) may be necessary.
In a recent study, Dr. Peter F. Svider of Rutgers New Jersey Medical School, Newark, and his colleagues analyzed 54 litigated sleep apnea cases, of which 33 (61%) were resolved in favor of the defendants (Otolaryngol Head Neck Surg. 2013 Dec;149[6]:947-53). Most of the cases (47) stemmed from patients who underwent surgery with perioperative complications, including death. Inadequate informed consent and monitoring, as well as inappropriate medications, were other findings.
Obstructive sleep apnea is a well-recognized complication of acromegaly with its bony and soft-tissue hypertrophy. The hypothetical situation described above is substantially modified from an actual case in which a 39-year-old man with acromegaly and sleep apnea died from cardiorespiratory arrest (Cornett v. W.O. Moss Regional Hospital, 614 So.2d 189 [La. 1993]). He had presented over the course of several years with repeated complaints of daytime sleepiness and sleeping while driving. Falling asleep in the examination room and abnormal blood gases were giveaway signs. Unfortunately, sleep apnea was left untreated.
Other litigated cases have included anoxic encephalopathy from a lost airway and inappropriate fentanyl dosing during and following aggressive surgery for mild/moderate obstructive sleep apnea, as well as cardiac arrest in a retired sailor during a routine endoscopic procedure. In the latter instance, the plaintiff alleged that there was a failure to take proper precautions in protecting the airway, given that the patient had a known case of obstructive sleep apnea.
What about other liabilities for injuries that are proximately caused by a failure to diagnose and treat?
A doctor is usually liable for negligent care only to his or her own patient, because the duty of care grows out of the doctor-patient relationship and is normally owed to the patient and no one else. However, in very limited circumstances, the duty may extend to other individuals who are family members or even total strangers.
Sleep apnea, by virtue of its sleep disturbances and resulting daytime sleepiness, poses a foreseeable risk of harm. Nonpatient third parties have successfully sued doctors for driving injuries arising out of the failure to diagnose, treat, or warn in a variety of medical conditions.
For example, the Iowa Supreme Court has held that a physician must warn a patient with newly diagnosed seizure disorder about the risks of driving (Freese v. Lemmon, 210 N.W.2d 576 [Iowa 1973]). In that case, a patient with a history of a single seizure injured a woman when he suffered a second seizure while driving.
By analogy, it seems reasonable to assume that the facts given in our hypothetical scenario may give rise to an action against the doctor not only by the patient, but by the injured nonpatient third party as well.
In many jurisdictions, sleep apnea has been accepted as a disability for purposes of the Americans with Disabilities Act (ADA). A disability is defined as a condition evincing substantial interference with a major life activity. Under the ADA, employers are required to make “reasonable accommodation” for disabled employees and cannot simply dismiss them by sole virtue of that disability.
However, qualification for the job must still be shown. One court ruled that a plaintiff with sleep apnea had failed to show that he was a qualified employee even if given his proposed “two-nap-a-day” accommodation (Jackson v. Boise Cascade Corp., 941 F. Supp. 1122 [Ala. 1996]).
Another interesting case involved an anesthesiologist who suffered from sleep apnea and who was snoring and sleeping during surgery. The hospital terminated his contract, and the anesthesiologist filed suit claiming disability discrimination. The 6th U.S. Circuit Court of Appeals affirmed the lower court’s decision in favor of the hospital, finding that the anesthesiologist was fired not because he had a disability, but because he had slept during surgical procedures (Brohm v. JH Properties, 149 F.3d 517 [6th Cir. 1998]).
Distinguishing between discharging someone for unacceptable conduct and discharging someone because of the disability, the court reasoned: “One suffering from chronic sleep deprivation may well be so tired that he cannot stay awake. But such sleep deprivation did not compel Brohm [the anesthesiologist defendant] to administer anesthetics during surgical procedures when he knew he was tired.”
On the other hand, a federal court in 2014 ordered the city of McPherson, Kan., to pay $920,000 in damages to a dismissed police officer suffering from sleep apnea. Although the city cited other factors for the termination, such as insubordination and conduct unbecoming an officer, it had focused on “sleeping on the job” as the basis for the termination. The officer reportedly experienced no further difficulties after he received medical treatment, and the city did not offer the officer an alternative to his graveyard shift or an opportunity to explain his medical condition.
Finally, a discussion of the legal aspects of sleep apnea is incomplete without noting that conducting and billing for sleep studies may occasionally be subject to abuse and/or fraud. The U.S. Department of Health & Human Services Office of Inspector General (OIG) has underscored the high utilization of sleep testing by sleep disorder clinics; in 2010 alone, Medicare reimbursement totaled some $410 million.
The OIG is targeting questionable billing practices under the False Claims Act (31 U.S.C. §§3729-3733) and for self-referrals (Stark Law). Medicare and Medicaid will only reimburse sleep studies that are reasonable and necessary. In addition, there are strict rules such as the mandatory use of properly trained and credentialed sleep technicians, and appropriate level of general physician supervision.
In its most recent prosecution, the federal government is going after the owners of a chain of sleep clinics in the San Francisco Bay area for sleep tests that were conducted in unapproved locations and/or by unlicensed technicians. In addition, the lawsuit alleges a Stark Law violation for self-referrals. The action is being taken in conjunction with a lawsuit filed by a former employee in a whistle-blower action. Under the False Claims Act, whistle-blowers who are private citizens, such as former employees, can file a qui tam action alone or in concert with the government, and they stand to collect a significant (e.g., 25%) portion of any recovery.
Dr. Tan is emeritus professor of medicine and former adjunct professor of law at the University of Hawaii, and currently directs the St. Francis International Center for Healthcare Ethics in Honolulu. This article is meant to be educational and does not constitute medical, ethical, or legal advice. Some of the articles in this series are adapted from the author’s 2006 book, “Medical Malpractice: Understanding the Law, Managing the Risk,” and his 2012 Halsbury treatise, “Medical Negligence and Professional Misconduct.” For additional information, readers may contact the author at [email protected].
Question: A patient who is a commercial truck driver has a long history of snoring and daytime sleepiness. His physical exam was remarkable for obesity, prominent extremities, a large tongue, and a prominent jaw. The treating doctor did not pursue additional work-up or treatment.
One day, the patient fell asleep while driving his truck and hit an oncoming vehicle, resulting in injuries to both patient and the other driver.
In this hypothetical scenario, which of the following statements is best?
A. The doctor may be found negligent for missing the diagnosis of acromegaly and accompanying sleep apnea, and for failing to treat and warn about driving risks.
B. The doctor may be liable to both his patient and the other injured driver.
C. The patient may be terminated from his job as a commercial truck driver, because he poses a danger to himself and the public.
D. Both A and B are correct.
E. All are correct.
Answer: D. Sleep apnea, an underdiagnosed and undertreated disabling condition, places the patient at substantial risk for injuries, chronic hypoxemia, and respiratory arrest. Excessive daytime sleepiness and fatigue may prove hazardous, particularly in those whose undivided attention is a requirement of their jobs, such as with truck drivers.
Diagnosis is established with a formal sleep study (polysomnography), and treatment with a continuous positive airway pressure (CPAP) device is usually effective. In severe or recalcitrant cases, surgical intervention (that is, uvulopalatopharyngoplasty) may be necessary.
In a recent study, Dr. Peter F. Svider of Rutgers New Jersey Medical School, Newark, and his colleagues analyzed 54 litigated sleep apnea cases, of which 33 (61%) were resolved in favor of the defendants (Otolaryngol Head Neck Surg. 2013 Dec;149[6]:947-53). Most of the cases (47) stemmed from patients who underwent surgery with perioperative complications, including death. Inadequate informed consent and monitoring, as well as inappropriate medications, were other findings.
Obstructive sleep apnea is a well-recognized complication of acromegaly with its bony and soft-tissue hypertrophy. The hypothetical situation described above is substantially modified from an actual case in which a 39-year-old man with acromegaly and sleep apnea died from cardiorespiratory arrest (Cornett v. W.O. Moss Regional Hospital, 614 So.2d 189 [La. 1993]). He had presented over the course of several years with repeated complaints of daytime sleepiness and sleeping while driving. Falling asleep in the examination room and abnormal blood gases were giveaway signs. Unfortunately, sleep apnea was left untreated.
Other litigated cases have included anoxic encephalopathy from a lost airway and inappropriate fentanyl dosing during and following aggressive surgery for mild/moderate obstructive sleep apnea, as well as cardiac arrest in a retired sailor during a routine endoscopic procedure. In the latter instance, the plaintiff alleged that there was a failure to take proper precautions in protecting the airway, given that the patient had a known case of obstructive sleep apnea.
What about other liabilities for injuries that are proximately caused by a failure to diagnose and treat?
A doctor is usually liable for negligent care only to his or her own patient, because the duty of care grows out of the doctor-patient relationship and is normally owed to the patient and no one else. However, in very limited circumstances, the duty may extend to other individuals who are family members or even total strangers.
Sleep apnea, by virtue of its sleep disturbances and resulting daytime sleepiness, poses a foreseeable risk of harm. Nonpatient third parties have successfully sued doctors for driving injuries arising out of the failure to diagnose, treat, or warn in a variety of medical conditions.
For example, the Iowa Supreme Court has held that a physician must warn a patient with newly diagnosed seizure disorder about the risks of driving (Freese v. Lemmon, 210 N.W.2d 576 [Iowa 1973]). In that case, a patient with a history of a single seizure injured a woman when he suffered a second seizure while driving.
By analogy, it seems reasonable to assume that the facts given in our hypothetical scenario may give rise to an action against the doctor not only by the patient, but by the injured nonpatient third party as well.
In many jurisdictions, sleep apnea has been accepted as a disability for purposes of the Americans with Disabilities Act (ADA). A disability is defined as a condition evincing substantial interference with a major life activity. Under the ADA, employers are required to make “reasonable accommodation” for disabled employees and cannot simply dismiss them by sole virtue of that disability.
However, qualification for the job must still be shown. One court ruled that a plaintiff with sleep apnea had failed to show that he was a qualified employee even if given his proposed “two-nap-a-day” accommodation (Jackson v. Boise Cascade Corp., 941 F. Supp. 1122 [Ala. 1996]).
Another interesting case involved an anesthesiologist who suffered from sleep apnea and who was snoring and sleeping during surgery. The hospital terminated his contract, and the anesthesiologist filed suit claiming disability discrimination. The 6th U.S. Circuit Court of Appeals affirmed the lower court’s decision in favor of the hospital, finding that the anesthesiologist was fired not because he had a disability, but because he had slept during surgical procedures (Brohm v. JH Properties, 149 F.3d 517 [6th Cir. 1998]).
Distinguishing between discharging someone for unacceptable conduct and discharging someone because of the disability, the court reasoned: “One suffering from chronic sleep deprivation may well be so tired that he cannot stay awake. But such sleep deprivation did not compel Brohm [the anesthesiologist defendant] to administer anesthetics during surgical procedures when he knew he was tired.”
On the other hand, a federal court in 2014 ordered the city of McPherson, Kan., to pay $920,000 in damages to a dismissed police officer suffering from sleep apnea. Although the city cited other factors for the termination, such as insubordination and conduct unbecoming an officer, it had focused on “sleeping on the job” as the basis for the termination. The officer reportedly experienced no further difficulties after he received medical treatment, and the city did not offer the officer an alternative to his graveyard shift or an opportunity to explain his medical condition.
Finally, a discussion of the legal aspects of sleep apnea is incomplete without noting that conducting and billing for sleep studies may occasionally be subject to abuse and/or fraud. The U.S. Department of Health & Human Services Office of Inspector General (OIG) has underscored the high utilization of sleep testing by sleep disorder clinics; in 2010 alone, Medicare reimbursement totaled some $410 million.
The OIG is targeting questionable billing practices under the False Claims Act (31 U.S.C. §§3729-3733) and for self-referrals (Stark Law). Medicare and Medicaid will only reimburse sleep studies that are reasonable and necessary. In addition, there are strict rules such as the mandatory use of properly trained and credentialed sleep technicians, and appropriate level of general physician supervision.
In its most recent prosecution, the federal government is going after the owners of a chain of sleep clinics in the San Francisco Bay area for sleep tests that were conducted in unapproved locations and/or by unlicensed technicians. In addition, the lawsuit alleges a Stark Law violation for self-referrals. The action is being taken in conjunction with a lawsuit filed by a former employee in a whistle-blower action. Under the False Claims Act, whistle-blowers who are private citizens, such as former employees, can file a qui tam action alone or in concert with the government, and they stand to collect a significant (e.g., 25%) portion of any recovery.
Dr. Tan is emeritus professor of medicine and former adjunct professor of law at the University of Hawaii, and currently directs the St. Francis International Center for Healthcare Ethics in Honolulu. This article is meant to be educational and does not constitute medical, ethical, or legal advice. Some of the articles in this series are adapted from the author’s 2006 book, “Medical Malpractice: Understanding the Law, Managing the Risk,” and his 2012 Halsbury treatise, “Medical Negligence and Professional Misconduct.” For additional information, readers may contact the author at [email protected].
Question: A patient who is a commercial truck driver has a long history of snoring and daytime sleepiness. His physical exam was remarkable for obesity, prominent extremities, a large tongue, and a prominent jaw. The treating doctor did not pursue additional work-up or treatment.
One day, the patient fell asleep while driving his truck and hit an oncoming vehicle, resulting in injuries to both patient and the other driver.
In this hypothetical scenario, which of the following statements is best?
A. The doctor may be found negligent for missing the diagnosis of acromegaly and accompanying sleep apnea, and for failing to treat and warn about driving risks.
B. The doctor may be liable to both his patient and the other injured driver.
C. The patient may be terminated from his job as a commercial truck driver, because he poses a danger to himself and the public.
D. Both A and B are correct.
E. All are correct.
Answer: D. Sleep apnea, an underdiagnosed and undertreated disabling condition, places the patient at substantial risk for injuries, chronic hypoxemia, and respiratory arrest. Excessive daytime sleepiness and fatigue may prove hazardous, particularly in those whose undivided attention is a requirement of their jobs, such as with truck drivers.
Diagnosis is established with a formal sleep study (polysomnography), and treatment with a continuous positive airway pressure (CPAP) device is usually effective. In severe or recalcitrant cases, surgical intervention (that is, uvulopalatopharyngoplasty) may be necessary.
In a recent study, Dr. Peter F. Svider of Rutgers New Jersey Medical School, Newark, and his colleagues analyzed 54 litigated sleep apnea cases, of which 33 (61%) were resolved in favor of the defendants (Otolaryngol Head Neck Surg. 2013 Dec;149[6]:947-53). Most of the cases (47) stemmed from patients who underwent surgery with perioperative complications, including death. Inadequate informed consent and monitoring, as well as inappropriate medications, were other findings.
Obstructive sleep apnea is a well-recognized complication of acromegaly with its bony and soft-tissue hypertrophy. The hypothetical situation described above is substantially modified from an actual case in which a 39-year-old man with acromegaly and sleep apnea died from cardiorespiratory arrest (Cornett v. W.O. Moss Regional Hospital, 614 So.2d 189 [La. 1993]). He had presented over the course of several years with repeated complaints of daytime sleepiness and sleeping while driving. Falling asleep in the examination room and abnormal blood gases were giveaway signs. Unfortunately, sleep apnea was left untreated.
Other litigated cases have included anoxic encephalopathy from a lost airway and inappropriate fentanyl dosing during and following aggressive surgery for mild/moderate obstructive sleep apnea, as well as cardiac arrest in a retired sailor during a routine endoscopic procedure. In the latter instance, the plaintiff alleged that there was a failure to take proper precautions in protecting the airway, given that the patient had a known case of obstructive sleep apnea.
What about other liabilities for injuries that are proximately caused by a failure to diagnose and treat?
A doctor is usually liable for negligent care only to his or her own patient, because the duty of care grows out of the doctor-patient relationship and is normally owed to the patient and no one else. However, in very limited circumstances, the duty may extend to other individuals who are family members or even total strangers.
Sleep apnea, by virtue of its sleep disturbances and resulting daytime sleepiness, poses a foreseeable risk of harm. Nonpatient third parties have successfully sued doctors for driving injuries arising out of the failure to diagnose, treat, or warn in a variety of medical conditions.
For example, the Iowa Supreme Court has held that a physician must warn a patient with newly diagnosed seizure disorder about the risks of driving (Freese v. Lemmon, 210 N.W.2d 576 [Iowa 1973]). In that case, a patient with a history of a single seizure injured a woman when he suffered a second seizure while driving.
By analogy, it seems reasonable to assume that the facts given in our hypothetical scenario may give rise to an action against the doctor not only by the patient, but by the injured nonpatient third party as well.
In many jurisdictions, sleep apnea has been accepted as a disability for purposes of the Americans with Disabilities Act (ADA). A disability is defined as a condition evincing substantial interference with a major life activity. Under the ADA, employers are required to make “reasonable accommodation” for disabled employees and cannot simply dismiss them by sole virtue of that disability.
However, qualification for the job must still be shown. One court ruled that a plaintiff with sleep apnea had failed to show that he was a qualified employee even if given his proposed “two-nap-a-day” accommodation (Jackson v. Boise Cascade Corp., 941 F. Supp. 1122 [Ala. 1996]).
Another interesting case involved an anesthesiologist who suffered from sleep apnea and who was snoring and sleeping during surgery. The hospital terminated his contract, and the anesthesiologist filed suit claiming disability discrimination. The 6th U.S. Circuit Court of Appeals affirmed the lower court’s decision in favor of the hospital, finding that the anesthesiologist was fired not because he had a disability, but because he had slept during surgical procedures (Brohm v. JH Properties, 149 F.3d 517 [6th Cir. 1998]).
Distinguishing between discharging someone for unacceptable conduct and discharging someone because of the disability, the court reasoned: “One suffering from chronic sleep deprivation may well be so tired that he cannot stay awake. But such sleep deprivation did not compel Brohm [the anesthesiologist defendant] to administer anesthetics during surgical procedures when he knew he was tired.”
On the other hand, a federal court in 2014 ordered the city of McPherson, Kan., to pay $920,000 in damages to a dismissed police officer suffering from sleep apnea. Although the city cited other factors for the termination, such as insubordination and conduct unbecoming an officer, it had focused on “sleeping on the job” as the basis for the termination. The officer reportedly experienced no further difficulties after he received medical treatment, and the city did not offer the officer an alternative to his graveyard shift or an opportunity to explain his medical condition.
Finally, a discussion of the legal aspects of sleep apnea is incomplete without noting that conducting and billing for sleep studies may occasionally be subject to abuse and/or fraud. The U.S. Department of Health & Human Services Office of Inspector General (OIG) has underscored the high utilization of sleep testing by sleep disorder clinics; in 2010 alone, Medicare reimbursement totaled some $410 million.
The OIG is targeting questionable billing practices under the False Claims Act (31 U.S.C. §§3729-3733) and for self-referrals (Stark Law). Medicare and Medicaid will only reimburse sleep studies that are reasonable and necessary. In addition, there are strict rules such as the mandatory use of properly trained and credentialed sleep technicians, and appropriate level of general physician supervision.
In its most recent prosecution, the federal government is going after the owners of a chain of sleep clinics in the San Francisco Bay area for sleep tests that were conducted in unapproved locations and/or by unlicensed technicians. In addition, the lawsuit alleges a Stark Law violation for self-referrals. The action is being taken in conjunction with a lawsuit filed by a former employee in a whistle-blower action. Under the False Claims Act, whistle-blowers who are private citizens, such as former employees, can file a qui tam action alone or in concert with the government, and they stand to collect a significant (e.g., 25%) portion of any recovery.
Dr. Tan is emeritus professor of medicine and former adjunct professor of law at the University of Hawaii, and currently directs the St. Francis International Center for Healthcare Ethics in Honolulu. This article is meant to be educational and does not constitute medical, ethical, or legal advice. Some of the articles in this series are adapted from the author’s 2006 book, “Medical Malpractice: Understanding the Law, Managing the Risk,” and his 2012 Halsbury treatise, “Medical Negligence and Professional Misconduct.” For additional information, readers may contact the author at [email protected].
Reported pertussis underestimates true incidence by up to 93-fold
SAN DIEGO – The true incidence of pertussis in recent years in Americans less than 50 years old is estimated to be 58- to 93-fold greater than the laboratory-confirmed reported case count, Philip O. Buck, Ph.D., reported at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.
It’s widely accepted that national surveillance systems vastly underestimate the incidence of pertussis because most cases don’t get reported. In order to obtain a more complete picture of the situation, Dr. Buck utilized a regression equation to estimate the proportion of cough illnesses attributable to laboratory-confirmed pertussis.
A closely similar regression model has previously been utilized by other investigators in published studies that provided estimates of the true burdens of influenza (Epidemiol Infect. 2002 Aug;129:99-106) and respiratory syncytial virus (Eur J Pediatr. 2010 Aug;169:997-1008), noted Dr. Buck, director of U.S. Health Outcomes at GlaxoSmithKline in Philadelphia.
He applied the regression model to medical claims for ICD-9-CM–diagnosed pertussis in individuals under age 50 in the IMS PharmMetric Plus claims database for the years 2008-2013. The database includes more than 150 million enrollees. The average reported incidence of pertussis in individuals less than 50 years old during the study years was 9 cases per 100,000 per year; however, the average regression-estimated incidence was 649 per 100,000, a 72-fold greater figure.
During 2011-2013, the 3 most recent years covered by the study, the regression-estimated incidence of pertussis was 93-fold, 62-fold, and 87-fold greater than the reported rates.
Dr. Buck is employed by GlaxoSmithKline, which funded the study and markets pertussis vaccine.
SAN DIEGO – The true incidence of pertussis in recent years in Americans less than 50 years old is estimated to be 58- to 93-fold greater than the laboratory-confirmed reported case count, Philip O. Buck, Ph.D., reported at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.
It’s widely accepted that national surveillance systems vastly underestimate the incidence of pertussis because most cases don’t get reported. In order to obtain a more complete picture of the situation, Dr. Buck utilized a regression equation to estimate the proportion of cough illnesses attributable to laboratory-confirmed pertussis.
A closely similar regression model has previously been utilized by other investigators in published studies that provided estimates of the true burdens of influenza (Epidemiol Infect. 2002 Aug;129:99-106) and respiratory syncytial virus (Eur J Pediatr. 2010 Aug;169:997-1008), noted Dr. Buck, director of U.S. Health Outcomes at GlaxoSmithKline in Philadelphia.
He applied the regression model to medical claims for ICD-9-CM–diagnosed pertussis in individuals under age 50 in the IMS PharmMetric Plus claims database for the years 2008-2013. The database includes more than 150 million enrollees. The average reported incidence of pertussis in individuals less than 50 years old during the study years was 9 cases per 100,000 per year; however, the average regression-estimated incidence was 649 per 100,000, a 72-fold greater figure.
During 2011-2013, the 3 most recent years covered by the study, the regression-estimated incidence of pertussis was 93-fold, 62-fold, and 87-fold greater than the reported rates.
Dr. Buck is employed by GlaxoSmithKline, which funded the study and markets pertussis vaccine.
SAN DIEGO – The true incidence of pertussis in recent years in Americans less than 50 years old is estimated to be 58- to 93-fold greater than the laboratory-confirmed reported case count, Philip O. Buck, Ph.D., reported at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.
It’s widely accepted that national surveillance systems vastly underestimate the incidence of pertussis because most cases don’t get reported. In order to obtain a more complete picture of the situation, Dr. Buck utilized a regression equation to estimate the proportion of cough illnesses attributable to laboratory-confirmed pertussis.
A closely similar regression model has previously been utilized by other investigators in published studies that provided estimates of the true burdens of influenza (Epidemiol Infect. 2002 Aug;129:99-106) and respiratory syncytial virus (Eur J Pediatr. 2010 Aug;169:997-1008), noted Dr. Buck, director of U.S. Health Outcomes at GlaxoSmithKline in Philadelphia.
He applied the regression model to medical claims for ICD-9-CM–diagnosed pertussis in individuals under age 50 in the IMS PharmMetric Plus claims database for the years 2008-2013. The database includes more than 150 million enrollees. The average reported incidence of pertussis in individuals less than 50 years old during the study years was 9 cases per 100,000 per year; however, the average regression-estimated incidence was 649 per 100,000, a 72-fold greater figure.
During 2011-2013, the 3 most recent years covered by the study, the regression-estimated incidence of pertussis was 93-fold, 62-fold, and 87-fold greater than the reported rates.
Dr. Buck is employed by GlaxoSmithKline, which funded the study and markets pertussis vaccine.
AT ICAAC 2015
Key clinical point: The annual rate of pertussis in Americans less than 50 years old is up to 93-fold greater than the reported incidence.
Major finding: The true incidence of pertussis in Americans less than 50 years old is estimated to be 58-93 times greater per year than the reported annual rates during recent years.
Data source: This was a retrospective cohort study which utilized a regression model to estimate the true fraction of cough illness attributable to laboratory-confirmed pertussis through analysis of 6 years worth of medical claims data from a large national database.
Disclosures: The study was funded by GlaxoSmithKline. The presenter is a company employee.
Recent quitters win big in lung screening trials
DENVER – It’s never too late to quit smoking, results of lung cancer screening trials confirm.
Among more than 3,300 heavy smokers over age 50 who took part in two low-dose CT (LDCT) screening programs, former smokers had a 37% reduction in all-cause mortality, compared with current smokers, and those who were active smokers at the time of randomization but quit during the follow-up period had a 43% lower risk for death, compared with those who continued to smoke, reported Dr. Ugo Pastorino of the Instiuto Nazionale dei Tumori in Milan.
He noted that the U.S. National Lung Screening Trial (NSLT) showed that screening with low-dose helical CT was associated with a nearly 7% reduction in all-cause mortality over 7 years of follow-up, compared with patients screened with chest x-ray.
“But we have to keep clear in our minds that the benefit achieved by this trial of early detection in terms of mortality reduction is only 1% per year, so it’s a not a major improvement. It’s a start, but we have to aim to improve this mortality reduction,” he said at the conference sponsored by the International Association for the Study of Lung Cancer.
Neither the NSLT nor other randomized screening trials currently underway have examined in detail the effects of smoking status on screening outcomes, prompting Dr. Pastorino and colleagues to investigate the matter in two cohorts of smokers assigned to LDCT in screening trials.
The study included 3,381 heavy smokers with a median follow-up of 9.7 years and a total follow-up of 32,858 person-years. Men comprised 69% of the combined cohorts, who had a median age of 58 and a median smoking of 40 pack-years.
The investigators divided the participants into current smokers – those who continued to smoke throughout the screening period, or if they quit did so within 1 year of the end of follow-up or death – and former smokers, subdivided into early quitters, who had stopped smoking by the time of accrual, and late quitters, who were active smokers at the time of accrual or randomization but stopped smoking at least 1 year before the end of the follow-up period or at least 1 year before death.
In an analysis of the effects of smoking on mortality, controlled for gender, age, body mass index, lung function, and pack-years smoked, they found that the relative risk for death from any cause among both early and late quitters, compared with current smokers, was 0.74. When they excluded 239 quitters who had kicked the habit less than 2 years before the end of follow-up or death, the benefits of not smoking were even greater, with an RR of 0.61.
Interestingly, when they looked at the early quitters, compared with current smokers, the RR for quitting was 0.63, and the effect appeared even stronger among more recent (late) quitters, who had a RR for all-cause mortality of 0.57, compared with current smokers. (All comparisons significant as shown by 95% confidence intervals).
Also of note was the fact that lung cancer accounted for fewer than 30% of deaths, Dr. Pastorino noted.
Dr. Nise H. Yamaguchi of the Hospital Israelita Albert Enstein in Sao Paolo, Brazil, applauded Dr. Pastorino and colleagues for the study, and succinctly summarized the take home message.
“If you came here from all around the world to see all these fancy treatments and everything that you can’t do, go back home and help people stop smoking, because you cure lots of people and save many lives for sure,” she said.
DENVER – It’s never too late to quit smoking, results of lung cancer screening trials confirm.
Among more than 3,300 heavy smokers over age 50 who took part in two low-dose CT (LDCT) screening programs, former smokers had a 37% reduction in all-cause mortality, compared with current smokers, and those who were active smokers at the time of randomization but quit during the follow-up period had a 43% lower risk for death, compared with those who continued to smoke, reported Dr. Ugo Pastorino of the Instiuto Nazionale dei Tumori in Milan.
He noted that the U.S. National Lung Screening Trial (NSLT) showed that screening with low-dose helical CT was associated with a nearly 7% reduction in all-cause mortality over 7 years of follow-up, compared with patients screened with chest x-ray.
“But we have to keep clear in our minds that the benefit achieved by this trial of early detection in terms of mortality reduction is only 1% per year, so it’s a not a major improvement. It’s a start, but we have to aim to improve this mortality reduction,” he said at the conference sponsored by the International Association for the Study of Lung Cancer.
Neither the NSLT nor other randomized screening trials currently underway have examined in detail the effects of smoking status on screening outcomes, prompting Dr. Pastorino and colleagues to investigate the matter in two cohorts of smokers assigned to LDCT in screening trials.
The study included 3,381 heavy smokers with a median follow-up of 9.7 years and a total follow-up of 32,858 person-years. Men comprised 69% of the combined cohorts, who had a median age of 58 and a median smoking of 40 pack-years.
The investigators divided the participants into current smokers – those who continued to smoke throughout the screening period, or if they quit did so within 1 year of the end of follow-up or death – and former smokers, subdivided into early quitters, who had stopped smoking by the time of accrual, and late quitters, who were active smokers at the time of accrual or randomization but stopped smoking at least 1 year before the end of the follow-up period or at least 1 year before death.
In an analysis of the effects of smoking on mortality, controlled for gender, age, body mass index, lung function, and pack-years smoked, they found that the relative risk for death from any cause among both early and late quitters, compared with current smokers, was 0.74. When they excluded 239 quitters who had kicked the habit less than 2 years before the end of follow-up or death, the benefits of not smoking were even greater, with an RR of 0.61.
Interestingly, when they looked at the early quitters, compared with current smokers, the RR for quitting was 0.63, and the effect appeared even stronger among more recent (late) quitters, who had a RR for all-cause mortality of 0.57, compared with current smokers. (All comparisons significant as shown by 95% confidence intervals).
Also of note was the fact that lung cancer accounted for fewer than 30% of deaths, Dr. Pastorino noted.
Dr. Nise H. Yamaguchi of the Hospital Israelita Albert Enstein in Sao Paolo, Brazil, applauded Dr. Pastorino and colleagues for the study, and succinctly summarized the take home message.
“If you came here from all around the world to see all these fancy treatments and everything that you can’t do, go back home and help people stop smoking, because you cure lots of people and save many lives for sure,” she said.
DENVER – It’s never too late to quit smoking, results of lung cancer screening trials confirm.
Among more than 3,300 heavy smokers over age 50 who took part in two low-dose CT (LDCT) screening programs, former smokers had a 37% reduction in all-cause mortality, compared with current smokers, and those who were active smokers at the time of randomization but quit during the follow-up period had a 43% lower risk for death, compared with those who continued to smoke, reported Dr. Ugo Pastorino of the Instiuto Nazionale dei Tumori in Milan.
He noted that the U.S. National Lung Screening Trial (NSLT) showed that screening with low-dose helical CT was associated with a nearly 7% reduction in all-cause mortality over 7 years of follow-up, compared with patients screened with chest x-ray.
“But we have to keep clear in our minds that the benefit achieved by this trial of early detection in terms of mortality reduction is only 1% per year, so it’s a not a major improvement. It’s a start, but we have to aim to improve this mortality reduction,” he said at the conference sponsored by the International Association for the Study of Lung Cancer.
Neither the NSLT nor other randomized screening trials currently underway have examined in detail the effects of smoking status on screening outcomes, prompting Dr. Pastorino and colleagues to investigate the matter in two cohorts of smokers assigned to LDCT in screening trials.
The study included 3,381 heavy smokers with a median follow-up of 9.7 years and a total follow-up of 32,858 person-years. Men comprised 69% of the combined cohorts, who had a median age of 58 and a median smoking of 40 pack-years.
The investigators divided the participants into current smokers – those who continued to smoke throughout the screening period, or if they quit did so within 1 year of the end of follow-up or death – and former smokers, subdivided into early quitters, who had stopped smoking by the time of accrual, and late quitters, who were active smokers at the time of accrual or randomization but stopped smoking at least 1 year before the end of the follow-up period or at least 1 year before death.
In an analysis of the effects of smoking on mortality, controlled for gender, age, body mass index, lung function, and pack-years smoked, they found that the relative risk for death from any cause among both early and late quitters, compared with current smokers, was 0.74. When they excluded 239 quitters who had kicked the habit less than 2 years before the end of follow-up or death, the benefits of not smoking were even greater, with an RR of 0.61.
Interestingly, when they looked at the early quitters, compared with current smokers, the RR for quitting was 0.63, and the effect appeared even stronger among more recent (late) quitters, who had a RR for all-cause mortality of 0.57, compared with current smokers. (All comparisons significant as shown by 95% confidence intervals).
Also of note was the fact that lung cancer accounted for fewer than 30% of deaths, Dr. Pastorino noted.
Dr. Nise H. Yamaguchi of the Hospital Israelita Albert Enstein in Sao Paolo, Brazil, applauded Dr. Pastorino and colleagues for the study, and succinctly summarized the take home message.
“If you came here from all around the world to see all these fancy treatments and everything that you can’t do, go back home and help people stop smoking, because you cure lots of people and save many lives for sure,” she said.
AT THE IASLC WORLD CONFERENCE
Key clinical point: Quitting smoking results in a significant reduction in all-cause mortality among heavy smokers taking part in screening programs.
Major finding: Compared with current smokers, the relative risk for all-cause mortality among ex-smokers or recent quitters was 0.74
Data source: Data on two cohorts totaling 3,381 current or ex-smokers assigned to low-dose CT lung screening.
Disclosures: The study was supported by the Italian Ministry of Health.
ICU care improves survival without raising costs
Compared with care on a general hospital ward, ICU care improved survival without raising costs significantly in a study of more than 1 million Medicare patients hospitalized with pneumonia, published online Sept. 22 in JAMA.
The retrospective cohort study involved older patients whose condition was considered “borderline” – not one that would clearly benefit from ICU admission but also not one for which ICU admission could clearly be ruled out. The decision of whether to admit these study participants to a general ward or an ICU was deemed discretionary. “Contrary to [our] prespecified hypothesis, [our] findings suggest that ICU admission for borderline patients … is associated with reduced mortality without a considerable increase in costs,” said Dr. Thomas S. Valley of the division of pulmonary and critical care medicine, University of Michigan, Ann Arbor, and his associates.
The investigators analyzed data from the American Hospital Association’s annual surveys and the Healthcare Cost Reporting Information Systems regarding 1,327,370 Medicare patients admitted to 2,988 hospitals across the country during a recent 2-year period. A total of 328,404 patients (29.5% of the study population) were admitted to ICUs and the remainder to general hospital wards.
After the data were adjusted to account for numerous patient, disease, and hospital variables, ICU admission was associated with significantly lower 30-day mortality (14.8%), compared with general ward admission (20.5%) – an absolute reduction of 5.7%. Yet the differences between the two groups were nonsignificant regarding payments by Medicare ($9,918 for ICU vs. $11,238 for general ward care) and hospital costs ($14,162 for ICU vs $11,320 for general ward care).
These findings were consistent across numerous sensitivity analyses, including some that compared urban against rural hospitals, white against nonwhite patients, small against large ICUs, and severely ill against less severely ill patients, Dr. Valley and his associates said (JAMA. 2015 Sep 22;314[12]:1272-79. doi: 10.1001.jama.2015.11068).
There are several reasons why ICU care might be beneficial for “borderline” patients with pneumonia. Greater attention from nurses and other clinicians could allow for more timely recognition of decompensation; more aggressive care is more likely to head off the development of sepsis; better adherence to guideline-based treatment is known to improve mortality; and a greater likelihood of being managed by a pulmonary or critical care specialist with greater expertise in pneumonia care should improve outcomes, the researchers noted.
Their study findings have important implications for health care reform. “In order to contain U.S. health care costs, it has been suggested that reducing critical care bed supply would result in more efficient admission decisions and cost savings with minimal mortality decrements.” This “presumes that ICU admission for discretionary patients provides minimal benefit but substantially increases costs.” The results of this study clearly refute that assumption, Dr. Valley and his associates said.
This study provides important empirical evidence that ICU admission can benefit “low-risk” patients. It demonstrates that the value of intensive care extends beyond mere life support for patients with an acutely failing organ and instead includes all the organizational and human resources that comprise an ICU.
It would be tempting to use these results to justify more liberal ICU admission, but that would be untenable in this era of constrained health care resources. Rather than increasing ICU use, we should make general wards function more like ICUs. The task at hand is to study why intensive care saves lives, then use that information to make hospital care safe and effective for all patients, regardless of where in the hospital they are cared for.
Dr. Ian J. Barbash is in the division of pulmonary, allergy, and critical care medicine at the University of Pittsburgh. Dr. Jeremy M. Kahn is in the department of health policy and management at the university’s Graduate School of Public Health. Both Dr. Barbash and Dr. Kahn are also at the university’s Clinical Research, Investigation, and Systems Modeling of Acute Illness Center. Both authors reported having no relevant financial disclosures. They made these remarks in an editorial accompanying Dr. Valley’s report (JAMA. 2015;314:1240-41. doi: 10.1001/jama.2015.11171).
This study provides important empirical evidence that ICU admission can benefit “low-risk” patients. It demonstrates that the value of intensive care extends beyond mere life support for patients with an acutely failing organ and instead includes all the organizational and human resources that comprise an ICU.
It would be tempting to use these results to justify more liberal ICU admission, but that would be untenable in this era of constrained health care resources. Rather than increasing ICU use, we should make general wards function more like ICUs. The task at hand is to study why intensive care saves lives, then use that information to make hospital care safe and effective for all patients, regardless of where in the hospital they are cared for.
Dr. Ian J. Barbash is in the division of pulmonary, allergy, and critical care medicine at the University of Pittsburgh. Dr. Jeremy M. Kahn is in the department of health policy and management at the university’s Graduate School of Public Health. Both Dr. Barbash and Dr. Kahn are also at the university’s Clinical Research, Investigation, and Systems Modeling of Acute Illness Center. Both authors reported having no relevant financial disclosures. They made these remarks in an editorial accompanying Dr. Valley’s report (JAMA. 2015;314:1240-41. doi: 10.1001/jama.2015.11171).
This study provides important empirical evidence that ICU admission can benefit “low-risk” patients. It demonstrates that the value of intensive care extends beyond mere life support for patients with an acutely failing organ and instead includes all the organizational and human resources that comprise an ICU.
It would be tempting to use these results to justify more liberal ICU admission, but that would be untenable in this era of constrained health care resources. Rather than increasing ICU use, we should make general wards function more like ICUs. The task at hand is to study why intensive care saves lives, then use that information to make hospital care safe and effective for all patients, regardless of where in the hospital they are cared for.
Dr. Ian J. Barbash is in the division of pulmonary, allergy, and critical care medicine at the University of Pittsburgh. Dr. Jeremy M. Kahn is in the department of health policy and management at the university’s Graduate School of Public Health. Both Dr. Barbash and Dr. Kahn are also at the university’s Clinical Research, Investigation, and Systems Modeling of Acute Illness Center. Both authors reported having no relevant financial disclosures. They made these remarks in an editorial accompanying Dr. Valley’s report (JAMA. 2015;314:1240-41. doi: 10.1001/jama.2015.11171).
Compared with care on a general hospital ward, ICU care improved survival without raising costs significantly in a study of more than 1 million Medicare patients hospitalized with pneumonia, published online Sept. 22 in JAMA.
The retrospective cohort study involved older patients whose condition was considered “borderline” – not one that would clearly benefit from ICU admission but also not one for which ICU admission could clearly be ruled out. The decision of whether to admit these study participants to a general ward or an ICU was deemed discretionary. “Contrary to [our] prespecified hypothesis, [our] findings suggest that ICU admission for borderline patients … is associated with reduced mortality without a considerable increase in costs,” said Dr. Thomas S. Valley of the division of pulmonary and critical care medicine, University of Michigan, Ann Arbor, and his associates.
The investigators analyzed data from the American Hospital Association’s annual surveys and the Healthcare Cost Reporting Information Systems regarding 1,327,370 Medicare patients admitted to 2,988 hospitals across the country during a recent 2-year period. A total of 328,404 patients (29.5% of the study population) were admitted to ICUs and the remainder to general hospital wards.
After the data were adjusted to account for numerous patient, disease, and hospital variables, ICU admission was associated with significantly lower 30-day mortality (14.8%), compared with general ward admission (20.5%) – an absolute reduction of 5.7%. Yet the differences between the two groups were nonsignificant regarding payments by Medicare ($9,918 for ICU vs. $11,238 for general ward care) and hospital costs ($14,162 for ICU vs $11,320 for general ward care).
These findings were consistent across numerous sensitivity analyses, including some that compared urban against rural hospitals, white against nonwhite patients, small against large ICUs, and severely ill against less severely ill patients, Dr. Valley and his associates said (JAMA. 2015 Sep 22;314[12]:1272-79. doi: 10.1001.jama.2015.11068).
There are several reasons why ICU care might be beneficial for “borderline” patients with pneumonia. Greater attention from nurses and other clinicians could allow for more timely recognition of decompensation; more aggressive care is more likely to head off the development of sepsis; better adherence to guideline-based treatment is known to improve mortality; and a greater likelihood of being managed by a pulmonary or critical care specialist with greater expertise in pneumonia care should improve outcomes, the researchers noted.
Their study findings have important implications for health care reform. “In order to contain U.S. health care costs, it has been suggested that reducing critical care bed supply would result in more efficient admission decisions and cost savings with minimal mortality decrements.” This “presumes that ICU admission for discretionary patients provides minimal benefit but substantially increases costs.” The results of this study clearly refute that assumption, Dr. Valley and his associates said.
Compared with care on a general hospital ward, ICU care improved survival without raising costs significantly in a study of more than 1 million Medicare patients hospitalized with pneumonia, published online Sept. 22 in JAMA.
The retrospective cohort study involved older patients whose condition was considered “borderline” – not one that would clearly benefit from ICU admission but also not one for which ICU admission could clearly be ruled out. The decision of whether to admit these study participants to a general ward or an ICU was deemed discretionary. “Contrary to [our] prespecified hypothesis, [our] findings suggest that ICU admission for borderline patients … is associated with reduced mortality without a considerable increase in costs,” said Dr. Thomas S. Valley of the division of pulmonary and critical care medicine, University of Michigan, Ann Arbor, and his associates.
The investigators analyzed data from the American Hospital Association’s annual surveys and the Healthcare Cost Reporting Information Systems regarding 1,327,370 Medicare patients admitted to 2,988 hospitals across the country during a recent 2-year period. A total of 328,404 patients (29.5% of the study population) were admitted to ICUs and the remainder to general hospital wards.
After the data were adjusted to account for numerous patient, disease, and hospital variables, ICU admission was associated with significantly lower 30-day mortality (14.8%), compared with general ward admission (20.5%) – an absolute reduction of 5.7%. Yet the differences between the two groups were nonsignificant regarding payments by Medicare ($9,918 for ICU vs. $11,238 for general ward care) and hospital costs ($14,162 for ICU vs $11,320 for general ward care).
These findings were consistent across numerous sensitivity analyses, including some that compared urban against rural hospitals, white against nonwhite patients, small against large ICUs, and severely ill against less severely ill patients, Dr. Valley and his associates said (JAMA. 2015 Sep 22;314[12]:1272-79. doi: 10.1001.jama.2015.11068).
There are several reasons why ICU care might be beneficial for “borderline” patients with pneumonia. Greater attention from nurses and other clinicians could allow for more timely recognition of decompensation; more aggressive care is more likely to head off the development of sepsis; better adherence to guideline-based treatment is known to improve mortality; and a greater likelihood of being managed by a pulmonary or critical care specialist with greater expertise in pneumonia care should improve outcomes, the researchers noted.
Their study findings have important implications for health care reform. “In order to contain U.S. health care costs, it has been suggested that reducing critical care bed supply would result in more efficient admission decisions and cost savings with minimal mortality decrements.” This “presumes that ICU admission for discretionary patients provides minimal benefit but substantially increases costs.” The results of this study clearly refute that assumption, Dr. Valley and his associates said.
FROM JAMA
Key clinical point: ICU care improved survival without raising costs in older patients with pneumonia, compared with care on a general hospital ward.
Major finding: ICU admission was associated with significantly lower 30-day mortality (14.8%), compared with general ward admission (20.5%).
Data source: A retrospective cohort study involving 1,112,394 Medicare patients treated for pneumonia at 2,988 U.S. hospitals during a 2-year period.
Disclosures: This study was supported by the National Institutes of Health, the Department of Veterans Affairs Health Services Research and Development Service, and the Agency for Healthcare Research and Quality. Dr. Valley and his associates reported having no relevant financial disclosures.
USPSTF guideline: Tell smokers to stop, and provide cessation aids
The U.S. Preventive Services Task Force has issued a final grade A recommendation urging clinicians to ask all adults whether they smoke, advise them to quit if they do, and provide cessation aids to adults who use tobacco.
The guideline also includes Grade I statements, which say “the current evidence is insufficient to assess the balance of benefits and harms of pharmacotherapy interventions for tobacco cessation in pregnant women and electronic nicotine delivery systems for tobacco cessation in all adults (Ann Intern Med. 2015 Sep 22. doi: 10.7326/M15-2023).
The guideline reaffirms the 2009 USPSTF recommendation, which recommends clinicians ask all adults about tobacco use and provides tobacco cessation interventions to help them quit. The new guideline differs from the 2009 recommendation in that it calls for more evidence on the use of e-cigarettes for smoking cessation in adults and the use of medications to help pregnant women stop smoking.
“A large body of evidence on interventions for smoking cessation already exists, and the overall benefit of pharmacotherapy and behavioral counseling to promote smoking is well established,” says the new USPSTF guideline.
“Tobacco is the leading preventable cause of disease, disability, and death in the United States,” with cigarette smoking, specifically, causing more than 480,000 premature deaths annually and accounting for one in every five deaths, according to the guideline.
“In pregnant women, smoking increases the risk of congenital anomalies; perinatal complications, such as preterm birth, fetal growth restriction, and placental abruption; miscarriage and stillbirth; and neonatal or pediatric complications, such as sudden infant death syndrome and impaired lung function in childhood,” the guideline says.
According to a 2013 systematic review of 28 studies, rates of smoking abstinence at 6 months or more were 8% in groups that received physician advice, compared with 5% in groups that received no advice or usual care (risk ratio, 1.76; 95% confidence interval, 1.56-1.96).
Pharmacotherapy was effective at stopping nonpregnant smokers from continuing to smoke; a 2012 systematic review of 117 nicotine replacement therapy (NRT) studies found that 17% of participants who took any form of an NRT drug abstained from smoking for 6 months or more, compared with 10% of participants who received placebo or did not take an NRT drug (RR, 0.60; 95% CI, 1.53-1.68), the review says.
Combinations of behavioral counseling and pharmacotherapy for smoking cessation also were effective; “a 2012 good-quality systematic review” found the abstinence rate of participants who received combination pharmacotherapy and intensive behavioral counseling was 14.5%, at 6 months or more, compared with 8% among control participants who received “usual care, self-help materials, or brief advice on quitting (which was less intensive than the counseling or support given to the intervention groups)” (RR, 1.82; 95% CI, 1.66-2.00).
For pregnant women, “a good-quality systematic review of 86 studies done in 2013” found that behavioral interventions were effective at improving rates of smoking cessation. Compared with control participants, pregnant women who received any type of behavioral intervention before the third trimester had higher cessation rates late in pregnancy (15% vs. 11%; RR, 1.45; 95% CI, 1.27-1.64), the review says.
Responding to pubic comments, USPSTF said that “both intervention types (pharmacotherapy and behavioral intervention) are effective and recommended,” with combinations of interventions being the most effective at getting patients to stop smoking.
“Further research is still needed to elucidate specific features of complex behavioral counseling interventions, benefits of pharmacotherapy in specific populations [such as pregnant women and adults with mental health conditions], and the efficacy of newer technology-based interventions … such as Internet-based programs, mobile or smartphone applications, and text-messaging programs.” The document also called for investigations into the safety, benefits, and harms of electronic nicotine delivery systems.
The authors of the guidelines stated they had nothing to disclose.
The U.S. Preventive Services Task Force has issued a final grade A recommendation urging clinicians to ask all adults whether they smoke, advise them to quit if they do, and provide cessation aids to adults who use tobacco.
The guideline also includes Grade I statements, which say “the current evidence is insufficient to assess the balance of benefits and harms of pharmacotherapy interventions for tobacco cessation in pregnant women and electronic nicotine delivery systems for tobacco cessation in all adults (Ann Intern Med. 2015 Sep 22. doi: 10.7326/M15-2023).
The guideline reaffirms the 2009 USPSTF recommendation, which recommends clinicians ask all adults about tobacco use and provides tobacco cessation interventions to help them quit. The new guideline differs from the 2009 recommendation in that it calls for more evidence on the use of e-cigarettes for smoking cessation in adults and the use of medications to help pregnant women stop smoking.
“A large body of evidence on interventions for smoking cessation already exists, and the overall benefit of pharmacotherapy and behavioral counseling to promote smoking is well established,” says the new USPSTF guideline.
“Tobacco is the leading preventable cause of disease, disability, and death in the United States,” with cigarette smoking, specifically, causing more than 480,000 premature deaths annually and accounting for one in every five deaths, according to the guideline.
“In pregnant women, smoking increases the risk of congenital anomalies; perinatal complications, such as preterm birth, fetal growth restriction, and placental abruption; miscarriage and stillbirth; and neonatal or pediatric complications, such as sudden infant death syndrome and impaired lung function in childhood,” the guideline says.
According to a 2013 systematic review of 28 studies, rates of smoking abstinence at 6 months or more were 8% in groups that received physician advice, compared with 5% in groups that received no advice or usual care (risk ratio, 1.76; 95% confidence interval, 1.56-1.96).
Pharmacotherapy was effective at stopping nonpregnant smokers from continuing to smoke; a 2012 systematic review of 117 nicotine replacement therapy (NRT) studies found that 17% of participants who took any form of an NRT drug abstained from smoking for 6 months or more, compared with 10% of participants who received placebo or did not take an NRT drug (RR, 0.60; 95% CI, 1.53-1.68), the review says.
Combinations of behavioral counseling and pharmacotherapy for smoking cessation also were effective; “a 2012 good-quality systematic review” found the abstinence rate of participants who received combination pharmacotherapy and intensive behavioral counseling was 14.5%, at 6 months or more, compared with 8% among control participants who received “usual care, self-help materials, or brief advice on quitting (which was less intensive than the counseling or support given to the intervention groups)” (RR, 1.82; 95% CI, 1.66-2.00).
For pregnant women, “a good-quality systematic review of 86 studies done in 2013” found that behavioral interventions were effective at improving rates of smoking cessation. Compared with control participants, pregnant women who received any type of behavioral intervention before the third trimester had higher cessation rates late in pregnancy (15% vs. 11%; RR, 1.45; 95% CI, 1.27-1.64), the review says.
Responding to pubic comments, USPSTF said that “both intervention types (pharmacotherapy and behavioral intervention) are effective and recommended,” with combinations of interventions being the most effective at getting patients to stop smoking.
“Further research is still needed to elucidate specific features of complex behavioral counseling interventions, benefits of pharmacotherapy in specific populations [such as pregnant women and adults with mental health conditions], and the efficacy of newer technology-based interventions … such as Internet-based programs, mobile or smartphone applications, and text-messaging programs.” The document also called for investigations into the safety, benefits, and harms of electronic nicotine delivery systems.
The authors of the guidelines stated they had nothing to disclose.
The U.S. Preventive Services Task Force has issued a final grade A recommendation urging clinicians to ask all adults whether they smoke, advise them to quit if they do, and provide cessation aids to adults who use tobacco.
The guideline also includes Grade I statements, which say “the current evidence is insufficient to assess the balance of benefits and harms of pharmacotherapy interventions for tobacco cessation in pregnant women and electronic nicotine delivery systems for tobacco cessation in all adults (Ann Intern Med. 2015 Sep 22. doi: 10.7326/M15-2023).
The guideline reaffirms the 2009 USPSTF recommendation, which recommends clinicians ask all adults about tobacco use and provides tobacco cessation interventions to help them quit. The new guideline differs from the 2009 recommendation in that it calls for more evidence on the use of e-cigarettes for smoking cessation in adults and the use of medications to help pregnant women stop smoking.
“A large body of evidence on interventions for smoking cessation already exists, and the overall benefit of pharmacotherapy and behavioral counseling to promote smoking is well established,” says the new USPSTF guideline.
“Tobacco is the leading preventable cause of disease, disability, and death in the United States,” with cigarette smoking, specifically, causing more than 480,000 premature deaths annually and accounting for one in every five deaths, according to the guideline.
“In pregnant women, smoking increases the risk of congenital anomalies; perinatal complications, such as preterm birth, fetal growth restriction, and placental abruption; miscarriage and stillbirth; and neonatal or pediatric complications, such as sudden infant death syndrome and impaired lung function in childhood,” the guideline says.
According to a 2013 systematic review of 28 studies, rates of smoking abstinence at 6 months or more were 8% in groups that received physician advice, compared with 5% in groups that received no advice or usual care (risk ratio, 1.76; 95% confidence interval, 1.56-1.96).
Pharmacotherapy was effective at stopping nonpregnant smokers from continuing to smoke; a 2012 systematic review of 117 nicotine replacement therapy (NRT) studies found that 17% of participants who took any form of an NRT drug abstained from smoking for 6 months or more, compared with 10% of participants who received placebo or did not take an NRT drug (RR, 0.60; 95% CI, 1.53-1.68), the review says.
Combinations of behavioral counseling and pharmacotherapy for smoking cessation also were effective; “a 2012 good-quality systematic review” found the abstinence rate of participants who received combination pharmacotherapy and intensive behavioral counseling was 14.5%, at 6 months or more, compared with 8% among control participants who received “usual care, self-help materials, or brief advice on quitting (which was less intensive than the counseling or support given to the intervention groups)” (RR, 1.82; 95% CI, 1.66-2.00).
For pregnant women, “a good-quality systematic review of 86 studies done in 2013” found that behavioral interventions were effective at improving rates of smoking cessation. Compared with control participants, pregnant women who received any type of behavioral intervention before the third trimester had higher cessation rates late in pregnancy (15% vs. 11%; RR, 1.45; 95% CI, 1.27-1.64), the review says.
Responding to pubic comments, USPSTF said that “both intervention types (pharmacotherapy and behavioral intervention) are effective and recommended,” with combinations of interventions being the most effective at getting patients to stop smoking.
“Further research is still needed to elucidate specific features of complex behavioral counseling interventions, benefits of pharmacotherapy in specific populations [such as pregnant women and adults with mental health conditions], and the efficacy of newer technology-based interventions … such as Internet-based programs, mobile or smartphone applications, and text-messaging programs.” The document also called for investigations into the safety, benefits, and harms of electronic nicotine delivery systems.
The authors of the guidelines stated they had nothing to disclose.
FROM ANNALS of INTERNAL MEDICINE
Send patients reminders for flu vaccines, study says
ATLANTA – Mobile reminders from health care providers to their patients, notifying them to get influenza vaccinations, significantly increases the likelihood that those patients will get vaccinated, according to a study by Dr. Katherine A. Benedict and coinvestigators in the Enteric Diseases Epidemiology Branch at the Centers for Disease Control and Prevention. Dr. Benedict presented findings of the research at the International Conference on Emerging Infectious Diseases.
The researchers used data from the March 2012 National Flu Survey, a CDC “random digit dial telephone survey” of influenza vaccination trends in adults 18 years of age and older. They analyzed the data to determine whether or not patients received reminders, recommendations, or offers for influenza vaccinations from their health care providers since July 1, 2011. They did a logistic regression analysis to determine if there was any relationship between influenza vaccination rates and receipt of recommendations from health care providers.
Almost 73% of adults reported visiting a physician at least once since July 1, 2011, the start of data collection for the March 2012 study cycle, with 17.2% reporting that they received a reminder from their doctors to get a flu vaccine. Overall, 45.5% of adults ultimately got vaccinated, with 75.6% of those who reported receiving a reminder saying that they also were offered vaccinations by their doctors.
Adults who received recommendations for influenza vaccination from their health care providers were most likely to get vaccinated, and had an unadjusted prevalence ratio of 2.09. Next likely were those who received vaccination offers (PR = 1.90), and those who simply received reminders (PR = 1.33). Furthermore, those between 50 and 64 years old were found more likely to receive a recommendation or offer – PR = 1.23 and PR = 1.09, respectively – than were those in the 18- to 49-year age range (PR = 1.06 for recommendation, PR = 0.99 for offer).
The takeaway from this, according to the investigators, is that reminders should be sent at least once at the beginning of each influenza season. Prevalence ratios were consistently higher for patients with more frequent visits to their health care providers, meaning that continued interaction with and communication from doctors increases the likelihood of vaccination. Dr. Benedict also recommended sending additional reminders throughout the season, and that patients should either seek out or be referred to doctors who offer influenza vaccinations themselves.
Dr. Benedict did not report any relevant financial disclosures.
ATLANTA – Mobile reminders from health care providers to their patients, notifying them to get influenza vaccinations, significantly increases the likelihood that those patients will get vaccinated, according to a study by Dr. Katherine A. Benedict and coinvestigators in the Enteric Diseases Epidemiology Branch at the Centers for Disease Control and Prevention. Dr. Benedict presented findings of the research at the International Conference on Emerging Infectious Diseases.
The researchers used data from the March 2012 National Flu Survey, a CDC “random digit dial telephone survey” of influenza vaccination trends in adults 18 years of age and older. They analyzed the data to determine whether or not patients received reminders, recommendations, or offers for influenza vaccinations from their health care providers since July 1, 2011. They did a logistic regression analysis to determine if there was any relationship between influenza vaccination rates and receipt of recommendations from health care providers.
Almost 73% of adults reported visiting a physician at least once since July 1, 2011, the start of data collection for the March 2012 study cycle, with 17.2% reporting that they received a reminder from their doctors to get a flu vaccine. Overall, 45.5% of adults ultimately got vaccinated, with 75.6% of those who reported receiving a reminder saying that they also were offered vaccinations by their doctors.
Adults who received recommendations for influenza vaccination from their health care providers were most likely to get vaccinated, and had an unadjusted prevalence ratio of 2.09. Next likely were those who received vaccination offers (PR = 1.90), and those who simply received reminders (PR = 1.33). Furthermore, those between 50 and 64 years old were found more likely to receive a recommendation or offer – PR = 1.23 and PR = 1.09, respectively – than were those in the 18- to 49-year age range (PR = 1.06 for recommendation, PR = 0.99 for offer).
The takeaway from this, according to the investigators, is that reminders should be sent at least once at the beginning of each influenza season. Prevalence ratios were consistently higher for patients with more frequent visits to their health care providers, meaning that continued interaction with and communication from doctors increases the likelihood of vaccination. Dr. Benedict also recommended sending additional reminders throughout the season, and that patients should either seek out or be referred to doctors who offer influenza vaccinations themselves.
Dr. Benedict did not report any relevant financial disclosures.
ATLANTA – Mobile reminders from health care providers to their patients, notifying them to get influenza vaccinations, significantly increases the likelihood that those patients will get vaccinated, according to a study by Dr. Katherine A. Benedict and coinvestigators in the Enteric Diseases Epidemiology Branch at the Centers for Disease Control and Prevention. Dr. Benedict presented findings of the research at the International Conference on Emerging Infectious Diseases.
The researchers used data from the March 2012 National Flu Survey, a CDC “random digit dial telephone survey” of influenza vaccination trends in adults 18 years of age and older. They analyzed the data to determine whether or not patients received reminders, recommendations, or offers for influenza vaccinations from their health care providers since July 1, 2011. They did a logistic regression analysis to determine if there was any relationship between influenza vaccination rates and receipt of recommendations from health care providers.
Almost 73% of adults reported visiting a physician at least once since July 1, 2011, the start of data collection for the March 2012 study cycle, with 17.2% reporting that they received a reminder from their doctors to get a flu vaccine. Overall, 45.5% of adults ultimately got vaccinated, with 75.6% of those who reported receiving a reminder saying that they also were offered vaccinations by their doctors.
Adults who received recommendations for influenza vaccination from their health care providers were most likely to get vaccinated, and had an unadjusted prevalence ratio of 2.09. Next likely were those who received vaccination offers (PR = 1.90), and those who simply received reminders (PR = 1.33). Furthermore, those between 50 and 64 years old were found more likely to receive a recommendation or offer – PR = 1.23 and PR = 1.09, respectively – than were those in the 18- to 49-year age range (PR = 1.06 for recommendation, PR = 0.99 for offer).
The takeaway from this, according to the investigators, is that reminders should be sent at least once at the beginning of each influenza season. Prevalence ratios were consistently higher for patients with more frequent visits to their health care providers, meaning that continued interaction with and communication from doctors increases the likelihood of vaccination. Dr. Benedict also recommended sending additional reminders throughout the season, and that patients should either seek out or be referred to doctors who offer influenza vaccinations themselves.
Dr. Benedict did not report any relevant financial disclosures.
AT ICEID 2015
Key clinical point: Sending patients reminders to get their influenza vaccinations can significantly increase the likelihood that these patients will actually go out and get the vaccine.
Major finding: Adults who received a recommendation for influenza vaccination were more likely to get vaccinated, with an adjusted prevalence ratio (APR) of 1.15.
Data source: Retrospective review of adults 18 years and older in the March 2012 National Flu Survey.
Disclosures: Dr. Benedict did not report any relevant financial disclosures.
Respiratory problems make adenotonsillectomy recovery worse for kids
Respiratory compromise and secondary hemorrhage were the most common early side effects in children who had adenotonsillectomies; children with obstructive sleep apnea (OSA) have nearly five times more respiratory complications after surgery than children without OSA, a multistudy review concluded.
Graziela De Luca Canto, Ph.D., of the Federal University of Santa Catarina, Brazil, and her associates performed a data review by identifying 1,254 different citations found via electronic database searches; after eliminations, only 23 studies were included in the final analysis. Although children with OSA have nearly five times more respiratory complications after adenotonsillectomy than their peers, (odds ratio, 4.90), they are less likely to have postoperative bleeding, compared with children without OSA (OR, 0.41). Among both groups, the most frequent complication was respiratory compromise (9.4%), followed by secondary hemorrhage (2.6%).
Because children with OSA are more likely to require supplemental oxygen, oral or nasal airway insertion, or assisted ventilation in the immediate postoperative period than their peers, the authors suggested that anesthesiologists would be wise to screen patients for snoring, airway dysfunction, and other airway anatomic disorders before performing surgery.
“Children with OSA are clearly at higher anesthetic risk than are patients with normal upper airway function. … Despite the pressure to reduce costs, both surgeons and anesthesiologists should improve screening procedures, perhaps develop alternate surgical approaches, to decrease the risks,” the investigators wrote.
Read the full article in Pediatrics 2015 (doi: 10.1542/peds.2015-1283).
Respiratory compromise and secondary hemorrhage were the most common early side effects in children who had adenotonsillectomies; children with obstructive sleep apnea (OSA) have nearly five times more respiratory complications after surgery than children without OSA, a multistudy review concluded.
Graziela De Luca Canto, Ph.D., of the Federal University of Santa Catarina, Brazil, and her associates performed a data review by identifying 1,254 different citations found via electronic database searches; after eliminations, only 23 studies were included in the final analysis. Although children with OSA have nearly five times more respiratory complications after adenotonsillectomy than their peers, (odds ratio, 4.90), they are less likely to have postoperative bleeding, compared with children without OSA (OR, 0.41). Among both groups, the most frequent complication was respiratory compromise (9.4%), followed by secondary hemorrhage (2.6%).
Because children with OSA are more likely to require supplemental oxygen, oral or nasal airway insertion, or assisted ventilation in the immediate postoperative period than their peers, the authors suggested that anesthesiologists would be wise to screen patients for snoring, airway dysfunction, and other airway anatomic disorders before performing surgery.
“Children with OSA are clearly at higher anesthetic risk than are patients with normal upper airway function. … Despite the pressure to reduce costs, both surgeons and anesthesiologists should improve screening procedures, perhaps develop alternate surgical approaches, to decrease the risks,” the investigators wrote.
Read the full article in Pediatrics 2015 (doi: 10.1542/peds.2015-1283).
Respiratory compromise and secondary hemorrhage were the most common early side effects in children who had adenotonsillectomies; children with obstructive sleep apnea (OSA) have nearly five times more respiratory complications after surgery than children without OSA, a multistudy review concluded.
Graziela De Luca Canto, Ph.D., of the Federal University of Santa Catarina, Brazil, and her associates performed a data review by identifying 1,254 different citations found via electronic database searches; after eliminations, only 23 studies were included in the final analysis. Although children with OSA have nearly five times more respiratory complications after adenotonsillectomy than their peers, (odds ratio, 4.90), they are less likely to have postoperative bleeding, compared with children without OSA (OR, 0.41). Among both groups, the most frequent complication was respiratory compromise (9.4%), followed by secondary hemorrhage (2.6%).
Because children with OSA are more likely to require supplemental oxygen, oral or nasal airway insertion, or assisted ventilation in the immediate postoperative period than their peers, the authors suggested that anesthesiologists would be wise to screen patients for snoring, airway dysfunction, and other airway anatomic disorders before performing surgery.
“Children with OSA are clearly at higher anesthetic risk than are patients with normal upper airway function. … Despite the pressure to reduce costs, both surgeons and anesthesiologists should improve screening procedures, perhaps develop alternate surgical approaches, to decrease the risks,” the investigators wrote.
Read the full article in Pediatrics 2015 (doi: 10.1542/peds.2015-1283).
FROM PEDIATRICS
Hypothyroidism tied to idiopathic pulmonary fibrosis mortality
Hypothyroidism affected almost 17% of patients with idiopathic pulmonary fibrosis and was independently associated with their mortality, according to a report in the September issue of CHEST.
“We report, to our knowledge for the first time, an association between hypothyroidism and idiopathic pulmonary fibrosis,” wrote Dr. Justin Oldham of the pulmonary and critical care section of the University of Chicago and his associates. “Hypothyroidism, a largely autoimmune process, is common among patients with IPF and may represent an additional feature of autoimmunity in this patient population.” The retrospective study could not assess causality, but raises questions about whether autoimmune abnormalities contribte to or exacerbate IPF, and whether hypothyroidism and IPF share common underlying causes, they added.
Recent years have seen a “paradigm shift” away from immunologic or inflammatory causes of IPF in favor of alveolar injury and abnormal cellular repair mechanisms, but some studies point to autoimmunity in IPF, said the investigators. To further explore the question, they studied hypothyroidism – which in developed countries is most often autoimmune – among 196 patients with IPF with an equal number of age-and sex-matched controls with COPD (Chest 2015;148:692-700). Nearly 17% of IPF patients – including 13% of women and 28% of men – reported using thyroid replacement therapy with no history of thyroidectomy or radioactive iodine ablation. In contrast only 7% of COPD controls had a recorded diagnosis of hypothyroidism (odds ratio, 2.7; 95% confidence interval, 1.3 to 5.5; P = .01). Men and women with IPF and comorbid hypothyroidism had significantly shorter survival than did patients who had IPF only (P = .001). Hypothyroidism also independently predicted mortality in the multivariable analysis (hazard ratio, 2.1; 95% CI, 1.3 to 3.4), as did sequential increases in gender, age, and physiology (GAP) stage, the investigators said. “These conclusions held when transplant-free, transplant-excluded, and transplant-as-a-competing-event Cox regression models were constructed,” they reported. Furthermore, multivariable analyses of data from two IPF clinical trials (ACE-IPF and PANTHER) revealed similar associations among hypothyroidism, GAP stage, and mortality, they said.
Exactly how hypothyroidism contributes to IPF and IPF-related mortality is unclear, said Dr. Oldham and his associates. Because the study did not examine longitudinal changes in thyroid stage, they could not relate those trends to IPF progression, they noted. Although they excluded patients whose thyroid disease was known not to be autoimmune, they could not specifically confirm that all remaining patients with hypothyroidism had autoimmune thyroiditis, because most had been diagnosed years before. Future longitudinal studies should examine whether IPF and hypothyroidism share underlying causes, and should examine why hypothyroidism seems to increase IPF-related mortality, they concluded.
The National Institutes of Health funded the study. Dr. Oldham and five coauthors declared no competing interests. Senior author Dr. Imre Noth and one coauthor reported grant support and honoraria from NIH, Brystol-Myers Squibb, Gilead Sciences, Intermune, Medimmune, and several other pharmaceutical companies.
Hypothyroidism affected almost 17% of patients with idiopathic pulmonary fibrosis and was independently associated with their mortality, according to a report in the September issue of CHEST.
“We report, to our knowledge for the first time, an association between hypothyroidism and idiopathic pulmonary fibrosis,” wrote Dr. Justin Oldham of the pulmonary and critical care section of the University of Chicago and his associates. “Hypothyroidism, a largely autoimmune process, is common among patients with IPF and may represent an additional feature of autoimmunity in this patient population.” The retrospective study could not assess causality, but raises questions about whether autoimmune abnormalities contribte to or exacerbate IPF, and whether hypothyroidism and IPF share common underlying causes, they added.
Recent years have seen a “paradigm shift” away from immunologic or inflammatory causes of IPF in favor of alveolar injury and abnormal cellular repair mechanisms, but some studies point to autoimmunity in IPF, said the investigators. To further explore the question, they studied hypothyroidism – which in developed countries is most often autoimmune – among 196 patients with IPF with an equal number of age-and sex-matched controls with COPD (Chest 2015;148:692-700). Nearly 17% of IPF patients – including 13% of women and 28% of men – reported using thyroid replacement therapy with no history of thyroidectomy or radioactive iodine ablation. In contrast only 7% of COPD controls had a recorded diagnosis of hypothyroidism (odds ratio, 2.7; 95% confidence interval, 1.3 to 5.5; P = .01). Men and women with IPF and comorbid hypothyroidism had significantly shorter survival than did patients who had IPF only (P = .001). Hypothyroidism also independently predicted mortality in the multivariable analysis (hazard ratio, 2.1; 95% CI, 1.3 to 3.4), as did sequential increases in gender, age, and physiology (GAP) stage, the investigators said. “These conclusions held when transplant-free, transplant-excluded, and transplant-as-a-competing-event Cox regression models were constructed,” they reported. Furthermore, multivariable analyses of data from two IPF clinical trials (ACE-IPF and PANTHER) revealed similar associations among hypothyroidism, GAP stage, and mortality, they said.
Exactly how hypothyroidism contributes to IPF and IPF-related mortality is unclear, said Dr. Oldham and his associates. Because the study did not examine longitudinal changes in thyroid stage, they could not relate those trends to IPF progression, they noted. Although they excluded patients whose thyroid disease was known not to be autoimmune, they could not specifically confirm that all remaining patients with hypothyroidism had autoimmune thyroiditis, because most had been diagnosed years before. Future longitudinal studies should examine whether IPF and hypothyroidism share underlying causes, and should examine why hypothyroidism seems to increase IPF-related mortality, they concluded.
The National Institutes of Health funded the study. Dr. Oldham and five coauthors declared no competing interests. Senior author Dr. Imre Noth and one coauthor reported grant support and honoraria from NIH, Brystol-Myers Squibb, Gilead Sciences, Intermune, Medimmune, and several other pharmaceutical companies.
Hypothyroidism affected almost 17% of patients with idiopathic pulmonary fibrosis and was independently associated with their mortality, according to a report in the September issue of CHEST.
“We report, to our knowledge for the first time, an association between hypothyroidism and idiopathic pulmonary fibrosis,” wrote Dr. Justin Oldham of the pulmonary and critical care section of the University of Chicago and his associates. “Hypothyroidism, a largely autoimmune process, is common among patients with IPF and may represent an additional feature of autoimmunity in this patient population.” The retrospective study could not assess causality, but raises questions about whether autoimmune abnormalities contribte to or exacerbate IPF, and whether hypothyroidism and IPF share common underlying causes, they added.
Recent years have seen a “paradigm shift” away from immunologic or inflammatory causes of IPF in favor of alveolar injury and abnormal cellular repair mechanisms, but some studies point to autoimmunity in IPF, said the investigators. To further explore the question, they studied hypothyroidism – which in developed countries is most often autoimmune – among 196 patients with IPF with an equal number of age-and sex-matched controls with COPD (Chest 2015;148:692-700). Nearly 17% of IPF patients – including 13% of women and 28% of men – reported using thyroid replacement therapy with no history of thyroidectomy or radioactive iodine ablation. In contrast only 7% of COPD controls had a recorded diagnosis of hypothyroidism (odds ratio, 2.7; 95% confidence interval, 1.3 to 5.5; P = .01). Men and women with IPF and comorbid hypothyroidism had significantly shorter survival than did patients who had IPF only (P = .001). Hypothyroidism also independently predicted mortality in the multivariable analysis (hazard ratio, 2.1; 95% CI, 1.3 to 3.4), as did sequential increases in gender, age, and physiology (GAP) stage, the investigators said. “These conclusions held when transplant-free, transplant-excluded, and transplant-as-a-competing-event Cox regression models were constructed,” they reported. Furthermore, multivariable analyses of data from two IPF clinical trials (ACE-IPF and PANTHER) revealed similar associations among hypothyroidism, GAP stage, and mortality, they said.
Exactly how hypothyroidism contributes to IPF and IPF-related mortality is unclear, said Dr. Oldham and his associates. Because the study did not examine longitudinal changes in thyroid stage, they could not relate those trends to IPF progression, they noted. Although they excluded patients whose thyroid disease was known not to be autoimmune, they could not specifically confirm that all remaining patients with hypothyroidism had autoimmune thyroiditis, because most had been diagnosed years before. Future longitudinal studies should examine whether IPF and hypothyroidism share underlying causes, and should examine why hypothyroidism seems to increase IPF-related mortality, they concluded.
The National Institutes of Health funded the study. Dr. Oldham and five coauthors declared no competing interests. Senior author Dr. Imre Noth and one coauthor reported grant support and honoraria from NIH, Brystol-Myers Squibb, Gilead Sciences, Intermune, Medimmune, and several other pharmaceutical companies.
FROM CHEST
Key clinical point: Hypothyroidism was common among patients with idiopathic pulmonary fibrosis and was independently associated with mortality.
Major finding: Hypothyroidism predicted mortality in the multivariable analysis (hazard ratio, 2.1).
Data source: A retrospective hospital-based study of 392 patients with IPF (cases) or COPD (controls).
Disclosures: The National Institutes of Health funded the study. Dr. Oldham and five coauthors declared no competing interests. Senior author Dr. Imre Noth and one coauthor reported grant support and honoraria from NIH, Brystol-Myers Squibb, Gilead Sciences, Intermune, Medimmune, and several other pharmaceutical companies.
Silicosis seen in nearly all denim sandblasters
In a study of young men who had worked as denim sandblasters, nearly all developed silicosis, while most had evidence of radiographic progression and/or significant lung function loss more than 4 years after their exposure to silica dust had ended.
The findings, published in the September issue of CHEST, derive from a study of 145 former sandblasters first identified in Turkey in 2007. At that time all had already ended their work as sandblasters at various facilities at least 10 months prior, and some had worked as little as a month. Mean age in the cohort was under 24 years in 2007, and first exposures occurred before a mean 18 years of age (CHEST 2015;148[3]:647-54).
In 2011, Dr. Metin Akgun and colleagues at Atatürk University in Erzurum, Turkey, revisited this cohort for follow-up and found that nine of the subjects had died. The researchers identified 83 of the surviving subjects and were able to conduct chest radiographs and spirometry on 74.
Dr. Akgun and colleagues sought to determine whether the silicosis cases, based on the International Labor Organization definitions of silicosis, had increased beyond the 53% seen in 2007, and measured pulmonary function loss and radiographic progression 4 years later.
The researchers found evidence of significant (more than 12%) pulmonary function loss in 66% of the follow-up cohort, and radiographic progression in 82%. Silicosis was found in all but one subject. Mean total length of exposure to silicone dust was about 3.5 years for this group, though no subject had been exposed after 2007.
Of the 74 living sandblasters available for reexamination, the prevalence of silicosis increased from 55.4% to 95.9%.
The findings, Dr. Akgun and colleagues wrote, confirmed that silicosis could develop without further exposure to silica dust after a course of work in denim sandblasting.
Younger age and younger age at first exposure were significantly associated with radiographic progression, the researchers found. Progression, pulmonary function loss, and mortality were associated with having worked as a foreman and with sleeping at the workplace, both indicative of higher exposure.
The nine subjects who died between 2007 and 2011 were more likely to have worked in more factories, to have been younger when first exposed, and never to have smoked.
Although Turkey banned silica sandblasting of denim jeans in 2009 in response to silicosis concerns, “the occupational health consequences are global as long as sandblasted jeans are sold, because production has shifted to other countries, including Bangladesh,” the researchers wrote in their analysis, recommending that clothing manufacturers “clarify their policies on purchasing sandblasted denim in light of the mortality and morbidity from silicosis associated with this process in the global supply chain.”
Dr. Akgun and colleagues noted that their study was limited by their inability to recruit the remaining 62 workers they had first seen in 2007, of whom a higher percentage were foremen. This reduced their ability to evaluate in more detail the differences in outcomes by exposure level.
Also, they noted, tuberculosis tests and sputum cultures were not performed at follow-up, leading to the possibility that mycobacterial infection may have affected disease progression in some subjects.
The authors disclosed that hey had no outside funding or conflicts of interest related to their findings.
In a study of young men who had worked as denim sandblasters, nearly all developed silicosis, while most had evidence of radiographic progression and/or significant lung function loss more than 4 years after their exposure to silica dust had ended.
The findings, published in the September issue of CHEST, derive from a study of 145 former sandblasters first identified in Turkey in 2007. At that time all had already ended their work as sandblasters at various facilities at least 10 months prior, and some had worked as little as a month. Mean age in the cohort was under 24 years in 2007, and first exposures occurred before a mean 18 years of age (CHEST 2015;148[3]:647-54).
In 2011, Dr. Metin Akgun and colleagues at Atatürk University in Erzurum, Turkey, revisited this cohort for follow-up and found that nine of the subjects had died. The researchers identified 83 of the surviving subjects and were able to conduct chest radiographs and spirometry on 74.
Dr. Akgun and colleagues sought to determine whether the silicosis cases, based on the International Labor Organization definitions of silicosis, had increased beyond the 53% seen in 2007, and measured pulmonary function loss and radiographic progression 4 years later.
The researchers found evidence of significant (more than 12%) pulmonary function loss in 66% of the follow-up cohort, and radiographic progression in 82%. Silicosis was found in all but one subject. Mean total length of exposure to silicone dust was about 3.5 years for this group, though no subject had been exposed after 2007.
Of the 74 living sandblasters available for reexamination, the prevalence of silicosis increased from 55.4% to 95.9%.
The findings, Dr. Akgun and colleagues wrote, confirmed that silicosis could develop without further exposure to silica dust after a course of work in denim sandblasting.
Younger age and younger age at first exposure were significantly associated with radiographic progression, the researchers found. Progression, pulmonary function loss, and mortality were associated with having worked as a foreman and with sleeping at the workplace, both indicative of higher exposure.
The nine subjects who died between 2007 and 2011 were more likely to have worked in more factories, to have been younger when first exposed, and never to have smoked.
Although Turkey banned silica sandblasting of denim jeans in 2009 in response to silicosis concerns, “the occupational health consequences are global as long as sandblasted jeans are sold, because production has shifted to other countries, including Bangladesh,” the researchers wrote in their analysis, recommending that clothing manufacturers “clarify their policies on purchasing sandblasted denim in light of the mortality and morbidity from silicosis associated with this process in the global supply chain.”
Dr. Akgun and colleagues noted that their study was limited by their inability to recruit the remaining 62 workers they had first seen in 2007, of whom a higher percentage were foremen. This reduced their ability to evaluate in more detail the differences in outcomes by exposure level.
Also, they noted, tuberculosis tests and sputum cultures were not performed at follow-up, leading to the possibility that mycobacterial infection may have affected disease progression in some subjects.
The authors disclosed that hey had no outside funding or conflicts of interest related to their findings.
In a study of young men who had worked as denim sandblasters, nearly all developed silicosis, while most had evidence of radiographic progression and/or significant lung function loss more than 4 years after their exposure to silica dust had ended.
The findings, published in the September issue of CHEST, derive from a study of 145 former sandblasters first identified in Turkey in 2007. At that time all had already ended their work as sandblasters at various facilities at least 10 months prior, and some had worked as little as a month. Mean age in the cohort was under 24 years in 2007, and first exposures occurred before a mean 18 years of age (CHEST 2015;148[3]:647-54).
In 2011, Dr. Metin Akgun and colleagues at Atatürk University in Erzurum, Turkey, revisited this cohort for follow-up and found that nine of the subjects had died. The researchers identified 83 of the surviving subjects and were able to conduct chest radiographs and spirometry on 74.
Dr. Akgun and colleagues sought to determine whether the silicosis cases, based on the International Labor Organization definitions of silicosis, had increased beyond the 53% seen in 2007, and measured pulmonary function loss and radiographic progression 4 years later.
The researchers found evidence of significant (more than 12%) pulmonary function loss in 66% of the follow-up cohort, and radiographic progression in 82%. Silicosis was found in all but one subject. Mean total length of exposure to silicone dust was about 3.5 years for this group, though no subject had been exposed after 2007.
Of the 74 living sandblasters available for reexamination, the prevalence of silicosis increased from 55.4% to 95.9%.
The findings, Dr. Akgun and colleagues wrote, confirmed that silicosis could develop without further exposure to silica dust after a course of work in denim sandblasting.
Younger age and younger age at first exposure were significantly associated with radiographic progression, the researchers found. Progression, pulmonary function loss, and mortality were associated with having worked as a foreman and with sleeping at the workplace, both indicative of higher exposure.
The nine subjects who died between 2007 and 2011 were more likely to have worked in more factories, to have been younger when first exposed, and never to have smoked.
Although Turkey banned silica sandblasting of denim jeans in 2009 in response to silicosis concerns, “the occupational health consequences are global as long as sandblasted jeans are sold, because production has shifted to other countries, including Bangladesh,” the researchers wrote in their analysis, recommending that clothing manufacturers “clarify their policies on purchasing sandblasted denim in light of the mortality and morbidity from silicosis associated with this process in the global supply chain.”
Dr. Akgun and colleagues noted that their study was limited by their inability to recruit the remaining 62 workers they had first seen in 2007, of whom a higher percentage were foremen. This reduced their ability to evaluate in more detail the differences in outcomes by exposure level.
Also, they noted, tuberculosis tests and sputum cultures were not performed at follow-up, leading to the possibility that mycobacterial infection may have affected disease progression in some subjects.
The authors disclosed that hey had no outside funding or conflicts of interest related to their findings.
FROM CHEST
Key clinical point: At 4 years post exposure to silica dust, nearly all men who formerly worked sandblasting denim in textile factories developed silicosis.
Major finding: Prevalence of silicosis increased from 55.4% to 95.9% between 2007 and 2011, while radiographic progression was seen in 82% of subjects at follow-up, and pulmonary function loss in 66%.
Data source: Observational cohort of 145 Turkish men first recruited in 2007 and screened for silicosis, with 74 followed up clinically in 2011.
Disclosures: Study was funded by investigator institutions in Turkey. The researchers reported having no conflicts.
Oropharyngeal exercises significantly cuts snoring
Eight minutes of oropharyngeal exercises performed three times a day significantly reduced snoring, according to a report in the September issue of CHEST.
At 3 months, the snore index and the total snore index dropped significantly for the exercise group but not the control group, said Vanessa Ieto. Ph.D., of the Sleep Laboratory of the University of São Paulo in Brazil and her associates. The regimen improved snoring symptoms among primary snorers as well as patients with mild to moderate obstructive sleep apnea, although the apnea-hypopnea index only improved among patients with moderate OSA, the researchers added. “This set of oropharyngeal exercises is a promising treatment of large populations suffering from snoring who are currently largely ignored by the medical community,” they said.
Snoring is embarrassing and disruptive, and can exacerbate pharyngeal neurogenic lesions and carotid artery atherosclerosis, but few studies have objectively examined interventions for primary snorers or patients with mild OSA, the researchers said. In their randomized trial of 39 such patients, the intervention group performed six oropharyngeal exercises three times daily, while the control group patients practiced breathing exercises and wore nasal dilator strips at night. Both groups performed nasal lavage with saline solution three times a day. Average age was 46 years, and mean body-mass index was 28.2 kg/m2. A blinded researcher evaluated data from computerized polysomnography and a snoring recorder (Chest 2015;148:683-81). Nasopharyngeal exercises used in the study were as follows:
- Push tip of tongue against hard palate and slide tongue backward (20 times).
- Suck entire tongue up against palate (20 times).
- Force back of tongue against floor of mouth while touching tip of tongue to bottom incisors (20 times).
- Elevation soft palate and uvula while intermittently saying “A” (20 times).
- Place finger in mouth while pressing buccinator muscle outward (10 times per side).
- Chew and deglutinate on both sides of mouth whenever eating. Avoid perioral contraction.
After 3 months, the intervention group had significantly improved on both the snore index (snores per hour; P = .041 for change from baseline) and the total snore index (the total sound intensity of snores per hour; P = .033), the researchers said. The intervention group also improved significantly on several subjective measures, including perceived intensity and frequency of snoring and sleep quality. The control group only improved in terms of subjective snore frequency, the researchers said.
The apnea-hypopnea index did not drop significantly for the overall intervention group, but did improve significantly among patients with moderate OSA, they added. “The most likely explanation is that a ‘floor effect’ in the AHI prevented the observation of any effect on this metric among patients with mild or no OSA at study entry,” they said. “Our results point out that snoring, rather than AHI, is probably the best metric to follow patients with mild forms of OSA in whom the most significant complaint is snoring.”
The study was funded by Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP) and Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq). The researchers declared they had no competing interests.
Eight minutes of oropharyngeal exercises performed three times a day significantly reduced snoring, according to a report in the September issue of CHEST.
At 3 months, the snore index and the total snore index dropped significantly for the exercise group but not the control group, said Vanessa Ieto. Ph.D., of the Sleep Laboratory of the University of São Paulo in Brazil and her associates. The regimen improved snoring symptoms among primary snorers as well as patients with mild to moderate obstructive sleep apnea, although the apnea-hypopnea index only improved among patients with moderate OSA, the researchers added. “This set of oropharyngeal exercises is a promising treatment of large populations suffering from snoring who are currently largely ignored by the medical community,” they said.
Snoring is embarrassing and disruptive, and can exacerbate pharyngeal neurogenic lesions and carotid artery atherosclerosis, but few studies have objectively examined interventions for primary snorers or patients with mild OSA, the researchers said. In their randomized trial of 39 such patients, the intervention group performed six oropharyngeal exercises three times daily, while the control group patients practiced breathing exercises and wore nasal dilator strips at night. Both groups performed nasal lavage with saline solution three times a day. Average age was 46 years, and mean body-mass index was 28.2 kg/m2. A blinded researcher evaluated data from computerized polysomnography and a snoring recorder (Chest 2015;148:683-81). Nasopharyngeal exercises used in the study were as follows:
- Push tip of tongue against hard palate and slide tongue backward (20 times).
- Suck entire tongue up against palate (20 times).
- Force back of tongue against floor of mouth while touching tip of tongue to bottom incisors (20 times).
- Elevation soft palate and uvula while intermittently saying “A” (20 times).
- Place finger in mouth while pressing buccinator muscle outward (10 times per side).
- Chew and deglutinate on both sides of mouth whenever eating. Avoid perioral contraction.
After 3 months, the intervention group had significantly improved on both the snore index (snores per hour; P = .041 for change from baseline) and the total snore index (the total sound intensity of snores per hour; P = .033), the researchers said. The intervention group also improved significantly on several subjective measures, including perceived intensity and frequency of snoring and sleep quality. The control group only improved in terms of subjective snore frequency, the researchers said.
The apnea-hypopnea index did not drop significantly for the overall intervention group, but did improve significantly among patients with moderate OSA, they added. “The most likely explanation is that a ‘floor effect’ in the AHI prevented the observation of any effect on this metric among patients with mild or no OSA at study entry,” they said. “Our results point out that snoring, rather than AHI, is probably the best metric to follow patients with mild forms of OSA in whom the most significant complaint is snoring.”
The study was funded by Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP) and Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq). The researchers declared they had no competing interests.
Eight minutes of oropharyngeal exercises performed three times a day significantly reduced snoring, according to a report in the September issue of CHEST.
At 3 months, the snore index and the total snore index dropped significantly for the exercise group but not the control group, said Vanessa Ieto. Ph.D., of the Sleep Laboratory of the University of São Paulo in Brazil and her associates. The regimen improved snoring symptoms among primary snorers as well as patients with mild to moderate obstructive sleep apnea, although the apnea-hypopnea index only improved among patients with moderate OSA, the researchers added. “This set of oropharyngeal exercises is a promising treatment of large populations suffering from snoring who are currently largely ignored by the medical community,” they said.
Snoring is embarrassing and disruptive, and can exacerbate pharyngeal neurogenic lesions and carotid artery atherosclerosis, but few studies have objectively examined interventions for primary snorers or patients with mild OSA, the researchers said. In their randomized trial of 39 such patients, the intervention group performed six oropharyngeal exercises three times daily, while the control group patients practiced breathing exercises and wore nasal dilator strips at night. Both groups performed nasal lavage with saline solution three times a day. Average age was 46 years, and mean body-mass index was 28.2 kg/m2. A blinded researcher evaluated data from computerized polysomnography and a snoring recorder (Chest 2015;148:683-81). Nasopharyngeal exercises used in the study were as follows:
- Push tip of tongue against hard palate and slide tongue backward (20 times).
- Suck entire tongue up against palate (20 times).
- Force back of tongue against floor of mouth while touching tip of tongue to bottom incisors (20 times).
- Elevation soft palate and uvula while intermittently saying “A” (20 times).
- Place finger in mouth while pressing buccinator muscle outward (10 times per side).
- Chew and deglutinate on both sides of mouth whenever eating. Avoid perioral contraction.
After 3 months, the intervention group had significantly improved on both the snore index (snores per hour; P = .041 for change from baseline) and the total snore index (the total sound intensity of snores per hour; P = .033), the researchers said. The intervention group also improved significantly on several subjective measures, including perceived intensity and frequency of snoring and sleep quality. The control group only improved in terms of subjective snore frequency, the researchers said.
The apnea-hypopnea index did not drop significantly for the overall intervention group, but did improve significantly among patients with moderate OSA, they added. “The most likely explanation is that a ‘floor effect’ in the AHI prevented the observation of any effect on this metric among patients with mild or no OSA at study entry,” they said. “Our results point out that snoring, rather than AHI, is probably the best metric to follow patients with mild forms of OSA in whom the most significant complaint is snoring.”
The study was funded by Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP) and Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq). The researchers declared they had no competing interests.
FROM CHEST
Key clinical point: Eight minutes of oropharyngeal exercises performed three times a day for 3 months significantly reduced snoring.
Major finding: The snore index and total snore index significantly dropped for the exercise group (P .017 and .03) but not for the control group.
Data source: A randomized single-blinded trial of 39 patients with primary snoring or mild to moderate obstructive sleep apnea.
Disclosures: The study was funded by Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP) and Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq). The researchers declared they had no competing interests.
