ABSTRACT

BACKGROUND:

Venous thromboembolism (VTE) is a common complication of hospitalisation and is associated with significant morbidity and mortality. The use of appropriate thromboprophylaxis can significantly reduce the risk of VTE but remains underutilised. In England, a comprehensive approach to VTE prevention was launched in 2010. This study aimed to evaluate the impact of the implementation of the national programme in a single centre.

METHODS:

A prospective quality improvement programme was established at King's College Hospital NHS Foundation Trust in 2010. The multidisciplinary thrombosis team launched mandatory documented VTE risk assessment and updated thromboprophylaxis guidance. Root cause analysis of hospital-associated thrombosis (HAT) was implemented to identify system failures, enable outcome measurement and to facilitate learning to improve VTE prevention practice. The key outcomes were the incidence of HAT and the proportion of events preventable with appropriate thromboprophylaxis.

RESULTS:

Documented VTE risk assessment improved from less than 40% to >90% in the first nine months. 425 episodes of HAT were identified over two years. A significant reduction in the incidence of HAT was observed following sustained achievement of 90% risk assessment (RR 0.88, 95% CI 0.74 - 0.98; P=0.014). The proportion of HAT attributable to inadequate thromboprophylaxis fell significantly from 37.5% to 22.4% (P=0.005).

CONCLUSION:

Mandatory VTE risk assessment can significantly reduce preventable HAT and thereby improve patient safety.

ABSTRACT

BACKGROUND:

Sleep disturbances are among the most common symptoms of military personnel who return from deployment. The objective of our study was to determine the presence of sleep disorders in U.S. Military Personnel referred for evaluation of sleep disturbances after deployment and examine associations between sleep disorders and service-related diagnoses of depression, mild traumatic brain injury (TBI), pain and post-traumatic stress disorder (PTSD).

METHODS:

Cross-sectional study of military personnel with sleep disturbances who returned from combat within 18 months. Sleep disorder rendered by clinical evaluation and polysomnogram with validated instruments to diagnose service-related illnesses.

RESULTS:

Of 110 military personnel included in our analysis, 97.3% were male (mean age 33.6 ± 8.0 years; mean BMI of 30.0 ± 4.3) and 70.9% returned from combat within 12 months. Nearly half, 47.3% met diagnostic criteria for 2 or more service-related diagnoses. Sleep disorders were diagnosed in 88.2% and 11.8% had a normal sleep evaluation and served as controls. Overall, 62.7% met diagnostic criteria for obstructive sleep apnea (OSA) and 63.6% for insomnia. The exclusive diagnoses of insomnia and OSA were present in 25.5% and 24.5% respectively; 38.2% had comorbid insomnia and OSA. Military personnel with comorbid insomnia and OSA were significantly more likely to meet criteria for depression (p <0.01) and PTSD (p<0.01) compared to controls and those with OSA.

CONCLUSIONS:

Comorbid insomnia and OSA is a frequent diagnosis in military personnel referred for evaluation of sleep disturbances after deployment. This diagnosis, which is difficult to treat, may explain the refractory nature of many service-related diagnoses.

ABSTRACT

BACKGROUND:

The objectives of this systematic review were to: synthesize the literature on measures of activities of daily living (ADL) that have been used in individuals with chronic obstructive pulmonary disease (COPD); provide an overview of the psychometric properties of the identified measures and describe the relationship of the disease-specific instruments with other relevant outcome measures for individuals with COPD and health-care utilization.

METHODS:

Studies that included a measure of ADL in individuals with COPD were identified using electronic and hand searches. Two investigators performed the literature search. One investigator reviewed the study title, abstract and full-text of the articles to determine study eligibility and performed the data extraction and tabulation. In case of uncertainty, a second reviewer was consulted.

RESULTS:

A total of 679 articles were identified. Of those, 116 met the inclusion criteria. Twenty-seven ADL instruments were identified, of which 11 instruments were respiratory disease-specific while 16 were generic. Most instruments combined Instrumental ADL (IADL) with Basic ADL (BADL). The majority of the instruments were self-reported; only 3 instruments were performance-based. Twenty-one studies assessed psychometric properties of 16 ADL instruments in patients with COPD.

CONCLUSIONS:

Although several ADL instruments were identified, psychometric properties have only been reported in a few. Selection of the most appropriate measure should focus on the target construct (BADL or IADL or both), type of test (disease-specific vs. generic and self-reported vs. performance-based), depth of information obtained and psychometric properties of the instruments. Given the relevance of ADL to the lives of patients with COPD its assessment should be more frequently incorporated as a clinical outcome in their management.

ABSTRACT

BACKGROUND:

Patients with lung cancer often present with recurrence, even after resection. The identification of risk factors for recurrence after resection is useful.

METHODS:

Among 1338 patients with lung cancer who underwent a complete resection, 277 developed recurrences post-surgery. Data regarding the TNM factors, histological subtype and the presence/absence of vessel invasion were analyzed retrospectively using the survival tree method to identify groups with a high risk of recurrence after resection.

RESULTS:

The results revealed that the T factor, the N factor, and lymphatic (ly) and blood (v) vessel invasion were related to the risk of recurrence and six combinations of these factors were identified using the survival tree method; Group A: v = 0, T <= 1b, ly = 0; Group B: v = 0, T <= 1b, ly >= 1; Group C: v = 0, T >= 2a; Group D: v >= 1, N <= 1,T <= 2b; Group E: v >= 1, N <= 1, T >= 3; and Group F: v >= 1, N >= 2. The six groups were then further classified into three groups: a low-risk group (Group A), a moderate-risk group (Groups B, C and D), and a high-risk group (Groups E and F). The 5-year recurrence-free survival rate was approximately 98% for the low-risk group, 75% for the moderate-risk group, and 30 % for the high-risk group.

CONCLUSIONS:

Combining the T, N, v and ly factors allowed the precise identification of a group with a high risk of recurrence after resection.

ABSTRACT

BACKGROUND:

Suicide rates among lung cancer patients are higher than the general population. This study aims to identify patient and disease characteristics associated with suicide in lung cancer patients.

METHODS:

We conducted an analysis of subjects with primary lung cancer diagnosed between 1973 - 2008 recorded in the Surveillance, Epidemiology and End Results (SEER) database.

RESULTS:

Of 871,230 persons diagnosed with lung cancer, 1184 suicides were identified. The rate of suicide did not change considerably over time, with 8.83 compared to 7.17 suicides per 10,000 persons-years in 1973-79 and 2000-09, respectively. The standardized mortality ratio (SMR) of the entire cohort was 4.95, with an SMR of 13.4 within 3 months of a cancer diagnosis. Despite most subgroups having a higher SMR than the general population, a wide variation of suicide risk was seen amongst different subgroups, including histologic type (SMR 1.58 vs 7.28 in bronchoalveolar and small cell carcinoma, respectively). The highest SMR's were found in: males; older age; higher grade tumour; metastatic disease, and patients who did not receive or refused treatment. Despite the higher SMR among metastatic patients, over 50% of suicides occurred in those with locoregional, and potentially curable disease.

CONCLUSION(S):

Lung cancer patients have a higher risk of suicide compared with the general US population, especially within 3 months of diagnosis. Despite the higher SMR among poorer prognosis patients, a concerning proportion of suicides occur in potentially curable patients, highlighting the need for effective screening strategies to avoid this preventable cause of death.

ABSTRACT

BACKGROUND:

The association between levels of acute kidney injury (AKI) during ICU admission and long term mortality are not well defined.

METHODS:

We examined medical records of adult patients admitted to a large tertiary medical center with no history of end stage renal disease (ESRD), who survived 60 days from ICU admission between the years 2001-2007. The extracted data included demographic, clinical information, physiological data as well as dates of death.

RESULTS:

Among 15,048 patients, 12,399 (82.4%) survived 60 days from ICU admission and consisted the study population. 5663 (45.7%) did not develop AKI during their ICU admission, while 4589(37.0%), 1613 (13.0%) and 534 (4.3%) developed progressively severe levels of AKI as defined by the Acute Kidney Injury Network criteria (AKIN 1, AKIN 2 and AKIN 3 respectively). Only 42.5% of Patients who developed AKIN 3 survived two years from ICU admission. AKIN 3 patients had a 61% higher mortality risk two years from ICU discharge compared to patients who did not develop AKI. Patients who developed AKIN 1 and AKIN 2 had similar increased mortality risk two years from ICU admission (HR 1.26 and 1.28 respectively). Level of estimated glomerular filtration rate (eGFR) on ICU discharge and chronic kidney disease (CKD) were found to be associated with long term mortality.

CONCLUSIONS:

Patients who develop AKI in the ICU have significantly increased risks of death that extend beyond their high ICU mortality rates. These increased risks of death continue for at least two years after the index ICU admission.

ABSTRACT

BACKGROUND:

To evaluate the efficacy of "Ipsilateral Opposite Side Aspiration", a new method to overcome resistant pneumothorax after failure of a simple aspiration. The patient position is reversed (from prone to supine or vice versa) and the aspiration repeated.

METHODS:

Between January 1, 2010 and April 3, 2012, 129 consecutive CT-guided percutaneous needle biopsies of lung nodules were performed in 127 patients (75 men, 52 women; mean age 67.8 years; range 26-88 years). Two patients underwent repeat biopsies. The mean lesion diameter was 38 mm (range 8-110 mm). Core biopsy and FNA were performed in 126 procedures; in 3 cases, only FNA was performed. In the cases with symptomatic minimal pneumothorax and in all patients with pneumothorax >10 mm, immediate, simple manual aspiration was performed. Ipsilateral opposite side aspiration was performed when simple aspiration failed.

RESULTS:

Among 129 CT-guided biopsies, pneumothorax was detected by CT in 54 (42%); 51 (39%) during the biopsy. Delayed pneumothorax occurred in 2 patients (1.55%). Manual aspiration to treat pneumothorax was performed in 27 (21%) of 129 procedures. Simple aspiration was successful in 20 (74%) of these 27 cases. Ipsilateral opposite side aspiration was accomplished in the remaining 7 (26%) and was successful in 6 (86%). Two (1.55%) of 129 procedures required chest tube placement.

CONCLUSIONS:

Immediate, simple, percutaneous aspiration of iatrogenic pneumothorax was successful in 74% of patients needing treatment. Our proposed new method of ipsilateral opposite side aspiration offers a solution for patients who remain with resistant pneumothorax after simple aspiration.

ABSTRACT

AIM:

This study aimed to determine whether radiologic assessment of early bronchiectasis in young children with cystic fibrosis (CF) is dependent on lung volume.

METHODS:

This study, approved by the hospital ethics committee, included 40 young children with CF from a newborn screened population, contributing paired volume-controlled inspiratory and expiratory volumetric chest CT scans, acquired under general anaesthesia while clinically stable. Bronchiectasis was assessed using a semi-quantitative CT score in inspiration and expiration and the sensitivity of the expiratory CT to detect bronchiectasis was compared to the inspiratory CT using sensitivity, intraclass correlation coefficient and Bland-Altman plots. Matched inspiratory and expiratory airway vessel measurements were then obtained in a subset of 10 children and a linear regression model with generalised estimating equations to examine the relationship between lung volume and airway:vessel ratio after adjusting for age and vessel size. The number of visible airways in inspiration and expiration was compared in 20 children using the Wilcoxon signed rank test.

RESULTS:

The expiratory scan had poor sensitivity to detect bronchiectasis (sensitivity 0.46), and underestimated disease extent (p<0.001). Further, the airway:vessel ratio was consistently higher in inspiration, independent of age and vessel size (p<0.001), with significantly more airways were visible in inspiration, independent of age (median visible airways: 60 vs 31, p<0.001).

CONCLUSION:

Radiologic assessment of early bronchiectasis using chest CT is dependent on lung volume in young children with cystic fibrosis. Lung volume during image acquisition should be standardised to evaluate airway dimensions in young children using chest CT.

ABSTRACT

BACKGROUND:

Chronic obstructive pulmonary disease (COPD) is a common comorbidity in heart failure. The efficacy of implantable cardioverter-defibrillator (ICD) therapy has not been determined in heart failure patients with COPD.

METHODS:

We examined the incidence of ICD shocks and mortality in 628 consecutive patients who underwent defibrillator implantation at the Minneapolis Veterans Affairs Medical Center from 2006 to 2010.

RESULTS:

Mean age of the patients was 67±10 years and 99% were male. Patients with COPD (n=246, 39%) were functionally more limited (p<0.0001) and more likely to have ICD for primary prevention of sudden death (p=0.04) than those without COPD. Over a median 4.1 years [IQR25,75 2.2, 5.7] of follow-up, COPD patients had a higher incidence of appropriate shocks (29% vs.17%; p<0.0001) compared to those without COPD, whereas the incidence of inappropriate shocks was similar (9% vs. 10%, respectively; p=0.61). In multivariable analysis, COPD was associated with a 2-fold increase in the odds of appropriate ICD shock (95% confidence interval 1.3-2.9; p=0.001). Incidence of ICD shocks did not vary with severity of COPD. Although all-cause mortality was higher in COPD patients than those without COPD (29% vs. 21% respectively; p=0.029), one-year mortality (5.3% vs. 2.6%, respectively; p=0.08) and the average time from first appropriate ICD shock to death was comparable (median 2.3 years [IQR25,75 1.2, 4.4] vs. 2.8 years [IQR25,75 1.4, 5.3], respectively, p=0.29).

CONCLUSIONS:

Patients with COPD have a higher incidence of ICD shocks than those without COPD and appear to benefit from ICD therapy.

ABSTRACT

BACKGROUND:

The contribution of environmental tobacco smoke exposure (ETS) to pulmonary morbidity in children with sickle cell anemia (SCA) is poorly understood. We tested the hypothesis that children with SCA and ETS would have an increased prevalence of obstructive lung disease and respiratory symptoms compared to children with SCA but without ETS.

METHODS:

Parent-report of ETS and respiratory symptom frequency were obtained for 245 children with SCA as part of a multi-center prospective cohort study. 196 children completed pulmonary function testing. Multivariable regression models evaluated the associations between ETS exposures at different time points [prenatal, infant (birth-2 years), preschool (2 years -first grade) and current], and lung function and respiratory symptoms.

RESULTS:

Among 245 participants, a high prevalence of prior (44%) and current (29%) ETS was reported. Of the 196 children who completed pulmonary function testing, those with parent-reported infant and current ETS were more likely to have airway obstruction (defined as Forced Expiratory Volume in 1 second /Forced Vital Capacity ratio (FEV1/FVC) below the lower limit normal) compared to unexposed children (22.0% vs. 3.1%, p<0.001). Those with ETS also had a lower FEF25-75/FVC ratio (0.82 vs. 0.97, p=0.001) and were more likely to have evidence of bronchodilator responsiveness(23% vs. 11%, p=0.03). Current and prior ETS and in utero exposure were associated with increased frequency of respiratory symptoms.

CONCLUSIONS:

ETS exposure is associated with evidence of lower airway obstruction and increased respiratory symptoms in SCA.