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CONCLUSION: 1.- NO ETCGI optimal application appears to improve oxygenation and ventilation substantially. 2.- All patients survived the refractory hypoxemia. 3.-One patient died due to refractory septic shock, after a new episode of sepsis. 4.- No high levels of NO2 ( 1,0 ppm). 5.- No barotrauma episodes, in spite use high tidal volume (two patients development barotrauma previous and were treated with NO ETCGI without ventilatory problems). REFERENCE: 1.Herrero S,
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FUNDAMENTAL FREQUENCY MEASURES WITH MORPHEUS OF HUMAN SLEEP ELECTROENCEPHALOGRAPHY(EEG) IN SEVERE SLEEP APNEA WITH EARLY INTERVENTION OF CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP) Richard K. Bogan MD* Jo Anne Turner MSN Alex Novodvorets MS Koby Todros BS Baruch Levy BS SleepMed, Columbia, SC PURPOSE: To evaluate a new measure of EEG synchrony or stability using fundamental frequency analysis provided by Morpheus in subjects with severe obstructive sleep apnea (OSA) adequately treated with CPAP using a split night protocol. METHODS: A total of 27 adults were selected with a primary diagnosis of obstructive sleep apnea and who were treated with CPAP during their initial study. Each individual had a baseline and treatment period. Only those individuals with a respiratory disturbance index (RDI) 10 episodes per hour and oxygen saturation greater than 85% during the ideal CPAP titration period were selected. When there was more than one CPAP level that this occurred, the multiple levels were included. Fundamental frequency values below 4 Hz are believed to represent increased EEG synchrony. The percentage of fundamental frequency below 4 Hz was calculated during the baseline period and ideal CPAP titration period (total sleep time). RESULTS: Means with standard deviations are reported. There were 24 males (ages 25-77) and 3 females (ages 46-52). Body mass index was 35(7); Epworth Sleepiness Scale 12(5), and SleepMed Insomnia Index 16(8). Low oxygen saturation at baseline was 81%(6); oxygen saturation at ideal CPAP level 91%(2); RDI at baseline 71(26); and RDI at ideal CPAP level 3(3). Fundamental frequency under 4Hz during the baseline period was 12%(13) and at the ideal CPAP pressure 31%(13). Independent t-tests comparing % of fundamental frequency below 4Hz at the baseline period with the ideal CPAP period were significant p 0.001. CONCLUSION: Early intervention with CPAP in OSA improves sleep quality. Automated analysis that calculates modal frequency of adaptive segmentation and fuzzy logic segments in sleep EEG demonstrates EEG synchrony that is believed to reflect improvement in sleep quality. CLINICAL IMPLICATIONS: Enhanced resolution by automated analysis offers improved efficiencies, reproducibility, and insights into sleep states and processes.
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CLINICAL UTILITY OF BIOELECTRIC SIGNALS IN THE DIAGNOSIS OF OBSTRUCTIVE SLEEP APNEA (OSA) IN UNATTENDED SETTINGS Pierre Mayer MD* Vincent Jobin MD Francois Bellemare PhD Hotel Dieu of CHUM, Montreal, PQ, Canada PURPOSE: The standard diagnostic test of OSA, i.e. overnight polysomnography (PSG), is complex and difficult to perform outside the sleep laboratory. However, the value of electrophysiological and respiratory monitoring has not been assessed critically in unattended settings. In this study we evaluated whether full PSG is necessary to establish a diagnosis of OSA in unattended studies. METHODS: Full unattended PSG studies were conducted in the home place (25 tetraplegic patients)or in the hospital (25 surgical patients studied preoperatively)using a standard montage. Installation of the biosensors was performed by a trained sleep technician. Recording was initiated at a preset time and all signals stored on a digital storage media (Flash card) and subsequently downloaded to a desktop computer for analysis. No overnight monitoring was possible. The PSGs were first scored using standard criterions by one of 3 trained sleep technicians and an apnea/hypopnea index (AHI) calculated as the number of respiratory events per hour of sleep as determined by sleep staging. The analysis was then repeated on a separate day and in a blind fashion using respiratory variables only (i.e. without EEG and EMG signals) and a respiratory disturbance index (RDI) calculated as the number of respiratory events per hour of recording time. RESULTS: Sleep efficiency was 77.1 13.8%. Recording time exceeded sleep time by 117 79 minutes (p .03) but RDI (20.5 21.3) was not significantly different from AHI (22.9 24.2; p .116). Both were highly correlated (r2 .82). Using a AHI diagnostic cutoff value 15 events/h, the diagnostic sensitivity and specificity of RDI were both 86%. If a RDI cutoff value of 10 events/h was adopted instead, sensitivity would be 100%. CONCLUSION: Because of frequent arousal, the Rechtschaffen and Kales method for scoring sleep markedly underestimate sleep time as well
Evaluation of the Clinical Concepts of Normal Breathing, Types of Breathing and the Obstruction in Nasopharynx and Oropharynx
Frequency % No obstruction Nasopharynx obstruction Oropharynx obstruction Naso and Oropharynx obstruction Total n n n n NasalBreathing 61 68.54% 15 16.85% 6 6.74% 7 7.87% 89 OralBreathing 1 11.11% 4 44.44% 3 33.33% 1 11.11% 9 MixedBreathing 25 53.19% 8 17.02% 10 21.28% 4 8. 51% 47 Total 87 27 19 12 145
DISCLOSURE: Florence Sekito, None. A STUDY ON PREVALENCE ESTIMATES OF OBSTRUCTIVE SLEEP APNEA IN INDIAN POPULATION Rajendra Prasad MD* Rajiv Garg MD Ram K. Verma MD S. P. Agarwal MS R. C. Ahuja MD King Georges Medical University, Lucknow, India PURPOSE: To know prevalence estimates for key symptoms and features that can indicate the presence of obstructive sleep apnea(OSA) in Indian population. METHODS: Single centre cross sectional study done from August 2003 to July 2004 in consecutive apparently healthy attendants of 25-64 years age group coming to outdoor of Department of Pulmonary Medicine, King Georges Medical University, Lucknow, India. We recorded
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THE INCIDENCE OF POSSIBLE OBSTRUCTIVE SLEEP APNEA SYNDROME IN SUBJECTS WITH ACUTE MYOCARDIAL INFARCTION AND NORMAL CORONARY ANGIOGRAPHY Michael Chalhoub MD* Marwan Elia MD Mohammed Zgheib MD Theodore Maniatis MD Staten Island University Hospital, Staten Island, NY PURPOSE: The purpose of this study is to compare the incidence of possible obstructive sleep apnea syndrome (OSAS) in patients with acute myocardial infarction (AMI) and normal coronary angiography to the incidence of possible OSAS in patients with MI and abnormal coronary angiography. METHODS: All patients admitted to a university hospital with the diagnosis of AMI were evaluated. AMI was defined as having 2 out of 3 criteria: Chest pain, ST elevation of 1 mm in two contiguous leads, or elevated cardiac enzymes. Patients who underwent coronary angiography were included in the study. The subjects were asked a set of questions. The questions were scored from 1 to 3. The questions addressed the following: Epworth sleepiness scale (ESS). ESS 10 (score 1), ESS 18 (score 2), snoring (score 1), witnessed apneas (score 3), falling asleep in inappropriate situations (score 2), unrefreshed sleep (score 1), and history of OSA diagnosed by NPSG. The subjects were then classified into five classes. Class I highly unlikely to have OSA (score 1), class II unlikely to have OSA (score 2), class III likely to have OSA (score 3), class IV highly likely to have OSA (score 3), and class V definite OSA (OSA diagnosed by nocturnal polysomnography (NPSG)). The subjects were divided into two groups. Group I included patients with normal coronaries, whereas group II included patients with abnormal coronaries on angiography. RESULTS: A total of 55 patients were included in the final data analysis. 22 subject in group I, and 33 in group II.The results are summarized in the following table. CONCLUSION: The incidence of possible OSAS was significantly higher in patients with AMI and normal coronaries compared to patients with AMI and abnormal coronaries on angiography. 28.5% compared to 6% p value 0.035. CLINICAL IMPLICATIONS: Patients with AMI and normal coronary angiography should be investigated for the possibility of OSAS. Those found to have high likelihood of having OSAS should be sent for NPSG and adequate treatment offered.
SLEEP APNEA IN SARCOIDOSIS Majid M. Mughal MD* Joseph Golish MD Mani Kavuru MD Oluranti Aladesanmi MD Nancy Ivansek Daniel A. Culver DO Cleveland Clinic Foundation, Cleveland, OH PURPOSE: The main purpose of this study is to estimate the prevalence of sleep related breathing disorders in patients with sarcoidosis by using Sleep Apnea/Sleep Disorders Questionnaire (SA/SDQ) and Epworth Sleepiness Scale (ESS). METHODS: 70 consecutive patients with diagnosis of biopsy proven sarcoidosis seen at the sarcoid clinic were screened for sleep related breathing disorders using SA/SDQ and ESS. The SA/SDQ consists of 8 questions and 4 other items related to weight, smoking status, age, and body mass index, which are calculated to generate a raw score. Total scores range from 0-60. To suspect sleep apnea, cutoffs of 32 for women and 36 for men were used as a criteria for sleep study referral. RESULTS: 70 patients with sarcoidosis completed the questionnaires. There were 42 females and 28 males with a mean age of 48 10 years. 34% of pateints were African American. Mean duration of diagnosis was 78 months. 60% of patients had 2 or more organs involved. Approximately 2/3rd of patients were actively treated with steroids or other immunosupressive agents (mean prednisone dose was 7 mg/day). 39 patients had positive questionnaires (25 with positive SA/SDQ while 14 with positive ESS). Considering the reported 81% specificity of SA/SDQ for sleep apnea in general population, 39% of patients will most likely have sleep apnae syndrome by polysomnography. CONCLUSION: The prevalence of sleep apnea syndrome in patients with sarcoidosis is significantly high. In this study, we persented our experience with SA/SDQ as a screening instrument for sleep disordered breathing in a sample of patients with sarcoidosis. CLINICAL IMPLICATIONS: Screening tools such as the SA/SDQ are gaining increasing importance because of high prevalence of sleep disordered breathing in chronic diseases and the high cost of polysomnography. Sleep disordered breathing is highly prevalent in our sarcoid population and SA/SDQ may be a useful test in identifying patients at risk for sleep apnea syndrome. DISCLOSURE: Majid Mughal, None.
THE ACCURACY OF NON-RESTRICTIVE SENSING SYSTEM FOR EVALUATING SLEEP APNEA SYNDROME UNDER THREE-DIMENSIONAL FIBER-GRATING SENSORS Hisashi Takaya MD* Toranomon Hospital, Tokyo, Japan PURPOSE: Nasal flow sensors are utilized for diagnosis of sleep apnea syndrome (SAS). Discomfort and fluctuation in sensitivity caused by body movements are problems when patients wear nasal flow sensors during polysomnography (PSG) tests. The aim of this study was to clarify the
Results are mean standard deviations unless otherwise specified. BMI Body Mass Index.
DISCLOSURE: Michael Chalhoub, None.
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IS OBSTRUCTIVE SLEEP APNEA (OSA) IN NON-OBESE PATIENTS A LESS SERIOUS DISEASE THAN IN OBESE PATIENTS? Ammar Ghanem MD* Syed Mahmood MD Marshall University, Huntington, WV PURPOSE: OSA occurs in non-obese patients,but they may exhibit different characteristics than obese patients with OSA. To elucidate this point,we investigated several physiological and clinical parameters among non-obese and obese OSA patients. METHODS: Of 254 patients referred to sleep clinic,we identified 102 patients with OSA(Apnea Hypopnea Index 5). We classified OSA patients with Body Mass Index(BMI) 30 as non-obese and those with a BMI 30 as obese. We conducted a retrospective evaluation that included demographic,physiological and clinical data and compared the non obese and obese groups. For statistical comparisons, continuous variables were analyzed by students t-test and categorical variables by chi-square. Fishers exact test was used for analysis when a variable contained less than 5 observations. RESULTS: Of 102 patients with OSA,17(16.7%)were non-obese and 85(83.3%)were obese. The groups of non-obese and obese OSA patients differed significantly in four parameters. Mean AHI was 13.5 in the non-obese group and 27.6 in the obese group(P 0.03). Non-obese patients were older(average age 57.1 years compared to 48.3 years among obese patients)(t-test,p 0.01);used more sedatives(usage of one or more sedatives by 52.9% in non-obese group compared to 24.7% in the obese group)(Chi-square,p 0.02);and,exhibited less upper airway narrowing(23.5% of the non-obese group compared to 55.1% in the obese group)(Chi-square,p 0.02). Only one non-obese patient(5.9%) was younger than 50,compared to 48 patients(56%)in the obese group(Chisquare,p 0.0001). There were no significant differences between nonobese and obese OSA patients in gender,family history of OSA,facial
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Variable (mean
SD)
Age Body mass index (kg/m2) Pulmonary Function (% predicted) FEV-1 FVC FEV-1/ FVC TLC ERV DLCO FEV-1 FVC FEV-1/FVC TLC ERV DLCO Arterial blood gases pH PaO2 PaCO2 Polysomnogram n (%) Apnea-hypopnea index 5 (n) *p-value 0.05
81 82 80 88 48 85
16 15 5 12 37 22
77 77 81 87 37 85 7.39 69 48.4 1
high probablity patients were scheduled for polyomnography. Sleep Disordered Breathing was identified in 70 per cent of those patients. CONCLUSION: The 6 point screening questionnaire appeared to delineate a higher risk group for sleep disordered breathing in this cohort of patients with known heart failure. Less than 30 per cent of the low probability cohort were ultimately studied. CLINICAL IMPLICATIONS: SDB is present in approximately 50 percent of patients with known stable CHF. A short simplified 6 point data set appeared to be sensitive in selecting patients with a high probability for SDB. Use of the questionnaire should identify patients at risk for SDB earlier, and could prioritize their early evaluation and should result in earlier treatment. DISCLOSURE: John Roehrs, None. THE IMPACT OF PHYSICAL CHARACTERISTICS AND POLYSOMNOGRAPHIC FINDINGS TO HEALTH RELATED QUALITY OF LIFE (QOL) IN A PATIENT WITH OBSTRUCTIVE SLEEP APNEA (OSA) Asegid M. Kebede MD* Amao Olusegun MD Samir Fahmy MD SUNY Downstate Medical Center, Brooklyn, NY PURPOSE: OSA is a relatively common condition with a prevalence of 5%. Significant reduction in QOL is the major complication OSA.Continuous positive airway pressure (CPAP) titrated to eliminate Apnea and Hypoapnea significantly improve quality of life. Previous study indicates there is no correlation between QOL and severity of sleep apnea. There are various physical and polysomnographic finding that associated with the decrease in health related QOL in this cohort study. The purpose of this study is to evaluate the impact of polysomnographic features and physical characteristics to health related QOL in a patient with OSA. METHODS: The Study was conducted in sleep laboratory of Kings County medical center, Brooklyn, New York. We studied 34 adult (22 male and 12 female) patients with mean age of 45 (19-72), a body mass index (BMI) of 41.99 and diagnosis of OSA (apnea-hypoapnea index more than 5). Patients with major medical and psychiatric illness were excluded. Baseline physical and polysomnographic characteristics were obtained. The health related QOL was assessed by administering medical outcomes short-form ( MOS SF-36), a 36-item questionnaire that summarizes health related QOL using eight subscales and two summary scores. The results were analyzed using Pearson correlation statistics. RESULTS: The was significant negative correlation between BMI and SF-36 physical score ( p 0.001). Subclass analysis also showed significant correlation between BMI and all components. There was also positive correlation between sleep efficiency and physical functioning and mental
DISCLOSURE: Georg Nilius, Grant monies (from industry related sources) The study was fianced by gift from fisher and Paykel healthcare A RANDOMISED SINGLE-BLINDED CROSS-OVER TRIAL OF SESAME OIL (NOZOIL) FOR THE TREATMENT OF NASAL SYMPTOMS ASSOCIATED WITH CPAP John F. Feenstra MBBS* Kelli Rixon BSc Craig Hukins MBBS Sleep Disorders Centre, Princess Alexandra Hospital, Brisbane, Australia PURPOSE: Nasal symptoms are a common side effect of CPAP therapy. Although most patients experience self-limiting nasal congestion, at least 10% complain of persistent nasal problems to some degree after 6 months of therapy. Nasal symptoms can be treated in a variety of ways (inhaled nasal steroids, antihistamines, topical saline sprays and heated humidification); there is limited trial data of their effectiveness. The ideal and best treatment is heated humidification. Unfortunately heated huCHEST 2005Poster Presentations
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Diagnostic vs. Titration Change in Sleep Efficiency (%) Change in Latency to REM-sleep (min) Change in Stage 1 Sleep (%) Change in Stage 2 Sleep (%) Change in Apnea-hypopnea index (per hour)
Improvement No Improvement with CPAP with CPAP p Value 13.1 (27.8) 40.8 (108) 4.8 (8.9) 5.0 (10.3) 21.7 (50.7) 9.6 (14.2) 48.9 (75.8) 2.9 (12.1) 7.5 (18.2). 3.3 (19.5) 0.010 0.023 0.050 0.023 0.094
DISCLOSURE: Marcel Baltzan, None. COMPLIANCE IN CHINESE PATIENTS WITH OBSTRUCTIVE SLEEP APNEA SYNDROME (OSAS): A SINGLE NURSE-CONDUCTED EDUCATIONAL SESSION WOULD MAKE A DIFFERENCE Maggie P. Lit RN* C.K. Ng MBBS W.H. O MBBS H.W. She MBBS W.L. Law MBBS Samuel Lee MBBS Johnny W. Chan MBBS Queen Elizabeth Hospital, Kowloon, Hong Kong PRC PURPOSE: CPAP is the cornerstone treatment for OSAS, yet its compliance was unsatisfactory. Attempt is made to look at the factors associated with compliance. METHODS: A retrospective study evaluating CPAP compliance in a group of newly diagnosed OSAS Chinese patients in a regional hospital over a 6-month period (August 2003 - February 2004). Objective and self-reported compliance was obtained 6 months after commencing CPAP. Acceptable compliance was defined as CPAP usage for at least 4 hours/day in at least 70% of the night. Suboptimal treatment was defined
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SUBJECTIVE SLEEP PERCEPTIONS FROM POST-TEST QUESTIONNAIRE AND OBJECTIVE SLEEP PARAMETERS AMONG AFRICAN AMERICAN AND CAUCASIAN POPULATION WITH OBSTRUCTIVE SLEEP APNEA Cynthia R. Crowder MD* Houman Dahi MD Narong Simakajornboon MD Denise Sharon Tulane University Health Sciences Center, New Orleans, LA PURPOSE: Currently, there are controversies about the relationship between OSA and subjective sleepiness. Recent study has shown the correlation between subjective sleep complaints and respiratory arousal. However, there is limited information on the relationship between subjective sleep perceptions and objective sleep parameters in different patient populations. METHODS: A retrospective study was performed in patients with obstructive sleep apnea. All patients completed post-test questionnaire after sleep study as part of our routine procedure. Any patients with significant neurological diseases, psychiatric disorder, central sleep apnea, severe periodic leg movements (PLMI 50) or incomplete records were excluded from the study. RESULTS: 79 patients met the criteria for entry into analysis; 41 African American (B) and 38 Caucasian (W). The average age is 47.5 10.1 years and the mean apnea-hypopnea index (AHI) is 25.9 19.5 per hour. There was no difference between age, sex, BMI or AHI between two groups. The subjective feeling upon awakening (Question 15 (Q15); scale 1-6) correlated with the arousal index (r 0.27, P 0.019), AHI (r 0.3, P 0.008), and apnea-hypopnea related arousal (r 0.24, P 0.038). There is a tendency toward significant correlation between subjective sleep quality (Question 7 (Q7), scale 1-4) and arousal index (r 0.22, P 0.054) as well as between Q7 and AHI (r 0.22, P 0.056). The subgroup analysis revealed a significant correlation between Q15 and arousal index only in African American population (r 0.36, P 0.02 [B] versus r 0.17, P NS [W]). However, Q15 correlated with AHI only with Caucasian population (r 0.20, P NS [B] versus r 0.46 P 0.01 [W]). CONCLUSION: It is concluded that subjective perception from post-sleep questionnaire correlates significantly with severity of apnea and frequency of arousals especially respiratory arousals. The subjective perception correlates only with the frequency of arousals in African American population, while subjective perception of Caucasian population correlates directly with severity of apnea.
DISCLOSURE: Cynthia Crowder, None. EFFECT OF ZOLPIDEM ON THE EFFICACY OF NASAL CONTINUOUS POSITIVE AIRWAY PRESSURE AS TREATMENT OF OBSTRUCTIVE SLEEP APNEA Prakash B. Patel MD* Richard B. Berry MD University of Florida, Gainesville, FL PURPOSE: Obstructive sleep apnea (OSA) patients using CPAP (Continuous Positive Airway Pressure) are frequently prescribed BZRA(Benzodiazepine receptor agonist) hypnotics. However, no prior studies have evaluated the effect of BZRAs on the efficacy of CPAP. CPAP works as a pneumatic splint so upper airway muscle tone is much reduced. Therefore, further reduction in muscle tone by BZRAs should be minimal. For this reason, we hypothesize that Zolpidem (selective BZRA with greater hypnotic than muscle relaxant properties)should not cause a change in the level of required CPAP to maintain an open airway. METHODS: To test this hypothesis, we conducted a double blind placebo controlled cross-over study in patients with OSA currently being treated with CPAP. Patients were studied on three nights in the sleep laboratory over three consecutive weeks (one night per week). On night one, the pressure level required to prevent apnea, hypopnea, and snoring was determined (optimal pressure). On the second night and third nights, either Placebo or Zolpidem 10 mg was given and subjects slept on the CPAP level determined by first night (optimal pressure). RESULTS: For our initial four patients, there was no significant difference in Total Sleep Time (TST), REM sleep, AHI overall, or AHI NREM sleep (see table). CONCLUSION: Study of a limited number of OSA patients suggests Zolpidem 10 mg does not significantly increase the AHI in a patient treated with an appropriate level of CPAP. We plan to study at least 20 patients to confirm this preliminary result. CLINICAL IMPLICATIONS: If further study confirms our preliminary findings this would suggests Zolpidem can be used safely in OSA patients with insomnia who are on CPAP. This may improve tolerance of CPAP in these patients. DISCLOSURE: Prakash Patel, None.
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Year preceding Year anteceding VCD diagnosis VCD diagnosis Health Care Measure n 43 n 43 Total Physician Visits Primary Care Visits Urgent Care Visits Hospitalizations Total Prescriptions 796 265 77 12 767 603 137 49 5 767
DISCLOSURE: Jeffrey Mikita, None. DISCLOSURE: Luke Short, None. REAL-TIME ANALYSIS OF EXHALED BREATH WITH MPLIMS: OBSERVED NITRIC OXIDE PROFILE Luke C. Short PhD* Thorsten Benter PhD Bergische Universitat Wup pertal, Wuppertal, Germany PURPOSE: An elevated concentration of nitric oxide (NO) in alveolar ventilation indicates inflammatory stress within the lung. Trace-gas analysis using mass spectrometers (MS) have been used extensively within the atmospheric community with great success. We present here the first description of time-resolved NO measurement in breath using photoionization MS, providing new capabilities for the medical investigator, such as isotopic tracing. METHODS: For NO measurement, we use resonance enhanced multiphoton ionization (REMPI) coupled with a time-of-flight MS with a medium pressure laser ion source. A single male subject breathes NO-free air for several minutes, and then the exhaled breath is monitored for NO. RESULTS: The ability of REMPI to differentiate among three different isotopomers of NO is demonstrated, and then the concentration profile of NO in exhaled breath is measured. A similar time-dependence concentration is found as observed by previous techniques. CONCLUSION: This study presents MPLI-MS as a new technique available for the time-resolved measurement of NO in breath. The resulting system can be made portable and brought into the medical setting using newer-generation, broad-bandwidth lasers. When measuring HIGH RESOLUTION COMPUTED TOMOGRAPHY EVALUATION OF AIRWAY DISTENSIBILITY IN ASTHMATIC AND HEALTHY SUBJECTS Antonio Castagnaro MD* Alfredo Chetta MD Emilio Marangio MD Panagiota Tzani MD Marina Aiello MD Raffaele Dippolito MD Nicola Sverzellati MD Maurizio Zompatori MD Dario Olivieri MD Dept of Clinical Sciences, Respiratory Disease Section, University of Parma, Parma, Italy PURPOSE: In bronchial asthma, airway wall remodeling may result in reduced airway distensibility. In this study, we assessed in asthmatic patients both the baseline airway caliber and distensibility by means of High Resolution Computed Tomography (HRCT). METHODS: We studied 7 patients (2 M, age range: 36-69 yrs) affected by chronic asthma (FEV1 range: 30-87 % of predicted; FEV1/VC range: 48-75 % of predicted) in stable clinical conditions and 6 healthy subjects (3 M, age range: 29-50 yrs), as a control group. In all subjects, HRCT scanning, obtained at suspended end-espiratory volume, was performed at rest and during ventilation with 6 and 12 cmH2O by nCPAP, both at baseline and after the inhalation of 200 mcg oxitropium bromide MDI.. External and lumen diameter (mm) of the right apical upper lobe bronchus were measured in all HRCT scans.
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Asthmatics Patients Baseline At rest external (mm) lumen (mm) external (mm) lumen (mm) 6.2 0.9 3.3 0.7 7.3 1.8 4.0 1.6 6 cmH2O 12 cmH2O 6.3 0.9 3.5 0.6 7.9 1.7 4.8 1.6* 6.7 0.8* 3.8 0.6* 7.8 2 4.7 1.7* At rest 7.3 1 4.4 0.6 8 1.6 5 1.5 After Oxitropium 6 cmH2O 12 cmH2O 6.9 0.7 3.8 0.4 8 1.8 5 1.4* 7.1 0.9 4 0.4 9 1.7 6 1.6*
Healthy Controls
*p
0.05 vs at rest
DISCLOSURE: Antonio Castagnaro, None. EXHALED NITRIC OXIDE IS INCREASED IN RESPONSE TO STRESS IN ADULT ASTHMATICS Jonathan S. Ilowite MD* Mary Bartlett RN Winthrop University Hospital, Mineola, NY PURPOSE: Nitric oxide in exhaled air (FENO) is a marker of airway inflammation in asthma. This study was undertaken to determine whether FENO increases as a result of stress. METHODS: This study was a prospective, unblinded study in an office setting. 20 adult asthmatics were recruited to participate. Subjects were initially put into a relaxed state using a progressive relaxation technique. They were then put into a stressful state by asking them to complete complicated mathematical problems. RESULTS: FENO was measured using standard techniques after relaxation and after stress. Pulse was monitored during the stressful intervention. FENO significantly increased after stress. Mean /-Standard Deviation (SD) for baseline FENO was 2.9 /- 2.1. After stress, mean /- SD FENO rose to 3.1 /- 2.1. This was significant by paired test. (p 0.03). CONCLUSION: A stressful situation can cause an immediate increase in the inflammatory state of the airways in adult asthmatics, as measured by FENO. CLINICAL IMPLICATIONS: This study provides insight into the mechanism in which a psychological stress could lead to worsening asthma. DISCLOSURE: Jonathan Ilowite, None. THE DIFFERENCES IN ASTHMA SEVERITY BETWEEN PREMENOPAUSAL AND POSTMENOPAUSAL AFRICAN AMERICAN WOMEN Celia Maxwell MD Reverly M. John MBBS* Alicia Thomas MBBS Howard University Hopsital, Washington, DC PURPOSE: Prolonged hormonal exposure has been linked to an increased severity of asthma among Caucasian women. Our aim is to determine if the same is true or are there differences in the severity of asthma among premenopausal(PREM) vs postmenopausal(PM)African American(AA)women. METHODS: We enrolled 37 women ages 18-82, who were admitted through the emergency department over a 2-year period with asthma exacerbation. In this retrospective chart review, asthma severity was defined by the National Heart Lung and Blood Institute guidelines. Menopause was defined as cessation of the menstrual cycle by natural or surgical means.Additionally, body mass index (BMI), age of onset of menarche and number of cigarette pack years (CPY) of smoking were recorded. RESULTS: Twenty (58.5%)of the women were PM, and 17 (41.5%)were PREM. The mean ages were 35 /-8.2 for PREM and 60 /-10 for PM women. There was no significant difference in population
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ASTHMA CARE PERCEPTIONS AND PRACTICES AMONG ASTHMA SPECIALISTS IN LEBANON Hani M. Lababidi MD* Mazen AbuAkl MD Makassed General Hospital, Beirut, Lebanon PURPOSE: Asthma is a common chronic condition. Despite published guidelines for the diagnosis and treatment of asthma, the real medical practices for this condition vary among different care providers. The purpose of this study is to evaluate the current perceptions and practices of asthma among asthma specialists in Lebanon. METHODS: A cross sectional survey was conducted on asthma specialists in Lebanon in November 2004. The studied parameters included asthma diagnosis, follow-up, treatment, patient education, use of asthma guidelines, demographic characteristics of providers and their involvement in continuous medical education. RESULTS: Out of 125 practicing pulmonolgists and allergists registered in Lebanon, 70 filled out the questionnaire (56%). These were 20 females (29%) and 50 males (71%). The average age was 42.6 8.5 years. There were 55 pulmonolgists (78.5%), 5 allergists (7.1%) and 10 with double specialty in pulmonary and allergy (14.3%). 81.4% of responders performed spirometry on newly diagnosed subjects with asthma, while 74.3% monitored peak flows. The frequency of use of different treatment modalities for asthma was 94.1% for inhaled steroids, 95.4% for long acting beta-agonists (LABA), 60.6% for Leukotriene antagonists, 32.8% for theophylline, 25.8% for oral anti-histamines and 5.2% for cromolyn sodium. The inhaler technique is often monitored by 65.2% and sometimes by 24.6%, while peak flow diary is often reviewed by 29.9% and sometimes by 34.3%. About 87.9% of the responders indicated that they follow asthma practice guidelines, 84.6% of them reported using the GINA guidelines. Around 92.6% of asthma specialists in Lebanon attended continuous medical education (CME) program on asthma in the past year.
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DOES ASTHMA KNOWLEDGE OF INTERNSHIP YEAR STUDENTS DIFFER THAN PHYSICIANS IN SPECIALIZATION TRAINING? Esra Uzaslan MD* Esref Erdem Funda Coskun MD Beril Erdogan MD Dane Ediger MD Mehmet Karadag MD Oktay Gozu MD Uludag University Medical Faculty, Bursa, Turkey PURPOSE: The goal of this survey was to assess the knowledge, attitudes and beliefs of interns (students in internship year of medical faculty)about asthma and its management and to compare the correct response rate of interns with physicians in specialization training (PST) in teaching hospitals. METHODS: An asthma questionnaire including 33 items was applied to interns (n:209,40% female and 60 % male) and PST (n:202,49% female and 51% male)of Uludag Medical Faculty in July 2004. RESULTS: The 89% of interns believed that asthma can be cured, whilst 84 % of PST believed so(p 0.05).The 13% of interns thought that when acute asthma attacks resolved, the disease can be cured, whilst 15% of thought so (p 0.05).The 76% of interns believed that asthma runs in families whilst 53% of PST believed so (p 0.001).The 99% of interns and 97% of PST knew that animal feathers were one of the triggers of asthma ((p 0.05).The 76% of interns and 47% of PST knew that cockroach was one of the triggers of asthma (p 0.001). The 57% of interns and 46% of PST thought that nutritional conditions can trigger asthma (p 0.05).There was not any significant difference on correct response rate to questions on about asthma signs. The 97% of interns believed that asthmatics can be treated without hospitalization, whilst 96% of PST believed so (p 0.05).The 19% of interns and 18% of PST thought that asthma medication should be sold without prescription (p 0.05).The 9% of interns and 9% of PST believed that asthma medication was addictive (p 0.05). The 90% of interns and 85% of PST thought that inhaler (vaporizer) was a good treatment (p 0.05).The 64 % of interns and 61% of PST believed that asthma care was expensive (p 0.05). CONCLUSION: The interns knowledge about asthma was generally better than the PST, but by the time passing this compact knowledge may decrease as we observed in PST. CLINICAL IMPLICATIONS: Postgraduate education about asthma should be offered every physician whatever their specialization is, when planning to improve asthma outcomes in society. DISCLOSURE: Esra Uzaslan, None. HOSPITAL-BASED PHYSICIAN ASSESSMENT OF KNOWLEDGE, ATTITUDES AND PRACTICE IN THE DIAGNOSIS AND MANAGEMENT OF ASTHMA GUIDELINES Ogee Mer A. Panlaqui MD* Eloisa S. De Guia MD Veterans Memorial Medical Center, Quezon City, Philippines PURPOSE: To determine the knowledge, attitude and practice of hospital based physicians in the diagnosis, management and prevention of asthma. METHODS: The study was conducted in a tertiary government hospital involving physicians in practice of Family Medicine, Internal Medicine, Pediatrics and Pulmonary Medicine. A 31 point questionnaire was distributed consisting eight subject areas: assessment, asthma diagnosis, education, pathology, prevention, pharmacology, severity and therapy. The score for each of the subjects and the total score were calculated and grouped according to the level of training of the physicians and specialties. The mean score for each group of physicians were compared using the one way analysis of variance with level of significance set at p 0.05 with 95% CI. RESULTS: A total of 144 (75.8%) physicians out of the 190 responded.The mean score is 45.8 /- 13.4 (mean, SEM) performing best in asthma diagnosis and scored poorly in prevention of asthma triggers. The pulmonary fellows in training got the highest mean score
POSTER PRESENTATIONS
CONCLUSION: The results of the study showed that there is a need for further improvement in the knowledge and understanding of the NHLBI Global Initiative for Asthma among physicians at the VMMC.Subject areas that should be emphasized in asthma guidelines dissemination are proper assessment, asthma education, prevention of asthma triggers, proper severity classification and choice of appropriate therapy. CLINICAL IMPLICATIONS: Proper diagnosis and management of asthma will reduce its fatal consequences. This can be achieved by ensuring physicians understanding of existing guidelines through continuing medical education.
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PILOT STUDY OF ANTI-IGE ANTIBODY IN THE TREATMENT OF SEVERE OBSTRUCTIVE PULMONARY DISEASE: UPDATE AFTER ONE YEAR Clifford G. Risk MD* John L. Ohman, Jr. MD Clifford Risk, MD, Marlborough, MA PURPOSE: To report on the continued experience with the use of omalizumab in patients with obstructive lung disease who may also have a comorbid asthmatic component mediated by IgE antibody. METHODS: All patients were drawn from the original pool of 250 patients in a pulmonary practice who had asthma or chronic bronchitis and qualifying levels of IgE ( 30 IU/ml). Seventeen patients have been studied. Eleven completed 12 months of therapy (4 completed 4 to 9 months of therapy). Age range was 48 to 82 years. Nine were females. Fifteen have heavy primary or secondary cigarette exposure. Sixteen had positive skin tests to relevant indoor allergens. Baseline FEV1 was below 60% predicted in 11 patients. IgE ranged from 32 to 496 IU/ml. End points were reduction in number of acute exacerbations requiring hospitalizations or unscheduled office visits, reduction in inhaler use and improvement in dyspnea or cough indices. A 12 month baseline period was compared was compared with treatment intervals after the first month of omalizumab therapy. RESULTS: Comparing the year before therapy to the treatment period, the average monthly exacerbation rate decreased from 0.20 to 0.11. Comparing the month before therapy with the final treatment month, the average daily number of inhalations of asthma inhalers decreased from 13.5 to 7.4. The average daily Fletcher dyspnea score decreased from 1.35 to 0.53. The average daily cough severity scale decreased from 1.12 to 0.59. Of the six patients that were prednisone dependent at baseline the average daily prednisone requirement decreased from 37 to 10 mg. CONCLUSION: Continued experience with the use of omalizumab in patients with severe chronic obstructive lund disease confirms the initial impression of effectiveness. The role of IgE in these patients may be significant in disease severity. This pilot study suggests that further controlled studies in this group of patients would be warranted. CLINICAL IMPLICATIONS: A patient population with chronic obstructive lung disease should be screened for the use of omalizumab therapy. Skin test reactivity to indoor allergens was common. DISCLOSURE: Clifford Risk, None.
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Primary outcomes: knowledge, self management, inhalation technique and exacerbation frequency incidences. Differerences between additional care (ACG) and control group (CG)
ACG (n 80) median# knowledge* initial final change score inhalation technique** final change score self management initial final change score exacerbation frequency? exacerbation*? 11% 24% 0,68 (0,49-0,94) incidence rate 83 (68-90) 0 (-5-10) 36 (25-56) 38 (25-63) 3 (-12-19) 1,46 72 (63-83) 0 (-8-12) 36 (25-48) 38 (25-53) 6 (-10-13) 3,65 0,85 0,40 (0,24-0,67) 0,84 initial 55 (33-73) 64 (38-77) 5 (-5-14) 78 (68-83) 59 (45-70) 0 (-5-9) 70 (63-80) 0,02 CG (n 77) median# p-value 55 (41-73)
CLINICAL EFFICACY OF AEROSOLIZED FLUTICASONE THERAPY IN THE EARLY MANAGEMENT OF ACUTE MODERATE EXACERBATIONS OF ASTHMA BY PMDI AND ZERO STAT V SPACER Sudhir K. Agarwal MD* Institute of Medical Sciences, Banaras Hindu University, Varanasi, India PURPOSE: To assess the utility of inhaled corticosteroids for the early management of acute exacerbations of asthma in the emergency room. METHODS: This randomized, double-blind, placebo-controlled study was conducted to evaluate the efficacy of high dose inhaled fluticasone with frequent beta-2-agonist therapy in patients of acute moderate exacerbations of asthma. Eighty patients between 15 and 45 years of age with acute moderate exacerbations of asthma were put on aerosolized 500 g of fluticasone at half hourly intervals for three doses with metered dose inhaler and zero stat V spacer. All patients received humidified oxygen and nebulized salbutamol (0.15 mg/kg in 3 ml saline) prior to fluticasone administration. The control group received placebo instead of inhaled fluticasone. Patients who had received corticosteroids in the preceding 72 h were excluded from the study. If there was an inadequate response or no response to treatment at the end of 2 hour, oxygen and salbutamol therapy were continued and given one dose of intravenous hydrocortisone and was started on an aminophylline infusion. RESULTS: Both fluticasone and control group showed a significant improvement in respiratory status at the end of 2 h. However, patients in the fluticasone group showed greater improvement in PEFR (P 0.05) and significantly lower proportion of patients required oxygen improvement in PEFR (P 0.01). The length of stay was significantly shorter in the fluticasone group than in the placebo group (P 0.01). CONCLUSION: Aerosolized fluticasone therapy with MDI and spacer together with salbutamol in the treatment of acute exacerbations of asthma helped in early recovery and decreased hospital stay. CLINICAL IMPLICATIONS: Inhaled fluticasone may be given with MDI and spacer in the treatment of acute exacerbations of asthma. DISCLOSURE: Sudhir Agarwal, None.
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Difference From Placebo in Mean Change From BL to Post-Dose in FEV1 (L) Month 3 Severity Group Moderate Severe 30 Mins 60 Mins 120 Mins 30 Mins 0.11 0.27 Month 6 60 Mins 120 Mins Days 2-22 17.76** 15.93* Days 163-190 11.47 30.24* Difference From Placebo in Mean Change From BL in A.M. PEFR (L/Min)
EVALUATION OF POST-TREATMENT EFFECTS OF LEUKOTRIENE RECEPTOR ANTAGONISTS Esra Uzaslan MD* Funda N. Coskun MD Dane Ediger MD Erkan Rodoplu MD Mehmet Karadag MD Ercument Ege MD Oktay Gozu MD Uludag University Medical Faculty Chest Disease Department, Bursa, Turkey PURPOSE: The aim of this study to evaluate the of post-treatment effects of Leukotriene Receptor Antagonists (LTRA) in persistent asthmatic patients who have been treated with inhaler steroid and LTRA, by investigating clinical and laboratory parameters before addition of LTRA, end of treatment with LTRA and at least three months after ending of LTRA treatment. METHODS: We retrospectively investigated clinical data of 19 asthmatic patients (16 females, 3 males, mean age 33.3 2.5 years) before LTRA treatment,last day of LTRA treatment and at least three months after ending of LTRA treatment and compared symptom score, medication score (number of controller drugs for asthma), total dose of inhaler steroid and lung function tests of patients for each visits. RESULTS: We found decreases in symptom score (p 0.01), medication score (p 0.05), total dose of inhaler steroid (p 0.05),and increases lung function tests (p 0.05) at the end of the treatment.When we evaluated same parameters at least three months after the ending of LTRA treament, we observed continuation of increases in FEV1 and PEF values (p 0.05) comparing to beginning and ending of treatment and also a significant decrease in total dose of inhaler steroid comparing to beginning of treatment (p 0.05). CONCLUSION: We come to the conclusion that in persistent asthmatic who use LTRA in addition to inhaler steroids,the improvement in lung function tests, symptom scores and medication scores are protected and the total dose of inhaler steroids needed for control of asthma is decreased,even 3 months after the ending of treatment. CLINICAL IMPLICATIONS: The post-treatment effects of LTRA continues three months after the discontinuation of the treatment in asthmatics.
DISCLOSURE: William Berger, None. ZILEUTON PROVIDED CLINICALLY RELEVANT REDUCTIONS IN THE NEED FOR RESCUE MEDICATION AND ORAL CORTICOSTEROIDS COMPARED TO PLACEBO IN MODERATE AND SEVERE ASTHMATICS Mark C. Liu MD* Malcolm N. Blumenthal MD Karen Walton-Bowen Johns Hopkins Bayview Medical Center, Baltimore, MD PURPOSE: Zileuton Provided Clinically Relevant Reductions in the Need for Rescue Medication and Oral Corticosteroids Compared to Placebo in Moderate and Severe Asthmatics. METHODS: This was a previously published, randomized, placebocontrolled, double-blind, parallel, multi-center six-month study of the safety and efficacy of zileuton (400 or 600 mg QID) in 373 patients with asthma on no chronic asthma treatment other than beta-agonists (J Allergy Clin Immunol 1996; 98(5):859-71). Assessments included beta-agonist use, acute asthma exacerbations requiring alternative treatment or oral corticosteroids, and daily and nocturnal symptoms, as well as mean FEV1 and other pulmonary function tests.In an exploratory secondary analysis of patients in the high dose zileuton 600 mg QID group, patients were stratified by baseline (BL) percent predicted FEV1 into two subgroups of asthma severity: moderate ( 60%- 80%) and severe ( 60%). RESULTS: Moderate and severe zileuton patients reported reduced daily number of occasions of beta-agonist use. Fewer zileuton patients experienced asthma exacerbations requiring alternative treatment and oral corticosteroid treatment. Improvements in daily and nocturnal symptoms were also reported. These differences were sustained throughout the six-month study.
Baseline Symptom score Medication score Inhaled steroid dose (mcg) FEV1 (L) PEF (L/sec) 1.3 0.8 1.4 0.9 875 583 2.62 0.9 5.68 1.7
Post-treatment 0.5 0.6 1.2 0.7 695 391 2.66 0.9 6.27 1.8
3 months later 0.9 0.8 1.3 0.2 445 216 2.75 0.8 6.77 1.8
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AUC of FEV1 (L x hours) FOR12 v Placebo After first dose After 12 weeks 4.50* 4.02 FOR24 v Placebo 4.71* 4.17 FOR12 v 24 -0.21 -0.15 ALB v Placebo 2.53 1.54
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SINGLE MEASUREMENTS OF INSPIRATORY CAPACITY ARE NOT BETTER THAN FEV1 IN PREDICTING SYMPTOM SCORES IN COPD Shirley F. Jones MD* John A. Cooper MD Mark T. Dransfield MD Birmingham VA Medical Center, Birmingham, AL PURPOSE: Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death in the United States. Although the forced expiratory volume (FEV1) is an accurate marker of mortality in population studies it has only shown a weak correlation with dyspnea and quality of life. It has been shown that changes in inspiratory capacity (IC), a measure of hyperinflation, correlate well with improvements in these outcomes. The aim of this study is to determine whether a single, baseline measurement of IC is a better predictor of measures of dyspnea and quality of life than FEV1. METHODS: We enrolled veterans with COPD from two pulmonary clinics. Demographic data was obtained and enrollees completed three questionnaires, the Medical Research Council Dyspnea Scale (MRC), the University of California San Diego (UCSD) Shortness of Breath Questionnaire and the St. Georges Hospital Respiratory Questionnaire (SGRQ). Spirometry was performed according to ATS standards and FEV1 and IC measurements were recorded. Correlation coefficients between FEV1, IC, and questionnaire scores were then determined and compared. RESULTS: 36 patients were enrolled. The mean age of our participants was 66 with the majority being Caucasian males (95%). The mean number of pack-years smoked was 71. The mean IC among enrollees was 68% predicted. The mean FEV1 was 40% predicted indicating severe airflow obstruction. The mean scores for the MRC, UCSD and SGRQ were 3.3, 67.5, and 46.5 respectively. Both FEV1 (r -0.58, p 0.001) and IC (r -0.47, p 0.004) correlated with the UCSD score though neither measure was superior (p 0.53). Neither FEV1 (r -0.24, p 0.15) nor IC
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% Of patients asked to perform Spirometry Category General Practitioner General Physician Chest Physician Pediatrician Asthma 9.36 19.99 54.92 5.42 COPD 11.11 22.83 56.70 Not applicable
DISCLOSURE: Sundeep Salvi, Grant monies (from industry related sources) Cipla Ltd. COMPARISON OF BRONCHODILATOR RESPONSE IN PATIENTS WITH CHRONIC OBSTRUCTIVE PULMONARY DISEASE AND BRONCHIAL ASTHMA G. Gandev MD* K. Gupta MD J. Williams MD K. Kanagarajan MD Coney Island Hospital, Brooklyn, NY PURPOSE: The response to bronchodilators is often used to distinguish chronic obstructive pulmonary disease (COPD) and bronchial asthma (BA). Numerous studies have shown that many patients with COPD exhibit significant bronchodilator response while some patients with BA may not. Our study compares the bronchodialator response in patients with COPD and BA. METHODS: Retrospective analysis of PFTs in patients referred with diagnosis of COPD and BA was done. Positive bronchodialator response using ATS criteria were noted in both groups. The patients were further stratified into those under the age of 55 and those over 55. The data was analyzed using independent t-test for the mean and chi square test for any variables with percentage. RESULTS: 78 patients with COPD and 76 patients with BA were identified. In the group younger than 55 years, there were 6 patients with COPD and 47 patients with BA. 20 patients with COPD had significant bronchodilator response (25.6%), and 34 patients with BA had significant bronchodilator response (44.7%). The overall difference in bronchodilator response between the two groups was statistically significantly (p 0.01). In the group younger than 55, 50% (n 3) of patients with COPD had significant bronchodilator response versus 42.6% (n 20) of patient with BA. For the age above 55, 23.6% (n 17) of patient with COPD had significant bronchodilator response versus 48.3% (n 14) of patient with BA and the difference in bronchodilator response for this age group was statistically significant (p 0.01). CONCLUSION: Even though patients with BA were more likely to have bronchodilator response a significant number of patients with COPD, exhibit the same. Bronchodilator response was observed in the older cohort of COPD patients as well. CLINICAL IMPLICATIONS: Bronchodialator response cannot reliably distinguish between BA and COPD. DISCLOSURE: G. Gandev, None. CHANGES OF DIFFUSION CAPACITY IN PATIENTS WITH CHRONIC OBSTRUCTIVE PULMONARY DISEASES (COPD) Yaling Zhu MD* Haoyan Wang MD Xiaohong Chang Chaoyang Hospital, Beijing, Peoples Rep of China PURPOSE: To assess the changes of diffusion capacity in different stages of COPD patients. METHODS: 95 stable COPD patients were divided into 4 groups: Stage I, II, III and IV according to EFV1/FVC% and FEV1% values, each with 8, 47, 34, 6 patients respectively. The transfer factor of the lung for carbon monoxide (TLco), pulmonary membrane diffusion capacity (Dm) and pulmonary capillary blood volume (Vc) were measured with single breathing method. RESULTS: TLco,Dm and Vc were decreased in all COPD groups, significant differences were found in stage II to Stage IV groups in comparison with those of the normal subject group. TLco and Dm were progressively decreased from stage I to stage IV while Vc were comparable among all stage groups. CONCLUSION: Diffusion capacity was progressively impaired with the severity of COPD.
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Group Normal subject COPD stage I COPD stage II COPD stage III COPD stage IV Normal subject
Dm 4.92 100.25 4.01 99.32 4.54** 69.39 3.27** 62.29 1.66** 43.60 4.92 100.25
retrosternal air (n 31; 46%). Patients with a CXR score 1 were older (63.5 10.3 vs. 58.1 11.1 years, p 0.01) and had more pack-years (48.5 20.8 vs. 36.7 18.9; p 0.01). Hyperinflation (increased TLC%), air-trapping (decreased FVC% and increased RV%) and gas exchange (decreased DLCO%) were all worse with increasing CXR scores as indicated in Table 1. A normal CXR score 0 virtually excluded the possibility of hyperinflation (negative predictive value 0.98). In contrast, a CXR score 1 was a good marker of functional hyperinflation (increased TLC% sensitivity 0.96) and air trapping (increased RV/TLC% sensitivity 0.81) while a score 2 was highly specific indicator of air trapping and decreased DLCO% (positive predictive values of 0.93 and 0.83 respectively). CONCLUSION: The CXR score is an accurate predictor of the degree of functional impairment in patients with COPD. A normal CXR score obviates the need to measure lung volumes. CLINICAL IMPLICATIONS: Disagreement between the CXR score and results of PFTs in the patient with COPD should prompt a search for technical errors in measurement.
Table 1
CXR Score 0 (n 41) FEV1 % FVC % TLC % RV % RV/TLC % DLCO % 65 75 96 125 44 80 12a 13.5c 10a 25a 8a 26a 1 (n 27) 51 70 111 179 54 73 p p 8b 13 12 46 14d 29e 2 (n 22) 43 64 112 187 60 58 14 16 15 34 9 22 p 3 (n 18)
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45 60 118 200 65 49
15 18 21 58 8 19
0.05; 0 vs.
PATIENT-REPORTED SYMPTOMS OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) IN CLINICAL TRIALS Steven Kesten MD* Shailendra Menjoge PhD Boehringer Ingelheim, Ridgefield, CT PURPOSE: Several respiratory symptoms are associated with COPD. We sought to determine the symptom most frequently perceived by patients to be the first symptom and the most troublesome of COPD and to identify patient characteristics associated with these perceptions. METHODS: An evaluation of pooled data was conducted from three clinical trials of tiotropium in COPD (205.264, 205.266, 205.284) in which patients reported the features of their disease at baseline. The trials had common inclusion criteria (age 40 years, diagnosis of COPD, no history of asthma, FEV1/FVC 70%, FEV1 60 to 65% predicted, smoking 10 pack-years). Data are expressed descriptively as means or proportions. RESULTS: There were 2,678 patients. Dyspnea was the most commonly reported first and most troublesome COPD symptom. In patients also reporting chronic bronchitis, the first symptom and most troublesome symptom was dyspnea (71% and 86%, respectively) followed by cough (19% and 8%, respectively). In patients also reporting emphysema, the first symptom and most troublesome symptom was dyspnea (77% and 90%, respectively) followed by cough (14% and 5%, respectively). Baseline data are displayed below according to the patient-reported first or most troublesome symptom:. CONCLUSION: Dyspnea is the first symptom and the most troublesome symptom of COPD and is reported as such irrespective of demographics and diagnoses of either chronic bronchitis and/or emphysema. In general, baseline demographic characteristics are unable to adequately distinguish which symptom patients will report as their most troublesome. CLINICAL IMPLICATIONS: The focus of clinical research in COPD should include evaluations of dyspnea as this appears to be the first and most troublesome symptom to COPD patients with differing demographic features.
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% of total % women/% men FEV1 (L) FEV1 predicted (%) COPD duration (yrs) Former smoker (%) Smoking history (pack-yrs)
% of total % women / % men FEV1 (L) FEV1 predicted (%) COPD duration (yrs) Former smoker (%) Smoking history (pack-yrs)
MECHANISM OF EXPIRATORY CRACKLES Raymond L. Murphy MD* Andrey Vyshedskiy PhD Ruqayyah M. Alhashem BS Rozanne Paciej BS Margo Ebril Brigham and Womens / Faulkner Hospitals, Boston, MA PURPOSE: Crackles are intermittent explosive sounds that are associated with a number of pulmonary disorders including Interstitial Pulmonary Fibrosis (IPF), Congestive Heart Failure (CHF), and Pneumonia (Pn). The mechanism underlying expiratory crackles generation is not very well understood. Some authors think that airway closing is responsible for expiratory crackles. Others claim that intermittent airway reopening during expiration is responsible for the crackling sounds. The goal of this research was to gain insights into crackle generation mechanism by systematic examination of the relationship between inspiratory and expiratory crackle characteristics and by testing the crackle patterns, as recorded by multiple microphones, against the predictions of the stress-relaxation quadrupole crackle generation model as developed by Fredberg and Holford. METHODS: Fifty five patients with over 2 inspiratory crackles per breath and over 2 expiratory crackles per breath were selected for this study from a pool of nearly 1000 patients who were examined using a multichannel lung sound analyzer (Stethographics, STG1602). Crackle characteristics such as frequency, amplitude, transmission coefficient, and polarity were calculated for each crackle. RESULTS: The frequency, amplitude, and transmission coefficients of expiratory crackles were very similar to those of inspiratory crackles. The majority of patients had predominantly positive polarity of inspiratory crackles (98% of patients) and predominantly negative polarity of expiratory crackles (81% of patients). Crackle polarity was also found to be dependent on the observation angle, consistent with predictions by the stress-relaxation quadrupole crackle generation model. CONCLUSION: The reported findings are consistent with the hypothesis that expiratory crackles are caused by events that are identical in mechanism and opposite in direction to that of inspiratory crackles. The expiratory crackle data can be explained by the closing of airways during expiration in accordance with the stress-relaxation quadrupole crackle generation model. CLINICAL IMPLICATIONS: While there are no immediate clinical benefits to knowing the mechanism of crackles, a clearer understanding of the mechanism of production of lung sounds offers the promise of improving noninvasive diagnosis of lung disorders. DISCLOSURE: Raymond Murphy, Grant monies (from industry related sources) The research was supported in part by a grant from Stethographics, Inc.; Shareholder Dr. Murphy is founder and CMO of Stethographics, Inc.
CHEST 2005Poster Presentations
DISCLOSURE: Steven Kesten, Employee S. Kesten and S. Menjoge are employees of Boehringer Ingelheim.; Grant monies (from industry related sources) Study 205.264 and 205.266 were funded by Boehringer Ingelheim and Pfizer. Study 205.284 was funded by Boehringer Ingelheim.
RELATIONSHIP OF SPIROMETRY RESULTS AND REASON FOR MECHANICAL VENTILATION (MV) TO HOSPITAL SURVIVAL IN PATIENTS WITH CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) Thomas B. Zanders DO* David G. Bell MD Ethan E. Emmons MD Brooke Army Medical Center, San Antonio, TX PURPOSE: In general, the mortality of COPD patients requiring hospital admission and MV is high. Many physicians rely on a patients spirometry results in guiding advance directive discussions and determining prognosis. There is unclear data to support that pre-morbid spirometry helps predict outcomes in mechanically ventilated COPD patients. METHODS: We conducted a retrospective chart review of 33 admissions of 29 patients with COPD requiring MV for acute respiratory failure (ARF) for whom preadmission spirometry data was available. Additional data obtained included age, sex, comorbidities, outpatient therapies, and reason for MV. The primary outcome was in-hospital mortality. RESULTS: Nineteen (58%) of the patients were male. The mean age was 69.2 years (range 56-85). There were 16 (49%) current smokers and 18 (55%) patients on home oxygen. The mean percent predicted forced expiratory volume in one second (FEV1) was 44.1% and percent predicted forced vital capacity (FVC) was 53.6%. A COPD exacerbation necessitated MV in 51.5% of the admissions, pneumonia in 21.2%, cardiac reasons in 12.1%, and other etiologies in 15.2%. Overall in-hospital mortality was 21.2% (7 of 33). Survivors and non-survivors had no statistically significant difference in preadmission FEV1, FVC, or FEV1/FVC ratio values (Table 1). Multivariate analysis demonstrated significantly lower in-hospital mortality for patients intubated due to COPD exacerbations as compared to other etiologies of ARF (Figure 1). CONCLUSION: We conclude that pre-morbid spirometry data does not correlate to in-hospital mortality in COPD patients requiring MV for ARF. It appears that patients with COPD requiring mechanical ventila-
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FACTORS THAT REFLECT CLINICAL STABILITY OF COPD PATIENTS Jee-Hong Yoo MD* Myung Jae Park MD Hong Mo Kang MD Kyung Hee University Medical Center, Seoul, South Korea PURPOSE: Chronic obstructive pulmonary diseases (COPD) is one of the leading cause of death and is increasing in incidence. The forced expiratory volume in one second (FEV1) is usually used to grade the clinical severity of COPD. However, assessment of functional capacity is also important to understand clinical state of patients. The aim of this study was thus to retrospectively examine what factors reflects clinical stability in patients with COPD. METHODS: Twenty-six patients with COPD volunteered and completed the test sequence, which included pulmonary function tests, 6-minute walk distance (6-MWD), complete blood count, blood chemistry, blood pressure, and body mass index. The patients were divided into two groups, stable and unstable group, according to the presence of acute exacerbation history during last one year. After dividing, we retrospectively validated factors that reflect clinical stability of patients. RESULTS: At presentation, Mean age of 26 patients was 65.3 9.0 years (mean SD). Sixteen patients were included in stable group and 10 patients in unstable group. FEV1 was 63.3 20.6% for stable group and 46.9 9.4 for unstable group (p 0.02). Mean 6-MWD was 461.9 88.3 meter and 298.0 72.1 meter respectively (p 0.01). The number of patients in each stage based on Global Initiative of Obstructive Lung Diseases (GOLD) showed significant difference between two groups (p 0.03) and number of patients who walked more than 400 meter was 13 out of 16 for stable group and no one for unstable group (p 0.001). 6-MWD and stage of COPD showed significant correlation (p 0.01). CONCLUSION: 6-MWD, a simple test to evaluate clinical status, showed significant correlation with GOLD stage of COPD. Multidimensional approach should be done to evaluate clinical stability. CLINICAL IMPLICATIONS: For the evaluation of severity of COPD, not only the degree of airflow limitation but also functional status such as 6-MWD should be included. DISCLOSURE: Jee-Hong Yoo, None.
DISCLOSURE: Raymond Murphy, Grant monies (from industry related sources) The research was supported in part by a grant from Stethographics, Inc.; Shareholder Dr. Murphy is founder and CMO of Stethographics, Inc. USING DISTRIBUTION-BASED STANDARD ERROR OF MEASUREMENT (SEM) METHOD TO DETERMINE MINIMAL IMPORTANT DIFFERENCE (MID) FOR THE SYMPTOM STATUS INDEX (SSI) Rohit D. Borker PhD* Michael Watkins PharmD Kate Knobil MD Amanda Emmett MS Chris Kalberg PhD GlaxoSmithKline, Research Triangle Park, NC PURPOSE: To assess the minimal important difference (MID) of the Symptom Status Index (SSI) using the distribution-based standard error of measurement (SEM) method. METHODS: The SSI is a diary-based index comprised of 4 VAS items: shortness of breath, tiredness, activity limitation, and frustration with symptoms. It has been shown to be a reliable, valid, and a responsive tool in COPD population. Individual item scores are summed to obtain the SSI total score. Patients record the severity of their symptom status on a 0mm (none/not at all) to 100mm (worst it has ever been/as bad as it can be) VAS. The SEM method was used to determine the MID because of its sample independent properties. This results from simultaneous incorporation of sample reliability and variability in its determination. The
WORLD COPD DAY EXPERIENCE IN ZONGULDAK PROVINCE OF TURKEY Meltem M. Tor MD* Tacettin Ornek MD Hakan Tanriverdi MD Muhammed E. Akkoyunlu MD Yalcin Dutkun MD Zonguldak Karaelmas University Hospital Department of Pulmonary Medicine, Zonguldak, Turkey PURPOSE: Chronic Obstructive Pulmonary Disease (COPD) is an important public health problem both in developed and developing countries. In Turkey too, COPD is an important lung health burden. Public education and early diagnosis are crucial in the prevention of COPD.We hereby present the results of our World COPD Day
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CHEST PHYSIOTHERAPY CHANGED VENTILATORY MECHANICS IN PATIENTS WITH SEVERE COPD Kayomi Matsumoto MS* Hajime Kurosawa MD Yuko Sano MS Naoki Mori MS Yoko Goto PhD Masahiro Kohzuki MD Tohoku. Univ. Grad. Sch. of Med. Dep. of Int. Med. and Rehab., Sendai, Miyagi, Japan PURPOSE: As one of chest physiotherapy (CPT) techniques, manual stretching of intercostal and other respiration related muscles to mobilize thoracic cage had been frequently performed in patients with airflow limitation, especially in Japan. Purpose of those techniques is supposed to improve chest flexibility and alleviate dyspnea. To examine hypothesis that CPT techniques in patients with chronic obstructive pulmonary disease (COPD) may change the mechanical properties of the chest. METHODS: Eight patients with COPD (mean age: 67.0 4.4 years, M:F 8:0) were studied. We performed physiological measurements including spirometry, oxygen consumption during quiet breathing at sitting position (VO2), maximal voluntary ventilation (MVV), and maximal inspiratory and expiratory pressures (MIP, MEP). Thoracic gas volume and specific airway conductance (sGaw) were also measured using body plethysmography. After those baseline measurements, the CPT described above including manual breathing support techniques were performed for about total 40 minutes. Immediately after the CPT, pulmonary function tests were repeated. RESULTS: Inspiratory capacity (IC) and vital capacity (VC) significantly increased (p 0.05, p 0.01). Forced expiratory volume in 1 second (FEV1) was unchanged. Functional residual capacity (FRC) and residual volume (RV) significantly decreased (p 0.01) after CPT. Both sGaw and VO2 were tended to decrease, but it could not reach to the statistic significance. MEP, MIP, and MVV were not significantly change. CONCLUSION: After CPT, lung volume decreased, and IC increased in patients with COPD. CLINICAL IMPLICATIONS: Decreased lung volume and increased IC by CPT possibly contribute to improve breathlessness in patients with COPD. Further research is needed to elucidate how long this effects last. DISCLOSURE: Kayomi Matsumoto, None.
SELF-MANAGEMENT EDUCATION PROGRAM FOR PATIENTS WITH CHRONIC OBSTRUCTIVE PULMONARY DISEASE HAS LONG TERM EFFECT ON QUALITY OF LIFE IMPROVEMENT Manon Labrecque MD* Khalil Raby PhD Marcel Julien MD Hopital Sacre-Coeur, Montreal, PQ, Canada PURPOSE: Purpose of this study was to investigate the effects on health related quality of life (HRQoL), and disease knowledges of a Self-management education programme(SMEP) for patients with chronic obstructive pulmonary disease (COPD). METHODS: The programme lasted 4 weeks (3 hours/week) and included teaching of how to use an action plan for self-treatment of exacerbations.Patients were evaluated at time 0 , at 3 months and 12 months. 61 COPD with a mean age of 70(53-84)and FEV1 48.8% of the predicted(SD:18.2%) that was stable on a standard medical regimen. OUTCOME MEASURES: The SF-36 Quality of Life Questionnaire (SF-36), St Georges Respiratory Questionnaire (SGRQ) and a Disease Knowledges Questionnaire (DKQ) based on the teaching programme . RESULTS: SGRQ total scores and domain scores were all lower (indicating a better HRQoL) 3 months, and 12 months after the programme comparing to before. These differences reach clinical significance for the SGRQ impact domain who was at (35.2 17.2) at time 0 , (28.2 19) at 3 months (P .001) and (24.2 17.8) at 12 months (P .001). For the SGRQ total score the value was (44.1 17.0) before, (39.8 15.3) at 3 months (p 0.006) and (35 17.4) at 12 months (p .001). For the SF-36, physical activity domain showed no significant difference; (33.8 8.6) before , (35.7 9.4) at 3 months and (36.8 11.3) at 12 months (NS). Psychological domain resulted in a score of (45.3 11.6) before , ( 50.8 10.7) at 3 months ( P .003) and (49.5 11.3) at 12 months (P .03) Concerning the DKQ, the pre- programme score was (59.4 % 11.4), (73.6% 13.4)(P 0.0001) at one month and 74.5 15.5 at 12 months,(P 0.0001).
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DOES COPD DISEASE STATE EDUCATION BY A HOMECARE PROVIDER [RESPIRATORY THERAPIST] AND EARLY IDENTIFICATION OF NEED FOR LONG-TERM OXYGEN THERAPY (LTOT) REDUCE RELAPSES OF EARLY STAGE COPD PATIENTS? A MEASUREMENT OF SHORT-TERM CHANGES IN DYSPNEA AND DISEASE Vernon R. Pertelle RRT* James Dudley RRT Apria Healthcare, Lake Forrest, CA PURPOSE: We evaluated patients with COPD who were prescribed aerosolized respiratory medications; administered by homecare provider to determine if assessment and education by homecare respiratory therapist (RT)could decrease emergency room (ER) visits and hospitalization by identifying their need for LTOT before a relapse. METHODS: Patients were evaluated retrospectively following winter months from April 2003 to April 2004. Inclusion criteria: (1) diagnosis of COPD, (2) chronic airflow obstruction (evidenced by COPD diagnosis), (3) age / 65, (4) education by homecare RT (5) receiving LTOT. Patients recieved oximetry at rest, activity, noctur-
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A RANDOMIZED TRIAL OF STRATEGIES FOR ASSESSING ELIGIBILITY FOR LONG-TERM DOMICILIARY OXYGEN THERAPY Gordon H. Guyatt MD Mika L. Nonoyama RRT* Christina Lacchetti Ron Goeree MA Diane Heels-Ansdell MS Roger Goldstein MB, ChB Respiratory Diagnostics & Evaluation Service, West Park Healthcare Centre, Toronto, ON, Canada PURPOSE: To determine the impact of alternative strategies for assessing eligibility for domiciliary oxygen on funded oxygen use, quality of life, and costs. METHODS: Randomized controlled trial involving applicants for a Government sponsored home oxygen program (HOP). Comparisons were an assessment system that relied on data collected and submitted by oxygen providers at the time of application and judgements by HOP personnel (conventional assessment) versus a system of data collection by a respiratory therapist that included, in patients unstable at the time of initial assessment, a repeat assessment after two months of stability, with judgements by the RT and a respiratory specialist (alternative assessment). Main outcome measures included use of funded domiciliary oxygen; quality of life; mortality; costs to the health care system. RESULTS: 276 applicants were allocated to the conventional arm and 270 to the alternative assessment. In the year following application, oxygen use was appreciably lower in the alternative arm with no between group differences in mortality, quality of life or resource use in the community. Although alternative assessment applicants had on average higher assessment costs by $155 per applicant, these costs were more than offset by decreased HOP costs of $596 per applicant.
EFFECTS OF PULMONARY REHABILITATION ON EXACERBATION RATE, HOSPITALIZATIONS, LENGTH OF HOSPITAL STAY AND PUBLIC HEALTH ECONOMICS IN PATIENTS WITH MODERATE-TO-SEVERE CHRONIC OBSTRUCTIVE PULMONARY DISEASE Epaminondas N. Kosmas MD* Helen Vey RPh Maria-Konstantina Fraggou MD Irene Papaneofytou MD Zoi Athanassa MD Antonia Koutsoukou MD Ioannis Vogiatzis PhD Olga Georgiadou MS Nikolaos Koulouris MD Dora Orfanidou MD Charis Roussos MD Pulmonary Rehabilitation Unit, Sotiria Chest Diseases Hospital, Athens, Greece PURPOSE: Chronic obstructive pulmonary disease (COPD) exacerbations are a significant cause of morbidity and mortality and with a substantially high cost worldwide. The objective of this study was to evaluate the impact of pulmonary rehabilitation (PR) on the exacerbation rate and on the frequency and duration of hospitalizations in patients with COPD. A secondary aim was to estimate the annual cost savings/patient of PR with respect to hospitalizations. METHODS: We studied 32 ex-smoking patients (age 62 7 years) with moderate-to-severe COPD (FEV1 38 6 %pred). Patients participated in a 12-week (36-session) program of PR consisting of education, nutritional intervention, physiotherapy, exercise and psychologic support. They completed a questionnaire for the previous year to assess the exacerbations while their emergency visits, admissions and length of hospital stay were found from the hospital records. Patients were followed for the year after PR with both scheduled and emergency visits and with telephone contacts. RESULTS: The total annual number of exacerbations reduced from 112 pre-PR (3.5/patient) to 88 post-PR (2.8/patient)while the emergency visits decreased from 89 (2.8/patient) to 70 (2.2/patient). The significant decreases were found in hospitalizations (from 54 or 1.7/patient to 35 or 1.1/patient; p 0.05) and in hospital stay (from 648 days or 20.2/patient to 357 days or 11.2/patient; p 0.01). Considering the costs of PR program and of hospital days, the overall result is that the cost-savings for the 32 patients amounted to 9627 (300 /patient in approximation). CONCLUSION: A comprehensive pulmonary rehabilitation program results to a significant reduction in frequency and duration of hospitalizations in patients with moderate-to-severe COPD. There is also a trend
CONCLUSION: Reassessment of applicants for domiciliary oxygen after several months of stability identifies an appreciable portion of initially eligible patients who are no longer eligible, thus reducing program costs to public funders without adverse consequences on quality of life, mortality, or other resource use. CLINICAL IMPLICATIONS: Limiting assessment of patients for eligibility for long-term oxygen to the period immediately following an exacerbation will lead to many patients receiving long-term oxygen in whom the benefit is uncertain. Many patients improve, physiologically and with respect to their quality of life, over the first three months following an exacerbation, and an appreciable additional group improve further between 3 months and one year. Optimizing oxygen use requires that the patients be reassessed, both at 3 months and at approximately one year after commencing oxygen.
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QUALITY OF LIFE FOR 5 YEARS AFTER LUNG VOLUME REDUCTION SURGERY IN PATIENTS WITH SEVERE COPD Yoko Goto PhD* Hajime Kurosawa MD Nobuyoshi Mori MD Masahiro Kohzuki MD Department of Occupational Therapy, School of Health Sciences, Sapporo Medical U, Sapporo, Japan PURPOSE: Chronic obstructive pulmonary disease (COPD) is characterized by progressive airflow limitation leading to disability. Patients with severe COPD suffer from dyspnea, which can subsequently cause a difficulty in performing routine activities of daily living and affect their quality of life (QOL). Lung volume reduction surgery (LVRS) has been reported to be an effective treatment modality for selected patients with advanced COPD to improve pulmonary function, lung mechanics, exercise tolerance, and dyspnea. However, the long-term effects of LVRS on QOL and psychological states such as anxiety and depression have not been fully elucidated. We evaluated QOL and psychological state before and after LVRS in patients with severe COPD for 5 years. METHODS: Eleven patients with severe COPD (Age: 66.1 5.9, VC: 2.3 0.7L, FEV1: 0.75 0.21L, RV:4.5 1.0L) who underwent LVRS were studied. QOL was assessed by Sickness Impact Profile (SIP). Psychological states (anxiety, depression) were measured by using the State Trait Anxiety (STAI) and the Self-Rating Questionnaire for Depression (SRQD). Serial measurements of QOL and psychological state were done before and 3, 12, 24, 36 and 60 months after LVRS. RESULTS: The best scores in SIP were obtained at 36 months after LVRS. Especially, physical-SIP scores at 12, 24, 36 months reached to normal range. However, psychosocial-SIP score at 60 months was worse than pre-LVRS. As for psychological state scores, STAI scores did not show significant changes during 36 months, and indicated in the range of high anxiety at 60 months after LVRS. The SRQ-D scores have been in the suspected level of depression for 60 months. CONCLUSION: It is difficult to maintain the beneficial effect of LVRS on psychosocial QOL and psychological states up to 5 years. CLINICAL IMPLICATIONS: It is important to evaluate not only physiological functions but also psychological changes, when the total outcome should be assessed to determine the long-term benefit of LVRS. DISCLOSURE: Yoko Goto, None. COPARATIVE STUDY OF MANAGEMENT OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) AS PER GLOBAL INITIATIVE ON OBSTUVTIVE LUNG DISEASE (GOLD) GUIDELINES AND ALTERNATE SYMPTOMS/DYSPNEA BASED STRATEGY Jai Kishan MD* Ashish Chawla MBBS Bal K. Kapoor MD TB & Chest Dept/Hospital Govt. Medical College, Patiala, India PURPOSE: GOLD guidelines emphasize the need of spirometery for diagnosis and management of COPD.However, in developing countries who share the major burden of COPD spirometery is not universally available hence an alternate strategy avoiding spirometery need to be developed. METHODS: 50 patients each in Group A & B were studied. Group A were classified on spirometery and managed managed as per GOLD guidelines and Group B graded on symptoms/dyspnea based approach. A comparision made of outcome measures like exacerbations,hospital visits/ hosptallizaion.Group B was classified acording to no dyspnea, dyspnea on unaccustomed exercise, on accustomed exercise,on normal routines of life or on lying in the bed and also on basis of cyanosis, oedema feet or CCF. RESULTS: Exacerbtion were equal (16%)in both the groups.12% of Group A & 16% of Group B patients were lost to folow up.Time for symptomatic imrovement was delayed in Group B but was not statitically significant.Patients when classified according to alternate strategy were falling in lower grade of spirometery based Gold guidelines and thus received lower grade of treatment. CONCLUSION: COPD can be graded and managed according to symptoms/dyspnea based approach. Even GOLD guidelines based management shoul be validated thoroughly. CLINICAL IMPLICATIONS: In resource poor countries symptoms/ dyspnea based COPD management can be employed. DISCLOSURE: Jai Kishan, None.
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VOLUME-REDUCING SURGERY FOR DIFFUSE EMPHYSEMA: EFFECT OF WAITING WITH OPERATION Gunnar N. Hillerdal MD* Kerstin Strom MD Karolinska Hospital, Stockholm, Sweden PURPOSE: Volume-reducing surgery for diffuse emphysema: effect of waiting with operation. METHODS: A Swedish study on Volume-reducing Surgery in diffuse Emphysema(EVRS)was performed during 1997 to 2000. Patients fulfilling strict criteria and having participated in a training program were randomized to either operation (Surgical Group, SG) or to continued training for one year (TG). After this year, patients in TG were offered surgery provided they were still fulfilling the criteria. 53 patients were randomized to each group, and the results showed a significant improvement in Health-related Quality of Life (QoL) and also lung function in the surgical group (Article in Press). In the TG, after the first year, surgery was performed in 32 patients. We compared the results with those who were operated in the SG. RESULTS: The QoL and Lung function was the same in both SG and TG at start (Total Score St Georges Respiratory Questionnaire 59; SF-36 Physical function 22.2 and 22.9, respectively; FEV1 per cent predicted 26 and 27, respectively, and RV % predicted 255 and 267, respectively). There were large improvements in the SG in these figures after 3 and 6 months which then had a tendency to worsen again but at 1 year there were still significant differences between the groups. After surgery in the training group, these patients also improved , but no to the same extent as had those in the SG after their operation; and at two years after randomization, the patients in the SG and those in the TG who had been operated one year later had only non-significant differences both in QoL and lung function, but with a tendency to worse figures in the TG. CONCLUSION: It seems that surgery should be performed early once the patient fulfills the criteria since this gives the patient a longer relief. CLINICAL IMPLICATIONS: Of importance when deciding on operation or postponing possible surgery. DISCLOSURE: Gunnar Hillerdal, None.
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SYSTEMATIC REVIEW OF DISEASE MANAGEMENT IN CHRONIC OBSTRUCTIVE PULMONARY DISEASE Sandra G. Adams MD* Paulla K. Smith RRT John E. Cornell PhD Antonio Anzueto MD Jacqueline A. Pugh MD University of Texas Health Science Center at San Antonio and The South Texas Vet, San Antonio, TX PURPOSE: The chronic illness care model (CICM) has been shown to improve outcomes in diabetes mellitus and congestive heart failure, but data regarding the effectiveness of a comprehensive model in patients with chronic obstructive pulmonary disease (COPD) are lacking. A systematic review of the literature was undertaken to determine the effectiveness of the components of the CICM in patients with COPD. METHODS: MEDLINE, CINAHL, and COCHRANE databases were searched from the earliest date available to January of 2005 to identify English-language articles that evaluated outcomes of adults with an intervention of at least one of the components of the CICM in patients with COPD. RESULTS: A total of 514 abstracts were screened, but only 32 articles were suitable for full abstraction and review. These studies were heterogeneous (different interventions and outcomes) and only a few met standard criteria for high quality. Outcomes such as symptoms, quality of life, lung function, and functional status were not significantly different between the intervention and control groups. However, the pooled relative risk (RR) and 95% confidence intervals (CI) for the emergency/ unscheduled visits for the group who received at least 2 components of the CICM was 0.575 (0.418, 0.790) and for the length of hospital stay was -0.522 (-0.721, -0.322). There was no significant change in healthcare utilization in the control groups or in patients who received only one component (such as self-management alone) of the CICM. CONCLUSION: Only limited data are available in the literature evaluating interventions of any of the components of the CICM in patients with COPD. However, the pooled data from the available studies demonstrated that patients with COPD who received interventions including 2 or more components of the CICM had lower rates of emergency/unscheduled visits and an overall shorter length of hospital stay than patients who received only one component or those who were in the control groups. CLINICAL IMPLICATIONS: Implementation of multiple components of the CICM in patients with COPD has the potential to significantly reduce healthcare utilization. DISCLOSURE: Sandra Adams, None.
POSTER PRESENTATIONS
EVALUATION OF HEALTHCARE RESOURCE UTILIZATION (HRU) AND COSTS OF ANEMIA AMONG CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) PATIENTS Michael T. Halpern MD* Jordana K. Schmier MA Marya Zilberberg MD Edmund Lau MS Exponent, Alexandria, VA PURPOSE: Anemia has been reported in 13-30% of patients diagnosed with COPD1,2,3. However, little information is available on the incremental economic burden resulting from concomitant anemia. We evaluated the impact of anemia on HRU and costs among COPD patients. METHODS: Retrospective data analysis of the Medicare 5% beneficiary encrypted files (BEF) was performed. All individuals with a COPD diagnosis code in the 1997-2001 BEF data were identified. COPD patients with anemia (A ) were identified using ICD-9 diagnosis codes or receipt of transfusion(s) in the absence of major GI bleeding, trauma, or surgery. A 6-month control period preceding the 1st COPD diagnosis (index date) served to compare disease severity. RESULTS: Of the 132,424 patients with COPD identified, 27,932 (21%) had an anemia code. A patients were more likely to be older, female and non-Caucasian (p 0.0001). Except for pre-dialysis chronic kidney disease (22% A vs. 9% without anemia [A-], p 0.0001), comorbidity burden was similar between the 2 groups. Average total annual Medicare reimbursement was $855 for A and $437 for A- before the index date; after the index date it increased by 71% to $1466 in the A group vs. 49% to $649 in the A- group. In both groups, the greatest cost driver before and after the index date was hospitalizations, accounting for 50% of the average payments. In regression models controlling for demographics, disease severity, and comorbidities, anemia maintained an independent and significant association with increased payments.
POOLED CLINICAL TRIAL ANALYSIS OF THE SAFETY OF TIOTROPIUM Steven Kesten MD* Michele Jara PhD Charles Wentworth MS Stephan Lanes PhD Boehringer Ingelheim, Ridgefield, CT PURPOSE: Marketing approval of pharmaceutical products is often based on efficacy and safety data from several thousand subjects. After approval, information may be obtained from larger numbers of patients from Phase IV clinical trials enhancing the ability to detect rare adverse events.
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HANDLING PERFORMANCE AND PATIENT SATISFACTION OF A METERED DOSE INHALER(MDI) WITH INTEGRATED DOSE COUNTER IN PATIENTS WITH COPD Courtney Crim MD* William R. Lincourt BS Nickolas W. Locantore PhD J. R. Carranza-Rosenzweig PharmD GlaxoSmithKline Inc., Raleigh, NC PURPOSE: Current methods that require patients to track inhaler doses are unreliable and can lead to circumstances where medication is unavailable. This study examined patient satisfaction and handling performance of an MDI fitted with an integrated dose counter in 219 patients with COPD. METHODS: Data were collected using self-report questionnaires that assessed previous MDI experience and overall satisfaction with the MDI with counter. Counter performance was assessed during a 30 or 50 day treatment period by measuring the discrepancies between the counter readings and the actuations reported on a subject recorded diary card. RESULTS: At baseline 65% of the patients reported feeling anxious not knowing the amount of medication left in their inhaler. Fifty-seven percent reported assessing the remaining quantity by shaking the inhaler and 43% reported waiting until it was completely empty. After using fluticasone propionate/salmeterol HFA or albuterol HFA MDI with Counter, 93% of patients were satisfied with it based on its ease of use and convenience. Ninety-one percent felt that it would allow them to monitor their medication use while 93% agreed that the counter would help them avoid running out of medication. A total of 308 discrepancies between subject-reported use and counter readings occurred in 15,835 device handlings (31,667 MDI actuations), constituting a discrepancy rate of 0.97 discrepancies per 100 actuations. Fifty-two percent of the subjects reported no discrepancies. For subjects reporting a discrepancy, the majority (90%) were of 1 or 2 actuations. CONCLUSION: These data support the need for a reliable, MDI actuation counting device and document the favorable patient perceptions of the MDI with Counter. The results showed a high level of concordance between the MDI with Counter and the subject-recorded diary card. CLINICAL IMPLICATIONS: The addition of an integrated dose counter to an MDI will provide patients with a reliable indication of remaining actuations in their inhalers and increase clinicians assurance that patients are not using their inhalers beyond the recommended number of labeled doses, a situation that clearly impacts patient health. DISCLOSURE: Courtney Crim, Grant monies (from industry related sources) Study supported by a grant from GlaxoSmithkline; Employee All authors are employees of GlaxoSmithKline Inc.; Product/procedure/ technique that is considered research and is NOT yet approved for any purpose. MDI dose counter is approved for Ventolin HFA in the US and for Seretide in the UK
ADDITION OF FORMOTEROL TO TIOTROPIUM PRODUCES BETTER FEV1 AND FVC RESPONSES WHEN MEASURED OVER 24 HOURS FOLLOWING SINGLE-DOSE ADMINISTRATION IN SUBJECTS WITH MODERATE-TO-SEVERE COPD Bill Brashier MBBS Ashwini Jantikar MBBS Manisha Maganji MBBS Anchala Raghupathy MBBS Sapna Valsa MS Partha Gokhale MD Purnima Mahadik MS Jaideep Gogtay MD Sundeep S. Salvi MD* Chest Research Foundation, Pune, India PURPOSE: Tiotropium, a new long-acting anticholinergic drug is recommended as first-line bronchodilator in the management of COPD. The aim of this study was to investigate whether addition of Formoterol, a long-acting b2-agonist produces a superior bronchodilator response when compared to Tiotropium alone in subjects with moderate-to-severe stable COPD. METHODS: 23 male subjects (mean age: 59.6 7.6 yrs) diagnosed with COPD and no histories of exacerbation over the previous 4 weeks, were recruited into this study. Single doses of Tiotropium (18mcg) and a combination of Tiotropium plus Formoterol [18 and 12 mcg respectively) administered through a single ihaler, were given with a pMDI plus non-static spacer on two separate study days, 4-7 days apart, in a randomized, double-blind, cross-over manner. FEV1 and FVC were measured at baseline and 5min, 15min, 30min, 60min, 2hr, 3hr, 4hr, 6hr, 8hr, 12hr and 24hr following the study drug administration with a Vitalograph Gold Standard dry bellows Spirometer. RESULTS: The mean baseline FEV1 value in this study population was 40.6 14.1% predicted. Tiotropium plus Formoterol produced a significantly better mean difference in area under the curve change from baseline to 24 hrs for both FEV1 (p 0.001) and FVC (p 0.02). Also, the mean difference in trough (24 hr) values from baseline were significantly better with the combination than Tiotropium alone [(FEV1 289.6mL vs 185.7mL; p 0.001)(FVC 503.5mL vs 297mL; p 0.007). The combination showed a faster onset of action for FVC, defined as an increase of at least 150mL from baseline (5.0 mins vs 12.1 mins; p 0.02) and tended to show a longer duration of action when compared to Tiotropium alone (FEV1: p 0.06; FVC: p 0.05).
IMPROVEMENT OF DYSPNEA IN COPD PATIENTS BY COMBINATION THERAPY WITH TIOTROPIUM PLUS SALMETEROL (T S) IN RESPONDERS AS WELL AS POOR RESPONDERS TO SALBUTAMOL J.A. van Noord MD* J-L Aumann MD E. Janssens MD J.J. Smeets A. Mueller P.J.G. Cornelissen PhD Atrium Medisch Centrum, Heerlen, Netherlands PURPOSE: Recommended mono- or combination therapy of longacting bronchodilators in COPD is successful if relief of dyspnea is provided. METHODS: A retrospective analysis was conducted in 93 patients (FEV1: 1.09 L / 39% pred) who completed a 4-way, double-blind, crossover study of tiotropium 18 mcg (qd), salmeterol 50 mcg (bid), T (qd) S (qd) or T (qd) S (bid). Patients were characterized as responder (R, 12% increase in FEV1 45 min after 400 mcg salbutamol) or poor responder (PR, 12%) on the basis of a single test. Effects on dyspnea (TDI, 1 unit is clinically relevant), FEV1, FVC and need for
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Mean*
Tio (qd) Salm (bid) T(qd) R 1.52 142 230 1.55 PR R PR R # 0.65 1.18 0.67 2.97 86 97 32 250 185 133 66 411 2.26 1.47 2.21 1.00
S(qd) T(qd) PR 1.93# 152 301 1.50 R 3.15# 262 407 1.12
TDI (focal score) FEV1 (0-12h) - ml FVC (0-12h) - ml Puffs salb (0-12h)
*
ECONOMIC IMPACT RESULTING FROM A CONVERSION TO LEVALBUTEROL EVERY SIX TO EIGHT HOURS Robert S. Pikarsky RRT* Russell A. Acevedo MD Tracey Farrell RRT Wendy Fascia RRT Crouse Hospital, Syracuse, NY PURPOSE: Crouse Hospital approved an automatic conversion from Racemic Albuterol (Alb) 2.5mg Q4h to either Levalbuterol (Lev) 0.63 mg Q6h or Lev 1.25 mg Q8h. To further maximize Respiratory Therapist time we took the next step of automatic conversion of all Lev Q6h to Lev Q8h. METHODS: All protocol treatments delivered between 10/04 and 4/05 were recorded. Pre-conversion estimates for Alb Q4h were twice the current Lev Q8h protocol. The ratio of Lev Q6h to Q8h delivered between 1/04 and 4/04 (prior protocol) was 85%:15%. The cost for unit dose Alb was $0.22. The cost for unit dose Lev was $1.85. We used the 0.26 hour per treatment time as reported in the AARC Uniform Reporting Manual. The FTE average cost (salary/benefits) $23.80/hr. All aerosol therapy was provided with the use of the AeroEclipse Breath Actuated Nebulizer (BAN). RESULTS: The table shows the drug and labor cost for the current protocol and the estimated number of treatments, with their respective costs, for the prior protocol and pre-conversion periods. For the current protocol, the drug cost of $16,482 is lower than the prior protocol and considerably higher than the pre-conversion period. Labor costs decreased with each protocol as the number of treatments dropped. The drop in labor cost more than offset the increase drug costs in each protocol. The largest savings was seen with the current Lev Q8h protocol. The Respiratory Care Departments total expenses for the first 3 months of this year was 8.6% under budget and 7.9% below the same time period in 2004. CONCLUSION: Hospital-wide conversion to Lev is cost-effective when administered on both a Q6h and Q8h frequency with the maximum benefit at the Q8h frequency. Therapist availability was enhanced with fewer scheduled treatments. CLINICAL IMPLICATIONS: The conversion to Lev allows the ability to meet our patient care demands and for the reallocation of workforce needs in an economically advantageous manner.
Means are adjusted for centre, patient within centre and period.
POSTER PRESENTATIONS
DISCLOSURE: JA van Noord, Grant monies (from industry related sources) First three authors received honorarium to conduct clinical research BREAKTHROUGH TREATMENTS RATES DURING A CONVERSION TO LEVALBUTEROL, TIOTROPIUM AND BREATH ACTUATED NEBULIZERS Robert S. Pikarsky RRT* Russell A. Acevedo MD Tracey Farrell RRT Wendy Fascia RRT Crouse Hospital, Syracuse, NY PURPOSE: In order to maximize therapist time, an auto-conversion to Levalbuterol (Lev) Q8h, Tiotropium (Tio) QD and AeroEclipse Breath Actuated Nebulizer (BAN) usage in mouthpiece (MP) mode was evaluated. METHODS: All patients assessed by Respiratory Therapists with the ability to perform aerosol treatments by mouthpiece were converted to Lev 0.63 mg Q8h by BAN MP. If ordered, Ipratropium (Ipra) 0.5 mg was converted to Tio 18 mcg QD. If unable to perform the MP treatment patients were converted to Lev 1.25 mg Q8h delivered by mask. If ordered, Ipra 0.5 mg was converted to Ipra 0.25 mg Q8h. All protocol treatments, including breakthrough treatments delivered between 10/04 and 4/05 were recorded. Treatment refusals and omitted treatments were recorded. The breakthrough data for Racemic Albuterol (Alb)was from our previous studies. RESULTS: The table shows the number of treatments(tx), the number of prn breakthrough treatments and the per-treatment and daily rates of breakthroughs per 100 treatments. Lev 0.63 mg Q8h MP had significantly lower breakthroughs rates than the Alb 2.5 mg Q4h, both in per-treatment and daily rates (p 0.05)* Alb/Ipra Q4h had significantly lower pertreatment rates when compared with Lev/Tio Q8h and Lev/Ipra Q8h (p 0.01)**; the daily breakthrough rates were not significantly different. Omitted treatments decreased from 2.28% to 1.95%. Patients refused 3.81% of scheduled treatments.
Breakthroughs per 100 tx *1.64 **1.95 Daily Breakthroughs per 100 tx *4.91 5.84
Pre-conversion Treatments Alb Q4h Treatments Lev Q6h Treatments Lev Q8h Total treatments Drug cost (dollars) Labor (hours) Labor cost (dollars) Total cost (dollars) Savings compared with current protocol $ 17,818
Prior Protocol 9,642 1,678 11,320 $20,942 2,943 $70,048 $90,990 $19,380
Current Protocol
Order Lev 0.63 mg Q8h (MP) Lev 0.63 mg Q8h/Tio 18 mcg Qday (MP) Lev 1.25 mg Q8h (Mask)
Breakthroughs 58 22
17,818 3,920
3092
74
2.39
7.18
CONCLUSION: The conversion from Alb Q4h to Lev Q8h allowed for a decreased frequency of daily medication administrations and a decrease
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AUC of FEV1 (L x hours) Elderly Patients Trial 1 Contrast FOR24 vs Placebo FOR12 vs Placebo FOR24 vs FOR12 N 394 1.701* 2.127* -0.426 Elderly Patients Trial 2 N 397 2.753* 2.459* 0.294 Elderly Patients Pooled N 598 2.251* 2.358* -0.108 All Age Groups Pooled N 1158** 2.430* 2.475* -0.045
HIGH SATISFACTION WITH FLUTICASONE PROPIONATE/ SALMETEROL VIA DISKUS REPORTED DURING EXPERIENCE PROGRAM IN PATIENTS WITH COPD Stuart Stoloff MD* Steven Samuels MD Sidney Braman MD Christy Brown PharmD Donna Kerney PhD Michael Cicale MD University of Nevada School of Medicine, Reno, NV PURPOSE: An initial experience program was conducted in patients with COPD to collect patient reported feedback about newly initiated therapy with fluticasone propionate/salmeterol 250/50 (FSC). METHODS: Patients completed 2 surveys; one at baseline (before initiating therapy with FSC 250/50) and one targeted for 30 days after starting therapy with FSC 250/50). The first survey collected patient demographics, duration of COPD diagnosis, smoking history, and satisfaction with prior treatment. The second survey assessed patient perceived impact of FSC 250/50 on breathing, and convenience and satisfaction with FSC therapy. RESULTS: A total of 973 patients completed both surveys. Completers were mostly female (62%), and 87% were 45 years of age. Two-thirds of the completers had been diagnosed with COPD for 1 year. At baseline, 58% of the population used prescription medications prior to starting FSC 250/50. The most common medications were ipratropium/albuterol (37%) and salmeterol (27%). Patients reported satisfaction with their prior therapy (5.52 on a 9 point scale), but 22% of patients were quite dissatisfied (1-3 on a 9 point scale). The second survey, completed an average of 51 days after starting FSC 250/50, showed that patients perceived improvement in their breathing overall (6.82 on a 9 point scale) and had a high level of satisfaction with FSC 250/50 (7.76 on a 9 point scale). Less than 4% of patients were quite dissatisfied ( 3 on a 9 point scale). FSC 250/50 was regarded as a very convenient medication (8.12 on a 9 point scale). CONCLUSION: Patients with COPD reported a high level of satisfaction with their treatment an average of 51 days after initiating therapy with FSC 250/50. CLINICAL IMPLICATIONS: High patient satisfaction with therapy may encourage increased compliance with therapy and therefore may result in improved outcomes. DISCLOSURE: Stuart Stoloff, Grant monies (from industry related sources) Received research grants from GlaxoSmithKline; Consultant fee, speaker bureau, advisory committee, etc. Received consultant fees from GlaxoSmithKline and serve on speaker bureau and advisory board for GlaxoSmithKline
CHEST 2005Poster Presentations
BRONCHODILATION IN ELDERLY PATIENTS WITH COPD: A SUB-GROUP ANALYSIS OF TWO RANDOMIZED CLINICAL TRIALS Umit Yegen MD* Denise Till MS Gregory P. Geba MD Novartis Pharmaceuticals Corporation, East Hanover, NJ PURPOSE: The efficacy of beta-agonists in elderly patients has received little attention to date. We performed an analysis based on pooled data from 2 large randomized, double-blind, multicenter clinical trials comparing Foradil dry powder inhalation capsules 12 g b.i.d. (FOR12) and 24 g bid (FOR24) with placebo. METHODS: Of a total of 1634 COPD patients randomized, 598 were 65 years of age, comprising the elderly subgroup. Serial measurements of FEV1 were performed pre-dose, and 5, 15, 30 and 60 minutes and hourly through 12 hours post AM dose on the first day and after 3 months of treatment. RESULTS: Elderly patients tended to have slightly lower FEV1 at baseline. Clinically and statistically significant bronchodilation ( 15% increase in FEV1) with both FOR doses compared to placebo was achieved throughout the 12 hour interval as shown by the area under the FEV1 curve (AUC; primary endpoint). These results were similar to the total study population (shown below). The incidence of adverse events (AEs) were also similar in the elderly subgroup compared to the full study population. CONCLUSION: FOR provided clinically significant and sustained increases in airflow in elderly patients with COPD that was similar in magnitude to the total study population with a similar tolerability profile.
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129 (93 171) 140 (101 194) 134 (96 190) 147 (104 - 214)
DISCLOSURE: L Spencer, Consultant fee, speaker bureau, advisory committee, etc. LTS and MB have been scientific advisors to Aventis Berhing and Bayer Healthcare.; Other DPP and JMS have no financial disclosures.
COMPARABLE PHARMACOKINETIC PROPERTIES OF TWO ALPHA1-PROTEINASE INHIBITORS AFTER SINGLE THERAPEUTIC DOSES James M. Stocks MD* Mark Brantly MD Alan Barker MD Friedrich Kueppers MD Charlie Strange MD James F. Donohue MD Robert Sandhaus MD University of Texas Health Center at Tyler, Tyler, TX PURPOSE: This study evaluated the bioavailability of a new preparation of alpha1-proteinase inhibitor (A1-PI), Zemaira (ZLB Behring LLC, [Z(A1-PI)]), with that of Prolastin (Bayer Corporation, [P(A1-PI)]) after single intravenous infusions. METHODS: This was a double-blind, randomized, controlled, 2x2 crossover study comparing a single dose of Z(A1-PI) and P(A1-PI) (60 mg per kg bodyweight). Patients with AATD were randomized (n 9 per group) to Z(A1-PI) followed by P(A1-PI), or P(A1-PI) followed by Z(A1-PI), with a washout period between infusions of 35 days. Bioavailability was measured by two baseline-adjusted area-under-the-curve (AUC) variables: area-under-the observed data up to Day 21 (AUD0-21) and AUD0- . The ratio of mean AUC variables (Z(A1-PI):P(A1-PI)) with 90% confidence intervals (CI) was calculated. Standard pharmacokinetic (PK) parameters Cmax, tmax, terminal t12, mean residence time, total clearance, and steady-state volume of distribution were also compared. RESULTS: The bioavailability of Z(A1-PI) was statistically non-inferior to P(A1-PI) as shown by the lower limit of the 90% CI for the mean AUC ratio (Z(A1-PI):P(A1-PI)) being greater than 80% for AUD0-21 and also for AUD0(Table). Furthermore, the PK profile of functional A1-PI levels following Z(A1-PI) and P(A1-PI) administration showed no clinically relevant differences in terms of mean (SD) Cmax (39.9 5.3 vs. 41.6 8.0 M), tmax (0.7 0.3 vs. 1.5 1.4 hours), terminal t12 (4.5 3.1 vs. 4.8 1.2 days), mean residence time (5.9 3.3 vs. 6.1 1.3 days), total clearance (636 115 vs. 583 108 mL/day) or steady-state volume of distribution (3.6 1.3 vs. 3.5 0.8 L). The PK profile was reflected by that of antigenic A1-PI levels. CONCLUSION: A single therapeutic dose of Z(A1-PI) was comparable and statistically not inferior to P(A1-PI) in bioavailability. There were no differences between Z(A1-PI) and P(A1-PI) in standard pharmacokinetic parameters. CLINICAL IMPLICATIONS: Since Z(A1-PI) is statistically not inferior to P(A1-PI) in bioavailability, a weekly infusion of Z(A1-PI) 60 mg per kg body weight is expected to augment and maintain A1-PI serum levels above the protective threshold of 11 M, and increase A1-PI levels in the lower lung, to a similar extent to that reported with P(A1-PI). DISCLOSURE: James Stocks, None.
POSTER PRESENTATIONS
Bronchodilator inhalation Positive group Baseline After Negative group Baseline After
Dm ml/min/mm Hg
TLco %Pred
Vc ml
40 11.10 5.34 18 18
50.08 20.82
LOWER RESPIRATORY TRACT BIOCHEMICAL EFFICACY OF INTRAVENOUS ADMINISTRATION OF A NEW FORM OF HIGHLY PURIFIED ALPHA1-ANTITRYPSIN L T. Spencer MD* David P. Pollock MD James M. Stocks MD Mark L. Brantly MD University of Florida College of Medicine, Gainesville, FL PURPOSE: To evaluate the biochemical efficacy and safety of a new source of highly purified, plasma derived alpha1-proteinase inhibitor (A1-PI) in individuals with alpha1-antitrypsin (AAT) deficiency. METHODS: A randomized, double-blind study compared Zemaira (ZLB Behring LLC) [Z] with Prolastin (Bayer Corporation) [P]. Patients received either Z or P (randomized 2:1) for 10 weeks by intravenous infusion (60 mg/kg functionally active A1-PI weekly). The P group was then crossed over to an open-label phase where all subjects received Z for 14 weeks. A subset of 15 patients with forced expiratory volume in 1 second 50% predicted underwent bronchoalveolar lavage. Antigenic AAT levels and AAT:neutrophil elastase (AAT:NE) complexes in the epithelial lining fluid (ELF) between baseline and Week 11 were measured by ELISA. RESULTS: Increases in ELF AAT levels were statistically significant in both treatment groups. Subjects receiving Z A1-PI had ELF values of 197.1 nM at baseline, increasing to 1125.5 nM after 10 weeks of treatment (p 0.0001), and those receiving P increased from 261.5 nM to 1192.5 nM (p 0.0121). Z A1-PI remained functionally active when delivered to the lung from the systemic circulation, as indicated by significant increases in ELF AAT:NE complexes from baseline to 11 weeks [2.8 nM to 66.8 nM (p 0.0012)]. Both Z and P were safely tolerated. CONCLUSION: The results indicate that both protein preparations are delivered to the lung in an equivalent manner after intravenous administration and that the exogenous protein is in a functional state capable of forming complexes with NE in the lung.
HEALTH-RELATED QUALITY OF LIFE (HRQOL) IN PATIENTS WITH ALPHA1-ANTITRYPSIN (AAT) DEFICIENCY AND EFFECT OF AUGMENTATION THERAPY: PRELIMINARY RESULTS Karen C. Chung PharmD Matthew E. Borrego PhD Jennifer Short BS* Loretta Kristofek RN Nancye Buelow David M. Gelmont MD University of New Mexico Health Sciences Center, Albuquerque, NM PURPOSE: AAT deficiency (AATD), a common genetic disorder which predisposes subjects to early onset emphysema, has been associated
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DISCLOSURE: Jennifer Short, Grant monies (from industry related sources) MEB and JS received a grant from Baxter BioScience to conduct data entry and analysis.; Employee KCC and DMG - Baxter BioScience.
DIFFERENCES IN MICROHETEROGENEITY AND NONTHERAPEUTIC PROTEIN CONTENT OF THREE COMMERCIAL PREPARATIONS OF PURIFIED HUMAN ALPHA1-PROTEINASE INHIBITOR Friedrich Kueppers MD* Utpal Patel MS Temple University School of Medicine, Philadelphia, PA PURPOSE: Three commercially available preparations of alpha1proteinase inhibitor (A1-PI) are derived from human plasma but differ in the purification steps employed during manufacture, leading to differences in purity. As little is known about the effect of purification on biochemical composition of the final active substance, we compared their microheterogeneity and non-therapeutic protein content. METHODS: Zemaira (ZLB Behring LLC) [Z], Prolastin (Bayer Corporation) [P] and Aralast (Baxter Inc) [A] were evaluated. Isoelectric focusing (Am J Hum Genet 1978; 30: 359-65) was performed to evaluate the relative proportion of different isoforms (M2, M4, M6) of A1-PI relative to historical values for normal serum (Scand J Clin Lab Invest 1969; 23: 97-103). Double diffusion experiments were performed to detect non-therapeutic serum proteins.
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DOPPLER TISSUE IMAGING IN THE EVALUATION OF RIGHT VENTRICULAR FAILURE IN PATIENTS WITH CHRONIC OBSTRUCTIVE PULMONARY DISEASE Vasiliy Pyankov MD* Yulia Chuyasova MD Kirov Medical Academy, Kirov, Russia PURPOSE: Right ventricular (RV) failure associated with pulmonary artery hypertension (PAH) in patients with chronic obstructive pulmonary disease (COPD) has important prognostic implications. The noninvasive evaluation of the RV failure in patients with COPD still represents a problem. The purpose of this study was to evaluate RV failure in patients with COPD using pulsed wave Doppler tissue imaging (DTI). METHODS: 46 males with COPD (mean age 57 8 years; mean FEV1 30 8%) were studied. All patients underwent clinical and laboratory examinations. RV wall thickness, RV end-diastolic diameter, RV systolic and diastolic functions were evaluated with two-dimensional echocardiography. The tricuspid inflow profile (E, A, E/A, DT) and hepatic vein flow velocity (S, D, A) were measured with pulsed Doppler. Peak velocities of the tricuspid annular motion (Sa, Ea, Aa, Ea/Aa) were derived from pulsed DTI. RESULTS: RV systolic dysfunction (RV ejection fraction 45% and Sa 11.5 sm/s) was detected in 13% of cases. RV diastolic dysfunction was detected in 100% of cases. Impaired relaxation pattern of tricuspid inflow (E/A 1.0 and Ea/Aa 1.0) was detected in 69.6%, pseudonormal pattern - in 17.4% (2.0 E/A 1.0 and Ea/Aa 1.0), restrictive pattern - in 13% (E/A 2.0). There were significant correlations between tricuspid annular motion (Ea/Aa) and tricuspid inflow profile (E/A) (r -0.56; p 0.019), RV wall thickness (r 0.72; p 0.001), RV end-diastolic diameter (r 0.70; p 0.001) and RV ejection fraction (r 0.70; p 0.001); between systolic pulmonary artery pressure and hepatic vein flow velocity (retrograde A velocity) (r 0.60; p 0.007). CONCLUSION: Our study confirmed high prevalence of RV systolic and diastolic dysfunction in patients with COPD. Physicians should detect RV failure in patients with COPD. CLINICAL IMPLICATIONS: The complex echocardiography evaluation with DTI provides a simple, rapid and noninvasive tool for diagnosis of RV failure in patients with COPD. DISCLOSURE: Vasiliy Pyankov, None.
POSTER PRESENTATIONS
CHRONIC OBSTRUCTIVE PULMONARY DISEASE INDUCED RIGHT VENTRICULAR DIASTOLIC DYSFUNCTION AND/OR FAILURE: FACT, FICTION OR A DILEMMA FOR NEW THERAPEUTIC INTERVENTIONS? Nestor J. Angomachalelis MD* Eva Serasli MD Alex Hourzamanis MD John N. Angomachalelis MD Nikos Salem MD Aristotle University of Thessaloniki, George Papanikolaou General Hospital, Thessaloniki, Greece PURPOSE: Up-to-date right ventricular diastolic function in Chronic Obstructive Pulmonary Disease (COPD) patients (pts)has not been thoroughly investigated. Thus, there is always a great dilemma to be recognised, whether right ventricular diastolic dysfunction (RVVD)and/or failure, related to COPD pathophysiology, is, indeed, a fact, fiction or a dilemma for new therapeutic interventions. METHODS: Fourty three consecutive pts with COPD and 14 age and heart rate-matched controls underwent M-Mode and Acoustic Quantification (AQ) echocardiographic evaluation of right ventricular systolic (RVS) and diastolic function, Doppler transtricuspid flow estimation and lung function tests (spirometry and blood gases analysis), as well as radionuclide ventriculography with Technetium-99m-pyrophosphate (Multigated Acquisition, MUGA).Pts were classified in three groups:
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THE PREVALENCE OF POLYCYTHEMIA IN A CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) COHORT Claudia Cote MD* Marya Zilberberg MD Samir H. Mody PharmD Bartolome Celli MD Bay Pines VAMC, Bay Pines, FL PURPOSE: Although thought to occur frequently, the actual prevalence of polycythemia among patients with COPD and its effect on outcomes in the current treatment environment is unknown. We characterized polycythemia prevalence and its association with outcomes in COPD. METHODS: We retrospectively analyzed data collected prospectively on 683 patients between 1/97 and 6/02 in a VA Pulmonary clinic for BMI, airflow obstruction, dyspnea, and exercise capacity (BODE) index validation1. Polycythemia (P ) was defined as Hb 17 g/dL in men and 15 g/dL in women2. All values are expressed as percentages or mean (SD). P values were derived using a 2-sided Students t-test or Chi-square statistic where appropriate. RESULTS: In this sample of 677 patients with known Hb values, polycythemia was present in 36 (5.3%) patients. The Table below compares P to non-polycythemic (P-) patients. CONCLUSION: Polycythemia is uncommon in COPD, occurring in 5% of patients, and is not associated with greater hypoxemia or any other important clinical expression of the disease. CLINICAL IMPLICATIONS: Additional studies are warranted to evaluate the prevalence and effects on outcomes of polycythemia in COPD patients.1Celli BR et al. N Engl J Med 2004;350:1005-12 2Harrisons online, accessed 11-12-04 http://www3.accessmedicine.com/ content.aspx?aID 58150&searchStr polycythemia.
A (n 116) Age (yrs) FEV1%predicted PaO2 (torr) BMI (kg/m2) Charlson Comorbidity index, points BODE index, points Supplemental O2 % on any Flow (L/min) Hospitalizations % hospitalized # hospitalizations/pt Days hospitalized/pt Follow-up (mos) 72.8 (9.3) 43.17 (16.95) 72.1 (13.3) 27.1 (6.7) 6.5 (3.5) 5.3 (2.6) 38 2.6 (0.7) 47 1.3 (2.2) 13.4 (30.3) 33.9 (21.7)
A(n 561) 69.5 (8.8) 42.07 (17.26) 71.9 (11.9) 26.3 (5.8) 4.8 (2.4) 4.7 (2.4) 34 2.6 (0.9) 38 0.9 (1.7) 7.8 (21.7) 37.2 (22.1)
p Value 0.0003 0.5 0.9 0.2 0.0001 0.0128 0.37 0.97 0.06 0.03 0.02 0.1511
(n 36) P- (n 641) p Value 0.0001 0.62 0.35 0.52 0.88 0.44 0.24 0.21 0.56 0.16 0.30 0.82 0.93
Hb (g/dL) 17.5 (0.8) 14.3 (1.5) On supplemental O2 (%) 31 34 Age (yrs) 68.7 (9.5) 70.2 (9.0) F/U time (mos) 34.3 (20.4) 36.7 (22.2) FEV1% 42.7 (18.3) 42.2 (17.2) Room air PaO2 (torr) 70.4 (11.3) 72.0 (12.2) 6MWD (m) 339.1 (131.1) 313.5 (125.6) MRC dyspnea 2.4 (0.8) 2.6 (0.9) Charlson co-morbidity 4.8 (2.1) 5.1 (2.7) 27.8 (4.6) 26.4 (6.0) BMI (kg/m2) BODE index 4.4 (2.4) 4.9 (2.5) 2-year respiratory mortality (%) 31 27 2-year all-cause mortality (%) 36 35
compares A to non-anemic (A-) patients. There was no difference between the groups with regard to the prevalence of O2 utilization or the
DISCLOSURE: Claudia Cote, Grant monies (from industry related sources) These analyses were supported by Ortho Biotech Clinical Affairs, LLC.; Employee Marya Zilberberg, MD and Samir H. Mody, PharmD are employees of Ortho Biotech Clinical Affairs, LLC.
CHEST 2005Poster Presentations
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INDEPENDENT CONTRIBUTIONS OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE AND ABDOMINAL AORTIC ANEURYSM TO MORTALITY RISK Dmitry Lvovsky MD* Ashok Fulambarker MD Mark E. Cohen PhD Sinan A. Copur MD Sunita Kumar MD Rosalind Franklin University of Medicine and Science, Chicago Medical School, North Chicago, IL PURPOSE: To determine mortality in patients with aortic abdominal aneurysm (AAA) and chronic obstructive pulmonary disease (COPD) as compared to patients with only AAA. METHODS: A retrospective cross-sectional study evaluated mortality for the four combinations of AAA ( or -) and COPD ( or -), using patient hospital records identified by ICD-9 codes. Other factors recorded and considered for predictive modeling included: coronary artery disease, peripheral arterial occlusive disease, hypertension, smoking, pulmonary function tests, hypercholesteremia, size and repair status of AAA. RESULTS: Data were available for 460 subjects (455 males), with 115 subjects in each of four groups defined by the presence or absence of COPD and AAA. Mean ages (SD) were 75.12 (6.41), 76.49 (6.61), 77.70 (5.64), and 76.60 (5.92) for COPD-/AAA-, COPD /AAA-, COPD-/AAA , and COPD /AAA groups, respectively (P 0.018, ANOVA, with only the oldest and youngest groups being significantly different, Tukey). Among these groups, mortality rates were 6.96, 66.96, 34.78, and 69.57 percent, respectively.Preliminary analysis, using logistic regression, found that COPD and AAA (P 0.0001) and their interaction (P 0.0002) were significant predictors of the binary mortality outcome. These effects were consistent when other factors were included in the model. The Table shows odds ratios for various grouping arrangements. The group-wise comparisons suggest that COPD had a significant effect on mortality in the absence (OR 27.10) or presence of AAA (OR 4.29), while AAA had a significant effect on mortality in the absence of COPD (OR 7.13) but not in its presence (OR 1.13). CONCLUSION: Among patients positive for AAA, the risk of death is significantly greater when COPD is present. Among patients positive for COPD, the risk of death is not significantly raised by AAA. This outcome might due to a mortality ceiling effect observed for COPD but not for AAA. CLINICAL IMPLICATIONS: Patients with AAA should be screened for COPD, because of the latters profound effect on mortality. Future studies on recognition and management of concurrent COPD and AAA seem warranted, with a potential to extend survival in this high-risk population.
POSTER PRESENTATIONS
SEX DIFFERENCES IN THE PREVALENCE OF PSYCHIATRIC DISORDERS AND PSYCHOLOGICAL DISTRESS IN PATIENTS WITH CHRONIC OBSTRUCTIVE PULMONARY DISEASE IN A CANADIAN SAMPLE Catherine Laurin BSc* Kim L. Lavoie PhD Simon Bacon PhD Philippe R. Stebenne BSc Gilles Dupuis PhD Andre Cartier MD Guillaume Lacoste BA M Julien MD Manon Labrecque MD Sacre-Coeur Hospital, Pneu mology Research, Montreal, PQ, Canada PURPOSE: Research has documented a high prevalence of psychiatric disorders in patients with chronic obstructive pulmonary disease (COPD). In general, psychiatric disorders are more common in women than in men. However, few studies have evaluated sex differences in the prevalence of psychiatric disorders in COPD patients. The present study evaluated the prevalence of mood and anxiety disorders in 62 women and 54 men with documented, stable COPD. METHODS: Patients (n 116) underwent a sociodemographic and medical history interview, followed by a structured psychiatric interview (ADIS-IV). All patients underwent spirometry and completed a battery of questionnaires measuring psychological distress and quality of life. RESULTS: A total of 57% of women vs. 35% of men met criteria for one or more anxiety disorder (Chi-Square 5.70, p .01), and 31% of women vs. 14% of men met criteria for one or more mood disorder (Chi-Square 4.03, p .05). The most common anxiety disorder among patients was panic disorder, affecting 27% of women and 11% of men (Chi-Square 4.83, p .05). The most common mood disorder was major depression, affecting 18% of women and 6% of men (Chi-Square 6.70, p .05). Women had significantly higher anxiety sensitivity and depression scores compared to men (ps .01). Women also reported being less confident in their ability to control respiratory symptoms compared to men (p .05) and perceiving themselves as more limited in their activities as a result of their disease (p .01), despite having comparable dyspnea scores (p .08).There were no differences in exacerbation rates (last year)
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OFF-PUMP CORONARY ARTERY BYPASS SURGERY IN A LOW CASE LOAD CENTER: MID-TERM FOLLOW-UP OF THE FIRST 107 PATIENTS Parwis Massoudy MD* Matthias Thielmann MD Julia Schafer MS Eva Assenmacher MD Christian Losch Axel Schmermund MD Ivan Aleksic MD Jarowit A. Piotrowski MD Walter O. Schuler MD Peter Kienbaum MD Raimund Erbel MD Heinz Jakob MD West German Heart Center, Department of Thoracic and Cardiovascular Surgery, Essen, Germany PURPOSE: Off pump coronary artery bypass (OPCAB) grafting is still discussed controversially in the cardiac surgical community. Early perioperative results are encouraging. Only few reports have focused on mid-term recurrence of angina and freedom from death or re-intervention. METHODS: 107 OPCAB patients (mean age 63 1 years, 77 male, mean additive EuroScore 4.1 0.3, mean logistic EuroScore 5.6 0.7%, number of distal anastomoses 2.0 0.1), operated on between January 1999 and December 2003, were systematically followed up comparing pre- and post-operative NYHA- and CCS-classifications and assessing freedom from death and re-intervention. 52 of 107 patients underwent postoperative angiography or multi-slice computed tomography (MSCT). 24 of the latter 52 patients were symptomatic, 21 with stable angina, 3 with unstable angina, the others underwent follow-up studies having given their informed consent. RESULTS: Perioperative 30 day mortality was 3%. Freedom from death or re-intervention at 5.5 years was 91% and 80%, respectively. Only three patients required re-intervention in an OPCAB-related vessel. CCS classification was 2.8 0.1 before surgery and 1.8 0.2 (p 0.01) at follow-up (3.3 0.3 years). NYHA classification was 2.7 0.1 and 2.2 0.1 (p 0.01), respectively. 52 patients (24 for cardiac symptoms) underwent coronary angiography or MSCT at a mean follow-up of 2.2 0.3 years. Left
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POSTER PRESENTATIONS
C1-ESTERASE INHIBITOR TREATMENT DURING EMERGENCY CORONARY ARTERY BYPASS SURGERY IN PATIENTS WITH ACUTE ST-ELEVATION MYOCARDIAL INFARCTION Matthias Thielmann MD* Guenter Marggraf MD Parwis Massoudy MD Markus Neuhauser PhD Stephan Knipp MD Markus Kamler MD Jarowit Piotrowski MD Heinz Jakob MD Thoracic and Cardiovascular Surgery, West-German Heart Center Essen, University, Essen, Germany PURPOSE: Myocardial inflammatory response including complement activation was demonstrated as an important mechanism of ischemiareperfusion injury and complement inhibition by C1-esterase-inhibitor (C1-INH) has recently shown cardioprotective effects in experimental and clinical settings. METHODS: The effects of C1-INH on complement activation, perioperative myocardial cellular damage and patients outcome were studied in patients undergoing emergency CABG due to acute ST-elevation myocardial infarction (STEMI) with (group 1,n 25) and without (group 2,n 25) bolus administration of C1-INH (40 IU.kg -1) during reperfusion and 6 hours (hrs) postoperatively (20 IU.kg-1) besides the same study protocol. Complement activation fragments (C4), C1-INH, and cardiac troponin I (cTnI) were measured preoperatively, and at 6, 12, 24, and 48 hrs postoperatively. Clinical data, adverse events and patients outcome were recorded prospectively. RESULTS: Patient characteristics were not different between groups. No drug-related adverse events could be observed in group 1. Constant plasma levels of C1-INH and a reduction of C4 fragments were found in group 1. Preoperative cTnI levels were elevated but not different between the groups. The postoperative release of cTnI was significantly lower (P 0.05;ANOVA) in group 1 with 6hrs between symptom onset and reperfusion compared to group 2 at 12 (38.5 22.1 versus 75.7 24.6 ng/mL), 24 (65.5 24.5 versus 95.2 28.3 ng/mL), and 48hrs (58.3 37.5 versus 87.5 41.2 ng/mL) after surgery, but remained unchanged between the groups among patients with a treatment delay of more than 6hrs. Adverse events, ICU and hospital stay, and in-hospital mortality (13.4% versus 14.3%) were not different between the groups. CONCLUSION: The present study is the first to evaluate the effects of complement inhibition during emergency CABG with STEMI. C1INH effectively inhibited complement activation and did not cause adverse effects. The reduced release of cTnI was only observed in
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ng/ml; Group II: 5.2 CKMB 13 ng/ml; Group III: CKMB 13 ng/ml. RESULTS: CKMB level above normal upper limit was relatively common after isolated CABG. Patient with CKMB 13 ng/ml (5 times of normal upper limit) were more frequently those with history of myocardial infarction (MI), left main disease and poor left ventricular function (EF 35%), preoperative IABP support, having a repeated procedure (Table 1). Difference of in-hospital mortality, morbidities (stroke, MI) and length of hospital stay was statistically significant between the three groups (Table 2). Based on multivariable analysis, patients with CKMB 13 ng/ml were more likely at risk for isolated CABG than those with CKMB 5.2 ng/ml (2 times of normal upper
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SURGICAL OUTCOMES FOR THE MANAGEMENT OF CHRONIC PULMONARY THROMBOEMBOLIC DISEASE Gonzalo V. Gonzalez-Stawinski MD* Arash Salemi MD Albert S. Chang MD Delos M. Cosgrove MD Bruce W. Lytle MD Nicholas G. Smedira MD The Cleveland Clinic Foundation, Cleveland, OH PURPOSE: Chronic pulmonary thromboembolic disease (cPE) results in significant morbidity and mortality. Surgical therapy is aimed at alleviating the effects of the thrombus on oxygen saturation, pulmonary hypertension, and improving outcomes. This study was conducted to determine our experience with pulmonary thromboembolectomy as a therapy for cPE. METHODS: A retrospective chart review identified patients undergoing pulmonary endarterectomy for chronic pulmonary thromboembolism. We obtained demographics, symptoms prior to surgical therapy, operative procedures, and outcomes. RESULTS: Between December 1994 and December 2003 a total of 30 patients were surgically treated for chronic pulmonary embolism. There were 13 males and 17 females. Average age was 49.2 yrs (range 21- 76 yrs). The most common presenting symptom was SOB in 26 (96.7%) patients. Half the patients (50%) had a past medical history of venous thromboembolic disease, 20% had a documented hypercoagulable state, but 93.3% of the patients had a vena cava filter placed preoperatively. Mean preoperative systolic pulmonary artery presssures (PAP) was 77.9 mmHg (range 53 107 mmHg). Surgical approaches included bilateral thromboembolectomies in 25 (83.3%) patients. Circulatory arrest was used in 29 (97%. Mean arrest time of 33.2 minutes (range 6 60 minutes). Postoperatively there was a decrease in mean systolic PAP to 41.4 mmHg (range 26-73 mmHg, p 0.001). While mean saturations (SAT) increased following surgical intervention (pre op SAT 94.2% vs. post op SAT 96.1%, p 0.014) this did not result in a decrease in supplemental oxygen use. The 30 day survival was 93.3 % with an overall survival of 80.3% (mean follow-up of 3.5 yrs, range 7d - 10.3 years). CONCLUSION: Pulmonary thromboembolectomy under circulatory arrest is a safe and effective intervention which significantly improves pulmonary artery pressures, oxygen saturation and is associated with good mid-term outcomes. CLINICAL IMPLICATIONS: Pulmonary thromboembolectomy is an effective means of therapy for patients suffering of disabiling pulmonary symptoms as a result of chronic pulmonary thromboembolic disease. DISCLOSURE: Gonzalo Gonzalez-Stawinski, None.
CHEST 2005Poster Presentations
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POSTER PRESENTATIONS
FACTORS INFLUENCING THE OUTCOME OF RESUSCITATION AFTER POSTOPERATIVE ARREST IN CARDIAC SURGERY PATIENTS Prashant C. Shah MD* Mikhail Vaynblat MD Murali Pagala PhD Dinesh Bhaskaran MD Joseph N. Cunningham, Jr MD Maimonides Medical Center, Brooklyn, NY PURPOSE: Cardiopulmonary arrest is an unexpected event in cardiac surgery patients in the postoperative period. Most studies have always advocated an expeditious conversion from closed-chest to open-chest CPR for cardiac arrest after cardiac surgery. The present study was designed to characterize the outcome of closed-chest compared with open-chest CPR, to define potential factors associated with unresponsiveness to closed-chest CPR, and to evaluate the need for open-chest CPR for this subgroup of patients. METHODS: A retrospective review was conducted for all cardiac surgical patients who underwent CPR for postoperative arrest between March 1995 and April 2002. Extensive data pertaining to preoperative, intraoperative characteristics, postoperative complications, and periarrest factors were collected. All data were analyzed using various statistical models. RESULTS: Of the 6,094 patients, 45 (0.74%) patients had a cardiac arrest within seven postoperative days and required CPR. Twenty-four (53%) patients underwent only closed-chest CPR, whereas 21 (47%) patients underwent a conversion from closed-chest to open-chest CPR. Within the closed-chest CPR group, 17 (71%) were successfully resuscitated, while 7 (29%) died. Within the open-chest CPR group, only 3 (14%) were successfully resuscitated, while 18 (86%) died. A chi-squared test showed that the difference in the proportion of successful outcome between closed and open CPR was significant (p 0.001). The 17 patients who were successfully revived with closed-chest CPR were compared against the other 28 patients as a whole who did not respond to closed-chest CPR. Univariate predictors of failed closed-chest CPR included the presence of preoperative hypertension (p 0.001), the presence of severe angina (p 0.06), and urgent/emergent nature of surgery (p 0.005). Univariate predictors of successful closed-chest CPR included elective nature of surgery (p 0.05) and shorter aortic crossclamp times (p 0.05).
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SURGICAL MANAGEMENT OF SUBAORTIC OBSTRUCTION IN CHILDREN WITH SINGLE VENTRICLE PHYSIOLOGY Mark Ruzmetov MD* Palaniswamy Vijay PhD Mark D. Rodefeld MD Mark W. Turrentine MD John W. Brown MD Indiana University School of Medicine, Indianapolis, IN PURPOSE: Optimal prevention and treatment of subaortic stenosis (SAS) in the univentricular heart (UH) and high pulmonary blood flow remains controversial, especially when complicated by aortic arch obstruction. Several surgical techniques have been used in infancy to palliate this group of patients. METHODS: From January 1980 to December 2004, 43 children with UH and systemic ventricular outflow obstruction underwent relief of SAS subsequent to pulmonary artery banding (PAB;n 34) and modified Norwood procedure (MNP;n 9). Median age at operation was 20 days (range; 2 to 298 days; 79% were less than 1 month) and the average preoperative pressure gradient across the ascending aorta and systemic ventricle was 72 17 mmHg (range 31 to 135 mmHg). Three techniques to relief SAS were performed: (1) the Damus-Kaye-Stansel (DKS) procedure (including MNP patients;n 32); (2) subaortic resection or ventricular septal defect enlargement (n 7); and (3) apical aortic conduit (AAC;n 4). RESULTS: Four patients (9%) died in the early postoperative period: three infants after DNP (33%), and one after PAB (3%;p 0.001). The overall survival at 1 and 10 years was 79% and 70%, respectively. Complete heart block requiring insertion of a pacemaker occurred in five patients (12%). Completion Fontan, hemi-Fontan and heart transplantation have been performed in 25, 21 and 1 patient, respectively. Follow-up was complete in all survivors at a mean time of 7.2 6.6 years (range; 3 months to 23 years). Outcome was significantly worse in patients with associated aortic arch obstruction (p 0.002), and with the presence of AAC (p 0.006) or DNP (p 0.02). CONCLUSION: Surgical relief of subaortic obstruction in patients with UH and high pulmonary blood flow can be effectively palliated with PAB or DNP. DKS construction and ventricular septal defect enlargement provide good long-term relief of SAS in select patients. SAS surgery should precede completion Fontan in most patients. CLINICAL IMPLICATIONS: Surgical relief of subaortic obstruction in patients with UH and high pulmonary blood flow can be effectively
CHEST 2005Poster Presentations
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CAN B-TYPE NATRIURETIC PEPTIDE LEVELS PREDICT THE OCCURRENCE OF ATRIAL FIBRILLATION IN THE POSTOPERATIVE PERIOD OF CARDIAC SURGERY? Alexandre R. Felipe MD* Renato V. Gomes MD Pedro M. Nogueira MD Marco Aurelio d. Fernandes MD Jorge Sabino MD Fernando G. Aranha MD Luiz Antonio d. Campos MD Hans Fernando d. Dohmann MD Hospital Pro-Cardaco, Rio De Janeiro, Brazil PURPOSE: The usefulness of measuring B-type natriuretic peptide (BNP) levels in the postoperative (PO) period of cardiac surgery (CS) has been frequently assessed.The objective this study is to correlate BNP levels and occurrence of Atrial Fibrillation (AF) in the PO period of CS. METHODS: Prospective study with a classic cohort of 77 patients (pts) undergoing CS and consecutively selected between August/2003 and January/ 2005. Their mean age was 66.9 9.89 years, 22 (28.5%) were females, and the mean Euroscore was 4.26. The BNP level was measured in the preoperative period (BNPPre), and in the first (BNP1) and sixth (BNP6) PO hours. The BNP level was quantitatively measured by use of immunofluorescence (Biosite Triage BNP Test). The occurrence of AF in the PO period was correlated with the following variables: Euroscore; age; sex; preoperative creatinine level and ventricular function; duration of ECC; SOFA on the first PO day; and BNP (Pre, 1, and 6) levels. The statistical analysis comprised the following tests: Student t; Chi-Square; Mann-Whitney followed by ROC curve construction; and principal component analysis. RESULTS: In the sample studied, 13 pts (16.8%) had AF in the PO period. A significant correlation was observed between the BNP levels [BNPPre (0.01), BNP1 (0.011), and BNP6 (0.03)] and the occurrence of AF. None of the other variables tested correlated with the occurrence of AF. After the principal component analysis, the 3 BNP levels maintained the correlation with the occurrence of AF. BNPPre had a better AUC (ROC) (0.727), in which values greater than 100 pg/dL correlated with the occurrence of AF. CONCLUSION: In the population studied, the occurrence of AF showed a correlation with the 3 BNP levels measured, and all of them were independently associated with the outcome. A BNPPre level greater than 100 pg/dL correlated with the occurrence of AF in the PO period of CS. CLINICAL IMPLICATIONS: The BNP showed to be a useful risk marker for the occurence of FA.
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LOW EXTUBATION TIMES IN CARDIAC SURGERY PATIENTS USING THE RAPID SHALLOW BREATHING INDEX Charles E. Oribabor MD* Naim Mansuroglu MD Felix Khusid RRT Anthony Patten Mary Suleiman Jessica Primiano Leonard Lee MD Anthony Tortolani MD New York Methodist Hospital: Affiliate Weill College of Cornell University, Brooklyn, NY PURPOSE: To utilize the Rapid Shallow Breathing Index (RSBI) to lower extubation times in open heart surgery patients. METHODS: We studied 167 open heart surgery patients prospectively between April 1st 2004 and March 30th 2005.This included 33 valve surgery patients,122 coronary artery bypass graft (CABG),5 Stanford A Aneurysm patients,1 aortic dissection,1 combined valve/aneurysm patient,4 off pump CABG patients and 1 pericardial stripping. No patients were excluded.EXTUBATION CRITERIA: Rapid shallow breathing index 105. EXTUBATION HALTING CRITERIA:(1)Medisatinal Hemorrhage 200cc/hour(2)Ramsay Sedation scale 4(3)Metabolic or respiratory acidosis on continuous positive airway ventilation.(4)Postoperative cardiogenic shock EXTUBATION TIME : defined as time from arrival in the intensive care unit to time extubated.REINTUBATION: was defined as any patient reintubated within 24 hours of extubation.Narcotic analgesia with morphine was used for postoperative pain.The patients cardiac anesthesiologists were informed of the weaning criteria with the RSBI that was going to be used.Drager ventilators; model EVITA XL; which calculate and display the RSBI continuously were used.All patients were placed in a semi recumbent position once the immediate postoperative blood samples had been taken.The head of the bed was raised to at least 45 degrees. Patients with intra-aortic balloon pumps were paced in a reversed trendelenburg position for weaning.Bedside physical therapy with incentive spirometers was commenced immediately post-extubation. RESULTS: The overall mean extubation time was 2hours 40 minutes. The mean extubation time was unaffected by outliers who did not meet the weaning criteria for extubation. This included a total of 6 patients who remained intubated for 18 hours. Zero reintubations. Overall mean extubation times were unaffected by the age,hemodynamic status,comorbidity, or ejection fraction. CONCLUSION: The utilization of the rapid shallow breathing index as the sole criteria for weaning has lead to significantly low mean extubation times in cardiac surgery patients.No increased rates of reintubation were observed.Postoperative narcotic analgesia did not increase mean extubation times. CLINICAL IMPLICATIONS: (1)Significant reductions in resource utilization of the respiratory department and ventilatory equipment.(2)Patient and family satisfaction at early extubation times. (3)Reduced length of stay in the intensive care unit. DISCLOSURE: Charles Oribabor, None.
POSTER PRESENTATIONS
DIFFERENT HEART-LUNG MACHINE CONCEPTS INFLUENCE PLATELET AND MONOCYTE SURFACE-MARKER EXPRESSION DURING CORONARY ARTERY SURGERY Thomas Waldow MD* Gunter Schumann MD Volker Schmidt Oliver Tiebel MD Gabriele Siegert MD Michael Knaut MD Klaus Matschke MD Herzzentrum Dresden, Dresden, Germany PURPOSE: Function of various cellular blood components is altered under conditions of cardiopulmonary bypass (CPB) which can lead to activation of pro- and anticoagulant systems. In the present study, the effects of two different heart-lung-machine (HLM) concepts on the expression of surface markers on monocytes and platelets are compared. METHODS: In a prospective, randomized and single-blinded study sixty patients with elective coronary artery bypass surgery were recruited into three groups. A standard system (group 1) was compared with a modified HLM containing of a Deltastream pump, surface-modified tubing, and reduced priming volume (Optimized Mini-Circulation Cardiopulmonary Bypass System (OMCPB)) (group 2). In group 3 patients were operated on without extracorporeal circulation (OPCAB). Blood was collected at different time points before, during, and until 48 hours after surgical intervention. Platelets were incubated with either CD42b-FITC-/ CD62P-PE- or Factor Va-FITC-/ Tissue Factor-PE-labeled antibodies. EDTA-anticoagulated blood was incubated with CD11b-FITC- / CD18PE- labelled antibodies. Samples were analysed applying flow cytometry.
CHEST / 128 / 4 / OCTOBER, 2005 SUPPLEMENT
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CIRCADIAN RHYTHM HAS NO EFFECT ON MORTALITY IN CORONARY ARTERY BYPASS SURGERY Ajay K. Dhadwal MD* Mikhail Vaynblat MD Shyama Balasubramanya MD Murali Pagala PhD Nancy Schulhoff RN Joshua H. Burack MD Joseph N. Cunningham Jr MD Maimonides Medical Center, New York, NY PURPOSE: Circadian variation affects atherosclerosis at many levels, including a circadian outcome in the treatment of myocardial infarction by angioplasty and thrombolysis.This has not been studied in the surgical patient. The circadian variation in mortality dependant on the time of surgery was examined in patients undergoing coronary artery bypass surgery (CABG). METHODS: A 4 year retrospective review of all CABG patients (n 3140) from 1999 to 2002 at a single institution with an accreditated training program was undertaken. The patients were divided into elective, urgent and emergency cases. The cases were subdivided according to the start time of the operation as morning (7am-2pm AM), afternoon (2pm-8pm AF) and night (8pm-7am NT) and as weekday (Monday to Friday WD) or weekend (WE) cases. The outcome was mortality within 30 days and compared for 4 different time frames: (1) AM vs. AF (2) AM vs. NT (3) AF vs. NT (4) WD vs. WE for each prioritized group. Risk factors and number of anastamoses were compared for each group. Sigma Statistical package and z-test for 2 group comparison were used for analysis. T-test was used to compare age and ejection fraction. RESULTS: No statistically significant difference in mortality was observed for the elective and urgent groups for each of the time periods compared (Table). The emergency cases had significantly increased deaths in the AM and NT compared to the AF (p 0.01 and p 0.05 respectively). There was no statistically significant difference with respect to age, gender, number of anastamoses performed, ejection fraction and preoperative risk factors between groups. CONCLUSION: The mortality for non-emergent CABG is independent of the timing of surgery. Circadian variation does not influence the outcome in cardiac surgical patients. CLINICAL IMPLICATIONS: This study demonstrates that the biological effect of circadian variation and environmental factors (eg. surgeon fatigue) has no effect on mortality in cardiac surgery. This reassures surgeons and patients alike that the outcome is independant of the time of the procedure.This should be noted prior to further work hour legislation being introduced.
Mortality (Deaths/Cases) Elective CABG Urgent CABG Emergency CABG
AF
NT
WD
WE
2/201 0/10 18/835 0/13 0.995% 0% 2.16% 0% 23/674 0/31 66/2060 5/152 3.41% 0% 3.20% 3.29% 1/37 5/18 AM vs AF: p 0.01 10/69 2/9 2.70% 27.78% AF vs NT: p 0.05 14.49% 22.22%
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Death 16,7% 3% 0% 0% 0%
DISCLOSURE: Pedro Miguel Nogueira, None. MANAGING LIFE THREATENING VIRAL MYOCARDITIS WITH DILATED CARDIOMYOPATHY BY DROTRECOGIN ALFA AND CIRCULATORY ASSISTED DEVICES Tsung P. Tsai PhD* Shyh M. Tsao MD Yi L. Wu MD Jung M. Yu MD Kuei C. Chan MD Kwo C. Ueng MD Chung Shan Medical University Hospital, Taichung, Taiwan ROC
POSTER PRESENTATIONS
PURPOSE: Acute fulminant myocarditis with dilated cardiomyopathy caused by Parvovirus B19 may present with cardiogenic shock refractory to the maximum dose of inotropics and intra-aortic balloon pumping (IABP). The benefits of extracorporeal membrane oxygenation (ECMO) support for patients with life-threatening myocarditis has been established. Drotrecogin alfa, recombinant human activated protein C, has antithrombotic, anti-inflammatory and profibrinolytic properties. The effectiveness from the circulatory support (ECOM or IABP) and activated protein C use in managing acute myocarditis with dilated cardiomyopathy caused by Parvovirus B19 has to be defined. METHODS: Four patients( 2 male, 2 female, mean age 37.2 years) presented with congestive heart failure 3 to 4 days after flu-like symptoms (intermittent fever 38 39C, dyspnea and chest tightness). Chest roentgenograms showed cardiomegaly and bilateral pulmonary infiltrates. EKG revealed non-specific ST wave changes. 2-D echocardiograms demonstrated severe myocardial dysfunction with LVEF, measured between 18.4 to 22% (mean, 19.5%). Coronary angiography was performed in each patient and excluded ischemic heart disease. Acute decompensation with more than 2 organ failure (heart and lungs) and unresponsive to more than 2 inotropics and acute respiratory therapy were indications for the use of circulatory support by IABP (3pts) and/or ECMO (3pts) as well as activated protein C (3pts). Serological test and myocardial biopsy for Parvovirus B19 was positive in 3 pts and one pt, respectively. RESULTS: All three pts with ECMO and IABP support were weaned. Follow-up LVEF measured were 53%, 53%, 55% and 60%, respectively. However one pt died one month later because the deterioration of her SLE condition and repeated infection. There were no neurologic sequelae in survivors. CONCLUSION: Use of circulatory support and activated protein C is an effective alternative for treating life-threatening viral myocarditis with dilated cardiomyopathy, especially caused by Parvovirus B19 virus. CLINICAL IMPLICATIONS: Parvovirus B19virus can cause severe myocarditis with dilated cardiomyopathy and circulatory collapse. Combined use of Drotrecogin alfa and ECMO and/or IABP is an effective novel therapy for this cohort of patients. DISCLOSURE: Tsung Tsai, None.
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Multivariate analysis of the associations between selected variables and all-cause mortality
All-cause death Age Male sex Left ventricular EF Previous MI Acute reperfusion Documented complete revascularization (acute or not) Hazard ratio (95% CI) 1 067 2 076 1 020 3 632 0 267 0 279 (0 997-1 142) (0 652-6 610) (0 939-1 108) (1 356-9 728) (0 072-0 992) (0 074-1 050) p Value 0 059 0 216 0 634 0 010 0 049 0 059
PERMANENT RIGHT PHRENIC NERVE PARALYSIS FOLLOWING CATHETER RADIOFREQUENCY (RF) ABLATION FOR PAROXYSMAL ATRIAL FIBRILLATION (PAF) Long X. Le MD* Patricia J. Sime MD University of Rochester School of Medicine, Rochester, NY PURPOSE: Introduction: Transcatheter radiofrequency ablation has emerged as an important treatment modality for PAF [1]. The risk of thromboembolism, pulmonary vein stenosis, and cardiac perforation has been documented. However, only one case of transient right phrenic nerve injury during pulmonary vein (PV) RF ablation has been reported [2]. We document a case of permanent right phrenic nerve paralysis following PV-RF ablation. METHODS: Case Report: A 61-year-old man with a 6-year history of PAF was admitted for PV-RF. His physical examination was unremarkable. An echocardiogram showed normal cardiac chamber size and function and four pulmonary veins. Electrophysiology studies revealed idiopathic AF with multiple pulmonary vein foci. PV-RF ablation was performed as described by Haissaguerre [1,3]. A total of 41 RF pulses for duration of 2080 seconds was required to ablate the arrhythmogenic foci. On post-procedure day one, he complained of dyspnea and orthopnea. A ventilation/perfusion scan was negative for pulmonary thromboembolism. A chest X-ray revealed elevation of the right hemidiaphragm (Figure I). Fluoroscopy confirmed paralysis of the right hemidiaphragm. Pulmonary function tests (PFT) revealed moderate restrictive pulmonary physiology (Table I). On postprocedure day six, his symptoms improved but right hemidiaphragm elevation persisted. Five months later, he was asymptomatic. However, the chest X-ray, fluoroscopy, and PFT revealed persistent right hemidiaphragm paralysis and restrictive pulmonary physiology. RESULTS: Discussion: Phrenic nerve paresis is an uncommon but potentially disabling complication of PV-RF ablation. Three mechanisms of injury have been implicated: 1. heat from the catheter contact site to the nerve [4]; 2. injury from the high intensity electromagnetic field generated at the catheter tip [5]; and 3. generation of a resonance current around the heart [6]. In this patient, the second mechanism seems most likely to induce direct nerve injury secondary to electroporation from locally generated electromagnetic field. CONCLUSION: Conclusion: This case report demonstrated that PV-RF ablation can induce significant nerve injury around the heart. CLINICAL IMPLICATIONS: Implication: Careful preventive precautions during the PV-RF ablation procedure are recommended.
CHEST 2005Poster Presentations
REDUCED EJECTION FRACTION AFTER MYOCARDIAL INFARCTION: IS IT SUFFICIENT TO JUSTIFY IMPLANTATION OF A DEFIBRILLATOR? Patrizio Pascale MD* Patrick Taffe PhD Claude Regamey MD Lukas Kappenberger MD Martin Fromer MD University Hospital, Division of Cardiology, Lausanne, Switzerland PURPOSE: Improved survival after prophylactic implantation of a defibrillator in patients with reduced left ventricular ejection fraction (EF) after myocardial infarction (MI) has been demonstrated in patients with remote MI experienced in the 1990s. The absolute survival benefit conferred by this recommended strategy must be related to the current risk of arrhythmic death which is evolving. This study evaluates the mortality rate in survivors of MI with impaired left ventricular function and its relation to pre-discharge baseline characteristics. METHODS: Clinical records of patients who had sustained acute MI from 1999 to 2000 and were discharged with an EF 0 40 were included. Baseline characteristics, drug prescriptions and invasive procedures were recorded. Bivariate and multivariate analyses were performed using a primary endpoint of total mortality. RESULTS: 165 patients were included. During a median follow-up of 30 months (interquartile range 22-36) 18 patients died. One and two-year mortality rates were 6 7% and 8 6%, respectively. Variables reflecting coronary artery disease and its management (prior MI, acute reperfusion, complete revascularization) had a greater impact on mortality than variables reflecting mechanical dysfunction (EF, Killip class). CONCLUSION: Mortality in survivors of MI with reduced EF is substantially lower than reported in the 1990s. CLINICAL IMPLICATIONS: This decreased absolute mortality implies a proportional increase in the number of patients needed to treat with a prophylactic defibrillator. The risk of event may even be sufficiently low to limit the detectable benefit of defibrillators in patients with the prognostic features identified in our study. This argues for additional risk stratification prior to the prophylactic implantation of a defibrillator.
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PFT on three days and five months post-procedure, showing restrictive physiology.*
Three-days post-procedure Predicted FVC FEV1 FEV1/FVC TLC 4.90L 3.41L 70 7.28L Observed 2.53L 2.22L 88 4.48L %Predicted 52% 65% 126% 62% Five-months post-procedure Predicted 4.59L 3.67L 79 6.88 Observed 2.72L 2.27L 83 4.53L %Predicted 59% 62% 105% 66%
DISCLOSURE: Pramod Deshmukh, None. THE IMPACT OF STRESS ON HEART RATE VARIABILITY OF ON-CALL PHYSICIANS Stavros E. Mountantonakis MD* Dimitrios A. Moutzouris MD Craig McPherson MD Yale University - Bridgeport Hospital, Bridgeport, CT PURPOSE: The analysis of heart rate variability (HRV) has been recommended for the study of the impact of work-stress on the autonomic cardiac control. The literature related to the effect of work stress on physicians on-call is extremely limited. Our study aimed to evaluate the role of stress on the HRV of on-call physicians. METHODS: Twenty six healthy physicians (11 men,15 women) undertook a 24-hour Holter-ECG recording while being on-call, as well as on a normal work-day at least 3 days after the day on-call. The mean age was 34 7,49 years (range: 25-51 years). All recordings started at 3 p.m. and lasted 24 hours. RESULTS: The physicians presented decreased values of Standard Deviation of all filtered RR intervals over the length of the analysis(SDNN) during the day-on call in comparison with a normal workday (SDNN: 89.9 and 110.9 respectively, p 0.05). The rhythm disturbances during the day on-call were clearly more (p 0.05) and included sinus tachycardia and bradycardia, sinus pauses, supraventricular tachycardia, as well as premature atrial and ventricular systoles. CONCLUSION: Psychological and physical stress at working environment as well as sleep deprivation may result in adrenergic surge that predisposes to cardiac arrhythmias. In our study, the on-call physicians presented decreased SDNN. Although it is already known that decreased HRV correlates with increased morbidity and mortality, the studies about the clinical use of this marker in healthy subjects are few. CLINICAL IMPLICATIONS: Our findings demonstrated a negative impact of stress on the cardiac rhythm during an on-call day. It would be interesting to further investigate the significance of occupational stress in arrhythmogenesis in healthy and non-healthy individuals as well as the prognostic value of decreased HRV seen in our study. DISCLOSURE: Stavros Mountantonakis, None. INCORPORATION OF MEDICAL ADVANCES IN CLINICAL PRACTICE WITHIN GUTHRIE HEALTHCARE SYSTEM Pramod M. Deshmukh MD* Sailatha Padmanabhan MD Sudhakar Sattur MD Mary Romanyshyn Steven Alexander Guthrie Medical Center, Sayre, PA PURPOSE: Despite a large body of scientific evidence, primary prevention of sudden cardiac arrest remains a clinical challenge. The extent of incorporation of medical advances in practice remains unknown. We sought to evaluate how MADIT II (the second Multi-center Automatic Defibrillator Implantation Trial) findings were utilized in retrospective manner. METHODS: Guthrie Healthcare System is a large multidisplinary organization serving 500,000 patients in a primary service area of seven counties and comprises of 228 physicians. We evaluated all echocardiograms performed between October 2003 (beginning of reimbursement by CMS for MADIT II criteria) to October 2004. Using ICD codes, patients with cardiomyopathy, ischemic heart disease, and heart failure were identified. This group was further stratified for MADIT II criteria. Medical records were evaluated for presence/absence of heart failure, presentation with clinical arrhythmias, events leading to implantation of devices, QRS morphology and duration, screening by individual physicians (including holter monitors, event monitors), and clinical referrals to electrophysiology services. RESULTS: A total of 3538 echocardiograms were performed between October 2003 and October 2004. Of these, 591 patients were identified to have cardiomyopathy and heart failure, 109 patients met MADIT II criteria. Thirty-one patients (28.4%) received ICD implant. Of these, 27 patients received biventricular ICD and 4 patients received biventricular pacemaker. Twenty-nine patients had either spontaneous or inducible ventricular tachycardia. Solely based on MADIT II criteria, only 2 patients
CHEST / 128 / 4 / OCTOBER, 2005 SUPPLEMENT
*FVC, forced vital capacity; FEV1, forced expiratory volume-1 second; TLC, total lung
POSTER PRESENTATIONS
DOFETILIDE THERAPY: IN PATIENTS WITH ATRIAL FIBRILLATION AND PACEMAKERS/DEFIBRILLATORS Pramod M. Deshmukh MD* Vera Hackett Sharad Chandrika MD Elizabeth Miller Guthrie Healthcare System, Sayre, PA PURPOSE: Dofetilide (Tikosyn) treatment for atrial arrhythmias requires initiation of the drug in the hospital, careful attention to multiple QTc intervals, and adherence to standard guidelines. Ventricular pacing, by widening the QRS interval, can prolong the QTc interval. As no data exists regarding monitoring of the QTc interval in patients with ventricular pacing, our objective was to assess the effect of ventricular pacing on QTc intervals in patients receiving dofetilide. METHODS: Over a two year period, 119 patients including 50 patients with implanted device (ID), [permanent pacemaker (PPM), internal cardioverter defibrillator (ICD)] and 69 patients without ID were admitted for initiation of dofetilide using institutional protocol. Baseline and serial QRS intervals and QTC intervals (with manual correction) were utilized to guide drug therapy. In patients with ID (PPM ICD), longer QTC intervals were accepted (in patients with PPM due to QRS widening; in the ICD group due to perceived safety) to achieve therapeutic drug effect. RESULTS: Fifty patients with ID (mean age 71.7 yrs), 68% with a history of antiarrhythmic therapy (AAR), were compared to 69 patients without ID (mean age 61.7 yrs), 50% of whom also had history of AAR. Their ECG parameters are shown in Table 1. Within the group with ID, QRS (duration) and QTc intervals were significantly longer than in PPM category. In each group, 96% of the patients were discharged to home in sinus rhythm and 4% of the patients required dofetilide to be discontinued due to torsade de pointes. After mean follow-up of 65 30 weeks in the ICD group, only one patient required discontinuation of dofetilide treatment due to torsade de pointes. None of the patients experienced a fatal outcome. CONCLUSION: Ventricular pacing is associated with significant QRS widening and, therefore, prolongation of QTc interval. CLINICAL IMPLICATIONS: Maximum limit of 500 msc. for QTc interval used for patients without ID may be safely extended by an additional 30 msc. in patients with ID and dofetilide therapy.
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DISCLOSURE: Vijay Shetty, None. TECHNICAL FEASIBILITY BASED ON LMCA STENOSIS CLASSIFICATION AND SHORT TERM CLINICAL OUTCOMES AFTER UNPROTECTED LMCA PERCUTANEOUS INTERVENTIONS WITH DRUG ELUTING STENTS: A SINGLE CENTER EXPERIENCE Narpinder Singh MD* Abdul Kani MD Augustin DeLago MD Albany Medical Center, Albany, NY PURPOSE: We sought to evaluate procedural technical feasibility; MACE including cardiac mortality at hospital discharge and thirty day follow up after stenting unprotected LMCA stenosis with DES stents. We also sought to classify and define the various anatomical variations of LMCA stenosis. METHODS: Total of forty one consecutive patients with LMCA stenosis underwent stenting in our institution. To define the location and complexity of LMCA disease lesions, we devised the classification of LMCA. DeLagos LMCA stenosis classification includes 4 types and three classes (Figure 1). Different stenting techniques were used based on location of lesions. Patients were followed for the first three months. A repeat coronary angiogram was requested routinely after six months. RESULTS: Mean age was 67 14 with range of 28 to 90. Forty-four percent were males; 28% were smoker; 72% had HTN; 75 % had DM; and 68 hypercholestremia. Fifty- six percent presented as UA, 8% as recent acute MI and 36 % had abnormal stress test. Initial procedural success rate was 100%. At 30 days follow-up was 0%. MI (Non Q wave) 4.8%. At 30-day follow-up, CVA, TVR, CABG and death outcomes were 0%. Mortality at three months was 2.4%. CONCLUSION: Conclusion: Stenting of the unprotected LMCA stenosis provided excellent immediate result. Unprotected LMCA stenosis can be treated safely and effectively with DES coated stent and may be
CHEST 2005Poster Presentations
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POSTER PRESENTATIONS
META-ANAYLSIS OF TRANSIENT LEFT VENTRICULAR APICAL BALLOONING SYNDROME BASED ON GENDER AND RACE Daniel Donohue MD* Mohammad-Reza Movahed MD University of California, Irvine Medical Center, Orange, CA PURPOSE: Transient Left Ventricular Apical Ballooning (LVAB) was first described in Japan in the early 1990s. Since then it has been reported in many countries worldwide. It typically presents after physical or emotional stress with chest pain, ECG changes, positive cardiac markers and marked akinesia of mid to apical left ventricular wall with ballooning appearance despite normal coronaries. The goal of this study was to perform meta-analysis of the published cases in regards to race and gender. METHODS: Using pubmed, we searched all published manuscripts relevant to left ventricular apical ballooning syndrome. We included case series and individual case reports in this study. We evaluated the effect of gender and race on the presentation of LVAB using uni and multi-variate analysis. RESULTS: A total of 185 patient cases were identified that were included in the analysis. Most cases were females, totaling 173 patients (93.5%). Asians and Caucasian were the majority of the reported races. Asians on average were older (70 /- 9.5 yo vs 64 /- 12.7 yo), less likely to have; their syndrome precipitated by emotional stress (26.5% vs 51.7%), positive cardiac markers (77.1% vs 97.6%), present with chest pain (55.4% vs 81.0%), or with T wave inversion (67.3% vs 95.8%), but were more likely to have ST elevation on EKG (97.1% vs 83.3%). There were no differences in regards to complications or death. CONCLUSION: LVAB is becoming more recognized in different races. While predominantly effecting females, the presentation is similar to men. However, there are significant differences in the presentation of LVAB between Asians and Caucasians. CLINICAL IMPLICATIONS: Clinical presentation of LVAB differs between Caucasians and Asian which needs to be considered in patient presenting with LVAB. DISCLOSURE: Daniel Donohue, None.
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STRESS-INDUCED APICAL BALLOONING SYNDROME CAN BE SUSPECTED BASED ON CLASSIC ECHOCARDIOGRAPHIC FINDINGS AND CLINICAL PRESENTATION Daniel Donohue MD* Chowdhury Ahsan MD Mohammad-Reza Movahed MD University of California, Irvine Medical Center, Orange, CA PURPOSE: Stress induced apical ballooning has been described as a reversible condition involving the apical left ventricular wall, sparing the base, and causing a ballooning appearance of the left ventricular during systole despite normal coronaries. However, there are no data about early diagnosis of Apical ballooning syndrome using echocardiography. METHODS: We are presenting four cases of apical ballooning seen at our institution with echocardiographic correlation. We compared angiogram with echocardiographic finding prior to angiogram. RESULTS: All Echocardiograms showed similar anatomical apical ballooning of the left ventricular apex. The diagnosis of apical ballooning syndrome was suspected based on echocardiography in conjunction with clinical data before cardiac catheterization was performed. In one case, in addition to classic left ventricular apical ballooning, marked right ventricular apical akinesia was present on the initial echocardiographic examination Subsequent angiograms in all patients showed classic apical ballooning and normal coronaries. CONCLUSION: Apical ballooning syndrome can be suspected based on classic echocardiographic findings and clinical data prior to angiography. CLINICAL IMPLICATIONS: Therefore, we suggest that echocardiography should be utilized more for the early diagnosis of this disease based on careful anatomical evaluation in conjunction with clinical data. Wall motion analysis should reveal apical ballooning appearance involving many coronary territories with discrepancy to electrocardiogram and cardiac enzyme elevation. Furthermore, the additional presence of right ventricular apical akinesia during echocardiographic examination makes the diagnosis of this syndrome more likely.
Table 1. Comparison of Demographic Profile of Patients With ILMCA Disease (Group I) With General Population Seen in Cardiac Catheterization Center (Group II).
Risk Factors Age (in years) Sex Male Female Race White Non-White Hypertension Hypercholesterolemia Diabetes Mellitus Smoking Family history Indication of Catheterization Angina Myocardial Infarction Elective Others (syncope, dyspnea on exertion, and others) Group I (n 46) 65 13 22 (48%) 24 (52%) 44 (96%) 2 (4%) 33(72%) 30(65%) 20(43%) 12(26%) 18(39%) 20 (43%) 9 (20%) 13 (28%) 4 (9%) Group II (n 83) 65 14 57 (69%) 26 (31%) 75 (90%) 8 (10%) 59 (71%) 58 (70%) 24 (29%) 18 (22%) 36(43%) 28 (34%) 23 (28%) 22 (26%) 8 (10%) P value Nsd* 0.02 0.02 Nsd Nsd Nsd Nsd Nsd Nsd Nsd Nsd Nsd Nsd Nsd
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THE PROGNOSTIC VALUE OF HIGH SENSITIVITY C-REACTIVE PROTEIN LEVEL IN PATIENTS WITH CHRONIC HEART FAILURE Ghaith M. Mulki MD Pamela Cianci MSN Marc A. Silver MD* University of Illinois at Chicago/Advocate Christ Medical Center, Oak Lawn, IL PURPOSE: High sensitivity C-reactive protein (hsCRP) assay has been found to be a useful biomarker for cardiovascular risk stratification. Little information exists regarding its prognostic impact in outpatients with heart failure (HF) as well as its correlation to other biomarkers or outcomes. METHODS: Serum levels of hsCRP were obtained in 89 patients with stage C HF. All patients were followed in a specialized HF management center for 2-24 months (average 13.5 6.06). The primary end point was major adverse cardiovascular events defined as cardiac hospitalization or cardiac death. RESULTS: The average age of the subjects was 62.8 14.2 years (range19-88). The etiology of HF was ischemic in 36 patients (40.45%) and non-ischemic in 53 patients (59.55%). There were 46 men and 43 women, 72 patients with systolic dysfunction and 17 patients with diastolic dysfunction defined as LVEF 50%. The baseline hsCRP ranged from 0.03 to 8.4 mg/dl and averaged 0.86 1.39 mg/dl. HsCRP levels were 0.1 mg/dl in 14 patients (15.8 %), 0.1-0.3 mg/dl in 25 patients (28%), and 0.3 mg/dl in 50 patients (56.2%) (p 0.0001). Adverse cardiovascular events were significantly higher in patients with increased hsCRP (88.23% vs. 19%, p 0.006, using hsCRP level of 0.2 mg/dl as a cutoff). Patients with systolic dysfunction had higher levels of hsCRP compared to patients with diastolic dysfunction (0.95 mg/dl vs. 0.46 mg/dl, respectively, p 0.030). There was no significant difference in hsCRP levels in ischemic HF compared to non- ischemic HF (0.92 mg/dl vs. 0.81 mg/dl, respectively, p 0.72). There was no significant correlation between baseline hsCRP levels and baseline BNP levels. CONCLUSION: Our findings establish that hsCRP is elevated in patients with stable Stage C HF independent of the etiology. Increased hsCRP levels were associated with significantly higher adverse cardiovascular events. The elevations in hsCRP and the cardiovascular outcomes are independent of other important biomarkers. CLINICAL IMPLICATIONS: In conclusion, our data suggests that elevated hsCRP is an independent prognostic marker for risk stratification in patients with chronic HF. DISCLOSURE: Marc Silver, None. HYPERKALEMIA AND RENAL DYSFUNCTION IN CONGESTIVE HEART FAILURE PATIENTS WITH CONCOMITANT USE OF SPIRONOLACTONE AND FUROSEMIDE Nobuyuki Anzai MD* Hiroko Anzai MD Rieko Mitobe MD Makiko Anzai MD Sadako Furuya MD Anzai Furuya Clinic, Oyama, Japan PURPOSE: This study aimed to identify predictors of hyperkalemia and renal impairment in congestive heart failure (CHF) patients taking spironolactone and furosemide.
IMPACT OF LEFT VENTRICULAR ASSIST DEVICE DESTINATION THERAPY ON VENTRICULAR RE-SYNCHRONIZATION Smitha G. Agadi MD* Helen Lonergan-Thomas RN Sharon Brennan RN Pamela Cianci MSN Mark Slaughter MD Marc Silver MD Advocate Christ Medical Center, Oak Lawn, IL PURPOSE: Heart failure (HF) is a lethal disease process that involves progressive ventricular remodeling and symptom worsening. Two strategies applied to HF populations include biventricular resynchronization pacing (BiVP) and left ventricular assist as destination therapy (DT). While there may be some overlap in these populations the therapies are generally thought of separately. Among the benefits of BiVP are ventricular resynchronization and improved oxygen consumption. Little information is known about the impact of DT on cardiac desynchronization and its impact on ventricular electromechanical recovery. METHODS: We analyzed the ECG intervals of 16 patients who received DT with a Heartmate XVE (Thoratec) secondary to end stage HF. Patients whose baseline ECG was paced (7) were excluded from analysis. The remaining 9 patients (8 men) were aged 50-79 (mean 64.8) years. The patients were supported from 1-180 days at the time of analysis. RESULTS: The mean patients were supported from 1-180 days at the time of analysis. Heart baseline and follow-up intervals are shown in the table below. CONCLUSION: While none of the intervals changed significantly during DT support, there was a trend towards improvement in QRS duration; of patients supported, the average improvement in QRSD was 15.4 msec (10.5%) whereas for patients supported 20 days the improvement was 37.5 msec (21%). The only 2 patients to improve QTc were those supported 180 days. On the other hand PR did not improve in any patient. CLINICAL IMPLICATIONS: In summary, DT allows for long-term ventricular support and recovery. Improvement in cardiac desynchronization without BiVP may also occur after ventricular support. Longer observation needs to be applied to this phenomenon and to consider the potential for LVAD support to restore normal ventricular resynchronization.
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DISCLOSURE: Smitha Agadi, None. CHEST RADIOGRAPHIC CORRELATES OF SERUM BNP LEVELS Shahnaz Begum MD Xiaoqian Zhang MD Louis Salciccioli MD Arash Gohari MD Jason M. Lazar MD* SUNY Downstate Medical Center, Brooklyn, NY PURPOSE: Beta natriuretic peptide (BNP)is a biomarker of intravscular volume and serum levels correlate with left ventricular filling pressures. The relationship between BNP levels and radiographicic findings has not been well studied. Accordingly, the purpose of this study was to determine the relationships between chest radiographic findings and serum BNP levels. METHODS: We studied 88 consecutive patients hospitalized with cardiac and/or pulmonary symptoms who had chest xrays and BNP levels determined within 24 hours. Chest radiographs were evaluated for the following findings: left atrial enlargement (LAE), pleural effusions, pulmonary vascular congestion (PVC), cardiothoracic (CT) ratio, and the vascular pedicle width (WPW). Pulmonary vascular congestion was noted to be absent, mild, or greater than mild. The VPW was measure was measured according to previously published methods (Ely). RESULTS: The duration of time between BNP levels and chest xrays was 80 /-20minutes. There was a direct correlation between serum BNP levels and CT ratio (r .29,p 0.03). There were no relationships between BNP levels and either VPW (r -.12, p .16) or age (r .10,p .50). BNP levels were unrelated to the presence of PVC (p .17),but were higher in patients with LAE (p .04)and pleural effusions (r .04). On multivariate analysis analysis, CT ratio was the only independent correlate of BNP levels (r2 .09, p .02). Log transformation of BNP levels improved the correlation with CT ratio (r .40, p .001), but did not alter other univariate or multivariate findings. CONCLUSION: In an unselected group of patients hospitalized with cardiac and/or pulmonary symptoms, serum BNP levels are chiefly related to the CT ratio but not to other radigraphic findings. CLINICAL IMPLICATIONS: Although the majority of studies focus on the diagnostic and prognostic value of BNP levels,a direct comparison to standard clinical evaluation is essential in understanding the clinical utility of serum BNP levle determination. DISCLOSURE: Jason Lazar, None. DETERMINANTS OF EXERCISE CAPACITY AND PERCEIVED EXERTION IN PATIENTS WITH PRESERVED LEFT VENTRICULAR SYSTOLIC FUNCTION Tanya Menard Louis Salciccioli MD Luther Clark MD Jason M. Lazar MD* SUNY Downstate Meidcal Center, Brooklyn, NY PURPOSE: Exercise capacity is known to be an important prognostic factor in patients with cardiovascular disease and in healthy subjects. While structural heart disease is found in a relatively small proportion, other factors are likely responsible for reduced exercise tolerance in these patients. Indices of left ventricular (LV) diastolic filling variably correlated with exercise time in select patient populations including hypertensives and the elderly. Moreover, no study has specifically addressed the contribution of LV systolic and diastolic functional abnormalities to both exercise duration and perceived effort. The objectives of the study were to determine echocardiographic correlates of exercise capacity and of perceived exertion in patients without structural heart disease. METHODS: We studied 111 consecutive patients, age 53 /-13 years, who were referred for echocardiographic stress testing. Patients underwent symptom limited treadmill exercise testing according to Bruce protocol in all cases. Standard blood pressures and 12 channel electrocardiograms were performed. Baseline 2 dimensional and Doppler echocardiographic images were recorded immediately prior to exercise. The primary end points were maximal exercise tolerance defined by mets and peak RPE.
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DOES THE AORTIC ATHEROSCLEROTIC PLAQUES SEVERITY CORELLATE WITH EMBOLIC EVENTS? Chandra K. Nair MD* Xuedong Shen MD Huagui Li MD Dhanunjay Lakkireddy MD Senthil Thambidorai MD David Cloutier BS Mark J. Holmberg MD Aryan N. Mooss MD Syed M. Mohiuddin MD The Cardiac Center of Creighton University, Omaha, NE PURPOSE: The impact of aortic atherosclerotic plaques (ASP) demonstrated by transesophageal echocardiography (TEE) is controversial. It is also unclear whether the severity of ASP correlate with embolic events. The purpose of this study was to investigate the incidence of embolic events in different grades of ASP. METHODS: We studied 277 consecutive patients (male/female 153/ 124, age 66.2 13.4 years) without left atrial thrombus by TEE. The thoracic aortic plaque severity was classified as Grade I (normal or minimal intimal thickening) in 86; Grade II (extensive intimal thickening) in 105; Grade III (atheroma 5mm) in 70; Grade IV (atheroma 5mm) in 11; and Grade V (mobile lesion) in 5 patients. The incidence of embolic events, mortality and clinical characteristics were evaluated in patients with different grades of ASP. RESULTS: The incidence of embolic events was increased with the severity of ASP (Grade II, 12%, Grade III, 16%, Grade IV, 27% and Grade V, 60%). Grade IV had the highest incidence of embolic events (6/16, 38%) compared to grade I (11/86, 13%) (p 0.038). There was no significant difference in age, left atrial diameter, spontaneous contrast echo in left atrium, left ventricular ejection fraction and the prevalence of coronary artery disease, old myocardial infarction, aortic stenosis, aortic valve calcification, mitral annulus calcification and left ventricular hypertrophy between the groups (p 0.05). There was no significant difference in the percentage of patients with therapuetic anticoagulation or antiplatelets between the ASP groups. During the follow-up of 38.7 32 months, there was no significant difference in cardiac mortality between the groups (p 0.05). CONCLUSION: The incidence of the embolic events is related to the severity of ASP. There was significant increase in the embolic events in patients with grade IV ASP. CLINICAL IMPLICATIONS: ASP detected by TEE is associated with embolic events and there is significant increase in the embolic events in patients with grade IV ASP. DISCLOSURE: Chandra Nair, None.
RIGHT VENTRICULAR MECHANICAL DELAY AND GLOBAL VENTRICULAR DYSFUNCTION Angel Lopez-Candales MD* Kaoru Dohi MD Raveen Bazaz MD Kathy Edelman University of Pittsburgh Medical Center, Pittsburgh, PA PURPOSE: Several abnormalities in both right ventricular (RV) size and function tend to occur in patients with pulmonary hypertension (PAH). However, there is no data regarding the effect of PAH on RV free wall mechanical activation in these patients that can contribute to global dysfunction. METHODS: We studied several well-established echocardiographic parameters used to assess RV performance in a heterogeneous group of patients with varying degrees of PAH as well as in a group of healthy volunteers and then used tissue Doppler imaging (TDI) to investigate if abnormalities in RV free wall mechanical activation occur with RV dysfunction. RESULTS: Prospective data collected in 20 patients with varying degrees of PAH (mean age 51 13 years, WHO class average 2.8 and mean pulmonary systolic pressure 78 24 mmHg) were compared to similar data retrospectively obtained from 20 healthy volunteers (mean age 45 15 years). Patients with varying degrees of PAH had worse RV performance parameters than healthy volunteers (RV fractional area change 37 13% versus 52 5%, p 0.0001; RV myocardial performance index 0.76 0.31 versus 0.29 0.11, p 0.0001; and Eccentricity Index 1.41 0.57 versus 0.98 0.06, p 0.005). Similarly, in these patients with an abnormal RV performance, TDI showed a statistically significant lower peak longitudinal RV free wall strain (-21.5 9.0% versus -28.0 4.1%, p 0.01) and a significantly delayed time-to-peak strain (459 76 msec versus 388 29 msec, p 0.0005) values than healthy volunteers; a very strong correlation between RV mechanical delay and RV fractional area change (r -0.89) was noted. CONCLUSION: RV free wall mechanical delay, as documented by TDI, was identified in patients with varying degrees of PAH. Furthermore, there is strong correlation between RV free wall mechanical delay and overall global RV performance in these patients.
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DISCLOSURE: Angel Lopez-Candales, None. SCREENING FOR ATHEROSCLEROSIS: INITIATING SECONDARY PREVENTION FOR HIGH-RISK YOUNG TO MIDDLE-AGED ADULTS Ana M. Schaper PhD* Vicki L. McHugh MS Sharon I. Barnhart RN Michelle A. Mathiason MS Kwame O. Akosah MD Gundersen Lutheran Health Systems, La Crosse, WI PURPOSE: The Framingham risk score is recommended for identifying individuals at high risk for a future event. However, the burden of cardiovascular disease resides in patients stratified as low and intermediate risk simply because of the large number of people receiving this classification. We propose the need to move beyond risk stratification for cardiovascular disease to identifying the presence of atherosclerosis in young to middle-aged adults who are truly at risk. The purpose of this analysis is to compare and contrast the role of Framingham risk stratification in the identification of atherosclerosis and risk for future events in a young to middle-aged population. METHODS: Men ( 55 years) and women ( 65 years) without prior coronary heart disease scheduled for elective cardiac catheterization were studied. Subjects underwent coronary angiogram, carotid ultrasound and fasting lipid testing on the same day. Framingham risk scores were calculated. Endpoints included the presences of atherosclerosis (carotid or coronary disease) and one-year outcomes (hard events and future revascularization). RESULTS: Men (n 110) and women (n 136) were studied. Atherosclerosis was present in 170 subjects (carotid disease n 149, coronary disease n 124). Per Framingham risk classification, 73%, 8%, 19% of subjects presented as low, intermediate and high risk, respectively. Median follow-up was 19 months. 25 subjects developed 35 events that included death (n 2), stroke (n 5), MI (n 5), and revascularization (n 23). Neither lipid testing nor Framingham risk scores predicted the presence of atherosclerosis or future events. Overall, 16% of subjects with atherosclerosis who were classified as low or intermediate risk had events compared to 14% of those at high risk. No future events occurred in subjects without documented atherosclerosis. CONCLUSION: Many young to middle-aged adults classified as low or intermediate-risk have atherosclerosis and develop cardiovascular events. Framingham risk scores were not predictive of either. CLINICAL IMPLICATIONS: By shifting to a focus on identifying and aggressively treating atherosclerosis, screening can easily be accom-
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THE USE OF RADIOLOGICAL IMAGING IN THE INITIAL WORKUP OF SYNCOPE M. Shubair MD N. Jallad MD H. Aziz MD M. Ismail MD* M.A. Khan MD St. Josephs Regional Medical Center, Paterson, NJ PURPOSE: To evaluate the workup of patients admitted to the hospital with syncope and to evaluate that clinical practice guidelines for syncope were followed. METHODS: We retrospectively reviewed medical records of 104 patients (50 males, 54 females, age range 23-93; mean age 63.8 yrs) with the principal diagnosis of syncope over a period of 6 months and examined their initial diagnostic workup including CT-head and carotid Doppler ultrasound. RESULTS: Only one patient had focal neurological deficit on initial presentation. Both his carotid ultrasound and CT-head were abnormal. 55 (52.8%) patients had carotid doppler ultrasound and 62 (59.6%) patients had CT-head despite normal physical examination; both tests were normal. CONCLUSION: These data suggest that the use of imaging studies in the evaluation of syncope has a low diagnostic yield. Careful history, and physical examination should help guide diagnostic testing. CLINICAL IMPLICATIONS: The use of published clinical guidelines for syncope is a good tool for the diagnostic workup. Patients with no focal neurologic deficit on physical examination are unlikely to benefit from radiological imaging. DISCLOSURE: M. Ismail, None.
POSTER PRESENTATIONS
CORRELATION OF CARDIOVASCULAR RISK SCORES WITH MYOCARDIAL HIGH-ENERGY PHOSPHATE METABOLISM Ralf H. Zwick MD* Gert Klug MD Matthias Frick MD Michael Schocke MD Christian Wolf MD Werner Jaschke MD Otmar Pachinger MD Bernhard Metzler MD Cardiology, Innsbruck University, Innsbruck, Austria PURPOSE: Our preliminary data suggested a decrease of human myocardial, high-energy, phosphate metabolism in patients with hypercholesterolemia. Therefore we intended to prove its association with established cardiovascular risk scores. METHODS: Our study included 99 healthy, asymptomatic male patients (mean age 52.2 /- 8.8) with normal ejection fraction. All underwent echocardiography and cycle ergometry to exclude a latent coronary insufficiency. Blood was taken to evaluate cardiovascular risk scores: ESC cardiovascular (CV) risk, ESC coronary heart disease (CHD) risk, Procam and Framingham CHD score. Then Phosphorus-31, twodimensional chemical shift imaging (31P 2D CSI) of the heart was performed in all subjects using a 1.5 Tesla whole-body magnetic resonance (MR) scanner. The ratios (R) between phosphocreatine (PCr) and beta-adenosine-triphosphate (beta-ATP) were calculated for the left ventricular myocardium and divided into tertiles (R1-R3). RESULTS: There was a significant effect regarding differences across tertiles (R1-R3) within the cardiovascular risk scores (Kruskal Wallis ANOVA for ESC CV, p 0.001; ESC CHD, p 0.001; Procam, p 0.003; Framingham CHD, p 0.001). Bivariat analysis revealed an association between myocardial PCr-beta-ATP ratios and the ESC CV (p 0.001, r -0.444), ESC CHD (p 0.001, r -0.434), Procam (p 0.027, r -0.222), Framingham CHD (p 0.001, r -0.380) score and patients with low R had a significant higher risk of cardiovascular events than those in the higher tertiles. CONCLUSION: We are the first to show a correlation between the myocardial high-energy, phosphate metabolism and cardiovascular risk scores.
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AN ABNORMAL RIGHT VENTRICULAR APICAL ANGLE IS INDICATIVE OF COMPROMISED RIGHT VENTRICULAR FUNCTION Angel Lopez-Candales MD* Kaoru Dohi MD Anca Iliescu MD Ross C. Peterson MD Kathy Edelman Raveen Bazaz MD University of Pittsburgh Medical Center, Pittsburgh, PA PURPOSE: Presence of right ventricular (RV) dysfunction is an adverse prognostic indicator but current echocardiographic methods have some limitations. METHODS: RV apical angles in systole and diastole were correlated with known parameters of RV function in patients without pulmonary hypertension (Group 1) and in patients with pulmonary hypertension (Group 2). RV apical angles were significantly smaller in both systole (22 7 degrees) and diastole (33 6 degrees) in Group 1 patients when compared to Group 2 (54 18 degrees, p 0.0001 and 59 17 degrees, p 0.0001, respectively). RESULTS: Group 2 patients had statistically larger RV systolic and diastolic areas (19 9 versus 8 3 and 27 9 versus 17 3, p 0.0001; respectively) and smaller maximal TV annular excursion (2.5 0.44 versus 1.5 0.66, p 0.00001; respectively) than Group 1. Group 2 had statistically larger RV apical angles in both systole and diastole when compared to Group 1 (54 18 and 59 17 versus 22 7 and 33 6, p 0.00001, respectively). The peak pulmonary systolic pressures were not only inversely correlated with RVFAC (R -0.62; p 0.001) but also with maximal TV annular excursion (R -0.69; p 0.001). A very strong linear correlation was noted between the RVEDA and RV diastolic apical angle (R 0.81, p 0.0001) and between the RVESA and RV systolic apical angle (R 0.89, p 0.0001). RV apical angle also had a statistically significant inverse correlation with measures of RV function. A representative end diastolic four chamber still frame image of a normal and a patient with an abnormal RV apical angle is shown. CONCLUSION: Therefore, we conclude that this new measurement of RV apical angle is simple and useful to quantify RV apical structural and functional abnormalities that are well correlated with global RV impairment in patients with chronic pulmonary hypertension. CLINICAL IMPLICATIONS: Ease of data acquisition, reproducibility, and lack of cumbersome geometric analyses allow for easy clinical application.
INTERVENTRICULAR SEPTAL FLATTENING OBSERVED ON THE MYOCARDIAL PERFUSION IMAGES STRONGLY CORRELATE WITH RIGHT VENTRICULAR OVERLOAD Mohammad-Reza Movahed MD* Absalam Hepner MD Paul Lazotte DO Norah Milne MD University of California, Irvine Medical Center, Orange, CA PURPOSE: Background: Flattening of the interventricular septum (D-shaped Septum) detected during echocardiographic examination is correlated with significant right ventricular (RV) overload. There are no reports of this finding with cardiac gated SPECT imaging. We report an observational study correlating this finding with the presence of RV overload. METHODS: Method: Retrospectively we compared eight cases with flattening of the interventricular septum on cardiac gated SPECT imaging of which echocardiographic correlations and clinical data were available for the presence of RV overload. RESULTS: Results: All patients but one had pulmonary hypertension ranging from 42 to 52 mmHg measured by echocardiographic doppler studies. Except one all patients had reasons for RV overload (chronic obstructive pulmonary disease in three, history of atrial septal defect in three, pulmonary embolism in one and obstructive sleep apnea in one). Septal flattening present on gated SPECT images was seen in 50% of the cases by echocardiography. Other signs of RV overload (RV enlargement, RV hypertrophy) were observed by echocardiography in five patients and by the gated SPECT in seven patients. CONCLUSION: Conclusion: The presence of interventricular septal flattening on gated SPECT studies correlates with right ventricular overload and should be routinely assessed during interpretation of gated SPECT studies. CLINICAL IMPLICATIONS: We suggest that more attention should be given to the shape of the interventricular septum during interpretation of gated SPECT studies and the term of septal flattening should be
CHEST 2005Poster Presentations
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LISTENING TO THE AORTIC VALVE: NOVEL ACOUSTIC ANALYSIS PREDICTS AORTIC VALVE CALCIFICATION AND CARDIOVASCULAR EVENTS Kian Keong Poh MB, BCh* Mark Y. Chan MBBS Hong Yang MD Lieng H. Ling MBBS National University Hospital, Singapore, Singapore PURPOSE: Aortic valve calcification (AVC) measured by multislice computed tomography (MSCT) has previously been shown to be of prognostic importance. We aimed to determine if a novel acoustic method of evaluating heart sounds in pts with valvular aortic stenosis (AS) or sclerosis is a useful alternative. METHODS: ECG-gated acoustic data recorded from the precordial aortic area using an electronic stethoscope were subjected to energybased continuous wavelet transformation by a laptop software program, which extract the dominant systolic frequency (DF). These were compared to AVC quantified in Agatston units (AU) by MSCT and echocardiographic indices of AS severity, determined independently. Patients were prospectively followed up for occurrence of cardiac death and symptom-driven aortic valve replacement. RESULTS: Of 50 pts (age 68 11 yrs, 58% males), 35 had lone AS of varying severity and 15 with aortic valve sclerosis. Mean aortic valve area indexed to body surface area (AVAI), AVC, DF and left ventricular ejection fraction (EF) were 0.94 0.50 cm2/m2, 1037 1476 AU, 103 69 Hz and 62 14% respectively. DF correlated significantly with AVC, maximal pressure gradient across the aortic valve (Pmax), AVAI and aortic valve resistance (r 0.62, 0.61, -0.51 and 0.60 respectively, all P 0.001). In a multivariate linear regression model incorporating AVC, AVAI and Pmax, the only independent predictor of DF was AVC ( 0.37, P 0.03). Over 15 7 months, 7 pts reached the composite endpoint. Pts with events had higher DF (170 65 vs 93 64 Hz, P 0.005). For prediction of the endpoint, the areas under receiver characteristic curves for DF, AVC, AVAI, age and EF were 0.82(P 0.007), 0.79(P 0.013), 0.88(P 0.001), 0.50(P NS) and 0.65(P NS) respectively. A threshold of 145 Hz for DF provided optimal sensitivity of 86% and specificity of 81% of predicting an event. CONCLUSION: DF derived from novel acoustic analysis of aortic valve stenosis or sclerosis correlates well with AVC by MSCT and offers prognostic information in these patients. CLINICAL IMPLICATIONS: Acoustic analysis of heart sound may provide a simple and useful non-invasive adjunct in the management of patients with aortic valve calcification. DISCLOSURE: Kian Keong Poh, Grant monies (from sources other than industry) National Healthcare Group (Singapore) and Singapore Heart Foundation grants.
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p 0.04 p 0.013
p 0.035
EVALUATION OF ASYMPTOMATIC PATIENTS WITH CRONIC CHAGAS DISEASE TRHOUGH THE ANALISYS OF DYNAMIC ELECTROCARDIOGRAM, ECHOCARDIOGRAM AND B-TYPE NATRIURETIC PEPTIDES Divina S. Oliveira-Marques PhD* Manoel F. Canesin PhD Claudio J. Fuganti MD Antonio C. Pereira-Barretto PhD Londrina State University, Londrina, Brazil PURPOSE: To evaluate asymptomatic patients with chronic Chagas disease in relation to the prevalence of ventricular arrhythmia, left ventricular dysfunction, and B-type natriuretic peptide levels ( BNP). METHODS: Clinical evaluation, electrocardiogram (EKG). cardiothoracic index (CTI),dynamic electrocardiogram, echocardiogram and BNP dosing were used to evaluate 106 patients from the Chagas Disease Outpatient Clinic, distributed into three groups: GI (50- normal EKG). GIIA (31-EKG with alterations characteristic of Chagas disease, and GIIB ( 25- EKG with other types of alterations). RESULTS: The most prevalent electrocardiographic alterations were: GIIA group: right bundle branch block, anterior division of de left bundle branch block and inactive areas (18% each); GIIB group: alterations in the infero-lateral repolarization and left ventricular hypertrophy (26%). CTI mean values were similar (p 0,383). The prevalence of ventricular arrhythmia was greater in the GIIA (77%) and GIIB (75%) groups than in the GI group (46%) (p 0,002). Ventricular dysfunction was more frequent in the GIIA (52%) and GIIB (32%) groups than in the GI group (14%) (p 0,001). Systolic dysfunction was more prevalent in the GIIA group (29%) than in the GIIB (20%) and GI (2%) (p 0,001). Diastolic dysfunction was more frequent in the GII (42%) and GIIB (28%) groups than in the GI (12%) group (p 0,005). B-type natriuretic peptide levels were 30 88 pg/ml for the GI group, 66 194 for the GIIA group and 24 82 for the GIIB group (p 0,121), respectively. CONCLUSION: Arrhythmia and left ventricular dysfunction were more prevalent in the asymptomatic patients with chronic Chagas disease and EKG alterations than in patients with normal EKGs. BNP levels were similar among the groups. CLINICAL IMPLICATIONS: Patients with asymptomatic chronic form of the Chagasdisease and electrocardiographic alterations will have to be submitted to the inquiry in relation to the presence of arrhythmias and ventricular dysfunction. DISCLOSURE: Divina Oliveira-Marques, None.
CHEST 2005Poster Presentations
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Type of Valvular Disease MR, all MR, mild MR, moderate MR, severe MS, all** MVP* AR, all AR, mild** AR, moderate AR, severe** AS, all Bicuspid aortic valve** TR, all** TR, mild TR, moderate* TR, severe** *p 0.01
Prevalence in Females (%) 24.4 16.5 6.1 1.9 1.6 0.4 5.5 11.5 2.6 0.4 2.1 0.3 18.5 11.9 4.4 2.3
Prevalence in Males (%) 25.0 16.5 6.3 2.2 0.4 0.7 14.9 10.1 2.5 1.0 2.3 0.9 16.7 11.6 3.7 1.5
Overall Prevalence (%) 24.7 16.5 6.2 2.0 1.0 0.6 15.2 10.9 2.6 0.7 2.2 0.6 17.7 11.7 4.0 1.9
DISCLOSURE: Mohammad-Reza Movahed, None. DENTITION AND AORTIC ATHEROSCLEROSIS; A TRANSESOPAHAGEAL ECHOCARDIOGRAPHIC STUDY Ricardo Castillo MD Louis Salciccioli MD Jason M. Lazar MD* SUNY Downstate Medical Center, Brooklyn, NY PURPOSE: Prior studies have shown a relationship between periodontal disease, acute myocardial infarction, and atherosclerosis. Microbes indigenous to the oral cavity and DNA of periodontal pathogens have been found in atheromatous carotid plaques. Oral pathogens may promote inflammation and thrombosis leading to atherogenesis Periodontal disease has been found associated with coronary artery, carotid, and peripheral vascular disease. The objective of this study was to determine a possible association between dental loss and aortic atherosclerotic disease. Transesophageal echocardiography (TEE) is an excellent technique to assess aortic atherosclerotic plaque. METHODS: In 115 patients (age 59 15 years, 63% female) referred for TEE, clinical data were recorded. Periodontal disease was determined
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IMPORTANCE OF EARLY FLUIDS RESUSCITATION IN MURINE SEPSIS: ECHOCARDIOGRAPHIC STUDY Massimiliano Guglielmi MD* Sergio Zanotti MD Walker Tracy MD Magali Zanotti BA Felicitas Ross BA Joseph E. Parrillo MD Steven M. Hollenberg MD Cooper University hospital/UMDNJ, Camden, NJ PURPOSE: Fluid resuscitation and antibiotic administration are critical components of the early treatment of sepsis. We evaluated the impact of three different early resuscitation regimens on cardiac performance in a murine model of sepsis. METHODS: 3 groups of 8 C57Bl/6 mice were made septic by cecal ligation and double perforation (CLP); 5 controls had sham ligation. After CLP animals received 1 of 3 fluid regimens: 35mL/kg normal saline bolus SQ after surgery only (None), 35mL/kg after surgery and then every 6hr, (Partial) and 100mL/kg after surgery and then every 6hr (Full). All 3 groups received ceftriaxone, 30mg/kg and clindamycin, 25mg/kg at 6 and 12hr. Animals were anesthetized briefly with isoflurane for echocardiography using a high-resolution ultrasound system (30Mhz scan-head). Stroke volume (SV, L) was assessed by Doppler in the aortic outflow tract and fractional shortening (FS, %) by M-mode in the short axis view. Cardiac output (CO, mL/min) was calculated as SV*HR. RESULTS: From 3 to 9hr after CLP, CO was reduced from 25 2 to 13 2 (None), 24 4 to 15 5 (Partial) and 26 5 to 17 4mL/min (Full), largely due to a reduction in SV, from 56 6 to 23 2 (None), 51 6 to 28 7 (Partial), and 58 7 to 32 5 L; (Full) (p 0.05 vs baseline and sham operated animals in all groups. Heart rate did not change significantly. Animals that received aggressive resuscitation (Full) reached a normodynamic state at 15hours, CO 23 7; SV 48 9; HR 475 74, p NS vs baseline and sham operated animals. Unresuscitated and underresuscitated animals remained in a hypodynamic state, CO 14 6; SV 30 10; HR 470 50 (None) and CO 15 3; SV 40 9; 395 35 (Partial), p 0.05 vs baseline, sham operated and aggressively resuscitated animals (Full). CONCLUSION: Adequate fluid resuscitation is mandatory to restore a normodynamic state in sepsis. In this murine model, which replicates clinical sepsis, early underresuscitation can lead to a sustained hypodynamic state. Early and aggressive resuscitation is necessary to reestablish normal hemodynamics. CLINICAL IMPLICATIONS: Even seemingly minor degrees of underresuscitation early could potentially impair hemodynamics in later phases of sepsis in patients. DISCLOSURE: Massimiliano Guglielmi, University grant monies.
EXERCISE INDUCED DIASTOLIC DYSFUNCTION Vimesh K. Mithani MD Fayez Shamoon MD Sanjeev M. Patel MD* Dulce De Guzman Phillip John Emlata Tarnate Irvin Goldfarb MD St. Michaels Medical Center, Seton Hall University School of Graduate Medical E, Newark, NJ PURPOSE: Diastolic function is not evaluated routinely during stress echocardiography. Little information exits regarding the incidence of diastolic dysfunction induced by exercise. The aim of this study was to assess change in diastolic function by exercise echocardiography. We hypothesized that patients with dyspnea may have higher incidence of exercise-induced diastolic dysfunction without evidence of ischemia. METHODS: We evaluated a cohort of 32 patients referred for exercise echocardiography for dyspnea. Transmitral inflow pattern and Tissue Doppler of mitral valve annulus were analyzed at rest and stress, along with evidence of ischemia. RESULTS: Echocardiographic evidence of diastolic dysfunction at baseline was found in 13 patients. Out of 19 patients who had normal diastolic function at rest, 9 patients (47%) developed exercise-induced diastolic dysfunction at stress without evidence of segmental wall motion abnormality suggestive of ischemia. These patients demonstrated evidence of a relaxation abnormality with transmitral inflow pattern and Tissue Doppler of mitral valve annulus. Exercise-induced diastolic dysfunction was more prevalent in female (67%), and hypertensive patients (78%), and it was associated with reduced exercise capacity (7 METs vs. 9 METs). It was not related to age, exercise-induced ischemia or higher left ventricular diastolic pressure evaluated by the ratio of early transmitral flow velocity with the early diastolic velocity of the mitral valve annulus (E/e 10). CONCLUSION: Exercise-induced diastolic dysfunction in patients with dyspnea is common in female and hypertensive patients. It is not related with exercise-induced ischemia. CLINICAL IMPLICATIONS: Exercise-induced diastolic dysfunction is common in patients who undergo stress echocardiography for symptoms of dyspnea. It should be one of the parameter evaluated during the test for these patients. DISCLOSURE: Sanjeev Patel, None.
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POSTER PRESENTATIONS
CLINICAL CHARACTERISTICS OF OBESE AND NORMAL WEIGHT HEART FAILURE PATIENTS Jun R. Chiong MD* Robert F. Percy MD Binu Jacob MD Hector P. Sanchez MD Anabel C. Castro MD Alan B. Miller MD University of Florida, Jacksonville, FL PURPOSE: Excess weight is associated with a significantly increased risk of coronary artery disease, heart failure, and death in the general population. In patients with established heart failure, studies suggest that a higher body mass index (BMI) results in better outcomes compared to patients with a healthy BMI. It is unclear if these findings are applicable to the population of outpatients with stable heart failure, as these observations are not the primary design or endpoints of these trials. METHODS: Given the uncertain role of obesity in the clinical management of patients with heart failure, we examined the relationship of weight and outcomes among our outpatients with stable disease. RESULTS: We analyzed obese (BMI 30 kg/m2) compared to normal weight patients (BMI 18.5 25 kg/m2) in our clinical information management for heart failure database (CIM-HF); there were 121 patients who fulfilled the criteria. Fifty-one patients had a normal BMI and seventy patients were classified as obese. There was no difference in age, gender or medical therapy for heart failure. More obese patients had a previous history of hypertension (90% vs. 71% p 0.008), diabetes (64% vs. 14% p 0.0001), advanced New York Heart Association (NYHA) functional class III and IV (66% vs. 53%, p 0.046) compared to normal BMI patients. Hospitalizations were higher for obese patients (1.5 1.7 vs. 1.1 1), but this was not significant. CONCLUSION: Symptoms are worse and co-morbidities are more prevalent in obese patients with systolic dysfunction and stable heart failure, compared to normal weight patients. CLINICAL IMPLICATIONS: Obese patients with chronic stable heart failure and systolic dysfunction (ejection fraction 40%) have worse outcomes than similar patients with normal body mass index.
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HEALTH-RELATED QUALITY OF LIFE IN PATIENTS WITH PULMONARY ARTERIAL HYPERTENSION Darren B. Taichman MD* Jennifer Shin MD Laryssa Hudd BA Christine Archer-Chicko RN Sandra Kaplan RN Robert Gallop MS Jason Christie MD John Hansen-Flaschen MD Harold Palevsky MD University of Pennsylvania, Philadelphia, PA PURPOSE: Improved outcomes with expanding treatment options for patients with pulmonary arterial hypertension present the opportunity to consider additional end-points in approaching therapy, including factors that influence health-related quality of life. However, comparatively little is known about quality of life and its determinants in patients with pulmonary arterial hypertension. The purpose of this study was to evaluate health-related quality of life in adults with pulmonary arterial hypertension, and identify factors associated with better or worse status. METHODS: Health-related quality of life was evaluated in 216 outpatients with pulmonary arterial hypertension using generic and respiratory-disease specific measurement tools. Most patients had either World Health Organization functional Class II or III symptoms. Demographic, hemodynamic and treatment variables were assessed for association with quality of life scores. RESULTS: Patients with pulmonary arterial hypertension suffered severe impairments in both physical and emotional domains of healthrelated quality of life. Patients with idiopathic (primary) pulmonary arterial hypertension had the best, and those with systemic sclerosis the worst health-related quality of life. Greater six-minute walk distance correlated with improved quality of life scores, as did functional Class II versus Class III symptoms. Hemodynamic measurements, however, did not correlate with quality of life scores. No differences in health-related quality of life were found between patients treated with calcium channel antagonists, bosentan or continuously infused epoprostenol.
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VALUE OF SERUM CREATININE LEVELS IN CARDIORENAL PATIENTS REFERRED FOR CARDIAC TRANSPLANTATION Shun Kohsaka MD* Kimberly Albright MD Reynolds M. Delgado, III MD Biswajit Kar MD Frank W. Smart MD Texas Heart Institute, Baylor College of Medicine, Houston, TX PURPOSE: pproximately one third to one half of patients with heart failure have renal insufficiency, which is one of the strongest predictors of mortality in these patients. However, there is little evidence with which to weigh the risks of cardiac transplantation in heart failure patients who have mild renal dysfunction. METHODS: We reviewed the clinical and laboratory data of 140 consecutive, stable heart failure patients who had mild renal insufficiency (serum creatinine, 1.1-2.5) referred to our institution for evaluation for cardiac transplantation from May 2004 to April 2005. We then assessed the association between renal dysfunction and 1-year outcomes (either death from any cause or admission for heart failure). The combined endpoint was compared with various levels of baseline serum creatinine values: mild (1.1-1.5), moderate (1.6-2.0), and severe (2.1-2.5). Of the 140 patients, 98 had follow-up visits where laboratory values were obtained. In this subgroup, logistic regression analysis was performed to the model hazard ratio (HR) to achieve the combined endpoint. RESULTS: The cohort was predominantly Caucasian (45%) and male (68%). After 1-year, the combined endpoint was met in 43%, 57%, and 42% of patients with mild, moderate, and severe elevations of serum creatinine, respectively. There was no statistical difference between the 3 groups (Kruskal-Wallis One-Way ANOVA p 0.36). However, in the 98 patients who had follow-up laboratory testing during the study period, a dynamic change in serum creatinine levels was strongly associated with a combined outcome (HR, 1.70; 95%CI, 1.22-24.6; P 0.02). This association remained significant even after adjustment for other clinical variables, including patient age and baseline serum creatinine levels (HR, 1.71; 95%CI, 1.18-26.1; P 0.02). CONCLUSION: A dynamic change in serum creatinine values during follow-up is a strong independent predictor of a worse prognosis for heart failure patients. CLINICAL IMPLICATIONS: These findings suggest that monitoring of serum creatinine values may offer a readily accessible tool to identify which heart failure patients would or would not benefit from cardiac transplantation. A prospective, randomized trial to test this hypothesis is warranted. DISCLOSURE: Shun Kohsaka, None.
POSTER PRESENTATIONS
ASSOCIATION OF REDUCED CARBON MONOXIDE DIFFUSING CAPACITY WITH MODERATE OR SEVERE LEFT VENTRICULAR DIASTOLIC DYSFUNCTION IN OBESE PERSONS Gautham Ravipati MD* Wilbert S. Aronow MD Jasdeep Sidana MD George P. Maguire MD John A. McClung MD Robert N. Belkin MD Stuart G. Lehrman MD New York Medical College, Valhalla, NY PURPOSE: To determine the association of reduced carbon monoxide diffusing capacity (DLCO) with moderate or severe left ventricular diastolic dysfunction (LVDD) in obese persons. METHODS: We investigated in 105 obese persons, mean age 45 years, the association of DLCO with LVDD. An abnormal DLCO was 80%. LVDD was investigated by Doppler and by tissue Doppler echocardiography. The Doppler echocardiographic data were analyzed blindly without knowledge of the clinical characteristics or whether the DLCO was normal or abnormal. RESULTS: An abnormal DLCO was present in 62 of 105 persons (59%). Moderate or severe LVDD was present in 35 of 105 persons 33%).Moderate or severe LVDD was present in 25 of 62 persons (40%) with an abnormal DLCO and in 10 of 43 persons (23%) with a normal DLCO (p 0.05). CONCLUSION: Obese persons with a decreased DLCO have an increased prevalence of moderate or severe LVDD.
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A SURVEY OF PATIENTS PERCEPTION OF DISEASE BURDEN IN CHRONIC COUGH Kaiser G. Lim MD* Ashok Patel MD Timothy I. Morgenthaler MD Mayo Clinic, Rochester, MN PURPOSE: We hypothesized that the burden of disease associated with chronic cough may include health care factors and concern over the meaning of the cough. We sought to understand how chronic cough affected patients socially, psychologically and physically. METHODS: All consenting adult patients presenting to our Pulmonary Division with chronic cough between November and February of 2003 were surveyed with a Cough-related Disease Burden Questionnaire (CRDBQ) prior to their evaluation and again 6 months afterward. RESULTS: 139 subjects were available for analysis. Sixty-five returned the second questionnaire. The top four complaints are shown in Table 1. Anxiety over underlying illness correlated with lifestyle interference, frequent doctor visits, medical expense, prescription expenses, frustration and spouse moving out of the bedroom. Sleep disturbances correlated with exhaustion (p 0.001). A third of patients under 65 years old had a spouse or roommate move out of the bedroom. On followup 6 months later, 18% reported complete resolution of cough, 34% had more than 50% improvement, 20 % had less than 50% improvement, 28 % reported that cough was worse (1/56) or unchanged (26.7%). Improved cough outcome was associated with less anxiety about an underlying serious illness at baseline (p 0.001). CONCLUSION: Both psychological and physical sufferings or burden of disease appear to be chief reasons for seeking medical evaluation. Aside from Anxiety, two important major sources of suffering for the patients are a) frequent physician visits and testing, and b) sleep disturbances. CLINICAL IMPLICATIONS: Frequent doctors visit and testing for cough as a disease burden is an important consideration since many chronic cough algorithms employ empirical therapy and multiple return visits. Anxiety, physician visits, medications, and sleep disturbances weigh highly in patients concerns about chronic cough.
Complaints Frustrated/Irritable/ Angry Frequent MD visit & testing for cough Sleep Disturbances Interferes w/ social gatherings
DISCLOSURE: Kaiser Lim, None. THE EFFECTS OF AGING ON THE HUMAN COUGH REFLEX D. A. Sams DO* Thomas Truncale DO Stuart M. Brooks MD University of South Florida, Tampa, FL PURPOSE: This study was designed to examine if there is a difference in the cough reflex between younger and older persons. A difference might explain the greater susceptibility of older persons to respiratory tract infections and pneumonia. METHODS: The study was the first granted approval by the Food and Drug Administration under an Investigational New Drug (IND) protocol for human capsaicin inhalation investigation. Two groups of normal subjects were recruited. All had normal spirometry, were current nonsmokers 10 years, had no prior/current respiratory disease/complaints
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CURRENT PRACTICE OF CHEST RADIOGRAPHY IN CRITICALLY ILL PATIENTS IN THE NETHERLANDS: A POSTAL SURVEY Marleen E. Graat Peter E. Spronk PhD Marcus J. Schultz PhD* Academic Medical Center, Amsterdam, Netherlands PURPOSE: Although the consensus opinion of the American College of Radiology is that daily routine chest radiographs (routine CXRs) are indicated in all ventilated patients (http://www.acr.org), studies suggest that routine CXRs can be safely abandoned (Krivopal, Chest 2004; Price, CCM 2000). METHODS: To ascertain current practice of CXRs in Dutch ICUpatients, a questionnaire was sent to ICUs throughout the Netherlands. Questionnaires were sent to the lead clinicians of ICUs with 5 beds. RESULTS: From the number of units responding (n 28, 43.1%), the majority (n 17, 60.7%) practiced a routine CXR-strategy, as opposed to a CXR on indication-approach. In most ICUs it was deemed necessary to have (routine) CXRs to ordeal on the presence or absence of ARDS, pneumonia or pneumothorax (n 20; 71.4%, n 19; 67.9% and n 21; 75.0%, respectively), as well as the position of invasive devices (n 21; 75.0%). In most hospitals a daily meeting with the radiologist was held to discuss CXRs (n 19; 67.9%), but in more than half of hospitals the ICU-physician thought that radiologists were not experienced enough to adequately judge CXR of critically ill patients (n 16; 57.1%). If a CXR was judged to be indicated, the reasons were in the majority of ICUs: introduction of invasive devices, such as endotracheal tubes, intravenous lines and thoracic drains (n 22; 78.6%, n 21; 75.0% and n 27; 96.4%, respectively), and hemodynamic/ventilatory deterioration (n 14; 50.0%); surprisingly, CXRs were also performed after resuscitation (n 12; 42.9%) and (mini)-tracheotomy (n 18; 64.3%). Finally, most ICU-physician thought that CXRs, either routine or on demand, influenced daily practice in not more than 20% of performed CXRs. CONCLUSION: In the Netherlands, the majority of ICUs still use routine CXRs, although this survey suggests that a large number of intensivists is doubting its value. CLINICAL IMPLICATIONS: There is important lack of concensus on usefulness of routine CXRs in the Netherlands. DISCLOSURE: Marcus Schultz, None.
A CLINICAL TRIAL TO COMPARE THROMBOPROPHYLAXIS OPTIONS IN THE MEDICAL ICU: CHALLENGES TO TREATMENT Tara Roque MD JulieAnne Thompson MD Tunay Kuru MD* Georgetown University, Washington, DC PURPOSE: To compare the efficacy of low-dose unfractionated heparin (LDUH) and enoxaparin for the prevention of deep venous thrombosis (DVT) in the medical ICU. METHODS: This was a prospective, randomized double-blinded trial to compare LDUH 5000 BID with enoxaparin. Patients were screened with a bedside Doppler ultrasound of the lower extremities at 48-72 hours of ICU admission and again at 7 days. All patients, older than 18 years of age, admitted to the MICU at Georgetown University Hospital were eligible. Exclusion criteria included pregnancy; contraindication to anticoagulation (e.g. uncontrolled hypertension,hemorrhagic stroke in the past 3 months, active gastrointestinal bleeding); ongoing anticoagulant therapy; intolerance to heparin; platelet count 80,000/ml; international normalized ratio (INR) 2.0. Written informed consent was obtained
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Table 1Demographics and Operative Characteristics of the Liver Transplant Patients <60yrs vs >70 yrs.
BMI Age yrs Patients 60 yrs (S.D) 49.8 ( /-1.18) 70 yrs 71.5 ( /-0.34) P Value MELD (S.D) 16.41 ( /-6.94) 16.88 ( /-6.82) 0.9 Kg/m2 (S.D) 28.53 ( /-5.37) 26.77 ( /-4.32) 0.27 OT Hrs (S.D) 5.35 ( /-1.57) 4.77 ( /-1.36) 0.09 WIT min (S.D) 35.08 ( /-2.45) 33.88 ( /-1.55) 0.86 CIT hrs (S.D) 7.21 ( /-32) 6.68 ( /-29) 0.60 Fluids ml (S,D) 3784 ( /-1068) 5535 ( /-2716) 0.003*
ACUTE PHYSIOLOGY AND CHRONIC HEALTH EVALUATION (APACHE)IV ICU LENGTH OF STAY BENCHMARKS FOR TODAYS CRITICALLY ILL PATIENTS Jack E. Zimmerman MD* Andrew A. Kramer PhD Douglas S. McNair MD Fern M. Malila MS George Washington University, Washington, DC PURPOSE: To describe the development and validation of APACHE IV benchmarks for ICU length of stay. METHODS: The equations used to generate ICU length of stay benchmarks were developed using ICU day 1 data for 116,209 admissions to 104 ICUs at 45 hospitals during 2002 and 2003. Of these admissions 69,692 were used for model development and 46,517 were used to validate the model. A linear regression procedure was used to estimate exact ICU stay in days and fractions of days. Predictor variables were similar to those used for APACHE III estimates, but new variables (mechanical ventilation, thrombolysis, the impact of sedation on Glasgow Coma Score (GCS), and a rescaled GCS and PaO2:FIO2) were added, and different statistical modeling (restricted cubic splines) was used. We assessed the accuracy of APACHE IV ICU stay predictions by examining the degree of correspondence between mean observed and mean predicted ICU stay (paired Students t-test), and by calculating a correlation coefficient (R2). RESULTS: Based on relative explanatory power, the most important predictor variables were the acute physiology score (50%), ICU admission diagnosis (14%), ventilator status (11%) and the inability to assess a GCS due to sedation (11%). As the acute physiology score rose there was a linear increase in ICU stay until the score exceeded 80, at which point ICU stay decreased. For the validation data set the aggregate mean observed ICU stay was 3.86 days and mean predicted was 3.78 days (p 0.001). Among 116 ICU admission diagnoses there were only two significant differences (p 0.01) between mean observed and mean predicted ICU stay. The models R2 was 0.215 indicating that the model accounted for 21.5% of the variation in ICU stay. CONCLUSION: APACHE IV predictions of ICU stay are well calibrated and should provide useful benchmarks for evaluating efficiency in U.S. ICUs. CLINICAL IMPLICATIONS: Clinicians can use these benchmarks to assess their units throughput efficiency and monitor the impact of protocols aimed at reducing ICU stay for specific patient groups. DISCLOSURE: Jack Zimmerman, Consultant fee, speaker bureau, advisory committee, etc. Medical and Research Consultant. HIGH TROPONIN LEVELS IN CRITICALLY ILL PATIENTS WITH RENAL FAILURE AND NO ACUTE CORONARY SYNDROME: INCIDENCE AND IMPACT ON MORTALITY Vijo Poulose MBBS* Siau Chuin MBBS Alvin Ng MBBS Chong-Hiok Tan MB, ChB Changi General Hospital, Singapore, Singapore PURPOSE: High cardiac troponin levels are commonly seen in medical intensive care (MICU) patients with renal failure and no clinical evidence of acute coronary syndrome (ACS). We looked at the incidence
POSTER PRESENTATIONS
GASTRIC IMPEDANCE SPECTROSCOPY AND HEMODYNAMIC VARIABLES BEHAVIOR IN DIFFERENT OUTCOMES AFTER CARDIAC SURGERY Nohra E. Beltran Vargas MS* Gustavo Sanchez-Miranda MD Montserrat Godnez Ursina Daz Emilio Sacristan PhD Universidad Autonoma Metropolitana, Iztapalapa, Mexico City, Mexico PURPOSE: When blood flow is arrested during cardiopulmonary bypass (CPB), the tissue suffers progressive alterations. Gastric impedance spectroscopy, a novel tool used to monitor and detect tissue ischemia is compared with hemodynamic variables as CI, MAP, MPAP, CVP, PCWP; and regional perfusion variables as PCO2 gap and gastric intramucosal pH, to find differences according to outcome for patients undergoing elective cardiovascular surgery. METHODS: Impedance spectrometry probe and nasogastric tube (ISP/NGT), and a tonometer were placed in the stomach of 56 patients under coronary artery bypass (CABG) and/or valvular surgery with CPB and aortic cross-clamp. Hemodynamic monitoring was performed via pulmonary artery and radial artery catheters, inserted before the operation. Impedance spectra of the gastric wall and hemodynamic variables were recorded perioperatively and for up to 4 hours after surgery. Pre-surgical and post- surgical measurements comparison was made to assess which variable is better associated with mortality using ANOVA. RESULTS: Eighteen (34.61%) patients developed complications within a 72h period after surgery; seven (13.46%) died. Nine (17.3%) patients developed complications after ICU release. Table 1 shows that impedance spectroscopy variables (R316 and X316) and CI showed significant differences between survivors and non survivors. The other hemodynamic and regional perfusion variables did not differ between groups. Only CI, CO2 gap and pHi showed statistical differences before and after surgery. CONCLUSION: Our data suggest that gastric impedance spectra may be a good predictor of outcome after cardiac surgery. Further analysis is ongoing to extract and assess the diagnostic/prognostic value of these measurements. CLINICAL IMPLICATIONS: Gastric impedance spectroscopy may be a useful tool to assess splanchnic perfusion and tissue viability in critical care patients.
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Medical Patients Number Mean ICU LOS (SD) Mean Hosp LOS (SD) Survival ProbabilitySAPS II (SD) Expected MortalitySAPS II Actual Mortality Surgical Patients Number Mean Hosp LOS (SD) Survival ProbabilitySAPS II (SD) Expected MortalitySAPS II Actual Mortality
M1 181 5.4 (7.1) 20.3 (24.5) 0.70 (0.29) 30.00% 32% S1 96 15.2 (8.9) 0.87 (0.180) 13.00% 8.30%
M2 49 5.6 (6.3) 34.4 (23.6) 0.57 (0.32) 43% 53% S2 103 28.3 (23.6) 0.84 (0.21) 16% 24%
DISCLOSURE: Nohra Beltran Vargas, Grant monies (from industry related sources) This research was supported by a grant from Innovamedica S.A. de C.V. with concurrent support from CONACYT.; Product/ procedure/technique that is considered research and is NOT yet approved for any purpose. Innovamedica is sole assignee of the patent related to the technology using in this work. The impedance spectrometer is not commercial yet.
0.0037
PREINTENSIVE CARE UNIT LENGTH OF STAY AND OUTCOME IN CRITICALLY ILL PATIENTS Raquel Nahra MD* Christa Schorr RN David R. Gerber DO Cooper University Hospital, Camden, NJ PURPOSE: To evaluate the relationship between pre-intensive care length of stay and outcomes of patients transferred to the Intensive Care Unit (ICU). METHODS: Data was obtained from the Project Impact database. Patients without a previous ICU admission transferred to the MedicalSurgical ICU (MSICU) between October 2002 and November 2004 were reviewed. Medical patients came from general care and telemetry floors. Surgical patients came from these areas, the operating room (OR), and the post anesthesia care unit. Patients were classified as surgical if surgery was performed in the OR within 7 days prior to ICU admission. Patients were grouped by hospital length of stay (HLOS) prior to ICU admission: medical patients HLOS 5 days (Group M1) or HLOS 6 days (Group M2); surgical patients HLOS 5 but 1 day (Group S1) or HLOS 6 days (Group S2). Variables analyzed included age, SAPS II survival probability, ICU and hospital LOS, and mortality. RESULTS: Groups were demographically similar. Group M2 was sicker than M1. Acuity was similar between S1 and S2. Mortality was higher among patients with pre-ICU LOS 6 days versus those with pre-ICU LOS 5 days. HLOS was longer in groups M2 vs. M1 and S2 vs. S1. ICU LOS did not differ based on pre-ICU LOS. Observed deaths exceeded predicted in group S2. CONCLUSION: ICU admission from a general care floor after 6 days is associated with poor outcome as compared to earlier admission. Previous studies have invoked suboptimal care prior to ICU admission as the reason for poorer outcomes. This idea is supported by the higher acuity of patients in Group M2. Poor organization, insufficient knowledge, failure to appreciate clinical urgency, inadequate supervision and failure to seek advice have been previousely suggested as factors in this suboptimal care. CLINICAL IMPLICATIONS: Improving outcomes in patients transferred to the ICU may require institutional changes. Prompt recognition of deteriorations in patient condition and earlier interventions, such as the institution of a rapid response team may result in securing better outcomes.
STUDY OF BACTEREMIA IN ICU PATIENTS Avanti Vigg MBBS* Arul Vigg MBBS Ajit Vigg MD Royal Preston Hospital, Preston, United Kingdom PURPOSE: To evaluate the incidence, microbiological pattern & clinical outcomes of blood stream infection among ICU patients. METHODS: A Retrospective study from a medical ICU (12 beds) in a tertiary care urban teaching hospital.Data was collected retrospectively for all patients admitted to medical ICU from 1st January to 31st December 2004. Number of blood cultures collected were noted isolated organisms were recorded. RESULTS: A total of 3657 patients were admitted to MICU during the 12 month study period. 2091 blood cultures were sent during the period. There were a total of 370 episodes of bacteremia. Seven patients had more than two episodes of bacteremia.The organisms were as follows :-Klebseilla Pneumoniae 10; Klebseilla species 40; Klebseilla Ornitholytica 3; Pseudomonas aerogenosa 12; Pseudomonas species 67; Staph.aureus 72; Strep.Pneumoniae 21; E.coli 26; Candida albicans 45; Citrobacter diversus 2; Citrobacter freundii 3; Enterobacter species 9; Acinetobacter species 3; Salmonella typhi 3; Coagulase negative Staphylococcus 23; Streptococcus group b 2 & group d 5. The mortality in patients with bacteremia was 177/370 (47.8%) while it was 103/1721 (5.9%). The mortality in those patients with 2 or more episodes of bacterima was 4/7 (57.1%). CONCLUSION: Bacteremia occurred in 10% of all ICU admissions. 1.9% had multiple episodes of bacteremia. Gram negative pathogens were the commonest organisms seen in our clinical practice. Pseudomonosa species were the commonest(n 79) followed by Staph.aureus (n 72) &
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INCIDENCE AND RISK FACTORS FOR HYPERCALCEMIA IN INTENSIVE CARE UNIT Nathalie Gagnon MD* Francois Lauzier MD Francois J. LeBlanc MD Laval University, Quebec, PQ, Canada PURPOSE: Immobilisation may be associated with excessive bone resorption leading to hypercalcemia and its complications such as delirium, renal failure and bowel dysfunction. Incidence, risk factors as well as clinical consequences of immobilisation-associated hypercalcemia are not known for patients with extended intensive care unit (ICU) stay. This retrospective cohort study was designed to evaluate the incidence as well as the risk factors of hypercalcemia for adult patients with extended (more than 28 days) ICU stay. METHODS: All medical records of adult patients with an ICU stay of more than 28 days from 2002 to 2005 were reviewed. For each patient, the highest ionized calcemia was noted as well as the following informations: age, gender, race, weight, admission diagnosis, date of highest ionized calcemia with its associated creatinine level, diagnosis of septic shock, diagnosis of acute respiratory distress syndrome (ARDS), continuous veno-venous hemofiltration (CVVH), mechanical ventilation, parenteral nutrition, and corticotherapy. RESULTS: Seventy-nine patients stayed in ICU for more than 28 days. Mean age was 53 18 year-old. Twelve patients (15%) died. 59 patients (75%) had mechanical ventilation, 13 (16%) had CVVH, 29 (37%) had ARDS. Sixteen patients (20%) had hypercalcemia with a mean ionized calcemia of 1,44 0,13 mmol/L (normal 1,15-1,29 mmol/L). Twelve of these patients were under CVVH. CONCLUSION: Hypercalcemia is frequent in patients with extended ICU stay. CVVH seems to be strongly associated with hypercalcemia. For those patients under CVVH, hypercalcemia may be explained by the high calcium concentration in our reinjection solutions (1,75 mmol/L). A prospective study is needed to determine the real incidence of immobilisation-associated hypercalcemia in patients without CVVH.
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n (111) 87 7 4 13
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UTILITY OF INHALED NITRIC OXIDE IN ADULT POSTOPERATIVE CARDIAC PATIENTS WITH RIGHT VENTRICULAR FAILURE Rammohan Marla MD* Douglas Oberly RRT Kevin P. Keating MD Frederick Knauft MD Hartford Hospital, Hartford, CT PURPOSE: Inhaled nitric oxide (INO) acts as a pulmonary vasodilator and has been FDA approved for hypoxic respiratory failure of the term and near term neonate. By lowering pulmonary vascular resistance, INO would be of potential benefit in patients with severe right ventricular dysfunction. This report describes the largest series in the literature on the effects of INO in adult postoperative cardiac patients with right ventricular failure. METHODS: Patients were considered eligible for inhaled nitric oxide therapy if they were 18 years of age, were post cardiac surgery, had moderate to severe right ventricular dysfunction by echocardiography, had a PAOP 18 mmHg or RVEDV 120 ml/m2, PVR 200 dynes/sec and were unresponsive or intolerant to maximal pharmacotherapy. Nitric oxide was initiated at 5 ppm and increased until maximal benefit was observed (maximum dose 80 ppm). Outcomes measured included oxygenation and hemodynamic variables, dose and duration of therapy, and mortality. RESULTS: Between March 1998 and October 2004, 97 patients received INO therapy. 40 (41%) patients survived to discharge from hospital. 57 (59%) died before discharge from hospital. Mean INO dose was 48 ppm for the survivors and 53 ppm for non-survivors. Hemodynamic parameters in all groups are shown in the Table. CONCLUSION: Our experience has shown that INO does decrease PVR and improve both CI and REF in patients with severe right ventricular dysfunction who have proven refractory to maximal pharmacotherapy. Our experience shows improved right heart hemodynamics. Using Receiver Operating Characteristic Curve, a CI of 2.5 discriminates survivors and non-survivors, however with low sensitivity (62.5) and specificity (66.7). CLINICAL IMPLICATIONS: INO can be effectively used to improve right heart function in postoperative cardiac surgical patients who did not respond to maximal pharmacotherapy. It is a useful adjunctive therapy in lieu of right ventricular assist devices in such patients.
RESIDENTS KNOWLEDGE AND LEARNING OF CRITICAL CARE PHARMACOTHERAPY: EVALUATION OF A FORMALIZED WEB-BASED EDUCATIONAL MODEL Nicole Weimert PharmD Brian R. Zeno MD* Joseph Mazur PharmD Alice Boylan MD Medical University of South Carolina, Charleston, SC PURPOSE: Little data have been published that define the knowledge base of US housestaff regarding critical care pharmacotherapy or whether this knowledge base can be effectively improved through a web-based self-study program. We therefore sought to determine housestaff knowledge of key critical care concepts, and to reassess this knowledge following completion of a series of educational modules. METHODS: This was a single center pilot study using housestaff (PGY1 through PGY3). Housestaff were given pretests consisting of 40 questions in ABIM format from several different aspects of critical care pharmacotherapy. This was followed by didactic powerpoint modules on each of the subjects designed by subspecialists in critical care. Following completion of each of the modules, a posttest consisting of the same questions was provided to evaluate objective improvement. The following subjects were included: antibiotics, antifungals, vasopressors and inotropes, status epilepticus, hypertensive emergencies, toxicology, sedation, neuromuscular blockade and nutrition. RESULTS: Fifteen housestaff completed the pretest, modules, and posttest. The pretest showed a deficit in knowledge across all subjects with an average of 29% of the questions being answered correctly. Although the posttest showed a modest 5% relative improvement following the modules, this did not reach statistical significance (p .18). CONCLUSION: Our housestaff come from a multitude of medical schools across the country and have USMLE scores well above the national average. Despite this, there was a uniform lack of education and/or retention in this area despite formalized pharmacology education during medical school. It appears that this an area that needs either
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DEATH: A ONE-COMPARTMENT DRUG MODEL EQUATION Terry Fagan MD* VA Medical Center, Wilkes-Barre, PA PURPOSE: To find an easier way to estimate and use serum levels of vancomycin and aminoglycosides. METHODS: The one compartment model with volume of distribution (Vd) in liters, and drug clearance (CLd) in liters/day was examined with drug clearance approximated by creatinine clearance (CCR). This model generally gives a reasonable approximation for vancomycin and the aminoglycosides. The equation for serum level half-life (T1/2) 0.693 * VD / CLd was used, along with peak serum level (P) and trough serum level (T), to give a useful one-compartment equation called DEATH. RESULTS: Define D as mg of drug given per day. Define H as number of drug half-lives between doses of the drug. Define E as drug excretion CCR. Define the amplitude A as P-T. Define T 2. Manipulation gives D E*A*T/H. Example1: CCR 40. You desire vancomycin P 32 and T 8. Then E 40, A 24, and the number of half-lives from 32 down to 8 is 2 . D 40*24*2/2 960. If vancomycin Vd 40 L, each dose would be 40*(32-8) 960. Hence your dosing would be 960 mg QD. Example2 CCR 20 , tobramycin 200 mg QD, estimated tobramycin VD 20 L. Then E 20, A 10 and D 200. Then 200 20*10*2/H. Hence H 2 half-lives. Thus the trough T must be 1/4 of the peak P, and since P-T 10, then P 13.3 and T 3.3. Example3: Amikacin 500mg Q 12h gives trough 10. Amikacin Vd 25 L. D 1000, A 20. The peak T 20 30. Peak of 30 to trough 10 requires 1.5 half-lives. Using the DEATH equation: 1000 E*20*2/1.5 gives E CCR 38 ml/min. CONCLUSION: The DEATH equation D E*A*T/H can be used to estimate dose, serum levels, and CCR. CLINICAL IMPLICATIONS: The DEATH equation is useful for vancomycin and aminoglycosides. DISCLOSURE: Terry Fagan, None.
Tracheostomy On MV 12 723.66 391.75 8.93 10.25 Off MV 6 1083.31 302.90 50.4 46.23
NO
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DISCLOSURE: JiYeon Choi, Product/procedure/technique that is considered research and is NOT yet approved for any purpose. The chemiluminescence analyzer (Model LR2000; Logan Research, Rochester, UK) is only available for research purposes at this time.
DAILY MEASUREMENT OF NASAL NITRIC OXIDE (NO) IN HEALTHY NON-SMOKERS AND TRACHEOTOMIZED MECHANICALLY VENTILATED PATIENTS JiYeon Choi MSN* Leslie A. Hoffman PhD Jigme M. Sethi MD University of Pittsburgh School of Nursing, Pittsburgh, PA PURPOSE: To describe the day-to-day variation in nasal NO (nNO) and ambient NO (aNO) and examine the relationship between nNO and aNO in healthy non-smokers and tracheotomized patients. METHODS: Two groups were recruited: 1) ten healthy non-smokers (50% male), aged 33.9 7.8 years with a body mass index 30, no cold or flu-like symptoms in 30 days, known allergies, prescribed medications in 7 days, or diagnosis of acute or chronic illness, and 2) three tracheotomized patients (33% male), aged 77.0 5.2 years, on mechanical ventilation (MV) for 43.67 31.90 days and undergoing daily weaning trial. Tracheotomy placement was 8.33 4.51 days after initiation of MV. nNO and aNO levels were measured using a chemiluminescence analyzer (Model LR2000; Logan Research, Rochester, UK) with a sampling flow rate of 250 ml/minute. RESULTS: In normals (n 10), nNO was measured for 3 consecutive days (30 measures). There was no significant day-to-day difference in nNO (p NS). In tracheotomized subjects (n 3), nNO was measured for two, 3 consecutive day periods with an intervening 10 days (18 measures). Twelve measures occurred while on MV and 6 measures occurred after weaning from MV (mean SD 723.66 391.75 ppb, and 1083.31 302.90 ppb respectively). aNO levels varied each day in both normal and tracheotomized patients (range 0.65 104.50 ppb, and 1.00 112.20 ppb, respectively). In both groups, there were no significant correlations between nNO and aNO (p NS).
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ACCURACY OF CLINICAL EVALUATION OF HEAD OF BED ELEVATION Nasir Awan MD* Chanaka Seneviratne MD Zenia Ceniza RN Taek S. Yoon MD Yizhak Kupfer MD Sidney Tessler MD Maimonides Medical Center, Brooklyn, NY PURPOSE: Maintaining head of bed elevation (HOBE) greater than 30 has been shown to decrease the incidence of ventilator associated pneumonia. We prospectively studied the accuracy of clinical estimation of HOBE. METHODS: HOBE was set at two levels 30 and 45 with the use of a protractor. Nurses and physicians were asked to determine the HOBE angle. The position of the observer, whether the estimation was performed at the foot or the side of the bed, was evaluated. RESULTS: One hundred and fifty nurses and fifty physicians participated in the study. Overall, when HOBE was 30, the average clinical estimation was 50 (P 0.001). When the HOBE was 45, the average clinical estimation was 70 (P 0.001). When the observer was at the foot of the bed, only 32 (16%) correctly estimated the position versus 90 (45%) of the observers correctly estimated bed position from the side of the bed (P 0.001). There was no difference between physicians and nurses in the accuracy of the clinical estimation of HOBE. CONCLUSION: Clinical evaluation of the angle of HOBE tends to overestimate the angle of elevation. Measurement of the HOBE from the side rather than the foot of the bed is more accurate. CLINICAL IMPLICATIONS: Use of protractors rather than clinical estimation should be encouraged to maintain HOBE greater than 30. DISCLOSURE: Nasir Awan, None.
DISCLOSURE: Antonio Raimondi, None. CURRENT PRACTICE OF TRACHEOTOMY IN EUROPE: A POSTAL SURVEY IN THE NETHERLANDS Denise P. Veelo MD Marleen E. Graat Peter E. Spronk PhD Marcus J. Schultz PhD* Academic Medical Center, Amsterdam, Netherlands PURPOSE: Tracheotomy is increasingly performed in critically ill patients requiring prolonged respiratory support, weaning and frequent broncho-pulmonary toilet. METHODS: To ascertain current practice of tracheotomy in critically ill patients a simple questionnaire was sent to intensive care units (ICUs) throughout the Netherlands. Questionnaires were sent to the lead clinicians of ICUs with 5 beds. RESULTS: From the number of units responding (n 28, 43.1%), the majority (n 17, 60.7%) practiced percutaneous tracheotomy as opposed to open surgical tracheotomy. In the majority of hospitals tracheotomy was performed by the intensivist (n 19, 67.9%), followed by the surgeon (n 15; 53.6%), and the ENT-physician (n 9, 32.1%). Tracheotomies were mainly performed in the ICU (n 20; 71.4%), than in the operation room, and more tracheotomies were performed by a team (i.e., for each tracheotomy procedure more than one physician was present, n 22, 78.6%) than by a single physician (n 2, 7.1%). In the majority of ICUs no antimicrobial prophylaxis was given before tracheotomy (n 23; 82.1%). Reasons for tracheotomy were polyneuropathy (n 13; 46.4%), prolonged mechanical ventilation ( 14 days) (n 22; 78.6%), and low GCS (n 18; 64.3%). Although it was the policy to perform the
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RESULTS: 103 patients treated with intensive insulin therapy were analyzed. Patients were treated for a mean of 8.8 6.7 days (range 1-33 days) and a total of 914 treatment days. The mean inclusion blood sugar was 10.7 4.5 (range 6.1-27). The target blood glucose was reached in a mean of 6.7 3.3 hours. Average daily blood glucose levels are shown in the figure. There were a total of 7480 readings above the target averaging 8 /100 treatment days. There were a total of 138 hypoglycemic episodes averaging 15/100 treatment days. CONCLUSION: Intensive insulin therapy protocol was effective in achieving the target level of 4.1-6.1 mmol/l in a relatively short time (6.7 hours) and for most of the treatment duration. This therapy was associated with the occurrence of hypoglycemia at a rate of 15/100 treatment days. CLINICAL IMPLICATIONS: Physicians using intensive insulin therapy need to be aware of the frequency of complications; the impact of which can be minimized by at least hourly monitoring of blood glucose.
INTENSIVIST DIRECTED PROTOCOL REDUCES ICU ADMISSIONS FOR PATIENTS IN DIABETIC KETOACIDOSIS Jay M. Nfonoyim MD* Joseph Ng MD Igor Berengolts MD Fasika Weldearegay MD Saint Vincents Catholic Medical Center, Staten Island, NY PURPOSE: Over 90,000 U.S. hospital admissions have DKA as a primary diagnosis. Despite published management guidelines, there are significant differences in treatment plan, rate of ICU admissions and length of stay. The use of an early intensivist directed protocol reduces the duration of acidemia and ICU admissions. METHODS: Patients admitted into the ED, with a primary diagnosis of DKA during a two month period in 2005 (Intervention) were treated with early intensivist driven protocol utilizing crystalloids and a constant infusion of insulin with IV boluses. Patients were treated with the standard 0.1 units/kg IV bolus and 0.1 unit/kg/hour IV infusion of insulin titrated to the blood glucose. However, in this study, the treatment was complimented with IV boluses of insulin based on blood glucose measurements. Outcomes measured were duration of acidemia, admission to ICU, and length of hospital stay. Controls were retrospectively obtained by reviewing an equal number of randomly selected charts of patients admitted for DKA during the same period in 2004. RESULTS: Both groups were matched according to their APACHE II scores. The duration of acidemia in the intervention group ranged from 2-13 hours, (mean 5.9) compared to the control group which ranged from 7-19.5 hours (mean 11) p 0.001. Of the intervention group, 10 percent were admitted to the ICU, compared to 30 percent of the control group. The mean length of stay for the intervention group was 4.0 days, compared to 4.5 days for the control group. CONCLUSION: In the management of DKA, early intervention by an intensivist directed protocol of crystalloids and insulin with intravenous boluses during and in addition to a constant infusion of insulin, reduces the duration of acidemia, subsequent admissions to the ICU and a trend towards a shorter length of stay. CLINICAL IMPLICATIONS: Involving a critical care team in the management of DKA patients early in their admission to the ER reduces the rate of admissions to the ICU thereby decreasing the total cost of the hospitalization. DISCLOSURE: Jay Nfonoyim, None.
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TableResults
Protocol recommendation Glucometer- Clinical based lab-based Total insulin (units) Mean 15.16 12.69 Difference 2.47 P 0.0025
POSTER PRESENTATIONS
1.52 0 to 4.82
DISCLOSURE: Srinivas Chakravarthy, Grant monies (from sources other than industry) This study was supported by an award from The CHEST Foundation of the American College of Chest Physicians and Ortho Biotech Products, LP.; Grant monies (from industry related sources) The glucometer, chemistry strips and reagents were provided by Roche. NON-SUCCESSFUL INTENSIVE INSULIN THERAPY IN ICU PATIENTS IS NOT ASSOCIATED WITH CHANGES IN QUALITY OF LIFE Jose Hofhuis RN Jan Bakker PhD Marcus J. Schultz MD Johannes H. Rommes MD Peter E. Spronk MD* Gelre Hospitals (Lukas site), Apeldoorn, Netherlands PURPOSE: Recent data showed that intensive insulin therapy (IIT) improved the mortality and morbidity in post-operative intensive care patients. IIT, bears the risk of hypoglycaemia, which might be associated with a decreased health related quality of life (HRQOL). We hypothesized that changes in HRQOL may be related to IIT. METHODS: All measured blood glucose values (BGs) in all patients admitted 48 hours to a 10-bed mixed IC from 2001 2003 were retrospectively collected. Severe hypoglycemia (BG 2.2 mmol/) and hypoglycemia (BG 4.4 mmol/l) were defined. Patient data were divided in two groups: successful IIT group: patients with 75% of BGs in normal range, and no (severe) hypoglycemia at any time during IIT; unsuccessful IIT group: patients that did not fulfil the former criteria. HRQOL was assessed using the Short-Form (SF)-36. Patients or proxies completed this questionnaire in the first 48 hours of admission and 6 months thereafter. RESULTS: Mean BG was 6,9 1,5 mmol/l in the succesful group (N 45) and 8,7 3,2 mmol/l in the unsuccesful group (N 286). In the succesful group, the percentage of patients with severe hypoglycemia and hypoglycemia was 3,3% and 31%, respectively. In the first group, scores in the physical functioning and general health domains decreased in the 6 month evaluation period (P 0,003 and P 0,001, respectively). No changes were found in the role physical, vitality, pain, social functioning, role emotional; and mental health domains. In the unsuccessful IIT group, scores in the physical functioning, role physical and general health domains decreased in the same period (all P 0,001). No changes were observed in the vitality, pain, social functioning, role emotional, and mental health domains. No differences between the groups could be demonstrated with respect to scores in the HRQOL domains 6 months after ICU discharge. CONCLUSION: HRQOL decreases after IC-treatment, particularly with respect to physical functioning and general health. This decrease was independent of successfulness of IIT.
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COMPUTERIZED PROTOCOLS FOR INTENSIVE INSULIN THERAPY: VARIATIONS IN RECOMMENDATIONS BASED ON DIFFERENT METHODS OF GLUCOSE MEASUREMENT Srinivas B. Chakravarthy MBBS* James F. Orme MD Boaz A. Markewitz MD Chris Lehman MD University of Utah, Salt Lake City, UT PURPOSE: Insulin protocols are increasingly used in ICUs to achieve desired glucose ranges while minimizing practice variation and potentially, harm to patients. Glucose levels may vary, however, with different testing methods, and these differences may be clinically significant. Point of care testing with glucometers is now widely performed, however, the adequacy of this method in critically ill patients is largely unknown. The purpose of this study is to evaluate the variations in recommendations given by a computerized insulin protocol to glucose levels obtained by different testing methods. METHODS: Patients admitted to the ICU with shock (SBP 90 mm Hg despite adequate volume resuscitation or requiring vasopressor therapy) were evaluated. When indicated, an arterial blood sample was obtained and glucose was measured using a glucometer (ACCU-CHEK Comfort Curve, Roche), as well as in the clinical laboratory (gold standard) using the colorimetric plasma glucose analyzer (VITRIOS). A simulation was subsequently run using this patient abstracted data on our computerized insulin protocol. The computerized protocol has been implemented in our ICU since January of 2003 and targets a glucose level of 80 to 110 mg/dl. The protocol uses the current blood glucose level as well as the rate of decline in glucose to determine the insulin infusion rate. RESULTS: Simulations were run on glucose results from 21 patients (61 total samples). The protocol treatment recommendation obtained for each glucose level determined by the glucometer was compared to the recommendation obtained for the corresponding glucose level determined by the clinical lab. See table for the results. Two out of the 21 patients in our simulation had a difference of greater than 1 unit/hour of insulin infusion rate, between the recommendations.
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DOES VARIATION ON SURGICAL TECHNIQUES ALTER OUTCOME OF LUNG BIOPSY FOR INTERSTITIAL LUNG DISEASE? Bhanumathi Lakshminarayanan MD* Antonio E. Martin-Ucar MD Michael F. Maguire MD Lynda Beggs David Beggs MD John P. Duffy MD Ellis Morgan MD Thoracic Surgery, Nottingham City Hospital, Nottingham, United Kingdom PURPOSE: The reported accuracy of surgical biopsy for interstitial lung disease (ILD) is highly variable. We have audited our results to determine whether operative techniques do alter outcomes. METHODS: 123 patients [68 men and 55 women with a median age of 57 (range from 18 to 84) years] underwent lung biopsy for diffuse interstitial lung disease in our unit from 1992 to 2004. Video assisted thoracoscopy (VATS) was used on 66 cases (54%) and the rest underwent traditional open biopsy. Outcomes of the study were: rate of definitive specific diagnosis, change of diagnosis and change of therapy, complications, and to assess the weight of surgical variables (surgical procedure, side, number and size of samples) as predictors of outcomes. RESULTS: There was one postoperative death (0.8%) and 13 patients (10%) had any complication. A definitive specific diagnosis was obtained in 91 cases (74%). A different diagnosis from presumed pre-operative one was encountered on 59 (48%) cases, and a definite change of therapy was confirmed on 27 (22%) of cases. The type of procedure (either VATS or open), or number and size of specimens did not significantly affect the chance of a definitive diagnosis, complications, change of diagnosis, or change in therapy. (Table 1, p non significant in all cases). CONCLUSION: Lung biopsy can be done safely with high rates of specific diagnosis and low incidence of complications. We have not proven that surgical variables alter the outcomes in terms of definitive or change of diagnosis, complications or change of therapy. CLINICAL IMPLICATIONS: Different approaches and techniques do not contribute to increase usefulness of surgical biopsy for ILD.
POSTER PRESENTATIONS
Specific Change of Change of diagnosis diagnosis therapy Technique VATS (n 66) Open (n 57) Side Right (n 64) Left (n 59) Number 1 sample (n 105) 1 sample (n 18) Size 4cm (n 69) 4cm (n 54) 50 (76%) 41 (72%) 47 (73%) 44 (75%) 76 (72%) 15 (83%) 50 (72%) 39 (72%) 28 (42%) 31 (54%) 33 (51%) 26 (44%) 51 (49%) 8 (44%) 30 (43%) 27 (50%) 14 (21%) 13 (23%) 13 (20%) 14 (24%) 22 (21%) 5 (28%) 12 (17%) 15 (28%)
DISCLOSURE: Toshihiko Sato, None.
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MINIMALLY INVASIVE CLOSURE TECHNIQUES FOR RECALCITRANT BRONCHOPLEURAL FISTULAS Lindsey Clemson BS* James Lynch RRT Eric Walser MD Joseph Zwischenberger MD Thomas Black MD University of Texas Medical Branch, Galveston, TX PURPOSE: The treatment most often recommended for persistent symptomatic central bronchopleural fistulas (BPF) involves thoracotomy with suture closure and transposition of a vascularized muscle flap or omentum to the bronchial leak site unfortunately, this can be ineffective or medically contraindicated. We used minimally invasive closure techniques including bioadhesives (glues), stainless steel coils and prolene mesh in combination with different imaging techniques to treat recalcitrant central BPF to achieve successful closure in 3 of 5 patients. METHODS: We initially (n 2) utilized cyanoacrylate glue injected transthoracically under fluoroscopic guidance into the BPF lumen forming a plug. Next, two patients failed muscle flap transposition and CT guided transthoracic injection of a single coil plus Albumin/Glutaraldehyde glue into the fistula. We then used a transtracheal guidewire positioned under fluoroscopy to identify the fistula and thoracoscopic placement of a prolene mesh patch over the defect secured by fibrin sealant to prevent glue dislodgement. Most recently, stainless steel coils and cyanoacrylate glue were transthoracically injected into and adjacent to a postpneumonectomy bronchial stump under thoracoscopic visualization. RESULTS: Glue injection under fluoroscopic guidance was successful once while in another, the glue plug was dislodged by coughing. Placing a prolene mesh patch over the BPF secured with fibrin sealant was successful in 1/2 patients. Our most recent effort was to traverse the fistula
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TISSUE SEALANTS: THE ROLE OF ALBUMIN/GLUTARALDEHYDE IN THORACIC SURGERY Thomas Black BS* James E. Lynch RRT Joseph Zwischenberger MD University of Texas Medical BranchGalveston, Galveston, TX PURPOSE: Sealants have been developed to achieve hemostasis or tissue adhesion during surgery. We examined the use of an Albumin/ Glutaraldehyde sealant in 16 thoracic surgery patients as an adjunct to controlling air leaks on the lung parenchyma following resection. Air leak
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DISCLOSURE: Edwin Van Velzen, None. PHARMACOKINETIC ANALYSIS OF ISOLATED LUNG PERFUSION WITH MELPHALAN IN PATIENTS WITH RESECTABLE PULMONARY METASTASES Marco J. Grootenboers MD* Jeroen M. Hendriks PhD Wim J. van Boven MD Catherijne A. Knibbe PharmD Paul E. Van Schil PhD Franz M. Schramel PhD St. Antonius Hospital, Nieuwegein, Utrecht, Netherlands PURPOSE: Prognosis of patients with pulmonary metastases remains poor with a 5-year survival of approximately 20-40% after complete surigical resection. Isolated lung perfusion (ILuP) is a promising surgical technique to deliver high-dose chemotherapy with minimal systemic toxicity, however exact pharmacokinetics of melphalan (MN) during ILuP remain unclear. An extension trial of a previous reported phase-I clinical trial of IluP with MN combined with pulmonary metastasectomy for resectable lung metastases was conducted to perform pharmacokinetic analysis.
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Pathology of Malignant Pericardial Effusion NSCLC&SCLC Breast Cancer Esophageal Neoplasm Non-Hodgkin-Lymphoma Leukemia Other Tumors and Metastatic Disease*
n 32 8 5 5 3 13
*(Thymoma 1, malig melanoma 1, chodrosarcoma 1, angiosarcoma 1, osteosarcoma 1, spindle cell neoplasm 1, rhabdomyosarcoma 1, nerve sheath tumor 1, mesothelioma 1, colon ca 1, ovarien ca 1, testicular ca 1, UKO)
DISCLOSURE: Siyamek Neragi-Miandoab, None. COMPUTER ASSISTED STAPLE RESECTION: UTILIZATION OF A NEW TECHNIQUE FOR MAJOR PULMONARY RESECTION DURING MINIMAL ACCESS THORACIC SURGERY Wickii T. Vigneswaran MBBS* Loyola University Medical Center, Maywood, IL PURPOSE: Computer assisted stapling of tissues (CAST) is a new technology in evolution. It provides the surgeon with more ability to carry out procedures when minimal access is used for major surgical procedures. Preservation of the chest wall mechanics is a major factor in patient recovery following pulmonary resection (PR). The posterolateral muscle dividing thoracotomy, the standard approach for major PR is associated with decreased pulmonary function and late muscle atrophy. The alter-
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SACOIDOSIS IN CHINA: A REVIEW OF HOSPITAL BASED COHORT Haiqing Chu MD* Tao Gui Shengxiang Ren BA Jingpo Zhang Huiping Li MD Guojun He MD Shanghai Pulmonary Hospital, Shanghai, Peoples Rep of China PURPOSE: To study how to avoid delaying the diagnosis and misdiagnosis through the substantive cases analyzed retrospectively. METHODS: Selected the sarcoidosis cases involved from 1980 to now from the archive of our hospital, analyzed their clinical manifestations, radiographic presentations, lab examinations such as PPD test, SACE, pulmonary function test, urine calcium and sera-calcium, 67Ga lung scan, and the way to confirm diagnosis. RESULTS: 1,There were 125 female patients (63.1%) and 73 male patients(36.9%) with the average age of 35.1 years old. The average duration of the disease was 6.1 months and stage evaluation showed that there were 3, 86, 91 and 18 cases from stage 0 to 3 respectively. 2,35.4% of the cases were found by the physical examination, while other 64.6% by complaint of various symptoms such as cough, breathless, fever, chest pain. The main extrapulmonary manifestation was superficial lymph node enlargement, eyesight faintness, and skin lesions. 3,The usual presentation of the chest X-ray and CT was hilar and/or mediastinal lymph node enlargement accompanied with bilateral diffusion lesion or not. It was prone to make a wrong diagnosis and the rate of misdiagnosis is as high as 39.9%. 4,Among the various biopsy means, mediastinoscopy lymph node biopsy is the most valuable, and the superficial lymph nodes, skin nodus, bronchial mucous and transbronchial lung biopsy are worth recommending. CONCLUSION: We should pay higher attention to sarcoidosis when the followings happen: middle-aged patients or young femalepatients; long duration of disease; mild respiratory tract symptoms accompanied with superficial lymph node enlargement or skin;eye involved; bilateral lung diffusion lesion in radiographic presentation accompanied with or without hilar, mediastinal lymphadenopathy. To avoid failing to diagnose or mistaking diagnosis ,we should go all out to confirm the diagnosis through the tissue pathological examination . CLINICAL IMPLICATIONS: The multifarious forms and presentations of Sarcoidosis and the low morbidity can make the diagnosis challenging, and it is prone to misdiagnosis in China.Through analyzing the cases respectively,we can learn more about this disease and enhance the diagnosis accurate rate. DISCLOSURE: Haiqing Chu, None.
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DISCLOSURE: M Drent, Grant monies (from industry related sources) Research grants; Consultant fee, speaker bureau, advisory committee, etc.; Employee.
TREATMENT OF IDIOPATHIC PULMONARY FIBROSIS SOLELY WITH ANTI-ACID GASTRO-ESOPHAGEAL REFLUX THERAPY: A CASE SERIES OF FOUR PATIENTS WITH LONGTERM FOLLOW-UP Ganesh Raghu MD Steve T. Yang MBBS* Carolyn Spada RN Jennifer Hayes RN Carlos Pelligrini MD Singapore General Hospital, Singapore, Singapore PURPOSE: Idiopathic pulmonary fibrosis (IPF) is a relentless, progressive and fatal disease with no known effective treatment. Increased acid gastro-esophageal reflux (GER) has been associated with IPF. We speculate that acid gastroesophageal reflux (GER) is an important factor for the development and/or progression of IPF. METHODS: Patients with new onset IPF and presenting with symptoms and documented gastro-esophageal reflux disease (GERD) or abnormal acid GER by 24-hour esophageal pH probe testing, who refused conventional therapy (prednisone and azathioprine) or other concurrent medical treatments implicated for IPF and chose to be treated solely with anti-acid GER therapy. RESULTS: Adequate suppression of acid GER was ascertained by 24-hour esophageal pH monitoring. Patients were followed regularly with pulmonary function tests (PFT) over 2-6 years. The PFTs (Forced vital capacity [FVC] and diffusion capacity for carbon monoxide [DLCO]) in all 4 patients stabilised or improved while being maintained on adequate daily treatment for acid GER, and were alive at last follow-up. None of the patients manifested acute exacerbation of IPF nor needed additional treatment for respiratory problems or antibiotics during this period. After maintaining 4 years of improved status in PFTs and exercise testing while adhering to treatment for acid GER, one patients deterioration correlated with poor compliance to daily treatment during the 5th year, although the PFTs at last follow-up 6 years since diagnosis showed stabilisation compared to baseline. Another patient stabilised upon adhering to anti-acid GER treatment after an initial period of deterioration that was associated with non-adherence. CONCLUSION: This case series suggests that acid GER might be an important risk factor for IPF progression and that adequate treatment for abnormal acid GER may in part improve the outcome of patients with IPF. We also hypothesize that pulmonary fibrosis occurs in individuals who are genetically susceptible to develop fibrosis from recurrent chronic acid GER. CLINICAL IMPLICATIONS: Future clinical studies are indicated to determine the efficacy of treatment for acid GER in IPF either in combination with other agents or as a sole agent.
CHEST 2005Poster Presentations
80%
20%
DISCLOSURE: Navasuma Havaligi, None. RESPONDER ANALYSES IN PATIENTS RECEIVING INFLIXIMAB FOR CHRONIC SARCOIDOSIS WITH PULMONARY INVOLVEMENT M. Drent MD* M. A. Judson MD U. Costabel MD R. M. duBois MD M. Kavuru MD K. H. Lo MD C. Andresen MD R. Schlenker-Herceg MD E. S. Barnathan MD R. P. Baughman MD University Hospital of Maastricht, Maastricht, Netherlands PURPOSE: Response to drug therapy may not be uniform across a heterogeneous population. Responder analyses, which dichotomize the response at a specific level of interest, can be helpful in gauging the utility of an intervention. The objective of this study was to evaluate the response to infliximab therapy in a randomized trial of 138 patients with chronic pulmonary sarcoidosis using clinically meaningful dichotomous endpoints for pulmonary function, symptoms, and physical function. METHODS: Primary and major secondary endpoint data at 24 weeks from a placebo-controlled study of infliximab were explored. The analyses are presented as the number (%) of responders using varying definitions for improvements in forced vital capacity (FVC), St. Georges Respiratory Questionnaire (SGRQ) score, Borgs CR10 dyspnea score post 6 minute walk (6MW), and 6 MW distance (6MWD). RESULTS: At week 24, there was a trend for more subjects having improved pulmonary function as measured by FVC with infliximab
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AEROSOLIZED INTERFERON GAMMA: A NOVEL APPROACH TO THERAPY IN IDIOPATHIC PULMONARY FIBROSIS? Hooman Mobassery MD* Rany Condos MD Gerald C. Smaldone MD SUNY at Stony Brook University Hospital, Stony Brook, NY PURPOSE: In controlled studies, subcutaneous injection of interferon gamma (IFN- ) has been shown to be ineffective in the treatment of idiopathic pulmonary fibrosis (IPF). One explanation for the lack of efficacy may be inadequate drug levels in the lung interstitium using subcutaneous dosing strategies. We have developed an aerosol of IFNdesigned to target the airways directly. We present the dose to the lung, local cytokine response, and clinical course in a 38 year old woman with biopsy proven usual interstitial pneumonia, treated with aerosolized IFN- . METHODS: The patient received 400 g of aerosol IFN- (two 200 g doses) three times per week. Pulmonary function test (PFT), exercise testing, and the University of California, San Diego shortness of breath questionnaire (SOBQ) were performed and completed prior to starting IFN- therapy and at the end of three months. Subsequent PFTs were performed at the discretion of the patients private pulmonologist. Bronchoalveolar lavage was assayed for transforming growth factor-beta (TGF- ) prior to the start and at the end of three months. The pattern of deposition and dose to the lung parenchyma were measured by gamma camera. RESULTS: Clinical responses included decreased dyspnea with improvement in her SOBQ measurement, stabilization of pulmonary function tests (improvement in DLCO/VA from 51% to 68% and stabilization of FEV1 and TLC) and improvement in objective parameters during exercise testing (increased maximal oxygen consumption). The dose to the lung parenchyma, as measured by gamma camera, was 54.4 g per treatment with a peripheral deposition pattern. With this regimen, bronchoalveolar lavage TGF- , a key molecular mediator of matrix deposition, levels decreased. CONCLUSION: This is the first report of aerosol treatment with IFN- and measurement of lung deposition in a patient with IPF. This study illustrates the potential use of aerosolized IFN- for the treatment of IPF by means of targeted therapy directly at the site of disease. CLINICAL IMPLICATIONS: This is a novel approach in the treatment of IPF. DISCLOSURE: Hooman Mobassery, Product/procedure/technique that is considered research and is NOT yet approved for any purpose. Interferone gamma is FDA approved but the delivery of this drug by aerosol is considered experimental.
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A NEW, RELIABLE MODEL OF EXPERIMENTAL PLEURODESIS IN MICE Evaldo Marchi MD* Francisco S. Vargas MD Milena M. Acencio BS Gabriela G. Carnevale BS Leila Antonangelo MD Eduardo H. Genofre MD Lisete R. Teixeira MD Pulmonary Division, InCor and University of Sao Paulo Medical School, Sao Paulo, Brazil PURPOSE: The experimental model of pleurodesis in rabbits has been useful in understanding the pathophysiology of the pleural inflammatory injury induced by several sclerosing agents. However, restrictions for the use of rabbits in laboratory investigation are making this model less accessible. The aim of this study is to present a new experimental model of pleurodesis in mice using talc or silver nitrate. METHODS: Two groups of ten C57BL/6 mice received 0.5mL intrapleurally of talc 4mg/gr or 0.05% silver nitrate. After 28 days the animals were sacrificed and the pleural cavity was opened and evaluated for evidence of macroscopic pleural adhesions and hemothorax (scores 0 to 4), atelectasis (scores 0-2) and microscopic pleural and alveolar inflammation and fibrosis (scores 0 to 4). Statistics: student t-test. RESULTS: Although both agents produced an efficient pleurodesis, silver nitrate was more effective than talc, with significant higher scores for pleural adhesions, microscopic pleural inflammation and fibrosis. Hemothorax, atelectasis and microscopic alveolar inflammation and fibrosis were negligible in both groups. CONCLUSION: Either talc 4mg/gr or 0.05% silver nitrate produced an efficient pleurodesis in our experimental model in mice. CLINICAL IMPLICATIONS: We describe a new model of pleurodesis that may overcome the restrictions to the use of large and medium-sized animals in laboratory investigation.
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A MODIFIED SIMPLE TECHNIQUE FOR CHRONIC INTRAPLEURAL CATHETER PLACEMENT IN THE MANAGEMENT OF MALIGNANT PLEURAL EFFUSIONS Maria Cirino MD* Jennifer Greenheck Kevin L. Kovitz MD Tulane University Health Sciences Center, New Orleans, LA PURPOSE: Bronchogenic carcinoma contributes to approximately one third of malignant pleural effusions, followed by breast cancer and lymphoma. Chronic tunneled intrapleural catheters are effective in the management of recurrent malignant effusions, significantly reducing symptoms with minimal patient discomfort and decreased length of hospital stay. The Pleurx catheter is usually placed into the pleural space using the Seldinger technique by inserting a dilator with a peel-away sheath over a wire. This step is the most difficult. The catheter is fed through the sheath and the sheath is peeled away. We report a simpler option. METHODS: We describe our experience using a modified technique for placement of the 16 catheters in 13 patients (eight as a primary procedure, eight as part of a thoracoscopy, 3 repeats). All but 2 had trapped lung. All patients had symptomatic malignant pleural effusions and the catheter was placed for palliation. Technique: Entry site is identified; sterile preparation and local lidocaine are used. 2 cm skin incisions are made 5cm apart. The catheter is inserted directly into the pleural space using forceps after tunneling between incisions without the need for a guide wire or dilator sheath. Suction of pleural contents confirms position. Anchoring and postoperative care are not changed. RESULTS: All patients had immediate relief of symptoms and catheters were placed where desired. There were no early or late complications. Catheters were removed when drainage ceased (1 removed by an ER practitioner unfamiliar with its function). Repeat catheters were placed for later occurring symptomatic effusions or in alternate large loculated spaces. CONCLUSION: This modified technique is simple, safe and we believe more efficient when performed by physicians trained for chest tubes and minimally invasive procedures. It is easy to learn, eliminates the introducer step, allows targeting of smaller, narrower, or oddly shaped spaces and does not increase the rate of complications. CLINICAL IMPLICATIONS: This modified technique may improve efficiency and widen the range of practitioners who safely and comfortably perform this important palliative procedure. DISCLOSURE: Maria Cirino, None.
POSTER PRESENTATIONS
SINGLE CENTER EXPERIENCE WITH 250 TUNNELLED PLEURAL CATHETER INSERTIONS FOR MALIGNANT PLEURAL EFFUSION Alain Tremblay MD Gaetane C. Michaud MD* University of Calgary, Calgary, AB, Canada PURPOSE: To describe the use of tunneled pleural catheter in the management of malignant pleural effusion in a large group of patients in a clinical setting. METHODS: Retrospective analysis of 250 sequential tunneled pleural catheter insertions in patients with malignant pleural effusion in a single tertiary care center. RESULTS: 250 tunneled pleural catheter procedures for malignant pleural effusion were performed in 223 patients (19 contralateral procedures and 8 repeat ipsilateral procedures) during a 3 year period. Symptom control was complete following 97 (38.8%) procedures, partial in 125 (50%), absent in 8 (3.2%) in addition to 11 (4.4%) failed insertions and 9 (3.6%) without assessment of symptoms at the 2 week follow-up visit. Spontaneous pleurodesis occurred following 103 (42.9%) of the 240 successful tunneled pleural catheter procedures and was more frequent when 20% or less of the hemithorax had fluid at 2 week follow-up (57.2% vs. 25.3%, p 0.001). Catheters stayed in place for a median of 56 days. Following successful catheter placement, no further ipsilateral pleural procedures were required in 90.1% of cases. Overall median survival
CONCLUSION: ITPC can relieve symptomatic HH, improve quality of life and reduce the number of repeated thoracentesis without an increased risk for encepahlopathy. No serious immediate or long-term complications were experienced. A randomized controlled trial would identify benefits of ITPC in HH.
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A SENSITIVITY ANALYSIS OF TUBE THORACOSTOMY FAILURE IN PLEURAL EFFUSION APPLICATIONS Kelvin K. Shiu DO* Mark J. Rosen MD Paul Mayo MD Beth Israel Medical Center, New York, NY PURPOSE: Tube thoracostomy is commonly used for the treatment of complicated pleural effusions. A fibrinolytic agent is often administered through the tube as an adjunctive treatment when drainage is deemed inadequate, but this decision is neither standardized nor consistent. We examined the variations in the definition of inadequate drainage and the potential failure modalities associated with the procedure. METHODS: This study applied probabilistic risk assessment (PRA) to perform a quantitative evaluation of different failure modalities. An event tree analysis was performed to model the temporal event sequence of identification of effusion location, assessment of loculation, and thoracostomy tube insertion and maintenance. Fault tree analysis was performed for each of these events taking into account multiple tube insertions, tube clogging and dislocations. Numerical values used for the quantification of tube thoracostomy failure were obtained from reviews of recently published trials and studies. A sensitivity analysis was also performed to prioritize the different failure contributors. RESULTS: The analyses showed that the presence of multiple loculations contributes significantly to the overall rate of tube thoracostomy failure in about 50% of cases. There are other failure modalities that lead to inadequate tube drainage, many of which are operator dependent, and others procedural and protocol dependent. Sensitivity analysis reveals that improvements in tube placement and in tube maintenance procedures could result in up to fifty percent reduction in tube thoracostomy failure. They may include pleural ultrasonography, and operator training. CONCLUSION: Many factors contribute to failure of adequate tube thoracostomy drainage, the most important being loculations of the effusion. Failure rates may be reduced with improvements in procedures and protocols related to tube placement and maintenance. CLINICAL IMPLICATIONS: This study reveals the potential difficulties of comparing different tube thoracostomy studies when the study populations comprise different loculated effusion percentages. Differences in tube insertion protocols and tube maintenance could also significantly affect the success of tube drainage. Our study further suggests that improvement in operator training in tube insertion and placement may reduce tube thoracostomy failure. DISCLOSURE: Kelvin Shiu, None.
RESULTS OF A SIMPLE METHOD IN PREDICTING THE THERAPEUTIC DECISION FOR THE MANAGEMENT OF PARAPNEUMONIC PLEURAL EFFUSIONS Evaldo Marchi MD* Andre L. Casarim MS Arianne C. Pereira MS Thoracic Surgery - Medical College of Jundiai, Jundiai, Sao Paulo, Brazil PURPOSE: Parapneumonic pleural effusions (PPE) are a common complication of pneumonias. Although several studies have suggested parameters to guide the management of PPE, this subject remain controversial. In this study we describe the outcome of patients with PPE treated based on a simple model of evaluation that guides the optimal therapeutic decision. METHODS: Seventy-five patients with PPE and negative bacteriological findings were evaluated according to their image (chest radiograms, ultrasound or CT scans) and pleural fluid (WBC counts, neutrophil percent and LDH levels) parameters. Based on the results of each parameter, models were created to test the sensitivity, specificity and predictive positive and negative values of the clinical or surgical (thoracostomy) therapeutic decision in predicting the outcome of the treated groups. RESULTS: PPE patients with bacteriological negative findings and with small effusions, WBC 1,000cels/mm3, %N 75% and LDH 1,000IU/L were clinically treated with a successful outcome (SE 92%; SP 90%). PPE patients with moderate or large effusions, or WBC 1,000cels/mm3, %N 75% or LDH 1,000IU/L were treated with early chest tube drainage and successful outcome (SE 95% and SP 92%).
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A COMPARISON OF ENDOBRONCHIAL ULTRASOUND GUIDED BIOPSY AND POSITRON EMISSION TOMOGRAPHY WITH INTEGRATEDCOMPUTED TOMOGRAPHY IN LUNG CANCER STAGING Mark Krasnik MD* Felix Herth MD Peter Vilmann MD Birgit G. Skov MD Sren S. Larsen MD Gentofte University Hospital, Copenhagen, Denmark PURPOSE: Exact staging of patients with non-small-cell lung cancer (NSCLC) is important to improve selection of resectable and curable patients for surgery. Positron emission tomography with integrated computed tomography (PET/CT) and endoscopic ultrasound guided fine needle aspiration biopsy (EBUS-TBNA) are new and promising methods, but indications in lung cancer staging are controversial. No studies have compared the 2 methods. The aim of this study was to assess and compare the diagnostic values of PET/CT and EBUS-TBNA for diagnosing advanced lung cancer in patients, who had both procedures performed. METHODS: 25 patients considered to be potential candidates for resection of verified or suspected NSCLC underwent PET/CT and EBUS-TBNA. The PET/CT and EBUS-TBNA diagnoses were confirmed either by open thoracotomy/scopy, mediastinoscopy or clinical follow-up. Mediastinal involment of lung cancer was defined as tumour-stage IIIA(N2), corresponding to N2-N3. Diagnostic values of PET/CT and EBUS-TBNA, with regard to the diagnosis of mediastinal involment of lung cancer, were assessed and compared. RESULTS: 10 patients had a pos PETCT for mediastinal involment while mediastinal involment were found in 5 patients with EBUS TBNA.The sensitivity of PET/CT and EBUS-TBNA were respectively 67%% versus 100% for N2-N3 disease . PET/CT had a specificity of 68%, positive predictive value (PPV) of 40% and a negative predictive value (NPV) of 87%. EBUS-TBNA had a specificity of 100%, PPV of 100%, NPV of 100% for mediastinal involment. CONCLUSION: EBUS-TBNA had a sensitivity , NPV and PPV for diagnosing advanced lung cancer, superior to PET/CT. DISCLOSURE: Mark Krasnik, None. WHICH AREA IN A METASTATIC LYMPH NODE OF LUNG CANCER SHOULD WE PUNCTURE BY ENDOBRONCHIAL ULTRASONOGRAPHY GUIDED TRANSBRONCHIAL NEEDLE ASPIRATION? Noriaki Kurimoto MD* Hiroaki Osada MD Teruomi Miyazawa MD Yuka Miyazu MD Atsuko Ishida MD St. Marianna University, Kawasaki, Japan PURPOSE: To assess the location of cancer cells in a metastatic lymph node from lung cancer for endobronchial ultrasonography guided transbronchial needle aspiration (EBUS-TBNA). METHODS: We checked 124 metastatic lymph nodes (LNs), which were resected at the operation, histopathologically. We classified 124 metastatic LNs into 3 major stages and 3 sub-stages. Stage I: early stage: stage Ia (marginal stage: metastasis located in the marginal area, the width
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FIBER BUNDLE OPTICAL COHERENCE TOMOGRAPHY SYSTEM FOR ENDOSCOPIC AIRWAY IMAGING Sari B. Mahon PhD* David S. Mukai BS Tuqiang Xie PhD Zhongping Chen PhD Matthew Brenner MD University of California, Irvine, Irvine, CA PURPOSE: Optical coherence tomography (OCT) is a novel, noninvasive technology which can provide high and ultrahigh resolution structural and functional endoscopic/bronchoscopic imaging information in biological tissues, in-vivo, in real time, at resolutions as fine as 1um. Movable components such as MEMS micro motors, mirrors and lenses, etc., needed to provide scanning for image generation in 2 or 3 dimensions have limited the utility of OCT endoscopy. We describe a novel approach to development of 3-D OCT probes using fiber-bundles for airway and pleural endoscopy that overcomes the requirement for internal moving parts within the probe. METHODS: Using high resolution coherent optical conduits, a fiber bundle comprised of 50,000 individual fiber cores was fabricated. Various lengths were tested, and performance was optimized with GRIN lenses at the proximal and distal ends, angled end polishing to prevent back reflections, and index matching between optical components. The coherence of the bundle preserves spatial identity from proximal to distal ends. This approach enables all moving parts to be located externally, proximal to the probe. Planar images are then scanned and constructed with our OCT system. RESULTS: This novel system was used to image samples of excised rabbit trachea (Figure 1). The OCT image can delineate the micro morphology of the normal rabbit trachea including mucosa, sub mucosa, glands and cartilage rings. When compared to the OCT image from our bench top OCT system, the current fiber bundle image fidelity, including signal to noise ratio, image depth, and contrast, is good, but slightly degraded. CONCLUSION: We describe a novel OCT endoscopic imaging probe approach based on a coherent fiber-optic bundle and demonstrate its feasibility in imaging tracheal tissue at transverse and axial resolution of approximately 12 and 10 um, respectively. CLINICAL IMPLICATIONS: Optimization of this fiber bundle method will enable the production of compact and solid 3-D capable imaging probes without any moving parts, that may be used for high and ultra-high resolution endoscopic diagnostics including airway and pleural applications.
DISCLOSURE: Sari Mahon, Grant monies (from sources other than industry) Department of Defense; Grant monies (from industry related
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DISCLOSURE: Faisal Khan, None. SILICONE AIRWAY STENTS IN THE TREATMENT OF PATIENTS WITH DIFFUSE TRACHEOBRONCHOMALACIA Adnan Majid MD* Rabih Bechara MD Yoshihiro Nakamura MD David Feller-Kopman MD Simon Ashiku MD Malcom DeCamp MD Armin Ernst MD Tufts-New England Medical Center, Boston, MA PURPOSE: To evaluate the effectiveness of airway stents in the treatment of diffuse tracheobronchomalcia (TBM) and their complications. METHODS: Single center retrospective analysis of medical records from patients with diffuse TBM referred to a major academic center from January 2002 to June 2004 who underwent central airway stenting (tracheal, main bronchus or both). Patient charts were reviewed for improvement of symptoms and complications. RESULTS: Number of patients stented: 29; number of patients with improvement of symptoms: 23(80%), without improvement of symptoms 6(20%); how did symptoms improve: off mechanical ventilation 4 (17%), less cough 12(52%), less shortness of breath 17(74%), less medications 4(17%); number of complications:24 (83%),time of complications: 3 months 20 (83%), 3months 4(17%), median 26 days (3-865 days); procedure related: 3(13%), stent related:21(87%) (infection 6(29%), migration 6(29%), obstruction 12(57%), breakage 1(5%),hemoptysis 1(5%),respiratory failure 2(10%), cough 2(10%)). CONCLUSION: Silicone stents improve symptoms in carefully selected patients with moderate to severe TBM. Unfortunately, treatment with these stents is associated with a significant number of short and long-term complications that limits their use. CLINICAL IMPLICATIONS: Airway stents currently have a role in identifying patients with diffuse TBM who will benefit from central airway stabilization. DISCLOSURE: Adnan Majid, None. USE OF SILICONE STENTS IN THE MANAGEMENT OF TRACHEOBRONCHIAL STENOSIS DUE TO TUBERCULOSIS Yonju Ryu MD* Eun Hae Kang MD Won-Jung Koh MD Gee Young Suh MD Man Pyo Chung MD O. Jung Kwon MD Hojoong Kim MD Division of Pulmonary and Critical Care Medicine, Samsung Medical Center, Seoul, South Korea PURPOSE: To assess the usefulness and safety of silicone stents placement and to compare those between widely used Dumon stents and newly designed Natural silicone stents in the management of tracheobronchial stenosis due to tuberculosis. METHODS: The medical records of 69 patients (31 Dumon and 38 Natural) requiring the placement of 75 silicone stents (35 Dumon and 40 Natural) for airway stenosis due to tracheobronchial tuberculosis were reviewed and analyzed. RESULTS: Ballooning was the leading method of dilation before stenting (90%). Immediate and lasting relief of dyspnea or improvement of FEV1 was no difference between the Dumon and the Natural group. In both treatment groups, an equal proportion of patients (58% of the Dumon group and 61% of the Natural group) had successful stent removal with median 18 months vs 13 months of stent in situ, orderly. During follow-up, the occurrence of stent-related complications such as migration (39% vs 63%), granuloma formation (42% vs 58%), mucostasis (19% vs 18%) and restenosis (48% vs 37%) were not significant different
CHEST 2005Poster Presentations
HEMODYNAMIC IMPACTS OF EXPIRATORY DYNAMIC COLLAPSE OF THE TRACHEA Faisal Khan MD* Elamin M. Elamin MD Mansura Ghani MD Southern Illinois University, Springfield, IL PURPOSE: Expiratory Dynamic Collapse of Trachea (DCT) was recently recognized as a possible mechanism for congestive heart failure (CHF). We studied the short and long term hemodynamic impact of tracheal stenting on DCT-CHF. METHODS: A 68 year-old male was evaluated for repeated episodes of CHF after prolonged coughing spells in spite of different treatments. Extensive cardiac and pulmonary diagnostic evaluation for CHF was unrevealing. At bronchoscopy, there was 90% expiratory collapse of the lower 6 cm of the posterior tracheal wall, without cartilaginous involvement. The hemodynamic impact of DTC was assisted by impedance cardiography with stroke volume index (SVI) measured at rest, during coughing, then two and four minutes after cessation of cough (Figure 1). Similar hemodynamic measurements (HM) were obtained six and twelve months after placement of an uncovered ultraflex tracheal stent (Microvasive, Natick, MA) to support the collapsible portion of the trachea. RESULTS: At six and twelve months post-stenting the patient had no recurrence of CHF with HM demonstrated a statistically significant stabilization of the SVI (p 0.01) (Figure 1). CONCLUSION: This was the first documented report of DCT-CHF with cough induced intrinsic-positive end expiratory pressure leading to decrease in SVI. The later was reversed by tracheal stenting with the benefits persisted at six and twelve months follow up. A prospective study is currently under way for further evaluation of that process. CLINICAL IMPLICATIONS: Expiratory Dynamic Collapse of Trachea should be considered in the work up of congestive heart failure.
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CT-GUIDED TRANSTHORACIC NEEDLE BIOPSY OF SARCOIDOSIS Alisa Johnson BA* Jeffrey S. Klein MD Santiago Miro MD University of Vermont College of Medicine, Burlington, VT PURPOSE: To determine the utility, sensitivity and complication rate of CT-guided transthoracic needle aspiration and core biopsy for sampling enlarged hilar and mediastinal lymph nodes in patients with presumptive sarcoidosis. METHODS: A retrospective review of all transthoracic needle biopsies performed at one institution from 1995-present for diagnosis of enlarged hilar or mediastinal lymph nodes thought to reflect sarcoidosis and either 1) symptoms requiring definitive diagnosis for treatment or 2) a history of malignancy where metastatic disease was a differential diagnostic consideration. RESULTS: 28 patients, age range 34-74, males 13, females 15, underwent CT-guided aspiration (n 28) and core (n 19) biopsy using an extrapleural approach when possible. 9 patients had a history of prior or concurrent malignancy. Using a combination or cytologic and histologic material, a diagnosis of sarcoidosis and exclusion of malignancy was possible in all patients (sensitivity 100%). 8/28 patients (28%) developed a postbiopsy pneumothorax, with 2 (7%) requiring small bore catheter drainage and one patient with self-limited hemoptysis. CONCLUSION: CT-guided transthoracic needle biopsy, using a combination of aspiration and core biopsy techniques, has a high yield and acceptable complication rate for the diagnosis of sarcoidosis presenting with enlarged mediastinal and hilar lymph nodes. CLINICAL IMPLICATIONS: This minimally-invasive technique can provide definitive pathologic diagnosis of sarcoidosis in patients with enlarged mediastinal and hilar lymph nodes, confidently excluding malignancy and obviating the need for further invasive diagnostic procedures. DISCLOSURE: Alisa Johnson, None.
THE EFFECTS OF THE AGE DURING FLEXIBLE BRONCHOSCOPY: PREDICTORS OF COMPLICATIONS Mario Polverino MD* ASL Salerno 1, Cava De Tirreni, Italy PURPOSE: Elderly patients generally show a good tolerance of flexible bronchoscopy (FBS). Patients age has not emerged as a specific risk factor for bronchoscopy complications; FBS is well tolerated in the elderly, so that major modifications of the procedure because of patients age alone are generally unnecessary. (Clin Chest Med 2001;22.2:301). In contrast, Davies et al. reported that 21% of patients over 60 yrs developed potentially serious, albeit transient, cardiac ischaemic events/rhythm disturbances (ERJ 1997;10:695). The aim of our study was to evaluate predictors of complications in FBS related to the patients age. METHODS: We retrospectively analyzed clinical and functional characteristics, as well as bronchoscopic procedures referring to 88 patients, divided into two groups: group A): 43 patients 65-yrs old and group B: 45 patients 3 66-yrs old. Collapse or consolidation were the most common indications for FBS in elderly patients (56%), whereas indications in group A were more heterogeneous. RESULTS: 2 out of 43 patients of group A (4.65%) and 9 out of 45 patients of group B (20%) showed minor complications during or after FBS. The greater prevalence of complications in the elderly was related to the greater number of diagnostic procedures in these patients (48 vs. 30) and to the comorbidities which were present in 9 out of 45 patients of group B: it is worth mentioning that no elderly patient suffered from complications in absence of comorbidity. CONCLUSION: Elderly age is not a risk factor for complications in flexible bronchoscopy. If any, they are due to the comorbidities and to the greater number of diagnostic procedures, related to the different pattern of clinical indications.
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PROMOTER -202 A/C POLYMORPHISM OF INSULIN-LIKE GROWTH FACTOR BINDING PROTEIN-3 GENE AND NONSMALL CELL LUNG CANCER RISK Jin Wook Moon MD* Yoon Soo Chang MD Young Sam Kim MD Chang Hoon Han MD Shin Myung Kang MD Moo Suk Park MD Sung Kyu Kim MD Joon Chang MD Se Kyu Kim MD Chul Min Ahn MD Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea PURPOSE: Insulin-like growth factor binding protein-3 (IGFBP-3) inhibits the mitogenic and anti-apoptotic activity of insulin-like growth factor (IGF) by blocking the binding of IGF to its receptor. However, under certain circumstances, IGFBP-3 can enhance the activity of IGF by protecting IGF from degradation. More than half of the inter-individual variations in IGFBP-3 levels are known to be genetically determined by the polymorphism at -202 locus of IGFBP-3 gene. Therefore, we attempted to ascertain whether the A-202C polymorphic variation of IGFBP-3 gene constitutes a risk factor for non-small cell lung cancer (NSCLC). METHODS: Our study included 209 NSCLC patients and 209 age-, gender-, and smoking status-matched control subjects. After extracting the genomic DNA, we amplified the 168-base-pair (bp) fragment encompassing the A-202C polymorphic site in IGFBP-3 gene. Each PCR product was digested with FspI enzyme and electrophoresed. The allele was designated either C or A depending on whether the FspI restriction site was present or not. RESULTS: The frequencies of each polymorphic variation in the control population were as followes: AA 95 (45.5%), AC 91 (43.5%), and CC 23 (11.0%). In the NSCLC subjects, the genotypic frequencies were as follows: AA 131 (62.7%), AC 73 (34.9%), and CC 5 (2.4%). We detected statistically significant differences in the genotypic distribution between the NSCLC and the control subjects (p 0.05, Pearsons 2 test). The NSCLC risk correlated significantly with AA genotype. Using CC genotype as a reference, the odds ratio (OR) for the subjects with AC genotype was 2.45 (95% CI: 1.17 - 5.40) and the OR for the ones with AA genotype was 4.58 (95% CI: 2.17 - 10.30). CONCLUSION: Our results indicate that there are differences in the genotypic distribution at the A-202C polymorphic site of IGFBP-3 gene between NSCLC and general populations. CLINICAL IMPLICATIONS: The dysregulation of IGF axis should now be considered as another important risk factor for NSCLC, a potential target for novel antineoplastic therapies, and preventative strategies in high-risk groups. DISCLOSURE: Jin Wook Moon, None.
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CD1 GENOTYPES IN LUNG CANCER PATIENTS Mehrnoosh Doroudchi PhD* Hossein Golmoghaddam MS Seid Mohammad A. Ghayoomi MD Abbas A. Ghaderi PhD Shiraz University of Medical Sciences, Shiraz, Iran PURPOSE: It has been suggested that CD1a and CD1d molecules induce tumor-specific immune responses by presentation of tumor cell glycolipids to specific T cells and NKT cells. A decrease in the CD1a expressing dendritic cells in lung cancer as a mechanism of tumor escape from immune system has been reported. Therefore, this study was conducted to compare the genotypic frequencies of CD1a and CD1d genes in lung cancer patients and healthy controls. METHODS: Polymorphisms in exon 2 of CD1A (C622T) and CD1D (A354T) genes, were studied in 64 Iranian lung cancer patients compared to 95 age/sex/ethnicity matched and 311 non-matched healthy blood donors by a Polymerase Chain Reaction Sequence Specific Primer method. RESULTS: The frequencies of CC, CT and TT genotypes of CD1A gene among patients were 75%, 18.8% and 6.2% compared to 78.9%, 28.1% and 0% in the matched control group and 79.7%, 18.7%, and 1.6% in the non-matched control group, respectively. There was a significant difference in the genotype frequencies of CD1A between lung cancer patients and matched controls (P 0.047). However, the difference became less significant by comparing CD1A genotypes between patients and 311 non-matched blood donors (P 0.085). No deviations from Hardy-Weinberg equilibrium in control groups were observed. The only observed genotype of CD1D among patients and controls was AA hompzygote genotype. CONCLUSION: Our results suggest that there is a correlation between CD1A genotypes and lung cancer. Although the exact effect of this polymorphism on the protein expression or function is not understood, the resulted substitution of Threonine with Isoleucine in the antigen binding groove of the CD1a protein might affect antigen presentation potential of the molecule. CLINICAL IMPLICATIONS: This study will help us in better understanding of genetic susceptibility to lung cancer and might provide opportunities for developing screening methods and/or lipid vaccines for cancer therapy in future. DISCLOSURE: Mehrnoosh Doroudchi, None.
SOLUBLE HER-2/NEU OVEREXPRESSION IN PATIENTS WITH LUNG CANCER Mohammad A. Ghayumi MD* Mehrnoosh Doroodchi MD Kambiz Aghasadeghi MD Shiraz University of Medical Sciences, Shiraz, Iran PURPOSE: The Her-2/neu oncogene encode a growth factor receptor, P185. Overexpression of this protein is thought to confer a growth advantage to tumors and has been associated with an adverse outcome in Non Small Cell Lung Cancer. METHODS: This study is a case-control, cross sectional study to evaluate the clinical usefulness of soluble Her-2/neu as a marker in the diagnosis of lung cancer. Level of soluble Her-2/neu in 43 lung cancer patients and 42 age/sex matched controls, measured by an enzyme immunoassay method. RESULTS: More than 93% of patients aged more than 55 years and 83% of lung cancer patients were smoker. Mean serum level of soluble Her-2/neu in cancer patients was 6.07 10.37 ngr/ml which was significantly higher than that of control (P 0.05). Cigarette smoking has no effect on the level of soluble Her-2/neu. A cut off level of 6.1 ngr/ml revealed a high specificity (95%) for diagnosis of lung cancer, with very low sensitivity (14%). Conclusion: The results of this study show the higher level of soluble Her-2/neu in the sera of lung cancer patients with high specificity and low sensitivity for a cut off level of 6.1 ngr/ml. CONCLUSION: The results of this study show the higher level of soluble Her-2/neu in the sera of lung cancer patients with high specificity and low sensitivity for a cut off level of 6.1 ngr/ml. DISCLOSURE: Mohammad Ghayumi, None.
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P53 CODON 72 POLYMORPHISM IN IRANIAN LUNG CANCER PATIENTS Mehrnoosh Doroudchi PhD* Seid Mohammad A. Ghayoomi MD Abdulmohammad Pezeshki MS Mohammad J. Fattahi MS Abbas A. Ghaderi PhD Shiraz University of Medical Sciences, Shiraz, Iran PURPOSE: To investigate G/C (Arg/Pro) polymorphism in exon 4 of the p53 tumor suppressor gene in Iranian lung cancer patients. METHODS: In this study, the frequency of the respective p53 alleles was investigated in 64 Iranian lung cancer patients and 205 ethnicitymatched healthy blood donors by an Allele-Specific Polymerase Chain Reaction method. RESULTS: The frequency of Arg allele was 59% in control group compared to 49% in the lung cancer patients. The frequencies of Pro allele in control and patient groups were 41% and 51%, respectively. Accordingly, there was no significant difference in the allele and genotype frequencies between the patients and controls, as a whole. However, a highly significant increase in the Pro allele was observed in patients with small cell lung cancer compared to controls (71% vs. 41%, P 0.009). In addition, a trend of increase in the Pro allele was observed in small cell lung cancer compared to non-small cell carcinoma of lung (71% vs. 46%, P 0.05). No significant difference was observed in the frequencies of p53 alleles between smoker and non-smoker patients (P 0.4). CONCLUSION: Our data indicate that, as a whole, there is no association between p53 codon 72 polymorphism and lung cancer, however, there is an accumulation of Pro allele in the small cell lung cancer in our patients. CLINICAL IMPLICATIONS: The presence of Pro allele of the p53 tumor suppressor gene in Iranian small cell lung cancer increases
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MANAGEMENT OF PATIENTS AT RISK OF LUNG CANCER USING CYTOMETRIC ASSAYS Bojana Turic MD* Roger A. Kemp PhD Perceptronix Medical Inc., Vancouver, BC, Canada PURPOSE: We believe that Automated Cytometry of Quantitatively (AQC) stained cells from sputum and buccal mucosa provide information that can be used to guide the management of patients at risk for lung cancer. We have studied whether it is possible to construct a management regime for patients at risk of developing lung cancer based on sequential application of simple assays. METHODS: Induced sputum specimens and buccal scrapings were collected from 120 patients with confirmed lung cancer and 810 high risk negative patients. The specimens were prepared to slide and stained using the Feulgen-thionin process, which highlights DNA distribution in cell nuclei. They were scanned using a fully automated image cytometer which produces a single score for each specimen, indicating the likelihood of presence of malignancy. The buccal and sputum cytometry scores were compared to see if the assay results provide essentially the same information or if they complement each other. The answer to this question suggests how the two tests can be used for patient management. RESULTS: The correlation of the tests outcomes was significant (correlation 0.37) and suggests the assays could be used in a sequential approach for managing patients. The buccal assay eliminated 262 negatives (32%) at the cost of 9 false negatives (7.5%). See the figure below. After the addition of the sputum assay results, 87 lung cancer cases were deemed suspicious (72.5%) at the cost of 125 (15.4%) false positives. CONCLUSION: A simple buccal test can eliminate one third of patients from more comprehensive testing. The further application of the sputum assay provides high sensitivity and specificity for detecting lung cancer. The AQC testing approach has undergone a validation trial involving 1183 patients from clinical sites in six countries. Patients were accrued from March 2003 until October 2004. Results of the trial will be unblinded in June 2005 and presented at the conference. CLINICAL IMPLICATIONS: Cytometry based assays may prove to be an important tool for management of high risk patients.
CORRELATION BETWEEN SURVIVIN EXPRESSION AND PROGNOSIS IN NON-SMALL CELL LUNG CANCER Sukran Atikcan MD* Ebru Unsal MD Funda Demirag MD Deniz Koksal MD Aydin Yilmaz MD Ataturk Chest Diseases and Chest Surgery Education Hospital, Ankara, Turkey PURPOSE: Survivin is a recently identified protein as an inhibitor of apoptosis, which supresses programmed cell death and regulates cell division. In this study, we investigated the prognostic significance of both nuclear and cytoplasmic survivin expression in non small cell lung cancer (NSCLC) and examined the association with clinicopathological parameters. METHODS: The study comprised 58 male patients diagnosed NSCLC with a mean age of 57.29 8.82 years; range 40-76 years. Patients underwent lobectomy (36%) or pneumonectomy (64%) with hilar and mediastinal lymph node sampling. Paraffin embedded tumor sections were retrieved for evaluation of nuclear and cytoplasmic staining of survivin. Clinicopathological data, stage and survival of patients were all determined. RESULTS: Cytoplasmic staining was found significantly increased in squamous cell carcinoma (p 0.003), whereas there was no association between nuclear staining and histopathological type (p 0.837). Also, both nuclear and cytoplasmic staining did not show any association with tumor stage (p 0.05). In univariate analysis there was significant correlation between nuclear survivin and short survival (p 0.0002). In multivariate survival analysis using Cox regression, only nuclear staining of survivin was determined as an independent prognostic factor (p 0.001). CONCLUSION: Localisation of survivin expression might have an important regulatory mechanism in carcinogenesis and tumor progression. Nuclear survivin expression in tumor tissues might predict the prognosis in NSCLC, whereas cytoplasmic survivin has no prognostic significance.
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DISCLOSURE: Sevin Baser, None. CORRELATION BETWEEN LUNG MASS SIZE IN NON-SMALL CELL LUNG CANCER (NSCLC) AND BRAIN METASTASES H. Aziz MD A. Blamoun MD M. Shubair MD M.M. Ismail MD* M.A. Khan MD St. Josephs Regional Medical Center, Paterson, NJ PURPOSE: The aim of our study was to determine whether the size of a primary NSCLC predicts the presence of brain metastases. METHODS: We retrospectively reviewed the size of lung mass by CT scan of the chest in 35 patients (16 males, 19 females, age range 41-95 yrs; mean age 67.4yrs) who were diagnosed with NSCLC during the past two years whose CT scans of the brain were negative for brain metastases. We then compared it with the size of the lung mass in CT scan of the chest in 35 patients (16 males, 19 females, age range 41-91 yrs; mean age 65.7 Yrs) who were also diagnosed with NSCLC but had CT scans of the brain that showed brain metastases. RESULTS: The size of lung mass in patients without brain metastases was smaller (mean 3.311 1.668cm; 95%CI 2.738-3.884) than in those with brain metastases (mean 4.866 2.612cm; 95%CI 3.969-5.763). At a cut-off of 3.9cm (determined by ROC curve analysis), the odds ratio of brain metastases was 13.96 (P 0.0001). CONCLUSION: There is direct correlation between the size of the lung mass and brain metastases in NSCLC. CLINICAL IMPLICATIONS: Lung mass size 3.9cm in NSCLC predicts the presence of brain metastases.
EFFECT OF SMOKING CESSATION AFTER DIAGNOSIS OF LUNG CANCER ON PERFORMANCE STATUS AND SURVIVAL Sevin Baser MD* Georgie A. Eapen MD Carlos A. Jimenez MD Amir Onn MD Vickie R. Shannon MD Leendert Keus Rodolfo C. Morice MD E. Lin The University of Texas MD Anderson Cancer Center, Houston, TX PURPOSE: To evaluate the impact of smoking history and smoking cessation after diagnosis on performance status and survival in patients with lung cancer. METHODS: Retrospective analysis of patients with NSCLC seen at our pulmonary function laboratuary between Jan01 and Nov01. Clinical characteristics, smoking history, comorbidities, survival, performance status, and pulmonary function tests were reviewed. We estimated the association between smoking status after diagnosis and survival and performance change from baseline to 6 months and 12 months. RESULTS: We studied 206 patients: 93 (45%) were smokers, 15 (7%) were nonsmokers, and 98 (48%) were former smokers ( 1year). There was no significant association between smoking history at diagnosis and change in performance status (ZUBROD) and survival. Of the 93 smokers, 46 quit and 47 continued smoking after diagnosis. Stage, age, gender, and comorbidities were similar between these two groups. There was no significant association between smoking status after diagnosis and patients survival. However, those who quit smoking maintained a better performance status at 6 and 12 months (p 0.006 and p 0.008) than those who continued smoking. CONCLUSION: Smoking history before and after diagnosis of lung cancer did not affect survival, but patients who quit smoking maintained a better performance status than those who continued smoking. CLINICAL IMPLICATIONS: Smoking cessation after diagnosis of lung cancer has a beneficial effect on performance status but not on survival.
Metastases 26 9
No Metastases 6 29
DISCLOSURE: M.M. Ismail, None. IMPACT OF PULMONARY DYSFUNCTION AS A CAUSE OF INOPERABILITY FOR PATIENTS WITH NON-SMALL CELL LUNG CANCER Sevin Baser MD* Vickie R. Shannon MD Georgie A. Eapen MD Carlos A. Jimenez MD Amir Onn MD Leendert Keus Rodolfo C. Morice MD E Lin University of Texas, MD Anderson Cancer Center, Houston, TX PURPOSE: To determine the role of pulmonary dysfunction as a reason for inoperability for patients with NSCLC who were considered for surgical treatment at the time of diagnosis. METHODS: We studied all patients with NSCLC referred for preoperative evaluation to our pulmonary function laboratory between January 2001 and November 2001. Clinical characteristics, staging, smoking history, comorbidities, and clinical notes were reviewed. Pulmonary function testing consisted of spirometry, lung volumes, DLCO, 133Xenon quantitative V/Q studies, and exercise testing when indicated. RESULTS: We evaluated 206 patients (M 120;F 86) with NSCLC. Mean age was 64.7 10.1 yrs. Average predicted FEV1 70.3% 19.6% (range 25%-123%). One hundred and thirty- two (64%) patients had at
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EFFECT OF PULMONARY DYSFUNCTION ON SURVIVAL AND PERFORMANCE IN PATIENTS WITH NON-SMALL CELL LUNG CANCER Sevin Baser MD* Amir Onn MD Carlos A. Jimenez MD Georgie A. Eapen MD Vickie R. Shannon MD Leendert Keus Rodolfo C. Morice MD E Lin University of Texas, MD Anderson Cancer Center, Houston, TX PURPOSE: To evaluate the effect of FEV1 (% of predicted) at the time of diagnosis on survival and performance status for patients with NSCLC. METHODS: Retrospective analysis of patients with NSCLC referred to our pulmonary function test laboratory between January 2001 and November 2001. Clinical characteristics, smoking history, comorbidities, survival, pulmonary function tests, and performance status (ZUBROD) at baseline, 6 months and 1 year were reviewed. RESULTS: We studied 206 patients (M 120;F 86) with NSCLC. Mean age was 64.7 10.1 yrs. Fourty-five percent were smokers, 48% were former smokers, and 7% were nonsmokers. Average predicted percent FEV1 70.3% 19.6% (range 25%-123%). Smokers and former smokers averaged 52.4 30 pack-yr. Sixty-three percent of patients had at least one type of comorbidity; DM 15 (7%), HTN 66 (32%), CAD 47(23%). Also 59 (29%) patients had other type of malignancies. The histologic types were; Adenocarcinoma 87(42%), squamous 72(35%), large cell 43(21%), and BAC 4(2%). The stages of patients were IA:28 (14%), IB:27(13%), IIA:8(4%), IIB:31(15%), IIIA:48(23%), IIIB:39(19%) and IV:25(13%). When corrected for tumor stage, comorbidities, and age there was no significant association between initial FEV1% and patients survival and change of their performance status. CONCLUSION: Pulmonary dysfunction measured by FEV1 % of predicted at the time of diagnosis did not independently affect survival or change in performance status for patients with NSCLC. CLINICAL IMPLICATIONS: Degree of pulmonary dysfunction measured by FEV1 is important for selection and outcome of surgically treated patients, but is not a determinant factor of performance and survival for patients with NSCLC overall. DISCLOSURE: Sevin Baser, None.
Reason for Inoperability Pulmonary dysfunction Unresectable local-regional disease Distant metastasis Cardiac dysfunction Cardiac risk pulmonary dysfunction Recurrence of disease Patient refusal Lost F/U
DISCLOSURE: Sevin Baser, None.
N 206 (%) 38 34 22 2 2 2 1 5 (19%) (17%) (11%) (1%) (1%) (1%) (0.5%) (2%)
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THE PULMONARY FUNCTION LOSS TO SMOKING PACKYEAR IS AN INDEPENDENT PROGNOSTIC FACTOR IN NONSMALL CELL LUNG CANCER PATIENTS HAVING SMOKING HISTORY Jeong-Seon Ryu MD* Hun-Jae Lee MD Jae-Hwa Cho MD Seung-Min Kwak MD Hong-Lyeol Lee MD Tai-Hoon Moon MD Jae-Kap Lee MD Inha University Hospital, Incheon, South Korea PURPOSE: Smoking is a major risk factor causing lung cancer and chronic obstructive pulmonary disease. Smoking status has been known to be an independent prognostic factor of lung cancer patients. We conducted this study to know if individual susceptibility to smoking is related to the survival in locally advanced or advanced non-small cell lung cancer (NSCLC) patients. METHODS: From our prospective cohort of the lung cancer, after excluding non-smokers, we included locally advanced or advanced NSCLC patients who were completed with treatment(n 186) or treated only conservatively(n 151) in this study. All patients were performed pulmonary function testing at the time of diagnosis. We estimated individual susceptibility to smoking using a formula of (100-%predicted FEV1)/pack-year and categorized it by quartile based on the distribution among study subjectsThe statistical analysis of the survival data was performed using SAS program (version 8.1). The duration of median survival were defined as the time from diagnosis to death attributed to lung cancer and that were estimated by Kaplan-Meier method. The difference of survival curve among subgroups were evaluated by log-rank test. To evaluate the effect of susceptibility to smoking on survival was prognosis, Cox proportional hazard regression analysis was performed. RESULTS: Clinical stage of the patients was IIIA in 65(19.3%), IIIB in 120(35.6%) and IV in 152(45.1%). The median survival time was 13.2months(95% CI: 11.9-15.0 months) for treatment group and 4.9months(95% CI: 3.8-6.5 months) for conservative care group (P 0.001). In log-rank test survival time were significantly different according to age, sex, body weight loss ( 5%), %predicted FEV1, clinical stage and individual susceptibility to smoking(P 0.005, 0.036, 0.001, 0.006, 0.001 and 0.001, respectively). The hazard ratio adjusting covariates among patients of highest quartile of susceptibility to smoking was 1.90(95% CI: 1.49-2.38). CONCLUSION: Therefore we suggest that individual susceptibility to smoking is an independent prognostic factor of stage III and IV NSCLC patients.
IMPACT OF PRE-TREATMENT SYMPTOM BURDEN, RESPONSE TO TREATMENT, AND LABORATORY PARAMETERS ON SURVIVAL IN SMALL CELL LUNG CANCER Anant Mohan MD* Abha Goyal Preet P. Singh Siddharth Singh R. M. Pandey MD Ashutosh K. Pathak PhD Manisha Bhutani MD Randeep Guleria MD All India Institute of Medical Sciences, New Delhi, India PURPOSE: Predictors of survival and response to treatment in patients with small cell lung cancer (SCLC) are ill-defined and unclear. In an attempt to assess the impact of simple characteristics like presenting symptoms and laboratory values on survival, we undertook this retrospective review of patients with SCLC. METHODS: All newly diagnosed SCLC cases from December 2001 through December 2004 were identified and clinical data on presenting symptoms and laboratory findings from their hospital records noted. The influence of various pretreatment factors on survival was investigated using Kaplan-Meier plots and Cox multivariate regression model. RESULTS: 76 subjects were included (84% males, 91% smokers). 57% patients had five or more symptoms at presentation. The median survival duration in patients with limited and extensive disease was 15.3 and 9.8 months respectively. Overall survival was significantly associated with cumulative symptom burden (p 0.02), and strongly with symptomatic response to treatment (p 0.001). Survival was also significantly associated with Karnofsky Performance Status (KPS)(p 0.04) and disease extent (p 0.03). Patients with higher hemoglobin, serum sodium and serum globulin had significantly better survival (p 0.02, 0.04, and 0.02 respectively). By multivariate regression analysis, hemoglobin, KPS and brain metastases were found to be significant predictors of survival (p 0.01, p 0.02, and p 0.01 respectively). Multimodal therapy with both chemotherapy (CT) and radiotherapy (RT) resulted in significantly greater
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IMPORTANCE OF EXERCISE TESTING IN DETERMINING EARLY RETURN TO WORK AFTER THE LUNG RESECTION Yoshinori Nagamatsu MD* National Hospital Organization Omuta National Hospital, Omuta Fukuoka, Japan PURPOSE: Issue of earlier return to work after the lung resection is very important for patients. Yet, there must be a determination of patients physical ability to go back to work. Therefore, the institute has conducted this study after lung resection. METHODS: Between 1998 and 2005, the institute operated total of 97 cases. 88 cases were lobectomy and 7 cases were bilobectomy, and 2 cases pneumonectomy. 55 out of 97 patients were male and 42 patients were female. The average age is 68 years old. The exercise testing and spirometric lung function testing were done before and after the surgery. The exercise testing measured the maximum oxygen uptake per minute per the body surface area (VO2max/m2) to determine patients physical ability, and spirometric lung function testing used two measurements such as the vital capacity per the body surface area (VC/ m2) and forced expiratory volume in 1.0 sec per the body surface area (FEV1.0/ m2). The institute decided 100 as its baseline before the surgery. RESULTS: The average results of two weeks after the surgery were the following: VO2max/m2 was 82%, VC/m2 was 68.7%, and FEV1.0/m2 was 72.4% compared to results from before the surgery. 4 weeks later: VO2max/m2 result was up to 88.1%, VC/m2 increased to 74.8%, and FEV1.0/m2 went up to 77.7%. In this study, predetermined physical ability level was 80% as acceptable level to return to work. 60 cases out of 96(62.5%) exceeded this level two weeks after the surgery; 71 cases out of 94 cases (75.5%) met this level 4 weeks after. CONCLUSION: The research shows the patients physical ability recoveries are quick after the lung resection; 62.5% patients have enough physical ability to return to work after two weeks, and 75.5% patients can go back to work 4 weeks after the surgery. CLINICAL IMPLICATIONS: It is possible to use these exercise tests to determine when a patient is able to go back to work and to encourage them to do so after the lung resection. DISCLOSURE: Yoshinori Nagamatsu, None.
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DOES PREOPERATIVE INTERVENTION PROGRAM IMPROVE POSTOPERATIVE OUTCOME IN HIGH-RISK PATIENTS UNDERGOING THORACIC SURGERY? Wai Ming M. Yung MBBS* Y.W. T. Mok MBBS S.O. Ling MBBS Y.N. Poon MBBS K.C. Wong MBBS C.W. Yim MBBS Kowloon Hospital, Hong Kong, Hong Kong PRC PURPOSE: To assess the effectiveness of preoperative intervention program in reducing the incidence of postoperative pulmonary complications (PPCs) and 30-day mortality rate after thoracic surgery in high-risk patients. METHODS: A 3-week preoperative intervention program, consisting of chest physiotherapy, exercise training, smoking cessation and psychological counseling, was offered to high-risk patients with preoperative FEV1 80% predicted or current smokers in a tertiary respiratory medical centre before undergoing thoracic surgery. The 30-day mortality rate and incidence of PPCs, which are defined as pneumonia, atelectasis, PaCO2 greater than 50mmHg lasting for more than 48 hours after surgery, and respiratory failure requiring mechanical ventilation, was compared to those of a group of patients who did not participate in the program (control group). RESULTS: Between April 1, 2000 and March 31, 2002, 42 patients in the intervention group and 27 controls were studied. The baseline characteristics between the 2 groups were comparable except age and the percentage of malignancy. 62% of patients in the intervention group completed the 3-week training. In the intervention group, the mean 6-minute walk distance improved by 38.6 metre (p 0.05) after training. There was no difference in the rates of PPCs and postoperative ICU admission & the hospital stay between the intervention and control
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ANEMIA AFFECTS OUTCOME AFTER SURGICAL RESECTION FOR EARLY STAGE LUNG CANCER Cliff P. Connery MD* Louis Harrision MD Karen McGinnis MD Maureen Reyes Andy Nabong BS Robert C. Ashton MD St. Lukes Roosevelt Hospital, New York, NY PURPOSE: Anemia has been implicated as a significant factor in the failure of response for solid tumors in patients undergoing radiation therapy and chemotherapy. The purpose of our study was to analyze the correlation of preoperative hemoglobin levels and survival after surgical resection for early stage lung cancer. METHODS: All patients undergoing resection for Stage I and II non-small lung cancer from January 2002 through December 2003 comprised the cohort. Patients were followed up to December 2004 or death. Demographics and risk factors, including age, prior thoracic surgery, coronary artery disease, congestive heart failure, hypertension, diabetes, renal failure, peripheral vascular disease, steroid use, ASA classification, Zubrod score, and neoadjuvent therapy, were analyzed along with preoperative hemoglobin levels. Data was collected prospectively, based on Society of Thoracic Surgeons database model. RESULTS: Preoperative hemoglobin was found to be an independent predictor of intermediate survival for patients undergoing surgical resection for early stage lung cancer. Hemoglobin levels greater than 14 resulted in 100 percent survival as compared to levels less than 12 which resulted in a 73.7 percent survival during the follow-up period. Using the Pearson Correlation, hemoglobin was a significant factor in survival (p 0.007). The mean time to death was shortest in Group I, 5.41 (0.1-13.8). One death occurred in perioperative period in the cohort, Group I. There was one transfusion in the cohort, group III. CONCLUSION: For patients with non-small cell lung cancer undergoing surgical resection, hemoglobin was found to be a predictor of survival. The exact mechanism or cause/effect relationship is theoretical at this time. The effects of tissue hypoxemia and free radical generation need to be studied to assess the effects they have on tumor cell survival. CLINICAL IMPLICATIONS: Further investigation is warranted to determine if hemoglobin is a marker of overall risk or if it is a determinant of survival. Additionally, the question of optimization of preoperative hemoglobin prior to surgical therapy and its effect on survival should also be investigated.
Hemoglobin (G/DL) Groups I II III IV Range 9.7-12.0 12.1-13.0 13.1-13.9 14.0-16.1 Mean 11.1 12.5 13.48 14.85 Frequency Alive 14 Dead 6 Alive 18 Dead 3 Alive 16 Dead 2 Alive 20 Dead 0 Percent 70 30 86 14 89 11 100 0
DISCLOSURE: Amit Patel, None. WEDGE VERSUS LOBECTOMY: COMPARING SURVIVAL IN STAGE I NON-SMALL CELL LUNG CANCER Dennis J. Rassias MD* Alexander Kraev BA John Vetto MD Mikhail Torosoff MD Adebambo Kadri MD Pasala Ravichandran MD Christina Clement BS Riivo Ilves MD Albany Medical Center, Albany, NY PURPOSE: The selection of lobectomy or wedge resection in stage I lung cancer remains controversial. We investigated the impact of each procedure on long term survival in a multi-center analysis. METHODS: The records of 293 patients were reviewed for age, sex, type of resection, tumor size, number of lymph nodes dissected, and pathology. Data was obtained through the Federal Social Security Death Index and Cancer Registries. Kaplan-Meier, Wilcox, Logistic Regression,
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PRIMARY LUNG CANCERS DISCOVERED AS SOLITARY PULMONARY NODULE: REVIEW OF 209 CASES Pier Luigi Filosso MD* Davide Turello MD Giovanni Donati MD Fausto Pernazza MD Ottavio Rena MD Caterina Casadio MD Enrico Ruffini MD Alberto Oliaro MD University of Torino, Department of Thoracic Surgery, Torino, Italy PURPOSE: to assess the prognostic factors and outcome of primary lung cancers (PLCs) discovered as solitary pulmonary nodules (SPNs). METHODS: between 1999 and 2003 314 patients (223 male-71%-, mean age 64 years-range 21-81 years-) underwent surgical resection of a SPN. Of these 209 (66%) were PLCs, 56 (17%) lung metastases and 49 benign lesions. RESULTS: One hundred and ten (75%) out of 209 PLCs were adenocarcinomas, 58 (18.7%) squamous cell carcinomas, 12 bronchioloalveolar carcinomas, 8 large cell carcinomas and 12 bronchial carcinoids. Nine patients had mixed tumors. Twenty-six (12.6%) were less than 1 cm. in size; 100 (47.5%) between 1.1 and 2 cm, and 83 (39.9%) between 2.1 and 3 cm. One hundred thirty-seven (65.7%) were N0; 25(11.9%) were N1 and N2, respectively; in 22 (10.5%) lymphadenectomy was not performed. Three and five year overall survival rates were 70% and 52%, respectively. The following prognostic variables resulted statistically significant at multivariate analysis: the tumor histology (p 0.0005), the tumor size (p 0.007), the presence of lymphnodal metastases (p 0.00001), the visceral pleura invasion (p 0.0002) and the extent of resection (anatomic vs. limited resection) (p 0.004). CONCLUSION: this is a surgical series with a high PLCs percentage (66%), the majority of which were at early stage. An early diagnosis and surgical treatment represent the treatment of choice, especially in high risk patients, providing a good survival. CLINICAL IMPLICATIONS: in high risk patients PLC should be considered in occasionally discovered SPN. Early diagnosis and possible surgical treatment are mandatory. DISCLOSURE: Pier Luigi Filosso, None. DEATH HAZARDS FOLLOWING SURGICAL RESECTION FOR NON SMALL CELL PRIMARY BRONCHIAL CANCER: A STUDY ON THE POSSIBLE CURABILITY OF THE DISEASE Adebambo M. Kadri MD* Riivo Ilves MD Albany Medical Center, Albany, NY PURPOSE: The favourable survival benefits of surgical resection for early stage non small cell primary bronchial cancer is well recognized. The value of lung resection for advanced lung cancer with locoregional spread
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PROGNOSIS AND SURVIVAL FOLLOWING SURGICAL RESECTION FOR LUNG CANCER WITH N2 INVOLVEMENT OF THE MEDIASTINUM Adebambo M. Kadri MD* Dennis Rassias MD Riivo Ilves MD Albany Medical College, Albany, NY PURPOSE: Surgical resection remains the primary modality for the potentially curative treatment of anatomically resectable non small cell lung cancer. The presence of mediastinal lymph node metastasis (N2 disease) is known for its association with a poor prognosis. The value and desirability of surgical resection for N2 disease remains controversial. The purpose of the study is to estimate the actuarial survival following surgical resection for N2 disease and determine the prognostic factors which influence survival.
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DISCLOSURE: Mordechai Kramer, None. ROLE OF LUNG TRANSPLANTATION IN THE MANAGEMENT OF PATIENTS WITH LAM: BASELINE DATA FROM THE NIH LAM REGISTRY Janet R. Maurer MD* Jar-Chi Lee MS Gerald Beck PhD Kevin K. Brown MD Joel Moss MD Jay H. Ryu MD CIGNA HealthCare, Avon, CT PURPOSE: Data on candidate selection and post-transplant follow-up in LAM patients is limited. An NIH-funded a Registry collected data on LAM patients including outcomes of patients undergoing or anticipating lung transplantation. Baseline pulmonary function (PFT) and quality of life data from that population is summarized. METHODS: Patients enrolled between 8/98 and 10/01. Six centers registered 243 patients. Initially, patients completed questionnaires detailing medical history, symptoms, laboratory values, treatment, and quality of life. PFTs were done. Follow-ups were at six months and/or yearly. RESULTS: Of the 243, 13 (5.3%) were transplanted before enrollment (Group A); 21 (8.6%) were transplanted during the Registry period (Group B); 48 (19.8%) were waitlisted or evaluated for transplant during the Registry period (Group C); 161 (66.3%) were not listed or considered for transplant (Group D). Baseline PFTs of Group D and Group A patients were not significantly different; however, baseline PFTs of Group B patients were significantly worse than PFTs of Group A or Group D patients (p 0.015 and 0.001, resp.). Group A patients scored better than Group B patients in the SF-36 physical domain (p 0.003) and in the overall St. George Questionnaire (p 0.006) and its activity domain (p 0.001). Group D and Group A scores were similar. CONCLUSION: More than one-third of LAM Registry enrollees either had undergone transplant or were considered for transplant. CLINICAL IMPLICATIONS: Pulmonary transplantation appears to be associated with both better pulmonary function and quality of life compared to patients with physiologically advanced disease prior to transplant (Group B). Funded by NIH (NHLBI) Grant No 1 U01 HL58440.
N* 13 21 48 161
DISCLOSURE: Janet Maurer, None. READMISSION TO AN INTENSIVE CARE UNIT AFTER LUNG TRANSPLANTATION: EXPERIENCE OF A SINGLE CENTER Deborah J. Levine MD* Luis Angel MD Sako Edward MD Stephanie Levine MD University of Texas Health Science Center San Antonio, San Antonio, TX PURPOSE: Short-term survival after lung transplantation has improved such that over 90% of recipients are discharged post-operatively. Long term survival, however, can be complicated by the need for readmission to an ICU in many patients. Respiratory failure is the most common cause for re-admission, however,we found that a significant number of admissions are required for non-pulmonary issues. The purpose of this study is to evaluate the nature and frequency of icu readmissions post transplant.
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MYCOBACTERIA ABSCESSUS IN LUNG ALLOGRAFT RECIPIENTS Leonardo Seoane MD* Denise Fuchs RN Gisele A. Lombard RN Stephanie G. Laplace RN David E. Taylor MD Vincent G. Valentine MD Ochsner Clinic Foundation, New Orleans, LA PURPOSE: Most rapidly growing nontuberculous mycobacterial infections are due to Mycobacterium abscessus. Isolated reports of M. abscessus infection after lung transplantation (LT) suggest this species poses a significant threat to lung allograft recipients(LARs). We report our experiences and clinical outcomes of M. abscessus infection following LT. METHODS: We performed a retrospective chart review of 197 LARs performed at our institution between 1991 and 2005. Infection was defined as symptoms in the prescence of chest radiograph changes and positive cultures from a bronchoalveolar lavage (BAL). RESULTS: Eight (4%) LARs were diagnosed with M. abscessus pulmonary infection. The transplant diagnosis included cystic fibrosis (3), emphysema (3), idiopathic pulmonary fibrosis (IPF)(1), and sarcoid (1). One LAR had M. abscessus prior to transplant and died because of disseminated infection peri-operatively. All underwent bilateral lung transplants except the LAR with IPF. The most common symptoms were dyspnea, cough, and fever. Two deaths may be directly attributable to M. abscessus, since both patients died of respiratory failure with granulomatous pnuemonia on autopsy. Five patients responded to therapy as demonstrated by improved symptoms and culture negativity on repeat BAL. CONCLUSION: The prevalence of M. abscessus is relatively low post LT. Although it may be a potentially fatal pathogen in LARs, the majority of infected LARs respond to therapy. A multi-institutional study may further our understanding of M. abscessus infections among LARs. CLINICAL IMPLICATIONS: M. absessus poses a significant threat to LARs. However, successful treatment of M. abscessus is possible post LT. DISCLOSURE: Leonardo Seoane, None.
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Table 1: Primary Diagnoses for Lung Transplant Recipients Readmitted to the ICU
Cause Pulmonary Cardiac Hematologic/Oncologic Neurologic Infectious Disease (not including pneumonia) Renal Endocrine Percent 59% (pneumonia, rejection, pleural effusion, pulmonary embolus) 10% 8% 8% 6% 6% 2%
DISCLOSURE: Deborah Levine, None. BRONCHODILATOR RESPONSE AS A PREDICTOR OF BRONCHIOLITIS OBLITERANS SYNDROME IN SINGLE AND DOUBLE LUNG TRANSPLANTS Forest H. Mealey DO* Kevin McCarthy RRT Jeffrey Chapman MD Cleveland Clinic Foundation, Cleveland, OH PURPOSE: Brochodilator (BD) response is frequently requested in lung transplant patients. In earlier studies, bronchial hyperreactivity, as determined by BD response and methacholine challenge, has been shown to correlate with the development of Bronchiolitis Obliterans (BO) and BO Syndrome (BOS), however, these studies were limited by small sample size, small numbers of single lung transplants (SLT) and the evolution of transplant medicine since completion. We reviewed data to determine if BD response predicts BOS in single and double lung transplants. METHODS: Data from 432 patients, transplanted from 1991-2005, were reviewed. Exclusion criteria included expiration within one year of transplant, follow up less than one year and anastomotic stenosis. All patients had serial spirometry per protocol pre and post albuterol MDI. BD response was determined by current ATS guidelines. BOS was determined by decline in FEV1 as per current ISHLT criteria. Data were analyzed using the chi-squared test. RESULTS: 221 patients met criteria. SLT was performed in 141 (63.8%) patients. 31/221(14%) patients had a significant BD response. 12/31 (38.7%) patients in the BD responder group developed BOS vs. 45/145 (31%) of non-responders. The difference was not significant (p 0.484). In SLT, 8/24 (33%) with BD response developed BOS vs. 29/119 (24.4%) non-responders (p 0.84). There were no significant
LONG-TERM OUTCOME FOLLOWING LUNG TRANSPLANTATION FOR PATIENTS WITH SARCOIDOSIS Amit Gaggar MD* Keith Wille MD Kevin Leon MD Katherine Hart BS Susan Kerkhof RN David McGiffin MD K. R. Young MD University of Alabama at Birmingham, Birmingham, AL PURPOSE: End-stage sarcoidosis is characterized by severe pulmonary fibrosis and often poorly responsive to medical therapy. Lung transplantation, therefore, may be the only treatment option. Currently, there are few studies evaluating long-term outcomes following transplantation for these patients. The aim of this investigation is to evaluate the post-transplant morbidity and mortality of patients with sarcoid, compared to recipients transplanted for idiopathic pulmonary fibrosis (IPF). METHODS: This study is a retrospective review of all lung transplant recipients at a tertiary care center over a 10-year time period (1994-2004). Data collected include patient demographics, bronchoscopy results, spirometry, development of bronchiolitis obliterans syndrome (BOS), and median survival post-transplantation. RESULTS: Over the study period, 300 patients underwent lung transplantation. Fourteen (4.7%) had sarcoidosis and 48 (16.0%) had IPF. Recipients in the sarcoid group were younger (mean age 41.3 versus 55.8 years*) and predominantly female (93% versus 38%*), compared to recipients in the IPF group at the time of transplant (* p 0.01, Mann-Whitney). Five of 14 (36%) sarcoid patients developed BOS versus 15 of 48 (31%) IPF patients (p ns). There was no significant difference in the time to BOS onset. Median survival was 1,365 days for the sarcoid
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TABLE 1
Obstructive Restrictive Age (years) 42 18 BMI (kg/m2) 21.4 4.3 Borg scale dyspnea with exercise 5.2 2.3 Exercise O2 sat 87 8 6-min walk distance (ft) 1143 421
DISCLOSURE: Leonardo Seoane, None. INCIDENCE OF UNDETECTED LUNG NEOPLASMS IN EXPLANTS OF LUNG TRANSPLANT RECIPIENTS: EXPERIENCE OF A SINGLE CENTER Deborah J. Levine MD* Luis Angel MD Andres Pelaez MD Scott Johnson MD John Calhoon MD Stephanie Levine MD University of Texas Health Science Center San Antonio, San Antonio, TX PURPOSE: Many pre-lung transplant recipients with end-stage lung disease are at high risk for lung cancer. Evidence of lung cancer has been considered a contraindication to lung transplantation mainly because of
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Table 1: Data of Five Lung Transplant Recipients With Undetected Lung Carcinoma
Pre-Transplant CXR CT Scan Indication Age/ for Smoking Type of Neoplasm Adenocarcinoma (poorly differentiated) 2 3 43 F 53 F Emphysema Emphysema Yes Yes Adenocarcinoma Bronchoalveolar Carcinoma 4 5 59 F 45 F UIP -one anti-trypsin Yes Yes Small Cell Carcinoma Adenocarcinoma (Invasive) Stage 1 Stage 1 Negative Negative Dead-1 day Alive 32 months Stage 1 Stage 1 Negative Negative Dead-36 months Dead-4 months Grade of 6 months Prior to Survival Post
SURVIVAL AFTER WEST NILE VIRUS MENINGOENCEPHALITIS IN A LUNG TRANSPLANT RECIPIENT Dale C. Lien MD* Justin G. Weinkauf MD Kathleen B. Jackson RN Pam Brown RN Andrea Taskinen RN Neil Skjodt MD University of Alberta, Edmonton, AB, Canada PURPOSE: Although the majority of West Nile Virus (WNV) infections are asymptomatic, severe neurologic injury and death may occur. Immunosuppressed lung transplant recipients are potentially at higher risk. However, the probability of developing severe disease after exposure, the clinical presentations, and the outcomes for lung transplant recipients contracting WNV are not well known. METHODS: We report one case of community acquired WNV infection in a lung transplant recipient who survived severe meningoencephalitis but with permanent neuromuscular impairment. The patient was a 48 year old male 2.5 years post bilateral transplant for idiopathic pulmonary fibrosis on immunosuppression with tacrolimus, mycophenalate, and alternate day prednisone. He was a farmer in rural western Canada in a highly endemic area of WNV in the summer of 2003.
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SURVEY OF CURRENT PRACTICES IN PULMONARY AND CRITICAL CARE FELLOWSHIP ORIENTATION PROCEDURES Maria R. Lucarelli MD* Catherine Lucey MD John Mastronarde MD The Ohio State University, Columbus, OH PURPOSE: The purpose of this survey was to identify current practices in fellow orientation procedures. METHODS: A 10 question survey was sent via email to current pulmonary and critical care medicine program directors identified in the American Thoracic Society (ATS) web registry. The survey sought to identify common characteristics of fellow orientation programs including duration, content and educational methods. RESULTS: Of the 141 deliverable email addresses, 87 responded (61.7%). Of the programs who responded, 86% had a formal fellows orientation. The mean time frame spent in fellow orientation was 5-10 hours in didactic sessions and 0-5 hours in wet labs. Only twenty-four programs (28%) spent more than 15 hours in didactic sessions while no programs spent more than 15 hours in wet labs. The most common didactic topics were bronchoscopy in 69 programs (80.2%), pulmonary function testing in 63 programs (73.3%) and orientation to hospital services in 63 programs (73.3%). The least commonly covered topics were moderate/deep sedation in 38 programs (44.2%) and intubation in 39 programs (45.3%). The most common use of wet labs was for bronchoscopy training in 60 programs (81.1%) and ventilator management in 45 programs (60.8%). Thirty-seven responding programs (43%) used simulators in fellow orientation. The most frequently used simulator was a bronchoscopy simulator in 31 programs (36%). The majority of program directors did not offer formal wet lab or simulator training, relying instead on on-the-job training experiences during their fellowship. CONCLUSION: This survey demonstrates that early fellowship training experiences differ across programs in terms of duration, content and methodology. Given the variability in skill level exhibited by entering fellows and understanding the importance of procedural competence to patient safety, an early standardized approach to clinical and procedural training can assure that entering fellows possess the requisite cognitive and psychomotor skills to safely embark on training in the critical care arena. CLINICAL IMPLICATIONS: Establishing competency earlier in fellow training, has the potential to decrease medical errors and procedure related complications. DISCLOSURE: Maria Lucarelli, None.
PUBLICATION OF RESEARCH UNDERTAKEN IN A CANADIAN TEACHING CENTRE: A REVIEW BY A RESEARCH ETHICS BOARD Richard I. Hall MD* Cecilia DeAntueno Queen Elizabeth II Health Sciences Centre, Halifax, NS, Canada PURPOSE: Reporting of results from clinical investigations is an important component of the ethical conduct of research. We conducted a review of the publication record of all protocols submitted to our Research Ethics Board (REB) for the periods 1995-1996. METHODS: Protocols for studies closed by the principal investigator (PI) were identified from the REB database. We identified the local PI, the sponsor, and the phase of clinical investigation. For each publication, we identified publication authors, publication title, journal, and whether a randomised clinical trial or not. For data analysis Systat V10 was utilised. p 0.05 was taken as statistically significant. RESULTS: We identified 110 unpublished studies and 85 publications (44%). The median time to publication was 32.5 mos (975 days)(mean 33.1 17.8 mos) and the median number of subjects enrolled per study was 329. For unpublished studies, subject recruitment was reported for 45 studies. In these studies there was a median of 2 subjects recruited by local investigators per study. Physicians authored 79/85 publications (93%) and were the principal investigators in 89% (173/195) of studies. Publication by sponsor is given in the Table. Of the 85 published studies, results could be described as positive findings in 72 (85%). Of 13 negative published trials, 11 were sponsored by the pharmaceutical industry, one by the health authority, and one by a federal granting agency. CONCLUSION: Publication of research results was unacceptable, less likely to occur if sponsored by the pharmaceutical industry, and more likely to occur if reporting positive findings. Calls for public registration of clinical trials appear warranted. CLINICAL IMPLICATIONS: Publication of research results is an ethical obligation of researchers and failure to publish results is considered by some to represent scientific misconduct. In addition failure to publish scientific results violates the social contract research subjects undertake when they participate in research and misinforms public policy through failure to provide adequate information upon which to base guidelines and perform meta-analysis. Our results suggest much further education around these issues is required.
QUALITY OF EDUCATION IN THE INTENSIVE CARE UNIT: A SUBSET ANALYSIS Jason M. Golbin DO* Robert Bruno DO Gerald Bahr MD Bushra Mina MD Lenox Hill Hospital, New York, NY PURPOSE: The ICU rotation at our hospital is often described as the most valuable educational experience in the internal medicine residency. Previously presented data demonstrated that this educational enhancement cannot be measured. We performed a subset analysis of this data to evaluate disparity among individual ICU topics.
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Selected ABIM Topic Pulmonary Artery Catheterization Acid-Base / Electrolyte Disorders COPD/Asthma Nutrition in the Critical Care Patient DKA / Hyperosmolar Coma Sepsis APACHE Medical Ethics in the ICU GI Bleed Weaning
n 8
n 11
50.0
12
72.7
11
22.7
72.7 33.3
11 6
80.0 32.5
10 8
7.3 -0.8
50.0
10
77.7
27.7
13 7 7 5 9
10 9 9 9 13
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MARKERS IN BREATH CONDENSATE IN PATIENTS WITH OCCUPATIONAL ASTHMA AND RHINITIS Jindriska Lebedova MD Pavlina Klusackova MD Petr Kacer PhD Marek Kuzma Daniela Pelclova MD* Tomas Navratil PhD Zdenka Fenclova MD Department of Occupational Medicine, 1st Medical Faculty Charles University, Prague, Czech Republic PURPOSE: Specific provocation tests are used to confirm diagnosis of occupational asthma or rhinitis. Decreases of FEV1 or nasal flow are considered to be main markers of positivity. Analysis of breath condensate brings more information for monitoring processes in airways during these tests. METHODS: Six patients (average age 38.7 years) with suspicion on occupational asthma (OA) and rhinitis (OR) and four controls (average age 53.8 years) were examined. Total immunoglobuline E (IgE), blood eosinophils, spirometry, rhinomanometry, non-specific bronchoprovocation test, specific bronchoprovocation tests with occupational allergens were performed. Leukotrienes C4, D4, E4 from breath condensate were analyzed by HPLC/MS, leukotriene B4 on solid phase extraction. Student t-test and correlation coefficient were used for statistical analysis. RESULTS: Occupational asthma was finally diagnosed in three patients, occupational rhinitis in three patients. In patients with OA, OR and controls IgE levels were 828.3 vs. 564.0 vs. 34.8 mg/l; FEV1 80.3 vs. 95.6 vs. 109.0 % predicted values; leukotrienes on admission B4 43.3 vs. 2.6 vs. 46.3 pg/mL; C4 114.0 vs. 54.7 vs. 85.0 pg/mL; D4 17.0 vs. 10.7 vs. 35.5 pg/mL; E4 20.0 vs. 13.7 vs. 28.3 pg/mL. Significant changes in FEV1 (p 0.05) were found between asthmatics and controls.Breath condensate leukotrienes were analysed also before specific test and at the time of maximal decrease of FEV1 or nasal flow during the test: OA patients - B4 (53.7 vs. 56.7 pg/mL), C4 (121.7 vs. 198.0 pg/mL), D4 (17.0 vs. 17.0 pg/mL), E4 (21.3 vs. 21.0 pg/mL), OR patients - B4 (13.0 vs. 17.3 pg/mL), C4 (266.3 vs. 257.3 pg/mL), D4 (19.3 vs. 17.0 pg/mL), E4 (17.3 vs. 15.6 pg/mL). No significant correlations were found. CONCLUSION: Maximum decrease of FEV1 during specific tests with occupational allergens in our small group of patients does not to seem to correspond with elevation of markers of obstruction in breath condensate. CLINICAL IMPLICATIONS: Changes in obstruction markers in breath condensate probably precede or follow decrease of FEV1. These possibilities will be tested in further provocation tests measurements. Acknowledgement: IGAMZCR NR8109-3/2004. DISCLOSURE: Daniela Pelclova, None.
LONG-TERM RESPIRATORY DISORDERS IN CLAIMERS WITH EXPOSURE TO CHEMICAL WARFARE AGENTS (CWA): REVIEW OF METHACHOLINE CHALLENGE TEST (MCT) RESULTS Abbas Nemati MD* Mahdi Rahmati MD Ali Moghimi MD Artesh University of Medical Sciences, Tehran, Iran PURPOSE: It is well documented that inhalation of sulfur mustard causes injury of the respiratory system. While all of the reports and surveys thoroughly document long-term pulmonary effects after significant exposure to mustard, there is no direct evidence that addresses the issue of long-term respiratory effects in individuals who were exposed to very low level of mustard and suffered no acute respiratory tract injury. The aim of this study is to evaluate the MCT findings in the veteran claiming exposure to CWA during Iran-Iraq war. METHODS: We studied 395 subjects which were selected among all those who were in chemically contaminated areas with chemical warfare agents (CWA) and had been registered for an annual checkup. Background data were collected. All subjects underwent diagnostic bronchoscopy and biopsy which was performed by one specialist. In all patients MCT, according to ATS guidelines, performed. RESULTS: Subjects were 395 men with the mean age of 41.46 (SD, 5.43) years which exposed to CWA averagely 18.7 (SD, 1.74) years ago. 132 patients (33.3%) had positive MCT. Results of MCT did not relate to the cigarette smoking (p 0.82), length time after exposure (p 0.88), age (p 0.36), bronchospic findings (p 0.36) and the presence of interstitial fibrosis (p 0.71). Kappa coefficient of the results of bronchoscopy and MCT in determining patients with airway disorders was not significant (p 0.36). CONCLUSION: This study shows that a major proportion (33%) of patients exposed CWA show airway hypersensitivity in their MCT which does not relate to any underlying factor, though it is not a diagnostic finding. In addition the results of bronchoscopy and MCT are not in concordance with each other. CLINICAL IMPLICATIONS: About one third of patients exposed CWA show airway sensitivity. DISCLOSURE: Abbas Nemati, None.
CHEST 2005Poster Presentations
XENON DIFFUSING CAPACITY DETECTS ABNORMAL GAS EXCHANGE IN A RAT MODEL OF PNEUMONITIS CAUSED BY STACHYBOTRYS CHARTARUM SPORE INHALATION Nishard Abdeen MD* Greg Cron PhD Albert Cross PhD Thomas Rand PhD Steven White MS Giles Santyr PhD Carleton University, Ottawa, ON, Canada PURPOSE: Xenon diffusing capacity, a novel noninvasive technique of measuring gas exchange analogous to carbon monoxide diffusion capacity,
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ANTI-GLOMERULAR BASEMENT MEMBRANE ANTIBODYNEGATIVE, GOODPASTURE-LIKE ALVEOLAR HEMORRHAGE SYNDROME IN YOUNG WOMEN WITH METHAMPHETAMINE USE AND MANUFACTURE Carl A. Kaplan MD* Michael S. Plisco MD Ashok Palagiri MD Saint Louis University School of Medicine, Saint Louis, MO PURPOSE: Illicit substances, such as cocaine, are associated with alveolar hemorrhage. Anti-Glomerular Basement Membrane (GBM) Disease and Goodpasture Syndrome with alveolar hemorrhage are rare immunologic diseases that are associated with a number of risk factors, and without treatment have significant mortality rates. Methamphetamine use is a growing public health concern, and its manufacture is common in regions of the United States. Methamphetamine has not previously been associated with alveolar hemorrhage. This study addresses the association with alveolar hemorrhage and methamphetamine. METHODS: A single institution retrospective case study from an urban university tertiary care hospital and referral center. A systematic review of pathology reports and database of cases with alveolar hemorrhage. RESULTS: A total of two cases (n 2), both 22 year-old females, were admitted with frank hemoptysis and acute respiratory failure. The medical history was significant for substance abuse, tobacco abuse and both were associated with the use and manufacturing of methamphetamine. Bronchoalvelar lavage demonstated alveolar hemorrhage in both, with increasingly bloody lavage fluid. Urinalysis was bland with normal creatinines. The open lung biopsy demonstrated, in both, primarily alveolar hemorrhage, with one associated with capillaritis with areas of organization. Immunofluorescence revealed prominant linear staining of the alveolar basement membranes for immunoglobulin IgG and complement C3, as did the glomerular basement membranes on the renal biopsies. Both were serum anti-GBM antibody negative. Plasmapheresis was performed in addition to the administration of parenteral corticosteroids, with resolution of the acute respiratory failure. There were no recurrences.
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CONCLUSION: MPM0-III is well calibrated to current clinical data and requires collecting only one additional term (code status). CLINICAL IMPLICATIONS: Use of MPM0-III will allow more accurate comparisons of actual versus expected outcomes based on patient condition at the time of ICU admission.
Variable Constant Coma-stupor HR 150 bpm SBP 90 mmHg Chronic Renal Chronic GI Metastatic Neoplasm Acute Renal Dysrhythmia Cerebrovascular Incident GI Bleed Intracranial Mass Age (in years) CPR w/i 24hr Mech. Ventilation Medical/Unscheduled Surgical Admission Zero Factors Full Code SBP x MV Admit Age x Coma Age x SBP 90 Age x ChronicGI Age x Mets Age x CardDys Age x ICM Age x CPR
Coefficient -5.397338 2.032949 0.4286778 1.578148 0.4041341 2.078154 3.187064 0.7026929 0.8247331 0.4103774 -0.1593359 1.838082 0.0387999 1.499682 0.891268 0.916912 -0.4025265 -0.8016462 -0.1620224 -0.0074014 -0.0092765 -0.0225957 -0.0328078 -0.0100795 -0.0168818 -0.0112155
DISCLOSURE: Thomas Higgins, Consultant fee, speaker bureau, advisory committee, etc. Dr. Higgins serves on the Cerner Critical Care Transformation Council (advisory committee).
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RESULTS: Of 226 admissions during the study period, 34 (17.4%) patients died in the ICU. The mean length of ICU stay was 6.4 days. A total of 42 patients (22%) were readmitted. The score developed from the statistical analysis of the 272 variables includes 8 simple variables with a maximum score of 41 (Table). The area under the receiving operating characteristic (ROC) curve was 0.74. CONCLUSION: This simple score, based on routinely collected variables, can help to evaluate the risk of readmission to the ICU after discharge. CLINICAL IMPLICATIONS: ICU readmission is associated with worse outcomes. Identifying patients at risk of readmission may prevent premature ICU discharge, may promote the use of increased surveillance such as intermediate care unit or telemetry on the floor, and may help prepare the patient, the relatives, and the heath care professionals for the possibility of readmission.
Variable Presence of decubitus ulcer Hyperleukocytosis or inflammatory syndrome (WBC 17,000/mm3 or CRP 20 mg/dL) Maximal sequential organ failure assessment (SOFA) score to 9 Paroxysmal atrial fibrillation or need for anti-arrhythmic medication Chronic obstructive pulmonary disease (COPD) or asthma requiring chronic treatment Morbid obesity or parenteral nutrition or decompensated diabetes Hypoalbuminemia (serum albumin 3.5 g/dL) Alteration of mental status, polytrauma or notable physical dependence
DISCLOSURE: Michael De Cubber, None.
Score 12 6 6 4 4 4 3 2
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DATA MINING THE ELECTRONIC MEDICAL RECORD TO EXAMINE OUTCOMES IN THE EMERGENCY DEPARTMENT Patricia B. Cerrito PhD* Dave Pecoraro University of Louisville, Louisville, KY PURPOSE: To use data mining techniques on the electronic medical record (EMR) in the Emergency Department (ED) with the intent of improving care while reducing costs. METHODS: All patient records for a 6-month period were examined. All records with an initial complaint related to shortness of air or related were extracted for a total of 1329 patient records. There were 53,000 charges ordered for these patients in the ED. The data mining techniques of text analysis, transactional time series, and association rules were used to examine the data. RESULTS: A total of 187 patients were discharged to ICU after the ED, with 25 of the 187 originally triaged as non-urgent. In contrast, only 2 out of 626 discharged home were triaged as emergent. Although there is no standardization in the language of initial patient complaints, there is a general grouping of ten different complaints as listed in the table. Bronchitis and asthma require a similar amount of time in ED treatment; COPD requires an extra 100 minutes of treatment time on average compared to the other two conditions. Patients complaining of shortness of air were tracked into a heart protocol, receiving tests of Troponin and CBC; or were tracked into a respiratory protocol, receiving oxygen and mini-nebulizer treatment. There was 87% confidence that glucose testing was associated with EKG and CBC, a 70% confidence that it was associated with Troponin test, but almost no association with SOA treatments. CONCLUSION: Data mining the EMR can provide useful information that can be used to improve care while reducing costs. There is sufficient variability in treatment for patients with similar complaints that the variability can be examined and reduced while developing optimal treatment patterns. CLINICAL IMPLICATIONS: Once the variability in treatment is documented, it can be examined to develop standardized protocols for patient complaints. Optimal paths of care can be developed. Specific protocols can also reduce the time needed to treat patients in the ED.
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DISCLOSURE: Thomas Higgins, Consultant fee, speaker bureau, advisory committee, etc. Dr. Higgins serves on the Cerner Critical Care Transformation Council; Grant monies (from industry related sources); Dr. Nathanson received grant funding from Cerner.
THE ICU DISCHARGE SCORE TO EVALUATE THE RISK OF READMISSION Michael De Cubber MD* Marta Trabbach MD Francesca Garcia Lizana MD Christian Melot MD Jean-Louis Vincent MD Erasem Hospital, Brussels, Belgium PURPOSE: To determine the clinical and laboratory features of patients who are readmitted to the ICU after discharge, and to use these to develop a score to predict risk of readmission. METHODS: In this observational cohort study in a mixed, 31-bed, medico-surgical intensive care unit, 226 consecutive adult ICU admissions were included during a 13-week period (excluding patients admitted for uncomplicated postoperative surveillance).Variables related to epidemiology, past history, clinical and lab data were recorded. Data were analyzed by univariate regression analysis. Continuous variables were transformed in categorical variables using the threshold obtained by a Lowess smoothing function. The categorical variables were entered into a multiple logistic regression model. The coefficients of the regression were used to compute the score for each significant item. A p 0.05 was considered significant.
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ASSESSMENT OF ACUTE PHYSIOLOGIC AND CHRONIC HEALTH EVALUATION AND THE SIMPLIDIED PHYSIOLOGIC SCORES IN A POST-TRAUMATIC SURGICAL INTENSIVE CARE UNIT Meurant Francois MPH* Hopital Kirchberg, Luxembourg, Luxembourg PURPOSE: The Acute Physiologic and Chronic Health Evaluation (APACHEII ) has been extensively used in Intensive Care Unit (ICU) setting over the past 10 years ,as has been the Injury Severity Score (ISS) using an anatomical descriptive scoring . The Simplified Acute Physiology Score( IGSII ) belongs to a new generation of scoring systems : its main innovation is that the different parameters and their weighting are derived from statistical analysis. However the accuracy of APACHE II and IGSII scoring systems have to date not been specifically studied in general trauma surgical patients(TSP).To assess whether the APACHE II and IGS II scores and their derived predictors of risk of death(ROD)are applicable to TSP?. METHODS: During a16 month period TSP admitted to our ICU had APACHE II and IGSII scores with their derived ROD calculated. Receiver Operating Characteristic (ROC) curves and Goodness-of-Fit test were used to assess the accuracy of the scores. RESULTS: 62 TSP were included over 93 total trauma patients (median ISS score was 16.0, range 11 to 43), there were 10 in-hospital deaths from haemorrhage. The median APACHE II score was 12.0( range 0 to 40) with a mean ROD of 17.0 19.6%. The median IGSII was 22.0 ( range 0 to 60) and its derived mean ROD was 15.0 19.2%. The area under the ROC curves was 0.850 for the APACHE II and 0.858 for the IGS II demonstrate a good discrimination. The goodness-of-fit test indicated that both scores were well calibrated (P 0.1 for APACHE II and P 0.25 for IGSII). Standardised mortality ratio was 0.65 from APACHE II and 0.86 from IGSII. CONCLUSION: The APACHEII and IGSII scores are both reliable and accurate in post-traumatic patients. Bleeding appeared as a poor prognostic factor. CLINICAL IMPLICATIONS: The IGSII scoring, using actually in european ICU, could be applied in all of critical intensive care patients, including traumatics patients, improving quality of job. DISCLOSURE: Meurant Francois, None.
EPIDEMIOLOGY OF WHEEZING INFANTS REFERRED TO A TERTIARY MEDICAL CENTER Heather Huxol MD Kimberly Kim MD Ron Morton MD Nemr S. Eid MD* University of Louisville, Louisville, KY PURPOSE: Persistent or recurrent wheezing is a common cause for referral to pediatric pulmonology. These patients require a detailed work-up to elicit the etiology of wheezing as they often represent a diagnostic dilemma. Objective: To examine the components of the diagnostic course typically taken in these infants and the primary diagnoses given. To compare the epidemiology of patients referred for wheezing with the two most common diagnoses, gastroesophageal reflux (GER) and asthma. METHODS: A retrospective review was performed on 56 infants, mean age 10 months; range 2- 31 months, referred for recurrent or persistent wheezing. All of these patients had infant pulmonary function tests. The majority of patients had chest x-rays, pH probe studies, and upper GI series. A few others had modified barium swallow studies, allergy testing, and sweat chloride tests depending on the clinical presentation. RESULTS: The most common diagnoses were GER and asthma. Asthma, both as a primary diagnosis or with secondary diagnoses, was found in 40/56 or 71% of patients. GER, alone or with other diagnoses, was found in 27/56 or 48% of patients. There was no difference between these two groups regarding a parental history of asthma, prematurity, or NICU stay. There was no difference in family size. There was no difference in reported cases of bronchiolitis or pneumonia between the two groups. Environmental smoke exposure was slightly more common in the GER group. More patients with asthma had pets versus those with GER. A history of breastfeeding was less common in the asthma group. More patients with asthma had attended daycare versus those with GER. A clinical history of reflux was much more common in the GER group. CONCLUSION: Although wheezy infants constitute a heterogeneous group of patients, the most common diagnosis in this cohort is asthma and gastroesophageal reflux. CLINICAL IMPLICATIONS: The aspects of epidemiology most helpful in distinguishing the asthma patients versus the GER patients included clinical history of reflux, history of breastfeeding, history of daycare attendance, and history of eczema. DISCLOSURE: Nemr Eid, None.
THE 24-HOUR TUBERCULIN TEST: A COMPARISON WITH THE 48-HOUR AND 72-HOUR READINGS AND ITS PREDICTIVE VALUE Alfredo A. Yap MD* Olivia C. Go MD University of Santo Tomas Hospital, Manila, Philippines PURPOSE: This study was done to determine the value of the 24-hour tuberculin test (TT), its comparison with the currently recommended 48and 72-hour readings, and the factors which may affect it. METHODS: A 0.1 ml 5 TU PPD was administered using the Mantoux Method. Induration was measured at 24, 48 and 72 hours. An induration 8mm at 72 hours defined a positive test. The subjects were 230 children, 6-15 years old, from Bukidnon, Southern Philippines, who were not previously diagnosed or treated for tuberculosis (TB), never had a TT and had no condition/s that may cause anergy. RESULTS: Among 230 subjects,117(50.8%)had positive tests at 72 hours. The mean (SD)induration size (mm) was significantly larger at 72 hours [9.48 (5.65)] than at 48- [8.17 (5.23)] and 24 hours [5.81 (3.7)], respectively. A positive correlation existed between the induration sizes at the three periods. At 24 hours, the presence of any induration had a sensitivity of 96.58%, specificity of 51.33% and positive predictive value (PPV) of 67.26%; an induration 4mm (half the cut-off),had PPV of 81.15%; an induration 8 mm had a sensitivity of 34.18% , but 100% specificity and PPV;an induration 8mm had a NPV of 59.74%; any induration associated with chest x-ray (CXR) suggestive of tuberculosis,
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LUNG FUNCTION TEST OF TOLUENE ABUSERS AMONG URBAN STREET CHILDREN AGES 7 TO 18 YEARS OLD Fatima B. Pogoy MD* Teresita S. de Guia MD Philippine Heart Center, Quezon City, Philippines PURPOSE: Toluene, an industrial solvent in adhesive compound is the most commonly abused inhalant among street children in Metro Manila. This study aims to determine the physiologic effects of inhaling toluene on the respiratory function of the study population. METHODS: General health status was assessed by history, physical examination and a questionnaire with emphasis on the respiratory symptoms. Spirometry using a Microloop (Micro Medical Limited) was performed using the standards of the American Thoracic Society. RESULTS: Thirty one (31) street children, 26 (84%)males, 5 (61%) females, with a mean age of 14 /-2 years were included. The mean duration of drug use is 2.6 /- 2.5 years with a frequency of 23 /- 20 hr per week. The most common respiratory symptoms in this series include dyspnea (38.7%, cough (35.5%), rhinorrhea (29%)and choking (12.9%). Results of spirometric studies showed 13 (41.9%)subjects with low FVC values 80% of predicted indicative of restrictive ventilatory pattern in patients who tested positive for toluene in the blood. FEV1 values were all normal (mean FEV1 89 /- 14.9%). There was a statistically significant correlation between the duration/frequency of inhalant abuse with toluene levels in the blood (p 0.04) and urine (p 0.006). CONCLUSION: This study has shown a positive correlation between toluene abuse by inhalation and the development of restrictive ventilatory pattern which is directly related to the frequency and duration of toluene inhalation. CLINICAL IMPLICATIONS: Solvent abuse is popular among children and young adults. Sniffing the fumes causes the hunger, pain and loneliness to be numbed for a moment providing escape from realities of life. It is now well recognized that solvent abuse not only can result in sudden death but also cause pathological changes in the lungs. It is therefore, the aim of this study to investigate the effects of Toluene exposure on the pulmonary function of these children. DISCLOSURE: Fatima Pogoy, Other Philippine Foundation for Lung Health Research and Development, Inc.research and Development, Inc.
POSTER PRESENTATIONS
CHRONIC INHALED CORTICOSTEROIDS DO NOT AFFECT SEVERE ACUTE ASTHMA EXACERBATIONS IN CHILDREN Christopher L. Carroll MD* Anita Bhandari MD Aaron R. Zucker MD Craig M. Schramm MD Connecticut Childrens Medical Center, Hartford, CT PURPOSE: Chronic therapy with inhaled corticosteroids (ICS) is known to reverse and suppress airway inflammation and can also increase airway responsiveness to beta-adrenergic agonists. We theorized that the chronic use of ICS would be associated with shorter duration of hospitalization in severely ill children with status asthmaticus. METHODS: An eight-year retrospective chart review (April 1997 to May 2005) was conducted of all children greater than two years old admitted to the ICU with a primary diagnosis of status asthmaticus. Baseline demographics and outcome measures were compared between children receiving and not receiving ICS prior to admission.
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THE EFFECT OF APNEA ON SLEEP ARCHITECTURE IN INFANTS WITH GENETIC OR METABOLIC DISEASE Wish Banhiran MD* Chulaluck Techakittiroj MD Teeradej Kuptanon MD Narong Simakajornboon MD Tulane University School of Medicine, New Orleans, LA PURPOSE: Several studies have shown that infants with genetic or metabolic disease have increased incidence of both central and obstructive apnea. However, those studies have not assessed the effect of sleep apnea on sleep architecture. Since apnea and associated hypoxemia and hypoventilation can lead to sleep fragmentation due to respiratory arousals, we evaluated the effect of apnea on sleep architecture in this population. METHODS: A retrospective review of polysomnographic recordings was performed in infants with genetic or metabolic disease and normal control infants who were referred to our sleep laboratory from 1999-2004. All infants underwent an overnight polysomographic studies. Any infants with significant lung diseases or infants who were on respiratory stimulants, or supplemental oxygen were excluded from the study. RESULTS: Thirty three infants met the criteria for entry into the analysis; 17 infants with metabolic or genetic disease [S] and 15 age-matched controls [C]. The average apnea index of infants with genetic or metabolic disease was 23.9 6.8/hr; 58.8 % (10/17) had predominately central apnea and 41.2 % (7/17) had predominately obstructive apnea. Infants with genetic or metabolic disease had significant lower average SpO2 (95.6 3.4 %[S] vs. 99.1 0.9[C]; P 0.05) and higher average EtpCO2 (44.6 5.7 mmHg[S] vs. 38.7 4.9[C]; P 0.05) during sleep. However, there was no significant difference in the sleep efficiency (73.1 12.8%[S] vs. 78.6 5.5[C]; P NS), percentage of REM sleep (54.3 16.2%[S] vs. 53.0 8.0[C]; P NS) and NREM sleep (42.2 14.3%[S] vs. 43.5 8.2[C]; P NS) between infants with genetic or metabolic disease and control. Analysis of the respiratory arousals revealed that only 11.6 % of apnea in infants with genetic or metabolic disease was followed by arousals. CONCLUSION: It is concluded that apnea in infants with genetic or metabolic disease is not associated with significant changes in sleep
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NIL NOCERE: ACQUIRED RESTRICTIVE THORACIC DYSTROPHY Francis Robicsek MD Alexander A. Fokin MD* Peter N. Kane MD Chad R. Swan MD Heineman Medical Research Laboratories, Carolinas Medical Center, Charlotte, NC PURPOSE: In 1995, Haller reported on a peculiar group of adolescents suffering from a condition coined acquired Jeunes syndrome, later also known as Acquired restrictive thoracic dystrophy (ARTD). All these patients underwent pectus excavatum repair at an early age, after which their chest failed to grow adequately and became rigid with severely restricted respiratory function. METHODS: To shed light on the cause of this heretofore unknown disease, we have studied clinically five patients with ARTD and coordinated our findings with the scarce literary data available on the subject. RESULTS: All the patients whose data were available presented with severe respiratory impairment. Evidently, in the course of their pectus repair their costal cartilages from the second rib down were radically extirpated, including their medial and lateral centers of growth. Some of the operative reports and all of our imaging studies also indicated that the perichondrial strips were sewn together behind the sternum to maintain its corrected position (Fig. 1). As a result, the patient developed a rib cage that remained infantile in size, odd in appearance and failed to rise in inspiration or fall when the patient exhales.
CONCLUSION: Performing repair of pectus excavatum the way described above is a grave mistake and should be avoided. We also disagree with those who suggest that the best way to avoid ARTD is to delay pectus repair to the age when the chest is already fully developed. As our experience of 300 patients operated at a very early childhood shows, the operation may be safely performed at any age, given appropriate operative plan and technique.
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RELATIONSHIPS BETWEEN RESPIRATORY FUNCTION AND SPINAL CHARACTERISTICS IN PATIENTS WITH SEVERE MOTOR AND INTELLECTUAL DISABILITIES SYNDROME Naoki Mori MS* Hajime Kurosawa MD Azuma Hiramoto MD Kayomi Matumoto MS Yuko Sano MS Emiko Fukuda PhD Hiromi Fujii PhD Masahiro Kohzuki MD Dep. of Int. Med. and Reha. Tohoku Univ. Graduate School of Medicine, Sendai, Miyagi, Japan PURPOSE: Severe motor and intellectual disabilities syndrome (SMIDS) is a term used to describe a heterogeneous group of disorders with severe physical disabilities and profound mental retardation. Patients with SMIDS have spinal deformity in high incidence, and showed to multiple scoliosis curve pattern. The purpose of this study is to examine the correlation between spinal characteristics (including scoliosis curve pattern and respiratory function. METHODS: Thirty patients with SMIDS (M:F 18:12, Age, 33.5 12.1, means SD)who were studied. All subjects were severe cerebral palsy, and were unable to sit independently. Spinal deformity were measured by Cobb Method (Cobb angles :CA) and Nash & Moe technique (vertebrae rotation grade :VRG). Scoliosis curve pattern were divided into three groups(thoracic, thoracolumbar and lumbar ) according to the different apical vertebrae by X-ray image. We measured tidal volume&, respiratory frequency observed during tidal breathing at static supine posture. RESULTS: CA and VRG, both were inversely correlated with tidal volume (CA:r -0.71, p 0.01,VRG:rs -0.59, p 0.01). CA and VRG, both were correlated with respiratory frequency(CA: r 0.67, p 0.01, VRG:rs 0.56, p 0.01). However, We did not find significant differences of respiratory function among curve patterns in patient with SMIDS. CONCLUSION: These results suggest that the spinal deformity restrictively affect respiratory patterns in patients with SMIDS. Scoliosis curve pattern did not affect respiratory function. CLINICAL IMPLICATIONS: To care to prevent spinal deformities especially in CA and VRG is very important in terms of maintaining respiratoy function. DISCLOSURE: Naoki Mori, None.
CONTINUUM OF CARE: THE ROLE OF TEACHING PROGRAMS IN THE PROVISION OF CARE TO VENTILATORASSISTED INDIVIDUALS IN URBAN AND RURAL REGIONS OF QUEBEC Rita Troini MA* McGill University Health Centre, Montreal, PQ, Canada PURPOSE: To present how the use of teaching programs can contribute to standardizing the care of ventilator-assisted individuals (VAIs) across hospitals, rehabilitation centers and regions to which VAIs return once discharged home. The National Program for Home Ventilatory Assistance (NPHVA) is a university-based program responsible for providing respiratory equipment and related homecare services to an adult and pediatric population requiring long-term mechanical ventilation. Diagnoses include neuromuscular diseases, Ondines syndrome, amyotrophic lateral sclerosis and high spinal cord injury. The NPHVA provides services to all regions of Quebec over a vast demographic area. In an effort to provide VAIs with the same care across all regions, the NPHVA developed teaching programs covering topics related to each VAIs illness, treatments and equipment. These programs are used in the training of patients, families, health care partners and frontline community health workers involved in the care of the patient at home. Binders personalized to each VAIs needs are provided. METHODS: We analyzed patient/family satisfaction surveys and other quality indicators to identify key elements contributing to the success of the NPHVA in providing homecare services to VAIs in urban and rural regions of Quebec. RESULTS: Three key elements were identified: 1) Teaching/training provided to the patient/family and frontline community health workers; 2) Regular home visits; 3) Timely exchange of information between the programs clinical specialists and frontline community health workers providing care to the patient in their region. CONCLUSION: The use of teaching programs contributes to an open exchange between all health care partners involved in the care of VAIs and can contribute to improving the continuity of care and the quality of life of this patient population. CLINICAL IMPLICATIONS: The training and dissemination of information to frontline health care workers in conjunction with continuous exchange of clinical and technical information between universitybased centers of expertise and community workers may prevent needless hospitalizations of VAIs due to lack of knowledge and training in home ventilator management and associated therapies. DISCLOSURE: Rita Troini, None. THE EVOLUTION AND CURRENT STATUS OF RESPIRATORY TECHNOLOGY DEPENDENT CHILDREN IN MANITOBA Raquel J. Consunji-Araneta MD* Karen Wachnian RN Diane Lauder RRT University of Manitoba, Winnipeg, MB, Canada PURPOSE: To describe the demographic and clinical characteristics of and type of respiratory technology utilized by respiratory technology dependent children (RTDC) in Manitoba (1982-2005). METHODS: Demographic and clinical data (age, sex, underlying condition) were collected retrospectively together with specific information regarding respiratory technology utilized (oxygen, tracheostomy,
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DELAYED SLEEVE RESECTION OF DISTAL LEFT MAIN BRONCHUS CRUSHING INJURY IN A CHILD AFTER SHORT COURSE OF STEROIDAL TREATMENT: CASE REPORT Alden H. Kirk MD* Giorgio M. Aru MD Fermin Romero MD University of Mississippi - Division of Cardiothoracic Surgery, Jackson, MS PURPOSE: We report for the first time on the delayed repair of a distal bronchial injury (BI) in a child, treated with steroids prior to definitive surgical repair. METHODS: An 8 year old child, run over by a truck, developed a left sided tension pneumothorax treated with a chest tube. Ten days later she was transferred to us for atelectasis of the left lung. The initial air leak had resolved and a flexible bronchoscopy showed bronchial disruption of the very distal left main stem bronchus. We planned a delayed repair considering that the injury in the distal left main bronchus carried a high risk of pneumonectomy during an early surgical repair for possible friability of the bronchial biforcation. She was discharged on low dose steroids and after 2 weeks a limited sleeve resection of the distal left main stem bronchus was performed through the left 4th intercostal space . Four years later, she is doing well and has a normal CXR.
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SIGNIFICANT IMPROVEMENT IN SPIROMETRY AFTER STEM CELL TRANSPLANTATION IN ONE DUCHENNE MUSCULAR DYSTROPHY PATIENT Zhiping Li RRT Yubiao Guo MD* Xiaoli Yao MD Cheng Zhang MD Canmao Xie MD Department of Pulmonary & Critical Care Medicine, the First Affiliated Hospital, Guangzhou, Peoples Rep of China PURPOSE: To describe the pattern of lung function abnormality and to investigate the changes in spirometry before and after autologus hematopoietic stem cell transplantation in one duchenne muscular dystrophy (DMD) patient. METHODS: Lung function was measured by maximum expiratory flow-volume loops and whole body plethysmography in one 14-yr old DMD patient before and three months after stem cell transplantation. RESULTS: Lung function test was characterized by restrictive pattern manifested by lung volume reduction and increased FEV1/FVC due to muscular weakness. Before stem cell transplantation, the FVC, FEV1 and MVV were 1.4L, 1.4L and 59.5L respectively. 3 months after stem cell transplantation, the patients FVC, FEV1 and MVV were significantly increased to 2.12L, 2.12L and 118.0L respectively. CONCLUSION: Although genetically modified myoblast transplantation remains controversial for DMD, a significant change in spirometry was found in this DMD patient after stem cell transplantation. CLINICAL IMPLICATIONS: Spirometric measurement provides a simple and useful means of assessing disease progression in DMD patients and should be considered when stem cell transplantation is planning.Furthermore, since DMD characterized by gradually developing muscular weakness, pulmonary physical rehabilitation should focus on the training of respiratory accessory muscles. DISCLOSURE: Yubiao Guo, None.
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PREVALENCE OF EMPHYSEMA-LIKE CHANGES OF THE LUNGS AMONG YOUNG HEALTHY ADULTS, AND AMONG THOSE WITH SIMILAR PHYSIOGNOMY TO PATIENTS WITH PRIMARY SPONTANEOUS PNEUMOTHORAX: A THORACOSCOPIC EVALUATION Kayvan Amjadi MD* Eef Vanderhelst MD Brigitte Velkeniers MD Marc Noppen MD Queens University, Kingston, ON, Canada PURPOSE: To thoracoscopically determine the prevalence of emphysema like changes (ELCs) among young healthy adults, and among healthy individuals who are age, gender, height, weight and smoking habit-matched to patients with diagnosis of primary spontaneous pneumothorax (PSP). METHODS: We performed bilateral thoracoscopic evaluation of the lungs in healthy individuals who were referred to us for thoracoscopic thoracic sympathectomy. Presence of ELCs, age, gender, height, weight, smoking habits, and pulmonary function tests were documented. Comparisons of these parameters were made between ELC-positive and ELC-negative individuals. Participants were enrolled into a registry, allowing long-term follow-up (6 years). Individuals were then matched to a group of 12 PSP patients (all male, mean age 29.9, range 17 43, mean height standard deviation (SD); 1.79 0.07 meters, mean weight SD; 68.7 9.9 kilogram, mean body mass index (BMI) SD; 21.3 2.7, smoker/non-smoker 0.6). Prevalence of ELCs among healthy individuals with matched characteristics was evaluated. RESULTS: Analysis was performed on 250 consecutive cases (male/ female 0.4, mean age SD; 29 10 years). ELCs were observed in 15/250 (6%) individuals (male/female 6/9, mean age 25.3, range 15 51). Compared to ELC-negative group, ELC-positive individuals had a significantly lower body mass index (BMI) (20.7 2.4 vs. 22.7 3.4; P 0.027), whereas all other parameters were similar. ELCs tended to be more prevalent among smokers; however, statistical significance was not achieved (P 0.76). Similarly, in the matched group, ELCs were observed in 6/101 (6%) individuals. During 6 years of follow-up, none of the ELC-positive individuals has developed pneumothorax. CONCLUSION: Thoracoscopically, ELCs were present in 6% of young healthy adults with no underlying lung disease. Low BMI ( 22) appears to play an important role in the development of ELCs. CLINICAL IMPLICATIONS: Given that far less than 6% of the population develops PSP, we hypothesize that ELCs in PSP population is at least in part due to their physiognomic features and not the obligatory cause of pnemothorax. DISCLOSURE: Kayvan Amjadi, None.
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Operating Characteristics of Each Tumor Marker and Combinations of Tumor Markers in Patients With Pleural Effusion
% Tumor Marker Serum CA 15-3 NSE CEA CA 125 Pleural Fluid CA 15 -3 NSE CEA CA 125 CA 15-3 NSE CA 15-3 in serum CA 15-3 in pleural fluid CA 15-3 in serum NSE in pleural fluid CA 15-3 in serum CA 15-3 and CEA in pleural fluid CA 15-3 in serum CA 15-3 in serum fluid CA 15-3 CA 15-3, 76.5 80 100 100 100 100 77.8 81.3 87 89 and NSE in pleural fluid NSE and CEA in pleural 80 88.9 88.9 80 84 76.2 77.3 76.3 77.3 77 21.11 5.21 3.60 1196.67 70 68.4 47.4 48.6 57.5 71.4 83.3 75 85.3 70.6 91.9 86.4 82.4 71.4 74.3 69.2 78.3 59.2 42 87 34.5 70.4 88.5 66.7 76 72 65 39 74 78 29.07 10.36 2.95 50.65 59.5 38.9 47.2 50 63.6 63.6 81.8 48.5 64.7 58.3 51.1 46.2 42.6 26.1 53 47.2 61 49 37 50 Cutoff % % % % Accuracy Sensitivity Specificity PPV NPV
diagnostic utility of four tumor markers in patients with pleural effusion. METHODS: Pleural and serum levels of carcinoembryonic antigen (CEA), carbohydrate antigen 15-3 (CA 15-3), neuron specific enolase (NSE) and cancer antigen 125 (CA 125) were assayed prospectively in 77 patients with pleural effusion (40 malignant and 37 benign).
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Table 1
Tuberculosis Protein (mg/dl) PSR-Protein Albumin-EF PSR-Albumin 1 globulin-EF PSR- 1 globulin 2 globulin-EF PSR- 2 globulin globulin-EF PSR- globulin globulin-EF PSR globulin * p 0.05 5.4 (4.9 5.7) 0.69 (0.65 0.73) 2.63 (2.35 2.9) 0.77 (0.71 0.83) 0.23 (0.2 0.3) 0.62 (0.54 0.7) 0.47 (0.4 0.6) 0.52 (0.46 0.6) 0.8 (0.62 0.9) 0.69 (0.6 0.77) 1.14 (0.9 1.4) 0.64 (0.57 0.7)
Malignancy 4.3 (3.7 4.9) * 0.61 (0.54 0.65) * 2.5 (2.1 2.8) * 0.77 (0.64 0.77) * 0.2 (0.14 - 0.23) * 0.53 (0.41 0.62) * 0.3 (0.2 0.4) * 0.36 (0.28 0.43) * 0.6 (0.46 0.71) * 0.52 (0.41 0.63) * 0.7 (0.52 0.9) * 0.55 (0.46 0.65) *
COMPARISON BETWEEN PLEURAL FLUID PH MEASUREMENTS OF SPECIMENS COLLECTED IN HEPARINIZED VERSUS NON-HEPARINIZED SYRINGES Ali H. Debek MD* Pierre Bou-Khalil MD Ghassan Jamaleddine MD Nadim Kanj MD Mohammad Khatib PhD American University of Beirut -MC, Beirut, Lebanon PURPOSE: Pleural fluid pH measurement is an important tool for characterizing the type of pleural fluid, establishing a diagnosis, and guiding clinical management. The current standard and widely accepted practice is to collect pleural fluid samples for pH measurement in heparinized syringes and to instantaneously process these samples at room temperature. We conducted a prospective study to investigate the changes in pleural fluid pH measurements collected in heparinized versus non heparinized syringes and processed at various time intervals while the samples are preserved at room temperatur. METHODS: This is a prospective study in an academic tertiary medical center. From 50 consecutive (n 50) thoracentesis, 1ml of pleural fluid was collected anaerobically in each of six 3 ml syringes. Three syringes were coated with heparin. Samples in each syringe type (heparinized (H) and non-heparinized (NH)) were processed for pleural fluid pH measurements at time 0 (T0), one hour (T1) and two hours (T2) post collection. All specimens were preserved at room temperature until the
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CONCLUSION: Total proteins and their subsets were significantly higher in the pleural effusion due to tuberculosis as compared to the malignant, suggesting a more intense inflammatory response in the tuberculous group. CLINICAL IMPLICATIONS: These data may colaborate in the differentiation between the tuberculous and malignant pleural effusions. DISCLOSURE: Roberta Sales, None.
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VIBRATION RESPONSE IMAGING (VRI): A NEW MODALITY FOR EVALUATION AND FOLLOW-UP OF PLEURAL EFFUSION (PE) Ram Mor MD* Tatiana Boikaner MD Avi Man MD Zipi Yemini Igal Kushnir MD Joel Greif MD Pulmonary Institute, Tel Aviv Med Center, Tel-Aviv, Israel PURPOSE: Imaging is essential for confirmation of PE, especially prior to taping. Chest X-ray (CXR) cannot be done effectively at bedside and involves radiation. Ultrasound requires expensive equipment and special skills. Follow-up of patients after drainage usually involves repeated radiation for weeks or months.The VRI system constructs a dynamic lung image from vibrations produced by airflow. The vibrations, hence the image, are altered by the airway and parenchymal abnormalities. The vibration energy from 40 sensors, attached to the back, is processed during breathing cycles and creates a dynamic image. The presence of fluid as well as compression and displacement of the lungs by PE are easily detected by this method. Changes in the amount of pleural fluid can be seen in successive VRI recordings. To evaluate this novel technology in the monitoring of PE compared to conventional CXR. METHODS: We analyzed the VRI of 10 patients (6 males) with avg. 69.7 yrs with PE. The presence of PE was confirmed by a standard CXR; one case of large PE ( 2 Lit.), 6 with moderate PE (12 Lit.) and 2 with small PE ( 1 Lit.). Repeated CXR and VRI were obtained following drainage in all cases. RESULTS: The characteristic VRI image of PE showed a meniscus shape in the lower lobe(s) and absence of vibration response (VR) in the area of the pleural fluid. Absence of VR was correlated to the region of PE as determined by the CXR in 9/10 (90%) patients. Following treatment, VRI images showed increased vibration response in the drained area in all 10 cases, which corresponded with CXR clearing. The decrease in fluid level after drainage was evident in all the VRI recordings. CONCLUSION: The VRI provides a simple, bedside, radiation-free approach to follow the course of pleural effusion; thereby, improving the cost effectiveness of bedside evaluation and follow up. CLINICAL IMPLICATIONS: The VRI provides a simple, radiationfree approach to follow the course of pleural effusion; thereby, improving the cost effectiveness of bedside follow up. DISCLOSURE: Ram Mor, None.
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POSTER PRESENTATIONS
METHODS: We analyze FVC, Maximum Inspiratory Pressure (PImax), Maximum Expiratory Pressure (PEmax) daily until the 6th day after CABG, and Atelectasis and pleural effusion (X-ray and CT) on the 6th day after CABG. It was studied 60 patients consecutively after CABG. Lower lobe atelectasis at X-ray was scored (0 no atelectasis; 1 plate-like atelectasis; 2 atelectasis of a single segment; 3 atelectasis of more than one segment; 4 lobar atelectasis). Pleural effusion on X-ray was scored (0 no pleural effusion; 1 blurring of the costo-phrenic angle; 2 effusion occupying one to two intercostal spaces; 3 effusion occupying more than two intercostal spaces). Pleural effusion volume on computerized tomography was estimated through the formula d 2 x l 2,
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Table 2:Values are means SE; V; S UP6(.O2, O2 consumption; . V; S UP6( CO2, CO2 excretion; RER, respiratory exchange ratio; V; S UP6(.E, minute ventilation; MVV, maximal voluntary ventilation; VT, tidal volume; fb, frequency of breathing; HR, heart rate; p 0.05 arm vs leg; * p 0.05 COPD patients vs control.
DISCLOSURE: Castagna Olivier, None.
PARAMETERS OF RESPIRATORY FUNCTION AS INDICATORS OF AEROBIC CAPACITY ATHLETES Nenad Ponorac MD Amela Matavulj MD* Nikola Grujic MD Zvezdana Rajkovaca MD Pedja Kovacevic MD Medical School, Department for Physiology, Banjaluka, Bosnia-Herzegovina PURPOSE: The term aerobic capacity represents the sum of aerobic metabolic processes in human organism. It is the bases of the physical working capacity. Parameters of respiratory function are very informative and appropriate for aerobic capacity researching. The purpose of this study was to check possibilities of using respiratory parameters as the indicators of aerobic capacity in athletes and to check differences in regard to non- athletes [1, 2]. The goals were: 1.Analyses of respiratory function parameters in various sports athletes 2.Comparison with values obtained in non-athletes. METHODS: This study included 67 athletes (rowers, soccers, and judo) and 28 non-athletes. Respiratory parameters (maximal voluntary ventilation / Ve, respiratory volume / RV and breathing frequency / Fr) were measured during determination VO2max, direct method. RESULTS: Results obtained show statistically higher Ve values in rowers (142 L/min) in regard to soccers (123 L/min) and judo (111 L/min). Successfully rowing requires high anaerobic capacity and so effective maximal voluntary ventilation. CONCLUSION: These results express the grater values of Ve and other parameters too, in athletes in regard to non-athletes. Reason for these results is just process of training. Other parameters of respiratory function were not useful for determination the aerobic capacity. CLINICAL IMPLICATIONS: These parameters are limitation factors for physical activities only in patients with obstructive and restrictive diseases.
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SECONDARY PULMONARY HYPERTENSION IN GERIATRIC POPULATION Sotir Polena MD Eirene Mamakos MD* Anwar Hague MD Christos Iakovou MD Rick Conetta MD Rajen Maniar MD Flushing Hospital Medical Center, Flushing, NY PURPOSE: Pulmonary hypertension (PH) is a disease with a very poor prognosis. Although primary PH remains a rare pathology, PH related to other diseases is being diagnosed quite often. Chronic respiratory disorders, hypoxia, thromboembolic events, valvular disorders, systolic and diastolic dysfunction etc have all been listed as potential pathologies that can lead to the development of the secondary PH. One of the reasons for the increased prevalence of the secondary PH is attributed to the aging population. The aim of our study is to identify the etiological factors (comorbidities) that contribute to the development of the secondary PH in geriartric population. METHODS: We conducted a retrospective analysis of 153 elderly patient charts after an echocardiografic study, which identified moderate pulmonary hypertension ( 50mm Hg). The medical charts were reviewed in detail, data from the echo-lab and findings from the computerized tomography (CT) of the chest were analyzed. RESULTS: The study population consisted of elderly patients (mean age 76.8) 66% male and 44 females. Systemic hypertension was found to be present on 72 % of the patients (110). Two (1.3%) patients were found to have severe mitral valve dysfunction. Left atrium and left ventricule diameter was enlarged in 75% (115) of the patients. Moderate to severe systolic dysfunction (EF 30%) was recorded in 28% (43) of the patients and dyastolic dysfunction in 17% (26). CT findings were categorized in normal findings, airway disease, interstitial/ inflammatory changes, and pulmonary embolisms (PE), respectively 12%, 20%, 68%, 11%. In a few CTs combined interstitial changes with pulmonary embolism were found. CONCLUSION: The etiology of secondary pulmonary in geriartric population is mainly attributed to systemic hypertension, interstitial/ inflammatory pulmonary disorders, systolic and diastolic dysfunction. History of airway disease, PE, and valvular dysfunction are also important. CLINICAL IMPLICATIONS: Aggressive treatment of cardiopulmonary disorders in geriartric population can delay or even stop the development of the secondary PH. DISCLOSURE: Eirene Mamakos, None.
POSTER PRESENTATIONS
DISCLOSURE: Claire Gilbert, Shareholder Pfizer Ltd; Employee Pfizer Ltd. OUTCOMES OF INVESTIGATING PULMONARY ARTERY HYPERTENSION Vinay K. Sharma MBBS* Karim Djekidel MD Graduate Hospital, Philadelphia, PA PURPOSE: With increasing use of echocardiography, an increasing number of patients are being identified as having pulmonary artery hypertension (PAH). In patients with normal systolic left ventricular (LV) function, extensive work up is often performed, even in patients in whom a comprehensive history, physical examination and chest radiograph does not suggest an underlying diagnosis. This descriptive study investigates the characteristics of these patients and the outcomes of diagnostic testing. METHODS: Pulmonary consult sheets over a period of 4 years were reviewed, and patients with newly diagnosed PAH, by echocardiography, identified. Patients with a likely etiology for PAH on history or examination were excluded from the study. Medical records were then reviewed and the following data abstracted: patient demographics, co-morbid conditions, medications taken, and results of echocardiography, chest CT scan, PFT, polysomnogram, serologies for connective tissue disorders, and tests for pulmonary embolism (PE) (ventilation-perfusion scan or PE protocol chest CT). RESULTS: Twenty-six patients were included in the study. Twenty (77%) were women. Mean age was 66 ( 11) years and 19 (73%) were hypertensive. The mean pulmonary artery systolic pressure was 60 ( 12) mmHg and LVH was present in 19 (73%). An average of 3.5 diagnostic studies were done. Three of 22 chest CT scans were abnormal: 2 with interstitial lung disease and one with severe emphysema. One of 18 PE studies was abnormal. Nine of 12 polysomnograms revealed obstructive sleep apnea. Two of 12 serologies were abnormal. 23 patients had PFTs: 16 had minor abnormalities, 4 had severe restriction and one severe obstruction. Five (19%) had relatively normal studies except for elevated PAP on echocardiography. Seven (27%) patients had LVH and no other abnormality that adequately explained PAH. Six (23%) patients had LVH and OSA. CONCLUSION: The prevalence of hypertension and LVH was unexpectedly high in our cohort of PAH. Except for polysomnograms, the other studies had poor diagnostic yields. CLINICAL IMPLICATIONS: LVH with diastolic dysfunction may be the underlying etiology in a significant proportion of patients with PAH. DISCLOSURE: Vinay Sharma, None.
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ESTABLISHING A MINIMALLY IMPORTANT DIFFERENCE IN 6-MINUTE WALK DISTANCE AND SF-36 AMONG PATIENTS WITH PULMONARY ARTERIAL HYPERTENSION Claire Gilbert* Martin C. Brown Joseph C. Cappelleri PhD Tamiza Parpia PhD Stephen P. McKenna PhD Pfizer Ltd, Sandwich, United Kingdom PURPOSE: There are currently no guidelines or standards to help physicians determine whether or not the treatment provided to patients with pulmonary arterial hypertension (PAH) results in a clinically important benefit. This study was undertaken to define the level of change in exercise capacity, as measured by the 6-minute walk distance (6MWD), and functioning and well-being, as measured by the SF-36, that is clinically meaningful in patients with PAH: a minimally important difference (MID). METHODS: Data from a 12-week sildenafil study were used to evaluate an MID for 6MWD and the physical functioning, role-physical, social functioning, and vitality domains of the SF-36 in patients with PAH, using the following distribution-based approaches: Effect Size (ES), Standard Error of Measurement (SEM), and Standard Error of the
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Hemodynamics
PAH Echo PASP(mmHg) RV diameter(cm) mPAP(mmHg) PVR(WU) 79 3.06 52 12.7 19 0.7 16 7 PHLD 60 17 2.11 0.5 32 4 p 0.04 p 0.009 p 0.04
WARFARIN MANAGEMENT IN PULMONARY ARTERIAL HYPERTENSION IS SIMILAR BETWEEN BOSENTAN, PLACEBO, AND SITAXSENTAN Terrance Coyne MD* Richard Dixon PhD Encysive Pharmaceuticals, Houston, TX PURPOSE: Warfarin, commonly used in pulmonary arterial hypertension (PAH) is a difficult therapy to use, requiring frequent and ongoing monitoring to achieve safe and effective anticoagulation, with dosing influenced by changes in diet as well as drugs. As an inducer of CYP2C9, bosentan (BOS), a twice daily, nonselective ETRA, interacts with the metabolism of warfarin. As an inhibitor of CYP2C9, sitaxsentan (SITAX), a once daily, highly ETA selective ETRA, also interacts with the metabolism of warfarin. Here, we report on the management of warfarin from a multi-center, placebo (PBO)-controlled study, STRIDE-2. METHODS: STRIDE 2 included SITAX 100mg once daily, 50mg once daily, PBO, and an open-label, efficacy rater blinded, arm of BOS BID. BOS was dosed according to label. The protocol recommended that patients (pts) on warfarin randomized to SITAX or PBO were, at study entry, to have a single reduction in warfarin dose of 80%, followed by usual management. Pts on warfarin at study entry and randomized to BOS did not have warfarin dose adjusted. Warfarin doses at endpoint and the total number of dosing changes in the 18 week trial were assessed. RESULTS: 47% of pts were on warfarin at study entry. Results for wk 18 mean warfarin dose and mean number of dose changes per pt are shown in Table 1. CONCLUSION: Warfarin dose was higher in BOS pts and lower in SITAX pts than PBO, consistent with expectations. Nonetheless, warfarin dosing changes were equally frequent for pts treated with BOS, SITAX, or PBO, indicating no meaningful difference in management complexity. CLINICAL IMPLICATIONS: Warfarin is a difficult therapy to use and requires frequent and continuous monitoring. The management of warfarin in patients with PAH is similar between no ETRA therapy and the use of either bosentan or sitaxsentan.
Treatment Groups (n) PBO (33) SITAX 50mg (26) SITAX 100mg (27) Bosentan BID (29)
Warfarin dose at wk 18 3.7 2.7 2.8 1.2 2.1 1.0 5.1 2.9 (mg/d; mean sd) Mean # of changes in 1.6 1.8 1.8 1.7 warfarin dosing per pt
DISCLOSURE: Terrance Coyne, Employee Encysive Pharmaceuticals; Product/procedure/technique that is considered research and is NOT yet approved for any purpose. Sitaxsentan.
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Pre
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PASP (mm) PADP (mm) mPAP (mm) mRAP (mm) CO (L/min) CI (L/min) PCWP (mm) PVR (dynes/sec/cm5) PaO2 sat% 6MWD (ft) NYHA Class Hemoglobin (g/dL) Platelets (103 /mcl)
POSTER PRESENTATIONS
PASP pulmonary arterial systolic pressure, PADP pulmonary arterial diastolic pressure, mPAP mean pulmonary arterial pressure, mRAP mean right atrial pressure, CO cardiac output, CI cardiac index, PCWP pulmonary capillary wedge pressure, 6MWD six minute walk distance, NYHA New York Heart Association,
Patient 1 Age Gender Etiology of cirrhosis 56 F cryptogenic Patient 2 59 M alcohol Patient 3 53 M Hepatitis C, alcohol Child-Pugh class Complications B EV,GV, portal vein thrombosis, thrombocytopenia B EV, thrombocytopenia B Encephalopathy, thrombocytopenia
DISCLOSURE: Zoheir Bshouty, None. TREATMENT OF PORTOPULMONARY HYPERTENSION WITH ORAL SILDENAFIL Shiraz A. Daud MD* Murali M. Chakinala MD Washington University in Saint Louis, St Louis, MO PURPOSE: Pulmonary arterial hypertension (PAH) in the setting of portal hypertension, or Porto-pulmonary Hypertension (PPHTN), has an estimated prevalence of 3.5% to 12.5% in patients referred for liver transplantation. Complications of cirrhosis such as encephalopathy, high cardiac output state, and thrombocytopenia have made treatment with prostanoids challenging. Furthermore, Bosentan is contraindicated in chronic liver disease and severe pulmonary hypertension is a contraindication to liver transplantation. We report our experience with oral Sildenafil monotherapy in PPHTN. METHODS: This is a case series of three patients with PPHTN treated with off-label Sildenafil. Secondary causes of pulmonary hypertension were excluded. Laboratory and hemodynamic data, New York Heart Association functional class, and six-minute walk distance (6MWD) were obtained at baseline and after treatment for an extended period with Sildenafil. RESULTS: All three patients had improvements in their hemodynamics and 6MWD. Functional improvement was evident in all three patients. During the 31 patient-months of follow-up, there were no directly attributable side effects or complications of Sildenafil. CONCLUSION: Sildenafil is a safe and effective pulmonary vasodilator for patients with PPHTN. CLINICAL IMPLICATIONS: Because conventional PAH therapies are potentially problematic in the setting of cirrhosis, sildenafil should be considered as a chronic therapeutic choice in PPHTN and may serve as a bridge to liver transplantation.
Symptoms at presentation
EV
esophageal varices, GV
gastric varices
DISCLOSURE: Shiraz Daud, None. TREATMENT OF SECONDARY PULMONARY ARTERIAL HYPERTENSION WITH ENDOTHELIN RECEPTOR BLOCKADE Satyendra Sharma MBBS* Roger Philipp MD Tarik Kashour MD University of Manitoba, Winnipeg, MB, Canada PURPOSE: Secondary pulmonary arterial hypertension (SPAH) is an adverse outcome of a variety of systemic disorders. These include collagen vascular diseases, chronic thromboembolism, human immunodeficiency virus (HIV), portal pulmonary hypertension and other diseases. Progression of SPAH may persist despite stabilization of the causative disease and contributes to the poor quality of life and unfavorable survival in these patients. Treatment of the underlying cause and oxygen supplementation may alleviate symptoms, but no specific therapy to treat SPAH currently exists. Endothelin receptor blockade with bosentan has been shown to be beneficial therapy in the treatment of primary pulmonary hypertension but efficacy of this therapy in SPAH has not been established. METHODS: Retrospective review of patients followed through our clinic. RESULTS: We describe a case series of six patients with disparate causes of SPAH, who benefited from endothelin receptor blockade
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Factor Demographics mean age years High school graduate Female gender White race Never smoker Past Medical History Prior independence History of renal disease ICU day one albumin (g/dL) mean creatinine (mg/dL) median hemoglobin (g/dL) median ICU LOS (days) median LTACH day one albumin (g/dL) mean creatinine (mg/dL) median hemoglobin (g/dL) median LTACH LOS (days) median
31 (74%) 7 (17%)
9 (45%) 8 (40%)
0.0441 0.0449
2.80
0.85
2.31
0.58
0.95 12.1 30
1.3 11.75 27
2.37
/- 0.5
2.03
0.75 10.75 24
OUTCOME OF CHRONIC VENTILATED PATIENTS TRANSFERRD TO A STEP-DOWN RESPIRATORY CARE CENTER IN TAIWAN Fung J. Lin MD* Chang-Yi Lin MD Pei-Jan Chen MD Hsu-Tah Kuo MD MacKay Memorial Hospital, Taipei, Taiwan ROC PURPOSE: The aim of the study was to investigate the outcome of prolonged ventilated patients after their transferal from intensive care units (ICU) to the step-down respiratory care center (RCC) in Taiwan. METHODS: This was a retrospective observational study in a stepdown RCC. Adult patients who was admitted to RCC from October 2000 to September 2001 were eligible for the study. Admission criteria of RCC included age 17 years old, MV for 14 days, arterial oxygenation 60mmHg with the fraction of inspired oxygen (FiO2) 0.55, and positive end-expiratory pressure of 10 cmH2O. The primary outcome was the survival in the RCC and after discharge from the RCC. RESULTS: Total 224 cases were eligible for the survey, and 108(48.2%) patients were successfully liberated in the RCC. Those who failed weaning had a longer stay in the ICU and RCC (25.1 vs. 20.9 days, and 31.4 vs. 18.6 days with p 0.05). After discharge from the RCC, another 4.9% of the failed patients were weaned within the one year. Patients who failed weaning in RCC had a shorter survival time (5.2 vs. 10.4 months, p 0.05) and a lower one-year survival (23.6% vs. 44.6%, p 0.05). CONCLUSION: Patients who were transferred to RCC were still in critical condition, and 25% of these patients died during their stay in the RCC. However, a step-down RCC cound offer a continual care of these pronlonged ventilated (PMV) patients who could not be weaned when in
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FACTORS AFFECTING WEANING AND SURVIVAL OUTCOMES IN PATIENTS ON PROLONGED MECHANICAL VENTILATION Debapriya Datta MD* Paul Scalise MD Manchester Hospital, Manchester, CT PURPOSE: Literature is limited on weaning and survival outcomes in patients on prolonged mechanical ventilation (PMV), which is defined as ventilatory support 21 days . The objective of this study was to determine factors affecting weaning and survival outcomes in patients on PMV. METHODS: We retrospectively studied patients on PMV admitted for weaning to a regional weaning center over a 3-year period. The following data was abstracted from records: patients age, sex, precipitating cause of respiratory failure, duration of ventilatory support (Dvs), percent ideal bodyweight (%IBW), body mass index (BMI), serum albumin, prealbumen, BUN, serum creatinine (Cr), creatinine clearance (CrCl), hemoglobin (Hb), WBC count, total lymphocyte count (TLC) and serum TSH levels. Outcomes noted were liberation from PMV, defined as being off ventilatory support for 7 days and survival (alive at discharge or not). Multivariate analysis was used to determine relation between studied parameters and outcome. Chi square test was used to test statistical significance, with p 0.05 being deemed statistically significant. RESULTS: Of 202 patients studied, 48% were males. Mean age was 66.3 16 years. Cause of respiratory failure was cardiovascular surgery in 27%; other surgery in 14.5%; COPD in 21%; pneumonia in 9%; ARDS in 6%; neurological disease in 18.5% and CHF in 4%. Mean Dvs was 60.8 days (range 21-680 days). Sixty-seven percent were liberated from PMV; 33% failed to wean. Seventy-one percent survived to discharge. Dvs 12 weeks was associated with better weaning outcome. Table 1 depicts studied parameters in liberated patients and patients that failed to wean. On multivariate analysis, factors associated with adverse impact on liberation were: COPD as cause of respiratory failure, longer Dvs, lower CrCl. Factors associated with adverse survival outcome were CHF and COPD as causes of respiratory failure, higher Cr and lower TLC. CONCLUSION: Multiple factors affect weaning and survival outcomes in patients on PMV. CLINICAL IMPLICATIONS: More studies are needed to develop screening criteria for selection of appropriate patients on PMV for admission to weaning facilities.
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ASSESSMENT OF THE EFFICACY AND SAFETY OF SINGLEDOSE EXTENDED-RELEASE (ER) CEFUROXIME AXETIL IN ADULT INDIAN PATIENTS WITH ACUTE EXACERBATIONS OF CHRONIC BRONCHITIS (AECB) Anish A. Desai MD* A B. Mishra MD G Bhatia MD R S. Murlidaharn MD G S. Kadam MD Ashish S. Gawde MD Vidyagauri P. Baliga PhD Glenmark Pharmaceuticals Ltd, Mumbai, India PURPOSE: Cefuroxime axetil possesses activity against Streptococcus pneumoniae Moraxella catarrhalis and Hemophilus influenzae and has beta-lactamase stability. It is therefore useful in the treatment of acute exacerbations of chronic bronchitis. An extended-release (ER)preparation of cefuroxime axetil has been recently formulated. The present study evaluated the efficacy, tolerability and safety of this new ER- formulation of Cefuroxime in adult Indian patients with AECB. METHODS: Adults patients(n 125) with clinically and radiologically confirmed AECB were enrolled in this prospective, multicentric , open label, non-comparative Phase III study after obtaining informed consent. The study was approved by the respective Institutional Review Boards. Patients fulfilling the selection criteria received 1g. ER-Cefuroxime axetil once-daily for 10 days. Efficacy outcomes included clinical and bacteriological response at the end of therapy. Safety was assessed by monitoring. RESULTS: Following therapy with ER Cefuroxime, there was a significant reduction in body temperature, chills, dyspnea, chest pain by Day 3 which further improved on Day 10. There was a significant improvement in the quantity, consistency, nature and odour of sputum, intensity of cough and ausculatory findings by Day 3 which was sustained till the end of study. The effects of therapy on primary outcome measures are depicted in Table 1. Adverse events were reported by only 12% of the study population. CONCLUSION: ER-Cefuroxime axetil 1g. once daily was effective and safe in the treatment of AECB. CLINICAL IMPLICATIONS: ER-Cefuroxime axetil 1g. once daily is a useful therapeutic option in the treatment of Acute exacerbations of Chronic bronchitis.
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COMPARATIVE EFFICACY OF ORAL AND SEQUENTIAL INTRAVENOUS/ORAL MOXIFLOXACIN IN THE TREATMENT OF COMMUNITY ACQUIRED PNEUMONIA (CAP) IN THE VERY ELDERLY (AGE > 75 YEARS) Antonio Anzueto MD* Daniel Haverstock MS Frank Kruesmann PhD Shurjeel Choudhri MD Univ. of Texas Health Sci. Ctr., San Antonio, TX PURPOSE: To evaluate the efficacy and safety of sequential IV/PO and PO moxifloxacin (MXF) versus that of comparator (COMP) antibiotics in very elderly ( 75 years old) patients with CAP. METHODS: Data were pooled from all global, randomized, controlled trials of IV/PO (5 trials) and PO (5 trials) of MXF in the treatment of CAP. The pooled data were used to determine the clinical success rates and adverse event rates in the very elderly for both MXF and COMP-treated patients. The comparators were clarithromycin and amoxicillin in the PO studies and trovafloxacin, levofloxacin, ceftriaxone azithromycin and amoxicillin/clavulanate clarithromycin in the sequential IV/PO studies. RESULTS: Of the 908 very elderly patients identified in the pooled analysis, 215 (114 MXF, 101 COMP) received PO and 693 (349 MXF, 344 COMP) received sequential IV/PO therapy. Of these, 158 PO-treated (84 MXF, 74 COMP) and 497 IV/PO-treated (248 MXF, 249 COMP) patients were valid for the primary efficacy analysis. Clinical success rates in IV/PO studies were 90% (222/248) for MXF vs. 83% (206/249) for COMP (95% CI 0.3%, 12%). For PO studies clinical success rates were 95% (80/84) for MXF vs. 86% (64/74) for COMP (95% CI 0.7%, 18.6%). Adverse and serious adverse event rates were similar in MXF- and COMP-treated patients. CONCLUSION: Both IV and PO moxifloxacin were highly efficacious and safe in treating community acquired pneumonia in the very elderly and overall cure rates were significantly better in moxifloxacin treatedpatients than those achieved with the comparator regimens. CLINICAL IMPLICATIONS: Moxifloxacin appears to have excellent efficacy when used as empiric monotherapy for the treatment of CAP in very elderly patients. DISCLOSURE: Antonio Anzueto, Employee Dan Haverstock, Frank Kruesmann, Shurjeel Choudhri; Consultant fee, speaker bureau, advisory committee, etc.
POSTER PRESENTATIONS
DISCLOSURE: I Morrissey, Grant monies (from industry related sources) Oscient; Shareholder Oscient; Employee Oscient; Consultant fee, speaker bureau, advisory committee, etc. Oscient. THE EFFECT OF COMPUTERIZED ORDER SETS ON QUALITY INDICATORS FOR HOSPITALIZED PATIENTS WITH COMMUNITY ACQUIRED PNEUMONIA Kathryn Wood MPH Allyson Mirabella MD* Jonathan Gottlieb MD Thomas Jefferson University, Philadelphia, PA PURPOSE: Evaluate the impact of a computerized order set on the adherence to core measures in patients with Community Acquired Pneumonia (CAP). METHODS: Study was conducted as a retrospective chart review at a tertiary care academic medical center with mandatory computerized physician order entry (CPOE). Study population was defined as all adult patients admitted between December 2003 and October 2004 whose physicians used a standardized CAP order set. Controls were matched on age and gender over the same time period from patients without use of a CAP order set but within DRG 89 or 90. The groups were compared on five core measures: oxygenation assessment, pneumoccocal vaccination, smoking cessation counseling, and time to blood culture and antibiotics. Length of stay, appropriateness of antibiotic, and admitting services were also compared. RESULTS: The records of 20 order set and 20 controls were abstracted. Combining all CAP indicators, use of the order set was associated with a significantly greater proportion of quality indicators than controls (60% vs. 40%, p 0.0017). Use of order sets was associated with greater proportion of every quality indicator, although differences were not
RESISTANCE PHENOTYPES OF STREPTOCOCCUS PNEUMONIAE AND CLINICAL OUTCOME OF RESPIRATORY TRACT INFECTIONS TREATED WITH GEMIFLOXACIN Ian Morrissey PhD Thomas File MD* Lionel Mandell MD Glenn S. Tillotson MS SUMMA Healthcare, Akron, OH PURPOSE: Gemifloxacin (GEM) is a potent fluoroquinolone with excellent activity against respiratory tract infection (RTI) pathogens, including S. pneumoniae (SP). Pooled data from 17 phase III clinical trials for GEM with community-acquired pneumonia, acute bacterial sinusitis & acute exacerbation of chronic bronchitis patients (pts. METHODS: 530 Pts where SP was the sole pathogen & SP susceptibility known, were evaluated.Clinical success at end of therapy (EOT) & at follow-up (FU, approx. 1-3 weeks after treatment) was studied. Main comparators (CMP) were cefuroxime (61 pts), amoxicillin-clavulanate (37 pts), trovafloxacin (34 pts), cefuroxime & clarithromycin (28 pts), levofloxacin or clarithromycin (11 pts). Percentage success based on susceptibility to penicillin G (Pen) and/or macrolides (Mac) is shown (Table, S susceptible, NS non-susceptible, R resistant, N pts/group). RESULTS: See Table.
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% Success (N) Phenotype All SP PenS PenNS MacS MacR PenR & MacR Treatment GEM CMP GEM CMP GEM CMP GEM CMP GEM CMP GEM CMP EOT 92.5% (321) 90.4% (209) 93.3% (252) 91.0% (166) 89.7% (68) 88.4% (43) 93.0% (256) 92.0% (175) 90.3% (62) 81.3% (32) 85.7% (28) 82.4% (17) FU 88.8% (321) 86.0% (207) 88.9% (252) 86.0% (164) 88.2% (68) 86.0% (43) 88.3% (256) 86.2% (174) 90.3% (62) 83.9% (31) 85.7% (28) 82.4% (17)
% Success (number of patients) Treatment Gemifloxacin Comparator Gemifloxacin Comparator Gemifloxacin Comparator Gemifloxacin Comparator Gemifloxacin Comparator EOT 86.9% (1166) 87.2% (933) 86.9% (291) 86.6% (262) 87.6% (129) 86.6% (82) 85.6% (181) 83.7% (190) 88.8% (356) 86.0% (299) FU 80.9% (1164) 81.6% (928) 82.1% (291) 79.0% (262) 82.2% (129) 77.8% (81) 77.3% (181) 73.7% (190)* 82.9% (356) 79.9% (298)
DISCLOSURE: Thomas File, Consultant fee, speaker bureau, advisory committee, etc. TF & LM are consultants to Oscient. DOES TELITHROMYCIN EXHIBIT IMMUNOMODULATORY PROPERTIES IN CHRONIC AIRWAY INFLAMMATION? Maysah S. El-Deen MD Abdalla A. Abu Hussein MS* Gamal A. El-Kholy MD Amany Abouzeid MD Tanta Intl Cardiothoracic Vascular Center, Tanta, Egypt PURPOSE: The role of telithromycin in the treatment of respiratory tract infections is well established. However, telithromycin seems to have immunomodulatory properties in chronic airway inflammation, including the inflammatory allergic condition bronchial asthma. The aim of this trial was to establish whether our clinical observation of an extended 1-2 months treatment with telithromycin in patients with chronic inflammatory airway disorder is beneficial. METHODS: Open comparative clinical trial with male and female patients aged 18-65 years with persistent cough, chronic obstructive bronchitis (with and without acute exacerbations), COPD or bronchial asthma. We compared post-treatment symptomatic relief and peak flow meter results with baseline recordings, while monitoring for adverse events, including abnormal laboratory values. RESULTS: 84 patients (46 males, 38 females, age 37.3 8.4 years) were enrolled. After 60 days of treatment (47.3 3.2 days), symptomatic relief and improved spirometry were significantly better (p 0.05) than baseline recordings. The main adverse events were diarrhea and dizziness. CONCLUSION: Telithromycin may have a role in the treatment of chronic airway inflammatory conditions including bronchial asthma. This may be explained by its high tissue penetration characteristic, and the increasing evidence that atypical respiratory pathogens (Mycoplasma pneumonia, Moraxella catarrhalis, and Legionella pneumophila), against which telithromycin is reportedly active, play a major role in the pathogenesis and prognosis of chronic inflammatory airway disorders. CLINICAL IMPLICATIONS: Extended treatment with telithromycin may provide further benefits to patients with chronic airway inflammation, especially where atypical respiratory pathogens are suspected. DISCLOSURE: Abdalla Abu Hussein, None. PATIENT RISK FACTORS IN COMMUNITY-ACQUIRED PNEUMONIA INFECTIONS OUTCOME FOLLOWING TREATMENT WITH GEMIFLOXACIN I Morrissey MD T.M. File Jr. MD L.A. Mandell MD* G.S. Tillotson MS McMaster University, Hamilton, ON, Canada PURPOSE: Respiratory fluoroquinolones are important agents in the management of patients with community-acquired pneumonia (CAP).
DISCLOSURE: LA Mandell, Grant monies (from industry related sources) Oscient; Shareholder Oscient; Employee Oscient.
CARDIO-PULMONARY MEDICAL HISTORY AND THE EFFECT ON CLINICAL OUTCOME OF COMMUNITY-ACQUIRED PNEUMONIA INFECTIONS TREATED WITH GEMIFLOXACIN I. Morrisey MD T.M. File Jr. MD L.A. Mandell MD G.S. Tillotson MS* Oscient, Waltham, MA PURPOSE: Gemifloxacin is a potent new fluoroquinolone with excellent activity against community-acquired pneumonia (CAP) pathogens. METHODS: Pooled data from 5 phase III CAP gemifloxacin clinical trials were evaluated. Patients were grouped based on cardio-pulmonary disease and medical history (CPD). Clinical response (success or failure) at end of therapy (EOT) & at follow-up (FU, approx. 1-3 weeks after treatment) was studied. Main comparators for CPD patients were cefuroxime & clarithromycin (97 patients), trovafloxacin (66 patients) & amoxicillin-clavulanate (55 patients). RESULTS: Percent success is shown in the table (* includes all 3 CPD groups in table plus patients with a medical history of angina, pulmonary heart disease, cardiomyopathy, cardiac murmurs, tachycardia or myocardial infarction). CONCLUSION: Although in general ,gemifloxacin showed slightly lower success than pooled comparators against CAP patients , gemifloxacin showed higher success rates than comparator against CPD patients.This difference was greater at FU than at EOT. CLINICAL IMPLICATIONS: These data support the use of gemifloxacin in the treatment of CAP, especially where the patient has a history of CPD.
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DISCLOSURE: GS Tillotson, Grant monies (from industry related sources) Oscient; Shareholder Oscient; Employee Oscient; Consultant fee, speaker bureau, advisory committee, etc. Oscient. FLUOROQUINOLONE AS 2ND CHOICE THERAPY IN NOSOCOMIAL PULMONARY COMPLICATIONS AFTER RESECTION FOR LUNG CANCER Cosimo Lequaglie MD* Gabriella Giudice MD Centro di Riferimento Oncologico Basilicata, Rionero in Vulture, Italy PURPOSE: To value the effect of quinolone therapy in lung cancer resected patients with nosocomial pulmonary infection. METHODS: A multicentric study is reported on 38 complicated patients and submitted to pulmonary resection for cancer after prophylaxis with cephalosporin. The patients developed a microbiological tested pulmonary infection after resection procedure. A history of chronic bronchopulmonary disease was present in 26 cases, bronchial asthma in 4. The isolated pathogens on bronchoalveolar lavage were Haemophilus influenzae (n 15), Streptococcus pneumoniae (n 11), Moraxella catarrhalis (n 3), Mycoplasma pneumoniae (n 7), Chlamydia pneumoniae (n 1) and Legionella pneumophila (n 1). A quinolone, the Levofloxacin, was employed to the dosing of 500 mg IV twice day for 10 days.The patients have been observed for 10 days by the basal find of nosocomial infection after pulmonary resection. The basal sputum results positive in 8 cases as also to the first control at 4th day of therapy, without presence of pathogens at the 2nd test. The basal bronchoalveolar lavage results positive in the remainders 30 cases as also in 4th day, and it has been positive at the 2nd test in alone 2 cases, but with reduction of the bacterial count. All the isolated pathogens were sensitive in vitro to Levofloxacin. RESULTS: There was a clinical improvement with resolution of the symptoms in 36/38. Eradication was in 34 cases about the pathogen in cause and a presumed eradication in 2 ones: in the remainders 2, the partial eradication in 1, while in the last one there was a colonization. Five patients had diarrhea for about 5 days, 3 headache for 2 days of which 1 with nausea and 1 asthenia for 6 days. CONCLUSION: On the escort of the microbiological finds the effected therapy has allowed to not only reach the microbiological eradication but also a clean improvement of the symptoms with reduction of the postoperative hospitalization. CLINICAL IMPLICATIONS: The clean improvement of the symptoms with reduction of the postoperative hospitalization increased reduces the costs of admission. DISCLOSURE: Cosimo Lequaglie, None. PENETRATION OF AMPHOTERICIN B IN HUMAN LUNG TISSUE AFTER SINGLE LIPOSOMAL AMPHOTERICIN B INFUSION Cosimo Lequaglie MD* Franco Fraschini PhD Germana Demartini PhD Franco Scaglione PhD Centro di Riferimento Oncologico Basilicata, Rionero in Vulture, Italy PURPOSE: To investigate the tissue levels and distribution of amphotericin B in lung after i.v. administration of liposomal amphotericin B (L-AmB) in patients with lung cancer resected. METHODS: We enrolled 18 adult ( 18 ys) patients with primary or secondary lung cancers. All patients were informed about the prospective study. There were 12 males and 6 females, both sexes ranging in weight from 53 to 86 kg, and in age from 28 to 65 years. L-AmB was administered by 1 hour single infusion at fixed doses of 1,5 mg/kg, and it was administered from 10 to 25 hours before the surgery. The starting and the end points of infusion were noted, the same for arterial and vein ligatures, and the end point of pulmonary tissue sample collection. Moreover, 10 ml of blood sample at the artery closure were collected. L-AmB was assayed in blood and lung tissue by an HPLC validated method of Bekersky et all
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DISCLOSURE: Prashant Borade, None. DETECTION OF HISTOPLASMA CAPSULATUM ANTIGEN IN BRONCHIAL ALVEOLAR LAVAGE SPECIMENS BY IMPROVED ANTIGEN DETECTION ENZYME-LINKED IMMUNOASSAY Lawrence J. Wheat MD Ann M. Le Monte BS Chadi Hage MD* Kenneth S. Knox MD Debra Blue-Hnidy MD Thomas E. Davis MD Indiana University School of Medicine, Indianapolis, IN PURPOSE: Detection of H. capsulatum antigen by Enzyme-linked Immunoassay (EIA) is well documented, and an improved 2nd generation assay exhibits increased sensitivity and specificity for urine and serum specimens as compared to the original EIA. The purpose of this study is to compare sensitivity for detection of antigen in bronchial alveolar lavage (BAL) specimens in the 2nd generation vs. original H. capsulatum antigen assay. METHODS: BAL specimens previously submitted for H. capsulatum antigen detection were evaluated concurrently in the new 2nd generation vs. original immunoassays. RESULTS: Of the 39 BALs tested, 14 were positive in the 2nd generation assay vs. 10 in the original assay. For the positive specimens, the median antigen level was 4.15 EIA units in the 2nd generation vs. 1.36 EIA units in the original assay. CONCLUSION: Testing of BAL samples for H. capsulatum antigen may aid in rapid diagnosis. Sensitivity of antigen detection in BALs was greater in the 2nd generation assay. CLINICAL IMPLICATIONS: Bronchoscopy with BAL for Histoplasma antigen determination offers an adjunctive method for rapid diagnosis of pulmonary histoplasmosis. Improvements in the antigen immunoassay increase its sensitivity for diagnosis. DISCLOSURE: Chadi Hage, None. ENDOBRONCHIAL ASPERGILLOMA: A RETROSPECTIVE CASE REVIEW Doyun Kim MD* Yoonsu Chang MD Hyungjung Kim MD Chulmin Ahn MD Department of Internal Medicine Yonsei University College of Medicine, Seoul, South Korea PURPOSE: As compared to aspergilloma which is usually developed after complication of tuberculosis in Korea, endobronchial aspergilloma is a rare disease entity and clinical findings and natural course is not well known. We retrospectively analyze the clinical, radiological, and bronchoscopic finding and treatment options in patients confirmed as endobronchial aspergilloma. METHODS: From 1993 to 2005, eight patients were identified with endobronchial aspergilloma in Yongdong Severance hospital. We reviewed medical records for analysis of clinical, radiological, and bronchoscopic finding, and treatment options and result. All cases are confirmed as endobronchial aspergillosis by bronchoscopic biopsy and pathological finding. The patients ranged in age from 46 to 67 (mean 55.3). There are 3 males and 5 females.
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POSTER PRESENTATIONS
CYTOPATHIC CHANGES OF HERPES SIMPLEX VIRUS IN MECHANICALLY VENTILATED PATIENTS: WHAT DOES IT MEAN? Howard S. Weiss DO* Peter Spiegler MD Maritza L. Groth MD Winthrop University Hospital, Mineola, NY PURPOSE: Herpes Simplex Virus(HSV) causes tracheobronchitis and pneumonitis in critically ill patients. The characteristic endobronchial appearance is mucosal ulceration and membrane formation. We describe a series of critically ill patients with a normal endobronchial exam and cytopathic changes of HSV. METHODS: We reviewed all bronchoscopies performed in mechanically venilated patients in the medical ICU between October 2003 and March 2005 for evidence of mucosal lesions and cytopathic changes of HSV. Data including age, cause of respiratory failure, duration of mechanical ventilation and hospitalization prior to diagnosis, and level of HSV-1 IgG and IgM antibody(Ab)titers were recorded. RESULTS: Of 52 bronchoscopies performed, 7 subjects with cytopathic changes of HSV were identified (13.5%) and one with bronchoscopic features of HSV. This patient was immunosupressed and was excluded. The average age was 64.9 yrs (49-84 yrs). The duration of ventilation prior to diagnosis was 9.4d (0-14) and of hospitalization was 15.1d (8-47). HSV-1 Ab titers were obtained in 4 of 7 subjects. The HSV-1 IgG Ab was elevated in 4 of 4 subjects(100%)with an average level of 31.0(normal 0.90). The HSV-1 IgM Ab titer was elevated in 2 of 4 subjects with an average level of 1.3 of those with elevated levels (normal 0.91). Respiratory failure (RF) was due to pneumonia or atelectasis in all but one patient, who had microscopic polyangiitis. Five patients received therapy with acyclovir. No specific clinical features were seen in the subjects with HSV cytopathic changes compared to the rest of the sample. CONCLUSION: Cytopathic changes of HSV without obvious airway or parenchymal involvement are common in critically ill ventilated patients. To our knowledge, this has not been previously described in RF due to pneumonia or atelectasis. All cases occurred in fall and winter months (October to February). CLINICAL IMPLICATIONS: The significance of HSV cytopathic changes in critically ill ventilated adults and whether antiviral treatment is beneficial remains unknown. This may represent true herpes infection or that of another etiologic agent. Further studies are indicated to define whether treatment is necessary. DISCLOSURE: Howard Weiss, None.
BACTERIAL DIFFERENTIATION BY ION MOBILITY SPECTROMETRY: FIRST RESULTS OF A PILOT STUDY Pattrick Litterst Michael Westhoff MD* Lutz Freitag MD Vera Ruzsanyi PhD Jorg I. Baumbach PhD Lungenklinik Hemer, Hemer, Germany PURPOSE: Early diagnosis and specification of bacterial airway infection is of importance, especially in patients who are at high risk for respiratory failure, invasive or non-invasive ventilation and a prolonged hospital stay. METHODS: Ion mobility spectrometer (IMS) coupled to a multicapillary-column (MCC) identifies and quantifies volatile metabolites down to the ng/L- and pg/L-range of analytes within less than 500 s and without any pre-concentration. The IMS investigations are based on different drift times of swarms of ions of metabolites formed directly in air at ambient pressure. Head space over selected microbiological cultures was directly sampled for IMS-chromatograms. RESULTS: In this in-vitro study IMS-chromatograms of different bacteria (Staphylococcus aureus, Staphylococcus epidermidis, Streptococcus pneumoniae, Streptococcus agalactiae, Haemophilus influenzae, Klebsiella pneumoniae, Escherichia coli, Serratia marcescens, Pseudomonas aeruginosa, Enterobacter cloacae) and Candida albicans were obtained. The selected bacteria and Candida albicans could be defined and distincted by different metabolites. CONCLUSION: Ion mobility spectometry seems to provide a tool for precise bacterial analysis. The results of this pilot study have to be proved by an in-vivo study, especially in patients with airway infections as COPD-exacerbation and pneumonia. CLINICAL IMPLICATIONS: A future aspect might be the implementation of an IMS beside-test for the rapid diagnosis of airway infection including bacterial differentiation. DISCLOSURE: Michael Westhoff, None.
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MAP CVP MFI MFI MFI (mean, (mean; small medium large mm Hg) mm Hg) microvessels microvessels microvessels Before PLR After PLR 50 57 P 0,05 4 8 P 0,01 0,8 1,7 P 0,01 1,9 2,6 P 0,05 2,8 3,0 P 0,05
DISCLOSURE: Peter Spronk, None. USE OF VASOPRESSIN FOR SEPTIC SHOCK IN A NONMONITORED SETTING Manoj L. Karwa MBBS Kaye Hale MD* Montefiore, Bronx, NY PURPOSE: To review cases of septic shock treated outside the intensive care unit (ICU) setting with a fixed non-titratable continous infusion of vasopressin, determining its effects on survival, hemodynamics, and any adverse effects. METHODS: With permission from our IRB, we conducted a retrospective review of all patients that received vasopressin infusion for septic shock, between the dates of January 1, 2003 and December 31, 2003. In
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POSTER PRESENTATIONS
Germany Argentina Brazil Canada India Malaysia Australia US Mex Philippines n 1436 ICU Mortality APACHE II (mean) 2 OD Vent use Vasopres. 90% 89% 93% 75% 79% 69% 86% 9% 30% 93% 92% 75% 94% 10% 59% na 90% 64% na na 38% 90% 64% 59% 63% 37% 29% 93% 99% 89% 93% 29% 11% 91% 89% 88% 86% 53% 30% 87% 93% 76% 95% 76% 90% 84% 97% 19% 32% 29% 30% 94% 76% 79% 67% 14% 25% 38% 27 n 1326 46% 23 n 921 56% 23 n 889 32% 24 n 841 37% 20 n 684 56% 24 n 679 22% 21 n n n 493 41% 24
Fluid resuscitation 95% Albumin Low dose steroids Renal replacement 33% DroAA Unfx heparin* Low mole. Wt. Heparin* 5% 63% 48% 4.5% 46%
15% 4% 8% 21%
17% 2% 8% 17%
Leukocyte Adherence Normoxia Hypoxia Activated protein C Activated protein C hypoxia Alpha-lipoic acid hypoxia 1.6 14.5 2.0 4.4 0.6 .5 1.2 .8 1.5 0.4
Vascular Leak .14 .82 .19 .25 .10 .04 .14 .05 .14 .04
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AUTONOMIC NERVOUS SYSTEM-BASED EARLY GOAL DIRECTED THERAPY IN THE TREATMENT OF SEVERE SEPSIS AND SEPTIC SHOCK: PRELIMINARY EVIDENCE William C. Shoemaker MD Adam Colombo DO Joseph Colombo PhD* Department of Science and Technology, Bucks County Community College, Newtown, PA PURPOSE: To investigate the clinical efficacy of early goal-directed therapy based on autonomic nervous system (ANS) monitoring (noninvasive, simultaneous, independent measures of sympathetic (SNS) and parasympathetic nervous system (PSNS) activity) in patients with severe sepsis and septic shock. METHODS: 208 severe sepsis and septic shock patients were studied in an urban, level 1 university-run trauma service.: ANS monitoring measured the sequential patterns of SNS and PSNS activity immediately after admission to the emergency department (ED). Also measured noninvasive hemodynamic patterns, including: cardiac index (CI) by bioimpedance, as well as HR, and mean arterial pressure (MAP) to evaluate cardiac function, pulse oximetry to reflect changes in respiratory function, and transcutaneous oxygen (PtcO2) to reflect tissue perfusion/ oxygenation. RESULTS: In all patients autonomic balance (the ratio of SNS to PSNS activity) was markedly abnormal. These patients also had low MAP, CI, and PtcO2/FiO2 values associated with increased HRV that reflect increased autonomic activity. Patients with improved or restored ANS early in their ED stay, all survived; while the latter admission to ED had mixed results. ANS balance was not well-correlated with HR, BP, and CI. CONCLUSION: In nonsurvivors, severe sepsis and septic shock were associated with pronounced ANS imbalance. Survivors had relatively normal ANS balance. Patients that first presented poor ANS balance had balance improved due to therapy, also survived. CLINICAL IMPLICATIONS: Shows a correlation between the condition of severe sepsis and septic shock patients and their autonomic balance. DISCLOSURE: Joseph Colombo, Shareholder Joe Colombo, PhD is a share holder and part owner of Ansar, Inc.; Employee Joe Colombo is the Executive VP and Medical Director of Ansar, Inc.
INDEPTH DATABASE OF SEVERE SEPSIS PATIENTS SHOWS FEWER CARDIAC EVENTS IN DROTRECOGIN ALFA (ACTIVATED) PATIENTS VS PLACEBO PATIENTS Darell Heiselman DO* Stephen Lowry MD Jean-Francois Dhainaut MD Pierre-Francois Laterre MD Roland Schein MD Michael Seneff MD Jean-Pierre Sollet MD Antonio Artigas MD Jonathan Janes Frank Booth MD Andreas Sashegyi PhD Michael Cobas Meyer MD Akron General Medical Center, Akron, OH PURPOSE: This study was done to better understand treatment risks and benefits of drotrecogin alfa (activated) (DrotAA). METHODS: A blinded, independent clinical evaluation committee evaluated all serious adverse events (SAEs) within INDEPTH, a 4459 patient integrated database of five clinical trials of patients with severe sepsis. Trials were conducted by a single sponsor (Eli Lilly and Company). We report the incidence of cardiac serious adverse events in placebo treated patients (n 1231) and in those treated with DrotAA (n 3228). RESULTS: SAEs were characterized as occurring either during the study drug infusion period or during the 28-day survival observation period. Sepsis-related clinical outcomes and sepsis-related deaths were not considered SAEs unless attributable to study drug. Despite higher survival in DrotAA, overall SAEs rates were similar in both groups. Observed rates for MI and arrhythmia were significantly lower during infusion period and at 28 days.
Table 1
Variable Infusion Period: All SAE: N (%) All bleeding Arrhythmia w/o MI All non bleedingMyocardial Infarction Death at 28 Days following any Infusion Period SAE MI/ Thrombotic All stroke/ other arterial thrombotic events28 Day Observation Period: All SAE: N (%) Arrhythmia w/o MI Arrhythmia without MIMyocardial Infarction 0ther ? Death at 28 days YesDeath at 28 Days following any SAE DrotAA N 3228 199 (6.2%) 37 (1.15%) 11 (0.34%) 87/199 (43.7%) 425 (13.2%) Placebo N 1231 78 (6.3%) 30 (2.44%) 10 (0.81%) 47/78 (60.3%) 170 (13.8%) p Value* NS 0.0015 0.04 0.013 NS
In these rows only, the denominator for the calculation of percentage mortality is the number of patients at that time point with an SAE. 378S
AUTONOMIC AND HEMODYNAMIC ACTIVITY IN SEPSIS William C. Shoemaker MD Charles C. Wo BS Payman Fathizadeh MD Joseph Colombo PhD* Department of Science and Technology, Bucks County Community College, Newtown, PA PURPOSE: The aim is to evaluate early hemodynamic patterns of patients with severe sepsis and septic shock and compare/contrast the effects of sepsis as a primary etiologic event versus sepsis as a secondary complication after trauma, surgery etc. with simultaneously monitored sympathetic (SNS) and parasympathetic nervous system (PSNS) activities measured by the variability of the heart rate (HR) and respiratory rate (RR). METHODS: Level 1 university-run trauma service in a public hospital.Non-invasively monitored the early hemodynamic patterns in 208 severely septic patients beginning shortly after admission to the emergency department (ED). Simultaneously, monitored and compared the spectrum of HR and RR variability patterns, as markers of autonomic activity, with temporal hemodynamic patterns in 73 of these septic patients. The HR variability was measured to evaluate the low frequency area (LFa), which reflects SNS. The high frequency area (RFa) is indicative of PSNS activity. The LFa/RFa, reflects the relationship of SNS to PSNS. Concurrent noninvasive hemodynamic monitoring consisting of: a) cardiac output by bioimpedance, HR, and mean arterial pressure (MAP) to reflect cardiac function, b) pulse oximetry (SapO2) to reflect changes in pulmonary function, and c) transcutaneous oxygen (PtcO2) indexed to the FiO2 as a marker of tissue perfusion/oxygenation. RESULTS: Non-survivors had higher LFa and RFa values than the survivors did. The increased RFa preceded the increases in LFa in non-survivors and a higher percentage of sympathetic activity. These changes were more marked when measured before sedation and pain medication. In survivors, these patterns were associated with increased cardiac index (CI), and HR, normal MAP, SapO2, and normal tissue perfusion indicated by PtcO2/FiO2 ratios. Nonsurvivors had relatively normal CI, hypotension, tachycardia, poor tissue perfusion, borderline SapO2, and reduced oxygen delivery. CONCLUSION: In the period immediately after ED admission of patients with sepsis increased ANS activity was observed more pronounced in non-survivors. This activity was associated with increased HR, MAP, and CI, and a tendency toward reduced tissue perfusion/oxygenation. CLINICAL IMPLICATIONS: Established relation between hemodynamic variables and the ANS balance of Sepsis patients. DISCLOSURE: Joseph Colombo, Shareholder Joe Colombo, PhD is a shareholder and part owner of Ansar, Inc.; Employee Joe Colombo is the Executive VP and Medical Director of Ansar, Inc.
Lung Disease Gold Stage Gold Stage Gold Stage Gold Stage Restrictive Normal
% % Sepsis Pneumonia 3. 6 1.7 0.6 0.9 2.2 0.5 12.8 4.3 2.1 4.2 1.7 0.9
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SEVERE SEPSIS IS ASSOCIATED WITH AN APOPTOSIS-MEDIATED DECREASE IN HEPATIC BACTERIAL CLEARANCE Alix Ashare MD* Timur Yarovinsky PhD Martha Monick MS Gary Hunninghake MD University of Iowa, Iowa City, IA PURPOSE: The development of liver disease during the course of sepsis is associated with increased mortality. We hypothesized that worsening liver function would result in decreased bacterial clearance and be associated with increased dysfunction of other organs and increased mortality. METHODS: Mild and severe sepsis were generated in C57BL/6 mice via intratracheal inoculation with 103 or 104 organisms of Pseudomonas aeruginosa, respectively. To evaluate bacterial clearance by the liver, portal vein and right ventricle bacterial concentrations were measured using quantitative real-time PCR with primers specific for P. aeruginosa. Liver and cardiac injury was assessed by ALT and CK levels. Organ apoptosis was evaluated with a caspase-3 activity assay. Levels of IL-1 beta and TNF-alpha were measured by ELISA. To inhibit apoptosis, a subset of mice was pre-treated with the caspase inhibitor z-VAD-fmk. RESULTS: Mild and severe sepsis resulted in 20% and 60% mortality at 36 hours, respectively. Mild sepsis triggered a short but significant hepatic inflammatory response and some liver injury that returned to baseline by 24 hours. Effective bacterial clearance was not lost in this model. Severe sepsis caused a prolonged hepatic inflammatory response and liver injury that continued to worsen over time. Effective bacterial clearance was eventually lost in this model and was associated with increased injury to other organs, as well as increased mortality. Pretreatment with z-VAD-fmk resulted in preservation of hepatic bacterial clearance and increased survival 24 hours after infection with the severe sepsis model. CONCLUSION: We conclude that liver injury in sepsis is associated with decreased bacterial clearance, increased end-organ damage, and mortality. Inhibition of apoptosis preserves hepatic bacterial clearance and improves survival.
RISK FACTORS FOR CANDIDEMIA: COMPARISON BETWEEN MEDICAL AND SURGICAL INTENSIVE CARE UNIT PATIENTS Stephen B. Heitner MD* Glenn Eiger MD Robert Fischer MD Emma C. Scott MD Aba Somers MD Albert Einstein Medical Center, Philadelphia, PA PURPOSE: Candidemia is a potentially lethal and common infection in the intensive care unit (ICU). A number of risk factors for invasive candidiasis have been identified in previous studies. Our objective is to determine if there is a difference in the risk factor profile of medical ICU (MICU) and surgical ICU (SICU) patients. METHODS: A retrospective analysis was conducted at a large community-based teaching hospital. Subjects had positive blood cultures for Candida species and were admitted to the MICU and SICU over a two-year time period. Patients with known malignancies or other immunocompromising states were excluded. Demographic variables, Simplified Acute Physiological Score (SAPS), and known risk factors for candidemia were compared between MICU and SICU patients. Chi-square analysis and independent-sample t-tests were applied. RESULTS: Forty-three patients were included for analysis. MICU patients had significantly higher SAPS scores (57.8 vs. 41.1, p 0.005.).
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MYCOBACTERIUM TUBERCULOSIS AN UNUSUAL YET HIGHLY FATAL CAUSE OF SEPTIC SHOCK Raquel Nahra MD* Sergio L. Zanotti-Cavazzoni MD Anand Kumar MD Cooper University Hospital, Camden, NJ PURPOSE: To describe a group of patients with septic shock caused by M. Tuberculosis and compare their outcomes to those of patients with septic shock caused by other microorganisms. METHODS: Data was extracted from a multicenter database with information from the records of 2731 patients with septic shock. Patients with septic shock caused by M. Tuberculosis were identified by positive blood or multi-site cultures. RESULTS: A total of 2731 patients with septic shock were studied. Eleven patients (0.4%) had septic shock caused by M.Tuberculosis (MTB group). In the MTB group, the mean age was 44.2 ( 19.5) years, mean APACHE II score was 26 ( 8), 36% were males and 64% were females. Comorbid conditions included; alcohol use 54%, non-HIV immunosupresive diseases 36.4%, and diabetes mellitus 18.2%. None of these patients had documented HIV. Overall mortality in the MTB group was 81.8 %, and mean length of stay in the ICU was 12.7( 17.1) days. Inapropriate initial antimicrobial coverage based on culture results was given to five patients (45.5%) in the MTB group. When compared to patients with septic shock caused by other microorganism (OTH group), patients in MTB group were younger (44.27( 19.5) years vs 62.66 ( 16.4)) years p 0.0002), and more likely to have alcohol use as a comorbidity (54.4% vs 13.8 %, p 0.0013). Patients in the MTB group were more likely to receive inappropriate initial antimicrobial therapy than patients in the OTH group (45.5% vs 18.6%, p 0.0039). Patients in the MTB group had a higher mean ICU LOS (12.21 days vs 8.1 days ), had a higher overall mortality (81.8% vs 56.2% , p 0.12 ), and were more likely to develop hepatic failure (p 0.0039). CONCLUSION: M. Tuberculosis is an uncommon cause of septic shock. However, when it occurs it is associated with increased morbidity and mortality and a significant delay in institution of appropriate antituberculous treatment. CLINICAL IMPLICATIONS: Mycobacterium Tuberculosis should be thought of as a possible cause for septic shock in apropriate clinical situations. DISCLOSURE: Raquel Nahra, None.
THE CLINICAL SIGNIFICANCE OF SPONTANEOUS AROUSALS INDEX (SAI) DURING POLYSOMNOGRAPHY Joe G. Zein MD* Maroun M. Tawk MD Tarek Dernaika MD Gary T. Kinasewitz MD William C. Orr PhD The University of Oklahoma, Health Sciences Center, Oklahoma City, OK PURPOSE: Sleep arousals are important for reestablishing a patent airway subsequent to an obstructive event and to protect against prolonged hypoxemia. Spontaneous arousals (SA) are also considered among the clinical indicators of upper airway resistance syndrome (UARS). We examined the frequency and clinical significance of SA in patients referred for evaluation of obstructive sleep apnea (OSA). METHODS: This was a retrospective study of 118 consecutive adult patients presenting for polysomnography from October 2002 till March 2003. A multivariate logistic regression was constructed with the rate of SA as the dependent variable. Apnea Hypopnea Index (AHI), Sleep efficiency (SE), mean SaO2, and stage 1 were independent variables. Arousals were defined according to the American Academy of Sleep Medicine established criteria. Data are presented as mean SEM. RESULTS: The mean total recording time was 396 6 with a total sleep time of 308 10 min. An increased SAI ( 10/hr) was present in 20
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Normal
Generalized
Temporal lobe
Frontal lobe
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Mean spindle 0.69 0.24 0.72 0.21 1.47 1.12 0.63 0.21 0.37 duration in seconds ( SD) Spindle time /epoch in 0.03 0.02 0.02 0.03 0.05 0.08 0.02 0.01 0.84 stage 2 sleep Spindle number 3.4 3.3 2.8 2.8 2.6 2.2 3.4 1.8 0.37 per epoch
DISCLOSURE: Juliana Rajter, None. ADVANCED AUTOMATED ANALYSIS OF HUMAN ELECTROENCEPHALOGRAPHY (EEG) USING MULTIDIMENSIONAL MATHEMATICAL ANALYSES OF FREQUENCY CHANGES COMPARED TO TRADITIONAL RECHTSCHAFFEN AND KALES (R&K) SCORING OF A KNOWN BIOLOGICAL SLEEP SIGNAL Richard K. Bogan MD* Jo Anne Turner MSN Alex Novodvorets MS Koby Todros BS Baruch Levy BS SleepMed, Columbia, SC PURPOSE: To assess the use of an automated system (Morpheus) in the analysis of human EEG frequency changes in pre and post severe obstructive sleep apnea using a split night protocol. To correlate adaptive segmentation and fuzzy logic frequency changes using Markov models to traditional R&K. METHODS: A total of 23 adults were studied with a diagnosis of severe obstructive sleep apnea. Each subject underwent polysomnography (PSG) and received early intervention CPAP therapy during initial study. Only individuals with oxygen saturations greater than 85% and respiratory disturbance index (RDI) less than 10 episodes per hour during the ideal CPAP titration period were included. Fundamental frequency segments were measured using Morpheus algorhythms. Sleep states were analyzed using traditional R&K rules. RESULTS: Means and standard deviations are reported for 23 adults. RDI pre CPAP was 73.5 (26) with low oxygen saturation of 81%(7). Pre and post CPAP periods for the sleep states that reached statistical significance by automated analysis during study time were: high frequency(HF) pre 30%(15), post 23%(11); low frequency(LF) pre 3%(4), post 8%(5); mixed frequency-1(MF1) pre 15%(8), post 25%(7); delta pre 2%(4), post 4%(5); beta pre 5%(5),post 2%(2); under 4 Hz pre 5.2%(7), post 12.6%(5). Significant R&K sleep state results are as follows as a % of time in bed: sleep efficiency pre 76%(16), post 84%(9); Stage II pre 58%(16), post 35%(12); Stages III&IV pre 4%(8), post 15(9); REM pre 4%(9), post 26(11). Signals analyzed but not found to be statistically significant were: Morpheus mixed frequency 2, theta, alpha, and sigma segments; R&K Stage I. CONCLUSION: The automated analysis demonstrates a different methodogy for analyzing a known biological sleep signal. In this study
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DISCLOSURE: Richard Bogan, Shareholder SleepMed Inc. OPTIMIZATION OF NON-INVASIVE VENTILATION PRESSURES USING COMBINED OXIMETRY AND CUTANEOUS CARBON DIOXIDE TENSION MONITORING Prashant N. Chhajed MD* Simone Gehrer Trupti P. Chhajed Ingrid Strobel Martin Brutsche MD Michael Tamm MD Werner Strobel MD Pulmonary Medicine, University Hospital Basel, Basel, Switzerland PURPOSE: To examine the safety, feasibility and utility of combined cutaneous carbon dioxide tension (PcCO2) and oximetry monitoring to re-titrate the non-invasive positive pressure ventilation settings in patients with chronic hypercapnic respiratory failure due to hypoventilation. METHODS: 12 patients with chronic hypercapnic respiratory failure underwent complete polysomnography and combined oximetry and PcCO2 measurement (Sentec AG, Switzerland) on the ear lobe. non-
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PNEUMATIC COMPRESSION DEVICES FOR TREATMENT OF RESTLESS LEGS SYNDROME Arn H. Eliasson MD* Walter Reed Army Medical Center, Washington, DC PURPOSE: Restless legs syndrome (RLS) is a troublesome condition manifested by sensory and motor symptoms that disrupt sleep onset or sleep maintenance. RLS is common, occuring with a estimated population prevalence of 10%. There are no consistently reliable treatment alternatives and pharmacological treatments are often associated with unacceptable side effects. An effective nonpharmacological treatment would be a highly attractive option. METHODS: A convenience sample of patients reliably diagnosed with RLS was asked to wear pneumatic compression devices for at least one hour each evening for at least 30 days. Symptoms of RLS severity and related quality of life measures were evaluated before and after treatment. RLS severity was measured using a validated 10-item questionnaire. Quality of life indices were scored using the RLS Foundaton Quality of Life Instrument. Daytime sleepiness was gauged using the Epworth Sleepiness Scale (ESS). Patients were asked to track compliance using logs. RESULTS: Of eight patients enrolled (mean age 55 years, range 37 to 81, 6 women), one man withdrew due to inability to comply. Of the other seven patients, all improved regarding RLS severity with three patients (43%) experiencing complete resolution. Mean severity decreased from 24/40 to 7/40 (p 0.003). Social functioning improved from 87% to 98% (p 0.05), daily functioning improved from 76% to 94% (p 0.06), sleep quality improved from 30% to 54% (p 0.01), and emotional well-being improved from 61% to 88% (p 0.05). ESS did not change significantly, decreasing from 9.9 to 8.6 (p 0.14). Compliance averaged 87% of nights (range 58% to 100%). One patient was able to discontinue previously prescribed gabapentin and pramipexole while experiencing improvement in RLS symptoms. CONCLUSION: Pneumatic compression devices worn for one hour per day over days to weeks improve RLS symptom severity and quality of life measures. A proportion of patients experience complete resolution of RLS symptoms. CLINICAL IMPLICATIONS: Pneumatic compression devices are an effective treatment alternative for patients with RLS. This nonpharmacological therapy may preclude resorting to medications which may be ineffective or have unacceptable side effects. DISCLOSURE: Arn Eliasson, Other Aircast Industries of New Providence NJ supplied six pneumatic compression devices for use in this study. No other financial incentive or support was received.
RESTLESS LEGS SYNDROME IN LUNG TRANSPLANT RECIPIENTS Jose C. Yataco MD* Joseph Golish MD Marie Budev DO Omar Minai MD Cleveland Clinic Foundation, Beachwood, OH PURPOSE: Restless legs syndrome (RLS) is a neurologic disorder with a prevalence between 2.5 and 15% in the general population. Among solid organ transplant recipients, RLS was found in 45% of patients after heart transplantation in a cross-sectional study. In a prospective study, RLS cases disappeared after kidney transplantation in a group of patients on hemodialysis. The goal of this study is to determine the prevalence, severity and risk factors of RLS in a population of lung transplant recipients. METHODS: This is a cross-sectional, observational study that recruited consecutive patients in the transplant clinic. For the diagnosis and severity assesment of RLS, we used previously validated questionnaires published by the international RLS study group (IRLSSG). Demographic data and possible risk factors were obtained from medical records. RESULTS: RLS had a prevalence of 47.6% in 42 lung transplant recipients recruited. Among the RLS patients, 80% had a moderate to severe disorder based on the IRLSSG. The mean age in RLS patients (46.4 years 15.5) was similar to the mean age in patients without RLS (46.8 years 15.6) but there were more women in the RLS group (75%) compared to the non-RLS group (40.9%). Diabetes mellitus had a prevalence of 45.2% in the overall group but the frequency of diabetes did not reach statistical difference between the two groups (p 0.05). Chronic renal failure (defined as creatinine clearance 50cc/hr), was found in 42.8% in the overall group but had similar distribution in the RLS and non-RLS groups (p 0.05). CONCLUSION: RLS has a high prevalence in lung transplant recipients. Diabetes mellitus and chronic renal failure were frequent in lung transplant recipients but had similar distribution in the patients with or without RLS.
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THE IMPACT OF THE ATTENTION DEFICIT, MOOD, LEARNING AND PRAGMATIC DISORDERS ON THE PRESENTATION OF AN INSOMNIA DISORDER IN THE ADOLESCENT Clifford G. Risk MD* Nadine Y. Smith MS Clifford Risk, MD, Marlborough, MA PURPOSE: Adolescents presenting to a sleep center with a chief complaint of insomnia may suffer from an underlying attention deficit, mood, learning or pragmatic disorder. This study evaluated the presence of these dual diagnoses, and the effectiveness of patient-based therapeutic programs to improve the insomnia and comorbid diagnoses. METHODS: This study included 13 adolescents aged 10-17 who presented to a nationally accredited sleep center for evaluation of an insomnia condition. Diagnoses of attention deficit disorder, Aspergers syndrome, non-verbal learning disorder, anxiety, and depression were established by prior neuropsychological and psychiatric assessments. A patient centered learning program was structured to address specific attention and learning deficits and build compensatory strategies for long term acquisition and memory and learning skills development. Treatment of insomnia included non-pharmacological interventions (sleep hygiene, sleep restriction, relaxation therapies) and pharmacological interventions (hypnotics, benzodiazapines). Treatment for morning sleepiness and attention deficit included, when indicated, a wake-promoting agent, and interventions by a speech language pathologist and professional doctoral level education specialist with appropriate modifications of the academic environment. RESULTS: Attention deficit disorder was found in 7 adolescents; Aspergers syndrome and non-verbal learning disorder in 3; obsessive compulsive disorder, Tourettes syndrome or an anxiety disordre in 3 patients; depression in 3 patients; and leraning disorder in 1 patient. (Some adolescents carried dual diagnoses.) Treatment interventions were effective in 6 patients treated by us with respect to an improvement in sleep structure and efficiency, and in improved alertness and attentiveness, and knowledge acquisition. CONCLUSION: Adolescents presenting with insomnia may suffer from significant disordres of attention deficit, pragmatic and specific learning impairments, or anxiety and mood disorders. Diagnoses and design of a therapeutic intervention may improve the sleep disorder and their daytime attention and wakefulness impairments, and academic performance. CLINICAL IMPLICATIONS: Physicians and parents should be attentive to sleep disorder evaluations in the treatment of the adolescent with a primary diagnosis of an attention, learning or mood disorder, and a comorbid diagnosis of either insomnia or delayed phase sleep disorder. DISCLOSURE: Clifford Risk, None.
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RESULTS: 946 questionnaires were analyzed. Age: 10 to 81 (mean 36.5) with 59 % of females. 15 % had heart disease, 12 % lung disorders, 33 % known as snores, 39 % with ethylic habits, 16 % used sleeping pills and Epworths scale of 6.7 4.4. Sleeping hours of 6.9 2.6 and working hours of 8.2 hours 2.09. According to the Athens scale, 62 % had enough sleep time, 76 % had an overall satisfactory quality of sleep, 79 % had no awakening and 89 % had no somnolence. CONCLUSION: Lung disorders and overall quality of sleep were the
Odds Ratio City Age Gender Smokers Alcohol intake (gday) Heart disorders Lung disorders Pills Hours of sleep Hours of job 0.855 0,98 1,2 0.88 1,25 1,14 1,92 0,96 0,88 1,05
Std Err 0,94 0,007 0,25 0,21 0,24 0,27 0,50 0,26 0,05 0,04
zP
95% Conf Interval 1,06 1,00 1,87 1,42 1,85 1,84 3,22 1,63 1,00 1,14
-1,40 - 0,159 -1,57 0,116 1,26- 0,205 -0,49 - 0,619 -1,15 - 0,24 -0,57 - 0,56 2,504 - 0,012 -0,13 - 0,89 -1,81- 0,07 -1,10 - 0,26
POSTER PRESENTATIONS
only statistical variables associated to somnolence. The prevalence of snores (33 %) and apnea suggestive episodes (4 %) were similar to numbers reported else were. CLINICAL IMPLICATIONS: Lungs Diseases seem to be more related to somnolence that any other condition. DISCLOSURE: Gur Levy, None.
0,99
0.40
SLEEP HABITS IN VENEZUELA AND ITS CORRELATION WITH HEART AND LUNG DISEASE Gur Y. Levy MD* Julio Castro MD Juan A. Cardenas MD Benito Rodriguez MD Dolores Moreno MD Ismenia Chaustre MD Arnoldo Soto MD Guillermo Isturiz MD Jose M. Lopez MD Universidad Central de Venezuela, Caracas, Venezuela PURPOSE: Evaluate sleep habits and disorders among individuals from three cities in Venezuela and its correlations with lung and heart diseases. METHODS: A self-reported questionnaire sponsored by the Venezuelan Association of Sleep Medicine, was designed in order to know socio-demographic profile, heart and lung diseases, alcohol intake, cigarette-smoking habits and sleep medication. Athens insomnia scale and Epworths sleepiness scale were also included. Epworth score was used as a main outcome logistic regression (Forward stepwise), two separates models were performed to rule out overfiting; model A include only the questions related to somnolence and model B include comorbid conditions and baseline characteristics. Significance level was considered as 0.05.
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ISCP 9 Month Outcomes Total patients seen Committed to quit Agreed to follow-up Contacted 1 times Abstinent @ 1-9 mos
DISCLOSURE: Kathy Garrett-Szymanski, None. A COMPARATIVE STUDY OF THE ROLE OF PHYSICIAN ADVICE AND NICOTINE REPLACEMENT THERAPY IN SMOKING CESSATION Ashrafjit S. Chahal MD* Jai Kishan MD Anmol Dhillon MBBS Mata Kaushalya Hospital, Patiala, India PURPOSE: Cigarette smoking is the most prevalent modifiable risk factor for increased morbidity and mortality in the world. The WHO estimates that worldwide 1.1 billion people smoke, representing one third of the global population aged 16 years and above. If the present trend continues there will be 1 billion deaths due to tobacco during the 21st century compared to 100 million deaths during the 20th century. A study was conducted to evaluate the comparative role of physician advice and nicotine replacement therapy on smoking cessation. METHODS: A total of 150 smokers were enrolled in the study. They were divided into 3 groups of 50 each. One group received physician advice, the other nicotine replacement therapy and the third was given placebo. Fagerstorm score was used to quantify smoking dependence. The patients were followed for 6 months. RESULTS: Advice alone is as effective as nicotine replacement therapy in smokers who have a Fagerstorm score of 4 to 7. Smokers with a Fagerstorm score of 8 or more require more than advice alone. CONCLUSION: Most of the time, physician advice alone goes a long way in making people quit smoking. In patients with high dependence, nicotine replacement therapy should be used alongwith. The progress a patients makes after intervention is directly related to what stage it was in prior to intervention. CLINICAL IMPLICATIONS: Considering the enormous hazards of smoking, every patient coming in contact of the physician should be asked and advised about smoking. DISCLOSURE: Ashrafjit Chahal, None. DOES INTENSIVE SPORT AT SCHOOL HAVE AN IMPACT ON SMOKING IN ADOLESCENTS? Dominique Lauwers MD* Jacques LeComte MD Jean-Pol Quarre MD Anne Hoyez MD Philippe E. Pierard MD CHU Charleroi, Charleroi, Belgium PURPOSE: It has been suggested that regular sporting practice might have a positive impact on smoking habits in young people. We tried to assess this impact in a group of adolescents. METHODS: Students at the same school, aged 14 to 20 years, were studied with a questionnaire relative to smoking habits, knowledge of tobacco risks, impact of media and school messages about smoking. Two groups were distinguished : a sporting department (more than 8 hours sporting per week), and a traditional section (less than 3 hours). RESULTS: 212 students were examined with a detailed questionnaire and 208 of them were fully completed and relevant : 122 in the sporting section, 86 in the other group. 70 % of boys and 66 % of girls are non smokers in the sporting section, versus respectively 64 and 57 % in the other group. In both groups, 90 % of smokers intend to stop definitely in the near future. Teaching messages at school are poorly received, but information carried by the media is well perceived and tobacco risks are generally known but addiction is massively misjudged. When they are smokers, there is no significant difference of consumption habits between
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POSTOPERATIVE PULMONARY COMPLICATIONS AFTER ABDOMINAL SURGERY Fayez Bader MD* Peter R. Smith MD Muhammed Baig MD Jason Akulian MD Veronica Brito MD Siddarth Shah MD Michael Bergman MD Antonio Alfonso MD Long Island College Hospital, Brooklyn, NY PURPOSE: The frequency of, and risks for postoperative pulmonary complications (PPCs) after abdominal surgery (AS) are incompletely understood. Definitions of PPCs have been variable and the range of PPCs reported in the literature is wide (2-19%). In the present study we have used a definition of PPCs that is clinically relevant in terms of affecting key outcomes including morbidity, mortality, and length of stay (LOS). METHODS: Data for 200 consecutive Pts in 2004 were collected using CPT codes to identify AS performed at our hospital. PPCs were defined as 2 or more of the following for at least 2 consecutive days, occurring within 7 days of surgery: 1) new cough /sputum production, 2) physical exam c/w segmental or greater atelectasis or pneumonia 3) radiographic findings c/w segmental or greater atelectasis or pneumonia 4) temp 38 C. Additionally, exacerbation of preexisting lung disease, respiratory failure, and pulmonary embolism defined PPCs. Incentive spirometry is used routinely at our hospital after AS. A stepwise multiple logistic regression model was used for statistical analysis. RESULTS: PPCs occured in 9 of 200 (4.5%) cases (Table I). There were no PPCs after laparoscopy. There were no deaths. Risk factors for PPCs identified in univariate analyses are shown in Table II. Nasogastric tubes and a history of cardiac disease independently predicted risk in multivariate analysis. LOS was statistically greater in patients with PPCs (OR 1.17, 95% CI 1.08-1.27, p .001). CONCLUSION: These data suggest a low incidence of PPCs after AS. The reasons for a lower frequency of PPCs reflected by these data compared to many prior studies are multi-factorial including a more clinically relevant definition of PPCs, improved technology, and use of less invasive techniques (laparoscopy). CLINICAL IMPLICATIONS: Morbidity and potential mortality from PPCs can be reduced by preoperative risk assessment and appropriate perioperative management.
CHEST 2005Poster Presentations
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DISCLOSURE: Fayez Bader, None. CORRELATION ANALYSIS BETWEEN SIX MINUTES WALK DISTANCE AND RESPIRATORY MUSCLES STRENGH AND RESPIRATORY MUSCLES INCREMENTAL TEST IN COPD PATIENTS Evanirso S. Aquino BSc* Fernanda M. e Castro BA Isabel B. Lopes BA Thas M. Peres BA Cristiane Cenachi-Coelho MA Inacio T. Cunha Filho MD Uni-BH PUC Minas - Betim, Belo Horizonte, Brazil PURPOSE: The objective of this study was to correlate the respiratory muscles strengh(RMS) and respiratory muscles incremental test (RMIT)with six minutes walk distance (6MWD)in COPD patients. METHODS: COPD patients in clinically stable condition between 59 and 80 years of age were selected if they met following criteria: mild to severe airflow obstruction according to Global Initiative for Chronic Obstructive Lung Disease. All patients were submited to lung function test, respiratory muscles strength, assessed by maximal inspiratory mouth pressure and maximal expiratory mouth pressure (PImax and PEmax), respiratory muscles incremental test (RMIT) and 6MWT. RESULTS: 21 patients were studied (3 women and 18 mens). The mean age was 71,66 14,78 years. The results showed the positive correlation between Inspiratory endurance time assessed by RMIT and 6MWD (r 0,607 P 0,004), maximal inspiratory and expiratory load evaluated through RMIT with 6MWD (r 0,0598 P 0,004) and (r 0,442 P 0,004)respectively. PImax and PEmax were not statistically significant. CONCLUSION: The results of the present study demonstrate a moderate and positive correlation between respiratory muscles incremental test and six minutes walk distance. CLINICAL IMPLICATIONS: The respiratory muscles endurance training might contribute to exercise performance evaluated by six minutes walk distance in patients with chronic airflow limitation. DISCLOSURE: Evanirso Aquino, None. CORRELATION BETWEEN INDIRECT METHODS OF THE CORPORAL COMPOSITION ASSESSMENT AND RESPIRATORY MUSCLES STRENGTH AND ENDURANCE IN COPD PATIENTS Evanirso S. Aquino BS* Fernanda de M. Resgalla e Castro BA Isabel B. Vasconcellos Lopes BA Thas M. Peres BA Inacio T. Cunha Filho MD UNI-BH PUC Minas-Betim, Belo Horizonte - MG, Brazil PURPOSE: To do a prospective analysis between indirect methods of the corporal composition assessment and respiratory muscle strength and endurance in chronic Obstructive Pulmonary Disease (COPD) patients.
THE OXYGEN CONCENTRATIONS DELIVERED BY DIFFERENT OXYGEN THERAPY SYSTEMS Juan A. Garcia MD* Donna Gardner RRT David Vines RRT David Shelledy PhD Richard Wettstein PhD Jay Peters MD University of Texas Health Science Center at San Antonio, San Antonio, TX PURPOSE: To test the oxygen concentrations delivered by some of the available oxygen therapy systems in normal subjects. METHODS: Two different groups of ten healthy volunteers participated in two parts of this study. Nasal cannula (NC) O2 delivery was tested in the first group Simple masks (SM) and non-rebreathing (NRB) masks were tested in the second group. Each subject had a # 8 French nasal catheter inserted through a nare with the tip positioned immediately behind the uvula. The nasal catheters proximal end was connected to a syringe stopcock T piece system with the oxygen analyzer in line. Oxygen was administrated via the high flow NC (model ref 1600, Salter Labs, Alvin, Ca) at flows 6-15 L/min. For the SM (Hudson RCI, Temecula, Ca), oxygen was administer at 6-12 L/m, and for the NRB mask (Hudson RCI, Temecula, Ca), the flow was 6-15 L/min. At each different oxygen flow the subject breathed normally for five minutes. Using the oxygen sampling system, three gas samples (60 mL each) were withdrawn from the pharynx during inspiration and directed to the oxygen analyzer. The average FiO2 delivered was recorded for each one of the oxygen flows administered with the different systems. RESULTS: Table 1 shows the means SD for each device. Figure 1 shows the comparison between the different devices. CONCLUSION: The HFNC was able to provide higher mean FiO2 than the SM at flows of 6-10 L/min; at 12 L/min the delivered FiO2 was equal. HFNC compared to NRB mask delivered equal mean FiO2 at flows 8-15 L/min, and was superior at 6 L/min. Both masks will deliver less variable FiO2 than HFNC. CLINICAL IMPLICATIONS: If needed, HFNC can deliver similar FiO2 than NRB mask. Medical personnel should be aware of the high FiO2 variability this system may deliver.When switching from HFNC to SM, a higher O2 flow should be selected to achieve similar delivered FiO2. The simple rule for estimating delivered FiO2 with different oxygen systems is not accurate.
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THE OXYGEN ADHERENCE MODEL: IMPROVING HOME OXYGEN USAGE Deborah L. Cullen* Indiana University, Indianapolis, IN PURPOSE: A handful of studies have pointed to explanations related to a patients reluctance to wear a cannula or breathe oxygen for 15 hours a day. Fewer studies have determined strategies aimed at improving LTOT (Long Term Oxygen Therapy) use. Adherence is not generalizable and may differ with treatment or by condition. Adherence is a dimensional construct and no current explanatory theory or model specific to LTOT exists. LTOT adherence varies between 45-70% therefore an explanatory model is needed which addresses patient and treatment factors. METHODS: An Oxygen Adherence Model was developed which defined the variables, processes and barriers present when LTOT and a respiratory disability interact. This hierarchical and tiered model is related to established drug adherence constructs, respiratory health behavior theory, and physiologic variables inherent with chronic respiratory disease. RESULTS: Adherence will advance as the variables and domains in each tier are addressed. Tier 1, Chronic Respiratory Disability is defined by symptoms and physiologic deteriorization which is assisted via LTOT. Tier 2, Information Enhancement, is educational as the clinician assists the patient and family with understanding LTOT. Interventions and treatments related to Tier 3, Emotional and Psychological Limitations, should be focused to improving self-efficacy. Tier 4, Reduction of Treatment Barriers should be approached with the goal of therapeutic effectiveness. CONCLUSION: Health behavioral and psychological models explain general adherence behavior and have been effective in guiding interventional strategies for many conditions and health promotion. The Oxygen Adherence Model can be tested to determine approaches appropriate to limiting symptoms, improving physical limitations, educating the patient, addressing psychological and emotional variables as well as reducing barriers to more effective oxygen therapy. CLINICAL IMPLICATIONS: Chronic disease management includes adherence plans. Most patients find LTOT a complex treatment. New strategies and research related to LTOT adherence may assist with improved LTOT utilization by patients.
Not tested
TRANSCUTANEOUS CARBON DIOXIDE TENSION AND OXYGEN SATURATION MONITORING VERSUS ARTERIAL BLOOD GAS MEASUREMENT Elisa Canturri MD Christian Domingo MD* Manel Lujan MD Miguel Gallego MD Amalia Moreno MD Humildad Espuelas RN Merce Gime` nez MD Albert Marn MD Corporacio Parc Taul, Sabadell, Spain PURPOSE: To evaluate the precision of a non-invasive digital ear-clip sensor providing continuous transcutaneous (Tc) monitoring of carbon dioxide tension (PaCO2) and oxygen saturation (SaO2%) using arterial blood gases (ABG) as the gold-standard technique. METHODS: Population: patients referred to the Pulmonary Function Testing Laboratory of our Institution. Instrumentation: Spirometry was performed on the admission day. The ear-clip V-signTM (SenTec) was placed and after stabilization, the lecture was performed. While the patient wore the ear-clip, ABG were performed, the blood was analyzed in two different blood gas analyzers and the mean value was taken as the gold-standard measurement. Statistical evaluation: Students t test for paired data was used to compare the mean values obtained from the Tc and the ABG measurement. A Pearson correlation coefficient (r) was obtained. Bland-Altman plot was used to detect bias in the readings. This evaluation was performed for the whole group and for sub-groups stratified according to lung obstruction severity and PaCO2 value (normal 45 mmHg; elevated PaCO2 ( 45 mmHg). RESULTS: 130 patients were included (10 were excluded for calibration problems of the sensor in two consecutive days). Data are given as mean SD.The subgroup analysis did not show relevant differences. The Bland Altman plot did not show marked dispersion at any values of PaC02. CONCLUSION: 1) The differences found in the measurements of PaCO2 and SaO2 with both methods, although statistically significant, were not clinically relevant. 2) Appropriate calibration and stabilization period of the Tc sensor is needed before a measurement is considered reliable. CLINICAL IMPLICATIONS: Tc measurement is a reliable method to determine carbon dioxide tension and oxygen saturation. In many cases, this technique can substitute ABG analysis.
Tier 1
Tier 2
Tier 3
Tier 4
Chronic Respiratory Disability Symptoms: Dyspnea, Fatigue, Anxiety, Depressed Mood Physiologic Deteriorization: Arterial Oxygen Desaturation Exercise capacity Body Mass Index Cognitive status Functional status
Information Enhancement Prescription Knowledge Treatment rationale Technical ability Motivational enhancement
Emotional and Psychological Limitations Denial Hopelessness Apathy Misery Isolation Burden Stigma Fear of addiction Fear of dependence Depressed mood Anger Health belief conflicts Treatment Barriers Poor provider support Limited clinician communication Not practically portable Expensive Inconvenient Duration of treatment Complexity Life style interference
DISCLOSURE: Deborah Cullen, None. STANDARDIZATION AND ENHANCED SAFETY OF EXTERNAL BATTERY SYSTEMS USED TO OPERATE PORTABLE VENTILATORS IN THE HOME CARE SETTING OF THE PROVINCE OF QUEBEC Brigitte Fillion RRT* Mc Gill University Health Center, Montreal, PQ, Canada PURPOSE: The aim of this project was to standardize and enhance the safety of the clients of the National Program for Home Ventilatory Assistance (NPHVA) using external battery systems to operate their portable ventilators in the home setting. METHODS: A partnership was formed between the McGill University Health Centres Biomedical department and the National Program for
CHEST 2005Poster Presentations
ABG
Tc *
(95%)
r*
CO2 42.16 7.2 40.93 8.4 mmHg SaO2% 93.46 4.4 94.35 4.4 * p 0.05
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RELATIVE SENSITIVITY AND LOWER LIMITS OF NORMAL FOR SPIROGRAPHIC MARKERS OF AIRWAY OBSTRUCTION James E. Hansen MD* Xing Guo Sun MD Karlman Wasserman MD Harbor-UCLA Medical Center, Torrance, CA PURPOSE: 1) Develop mean and 95% confidence lower limit of normal (LLN) formulae for FEV3/FVC for Black, Latin, and White men and women to supplement the findings of Hankinson et al. 2) Ascertain comparative variability of FEV1/FVC, FEV3/FVC and FEF25-75 in never-smoking adults and evaluate their utility in measuring the effects of smoking on airway obstruction. 3) Develop and use the concept of 1-FEV3/FVC to identify airway obstruction. METHODS: We identified 5938 never-smokers and 3570 current smokers with spirometric data meeting American Thoracic Society standards from the NHANES-III nationwide database. In these groups we developed regression formulae for the FEV3/FVC, quantified variability and LLN of the FEV1/FVC, FEV3/FVC and FEF25-75 to identify abnormalities in current-smokers, and evaluated 1FEV3/FVC as a marker of airflow obstruction. RESULTS: With normal aging, there were concurrent linear decreases in FEV1/FVC and FEV3/FVC and increases in 1-FEV3/FVC, the latter attributable to slower emptying of acini with longer time constants. By middle age these spirometric measurements worsened, on average, about 20 years earlier in current-smokers. Two-thirds of current-smokers who manifested airway obstruction had both FEV1/FVC and FEV3/FVC abnormal, while 1/6 had only FEV1/FVC abnormal and 1/6 had only FEV3/FVC abnormal. The normal variability of FEF25-75 is greatest and that of the FEV3/FVC is least. If 80% of mean predicted FEF25-75 values were used to identify abnormality, 25% of all never-smokers would have been falsely identified as abnormal. Using 95% confidence limits for FEF25-75, only 1% of never-smokers had isolated abnormal FEF25-75 while 42% of 683 smokers without restriction but with reduced FEV1/FVC and/or FEV3/FVC had normal FEF25-75 values (false negatives). CONCLUSION: FEV1/FVC, FEV3/FVC and 1-FEV3/FVC all characterize expiratory obstruction well. In contrast, FEF25-75 has an unacceptably large proportion of false negatives and false positives. CLINICAL IMPLICATIONS: Using 80% of mean predicted to define abnormality is statistically invalid. For valid spirographic assessment of airways obstruction, we recommend requiring statistically correct LLN and replacement of the FEF25-75 with the FEV1/FVC and FEV3/FVC. DISCLOSURE: James Hansen, None.
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RELIABILITY OF THE ERROR CODE FROM THE BEST TRIAL AS AN INDICATOR OF SPIROMETRIC TEST QUALITY USING AMERICAN THORACIC SOCIETY (ATS) CRITERIA Mayuko Fukunaga MD* Shobharani C. Sundaram MD Eugene J. Kim MD James Sullivan BA Steve H. Salzman MD Beth Israel Medical Center, New York, NY PURPOSE: Assessment of spirometric test quality is important in the interpretation of an individual patients study, in determining the overall quality of tests being performed by technologists, and when using the data in research. The 1994 ATS criteria for spirometry require three acceptable trials, two of which are reproducible. Computerized testing equipment often provide a five or six digit error code which summarizes whether these criteria have been met. The system in use at our institution provides an error code that identifies whether the reproducibility criteria have been met, yet reports acceptability only for the designated single best trial. The purpose of this study is to determine how frequently an error code from the best trial that is both acceptable and reproducible accurately indicates that all ATS criteria are met when all trial data are manually reviewed. METHODS: All spirometric tests performed on black, white or Hispanic patients in 2003 and 2004 at Beth Israel Medical Center were reviewed. Tests were performed in a SensorMedics Vmax 6200 Autobox (SenorMedics-Viasys, Yorba Linda, CA). The individual trials were manually reviewed for all spirometric studies that had an error code suggesting that ATS criteria for acceptability and reproducibility were met. RESULTS: There were 2416 tests which had an error code indicating that the best trial was acceptable and that reproducibility criteria were met. Among these 2416 tests, 1926 (79.7%) actually had three or more acceptable trials, 380 (16.0%) had two acceptable trials and 110 (4.6%) had only one acceptable trial. CONCLUSION: A final report error code which summarizes whether ATS criteria for reproducibility and acceptability were met can be misleading, unless it also reports how many individual trials meet ATS criteria for acceptability. CLINICAL IMPLICATIONS: Graphical and numerical data, including error codes, should be reviewed from all spirometric trials to best assess test quality prior to the use of the best trial data for interpretation or research. DISCLOSURE: Mayuko Fukunaga, None. SAFETY AND ACCURACY OF INHALATION OF CAPSAICIN AEROSOLS IN A NORMAL ADULT POPULATION D A. Sams DO* Thomas Truncale DO Stuart M. Brooks MD University of South Florida, Tampa, FL PURPOSE: A subjects death at Johns Hopkins, after inhalation of hexamethonium, led to the FDA discouraging further human research involving inhalation of non-approved medications/drugs. This report describes the safety of inhalation studies using pharmaceutical grade capsaicin and looks at the results of high pressure liquid chromatography (HPLC) analyses of administered doses compared to their calculated concentrations.
U.S. BORN ASIAN INDIANS HAVE HIGHER PULMONARY FUNCTION VALUES COMPARED TO IMMIGRANT ASIAN INDIANS Ahmet S. Copur MD Ashok Fulambarker MD* Mark E. Cohen PhD Monali Patel Sanjay Gill George Chacko RRT Joseph K. Rosman MD Frank Maldonado MD Rosalind Franklin University of Medicine and Science/The Chicago Medical School, North Chicago, IL PURPOSE: To evaluate differences in pulmonary function between US born Asian Indians and immigrant Asian Indians that might be attributable to environmental and socioeconomic factors. METHODS: We constructed regression equations to predict forced vital capacity (FVC), forced expiratory volume in one second (FEV1), and mid-expiratory flow rate (FEF25-75) in 90 male and 90 female healthy, non-smoking US born Asian Indians and 160 male and 90 female healthy, non-smoking immigrant Asian Indians, using Age and Height as predictors, as well as these predictors in combination with the binary country of origin variable. Age range in both groups was 18-35. Values were obtained by using a Spirolab spirometer, following strict ATS guidelines. RESULTS: The regression equations for each sex from each country of origin are shown in Table 1. When data for countries were combined and Country was considered as an independent variable in the regression, P-values for Country approached significance for Males (0.0655, 0.0958, 0.3739) and were significant for females ( 0.0001, 0.0001, 0.0925) for FVC, FEV1, and FEF25-75, respectively. As shown in Table 2, US born subjects had higher values for all measurements. CONCLUSION: US Born, Asian Indian men and women had greater pulmonary function values compared to immigrant Asian Indians. These differences approached statistical significance for men and were significant for women. CLINICAL IMPLICATIONS: The differences in pulmonary function between these groups could be attributed to differences in environmental and socioeconomic factors.
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Table 2Typical Pulmonary Function Values Derived for a 25 Year Old Man With a Height of 1.75 Meters and a 25 Years Old Woman With a Height of 1.65 Meters.
Immigrant US Born Asian TEST FVC FEV1 FEF25-75 Indian Men 4.35 3.74 4.29 Asian Indian Men 4.13 3.59 4.13 US Born Asian Indian Women 3.29 2.92 6.46 Immigrant Asian Indian Women 2.95 2.60 3.04
DISCLOSURE: Ashok Fulambarker, None. EVALUATION OF THE CORRELATION BETWEEN IMPULSE OSCILLOMETERY (IOS) AND CONVENTIONAL SPIROMETERY PARAMETERS IN PATIENTS WITH POSITIVE METHACHOLIN CHALLENGE TEST (MCT) Ali Moghimi MD* Abbas Nemati MD Mahdi Rahmati MD Iran University of Medical Sciences and Health Care Services, Tehran, Iran PURPOSE: IOS is a new method for the evaluation of the bronchial airway narrowing. In comparison with conventional spirometery IOS is more convenient and needs less patients cooperation. The aim of this study is to evaluate the correlation between the IOS and spirometery parameters in patients with positive MCT. METHODS: 42 patients with respiratory symptoms suggesting asthma and positive MCT were studied. All of them had performed an IOS test with MS Jeager device which measures both IOS and spirometery parameters. After administration of different concentrations of methacholin IOS and spirometery parameters were measured. After at least 20% fall in the serial FEV1s, the case considered positive for MCT. The crude and percent changes for X5, Z5, R5, R20, R central and R peripheral of IOS and FEV1, PEFR, MMEF, FEF25%, FEF50% and FEF75% were measured and compared with each other. RESULTS: Percent changes of predicted MMEF and FVC were not correlated significantly with any IOS parameter mentioned above. Significant correlations between the percent changes FEF25%, FEF50%, FEF75% and PEFR and some IOS parameters was not clinically significant (r 0.5). Changes in the percent of predicted FEV1 were correlated with percent changes of the predicted and crude values of R5 and R20, all with r 0.5. CONCLUSION: This study shows although there are some correlations between IOS and spirometery parameters, these are not clinically
Table 1
Total Number of Patients Males (%) / Females (%) Age [Mean (Range)] FEV1 12% [Number (%)] FEF25-75 25% [Number (%)] Positive Methacholine [Number (%)]
DISCLOSURE: Zoheir Bshouty, None.
378 220 (58.2%) / 158 (41.8%) 44.5 (16-71) 96 (25.4%) 55 (14.6%) 90 (23.8%)
THE IMPACT OF CHRONIC LUNG DISEASES ON THE QUALITY OF LIFE OF PATIENTS MEASURED BOTH BY DISEASE SPECIFIC AND GENERIC INSTRUMENTS Siu Pui Lam MBBS* Pui Shan Lam MBBS Wai Woon Ho MBBS Ho Pui So MBBS Wong Tai Sin Hospital, Hong Kong, Hong Kong PRC PURPOSE: Chronic lung diseases affected the quality of life of patients. We aimed to (1) evaluate the health related quality of life (HRQOL) in patients with chronic lung diseases (2) examine the correlation among the HRQOL measures. METHODS: Patients who joined the Pulmonary Rehabilitation Program between August and December 2004 were included. Pulmonary function, blood gases and 6-min walking test were assessed. HRQOL instruments included: SF-36 (Hong Kong), St Georges Respiratory Questionnaire (SGRQ) and the Functional Impairment Checklist (FIC). RESULTS: The group consisted of 28 male (60.9.%) and 18 female (39.1%) with a mean age of 74.1 (SD 9.5, range 39 87). The mean
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DISCLOSURE: Jason Williams, None. DO WE REALLY NEED TO CORRECT FOR LUNG VOLUME WHEN INTERPRETING THE DIFFUSING CAPACITY? Todd Whitman MD David A. Kaminsky MD* University of Vermont College of Medicine, Burlington, VT PURPOSE: The diffusing capacity of the lung for carbon monoxide (DLCO) is commonly used as a measure of gas exchange. The DLCO is usually reported as both an absolute number (DLCO) and corrected for alveolar volume (DLCO/VA). However, it remains unclear which one to use in interpretation. To resolve this dilemma we determined whether abnormal DLCO or DLCO/VA was more closely associated with abnormal gas exchange as measured by exercise oximetry.
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AIRWAY RESISTANCE IN PATIENTS WITH AIRFLOW LIMITATION ESTIMATED BY THE INTERRUPTER TECHNIQUE Hajime Kurosawa MD* Katsuhiro Maruta PhD Wataru Hida MD Yuko Sano MS Kayomi Matsumoto MS Maki Yamakawa MD Junko Niisato MD Masahiro Kohzuki MD Dep Int Med & Reha Sci, Tohoku Univ Sch Med, Sendai, Japan PURPOSE: Measurement of airway resistance (Raw) requires body plethysmography, which makes difficult to monitor in disabled patients. On the other hand, measurement of airway resistance using the ineterrupter technique (Rint) does not require the big and expencive apparatus, and has been reported in animal models, healthy subjects, pre-school children, and geriatric patients. However, little is known about Rint in patients with high airway resistance. In this study, measurements of Rint was compared those of conventional Raw using body plethysmography in patients with airflow limitation such as COPD. METHODS: We studied 7 patients including 5 with COPD (M:F 5:2, age 59 6.4 years). Rint was measured using a commercialized system (HI-801, Chest M.I., Tokyo). The algorism of Rint measurement in this system is based on a report by Chowienczyk et al. (Eur Respir J 4: 623, 1991). Raw were measured using body plethysmography. RESULTS: The mean FEV1, Rint, and Raw were 1.20 0.64L ranged from 0.57 to 2.13L (51 28%pred, 24-92%), 0.59 0.30 kPa/l/sec (0.28-1.12), and 0.30 0.14 kPa/l/sec (0.05-0.46), respectively. Although Rint was significantly correlated with Raw (r 0.86, p 0.05), the differences tended to be bigger in patients with high Raw. Since airway pressure curve after interruption was not linear, the oral pressure determination at the time point (t15) immediately after the valve interruption, computed by back extrapolating a line drawn through two points (t30 and t70), was difficult to interprete. CONCLUSION: These results suggest that Rint may be useful to estimate airway resistance even in patients with severe airflow limitation in this system, although the value of the mesurements were higher than the conventionally measured Raw. The determination of the oral pressure at the interruption established by Chowienczyk is needed to be physiologically reexamined.
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Table 1
Replacement therapy predicted ( SD) Function parameters FVC FEV1 FEF75 FEF50 FEF25
*
DEEP BREATH MANEUVER ASSESSMENT ON GAS EXCHANGE IN EISENMENGER SYNDROME PATIENTS WITH OBESITY Maria-Luisa Martnez-Guerra MD Luis-Efren Santos-Martinez MD* Edgar Bautista MD Tomas Pulido MD Gerardo Rojas MD David Mendoza MD Sandoval Jose-Luis MD Silvio Namendys MD Alicia Castanon RN Julio Sandoval MD Instituto Nacional de Cardiologa Ignacio Chavez, Mexico City, Mexico PURPOSE: Hypoxemia in Eisenmenger syndrome (ES) is a common feature of the disease. Improvement in PaO2 of severely obese patients with hypoxemia through a deep breath maneuver (DBM) and improvement on the V/Q match has been described previously.Objetive: To assess the impact of DBM on gas exchange (GE) on patients with both, ES and obesity. METHODS: 30 patients with ES with obesity and obesity without ES, both with a body mass index (BMI) major than 35 were included. GE was evaluated with ABG sampling at room air and 100% oxygen fraction. They went through routine evaluation including echocardiography and pulmonary function test. Values were expressed as mean SD. Independent student t test were used to compare groups. p 0.05 was considered as statistically significative. RESULTS: 30 patients were included in two groups: 1) ES obesity and 2) Obesity; Demographics variables as age, weight and height were: 55 617; 11 years old, 87 17 kgs, and 153.1 9.5 respectively. The gas exchange values in the groups were:. CONCLUSION: No changes were observed on GE with DBM in ES with obesity patients. CLINICAL IMPLICATIONS: DBM in severely obese patients is useful to evaluate GE, but en ES with obesity patients, the DBM has important limitations.
c 78 (24)
0,05
REGRESSION MODEL FOR THE ESTIMATION OF PREDICTED VALUES OF FORCED EXPIRATORY VOLUMES IN FIRST SECOND (FEV1) BY PREDICTED VALUES OF PEAK EXPIRATORY FLOW RATE (PEFR) IN YOUNG MEN Ali Moghimi MD* Abbas Nemati MD Mahdi Rahmati MD Iran University of Medical Sciences and Health Care Services, Tehran, Iran PURPOSE: FEV1 is accepted as gold standard of the assessing airway caliber which needs spirometer. Despite of FEV1, PEFR could be evaluated by simple peak flow meter instruments, so it will be very helpful to be able to estimate the amount of FEV1 in a patient by his or her PEFR. The aim of this study is to evaluate the correlation between the predicted values of FEV1 and PEFR in patients underwent methacholin challenge test (MCT) and design regression model of their correlation. METHODS: This is a prospective cross-sectional study on 142 young men with respiratory symptoms suggesting asthma which were candidates for MCT. All the patients underwent MCT and spirometery according to American Thorax Society guidelines. The measures of %FEV1 and %PEFR of patients were compared with each other. The normality of distributions was checked by Kolmogorov-Smirnov test. Pearson correlation coefficient was calculated and linear regression used for the statistical analysis. RESULTS: Mean age of patients was 20.83 (SD, 1.92) years and all were male. Although distribution of %FEV1 was not normal, thats square was distributed normally. %PEFR and square of %FEV1 were significantly correlated (r 0.758;p .000) and its regression model was (%FEV1 2 99.74 %PEFR 381.05) with R 0.75. The model was not dependent on the %PEFR and the high and low measures did not affect model. CONCLUSION: It is believed that assessment of airway caliber through PEFR monitoring may not be valid in some asthmatic subjects; yet, study of FEV1 and PEFR correlation looks like a different subject. In addition, it is first report of assessing correlation of PEFR with square of FEV1 which seems to result in a fit model. Like any regression models lack of plausibility is a major problem though further studies have to be considered.
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USEFULNESS OF QUANTIFERON-TB AS A DIAGNOSTIC TOOL FOR ACTIVE TUBERCULOSIS Youjeong Sohn MD Dookyung Yang MD* Junghun Huh MD Sookeol Lee MD Choonhee Son MD Minki Lee MD Yunsung Kim MD Eunju Son Chulhun Chang MD Dong-A University Hospital, Busan, Korea PURPOSE: The Quantiferon-TB test (QFT) is a whole-blood interferon (IFN)-gamma assay for the recognition of cell-mediated immune response to Mycobacterium tuberculosis infection. It is already known as a useful diagnostic tool for the latent tuberculosis, but there is no study whether it can be also used to detect active tuberculosis (TB). So we investigated usefulness of the QFT for the diagnosis of active TB. METHODS: We prospectively studied in two tertiary care hospitals from Aug. 2004 to Feb. 2005. 54 patients clinically suspected as active TB were enrolled; 39 patients were AFB culture positive or histologically confirmed and 15 patients were not. We measured IFN-gamma response to PPD in whole blood assay. RESULTS: The QFT of whole blood was positive in 25 out of 39 active TB patients and negative in 7 out of 15 non-TB patients. So the sensitivity, specificity, positive predictive value and negative predictive value of the QFT were 64.1%, 46.6%, 75.7% and 33.3%, respectively. CONCLUSION: Our result demonstrates that the QFT in whole blood is not useful for the diagnosis of active TB in the region where TB incidence is high. CLINICAL IMPLICATIONS: QFT in whole blood is not useful for the diagnosis of active TB in the region where TB incidence is high. DISCLOSURE: Dookyung Yang, None.
POSTER PRESENTATIONS
Study Group Mean SD 706.24 31.59 0.68 18.83 158.68 5.82 0.11 5.10
Control Group Mean SD 538.32 36.16 1.14 24.04 147.72 6.55 0.22 6.87
Stat. Signi. HS HS HS HS
DISCLOSURE: Jai Kishan, None. THE PREVALENCE OF LATENT PULMONARY TUBERCULOSIS (LTB) IN A NORMAL AND A HIGH RISK POPULATION GROUP S. Ali MBBS* N. Chew MBBS P. Manning PhD N. Noonan MD J. Keane MD C. Bergin MD St. Jamess Hospital, Dublin, Ireland PURPOSE: To assess the efficacy of screening and compare the incidence of Latent Tuberculosis (LTB) and clinical Tuberculosis in two different population groups. METHODS: We evaluated the screening data of two different groups in the countrys biggest Hospital. The normal population comprised the employees joining the Hospital, while the high risk group comprised of patients suffering from HIV. The cases with positive Mantoux had been offered CXR and once found clear of TB were labelled as LTB. RESULTS: The mean age of healthy group was 38 and HIV 51 years. 1948 were men in the healthy and 207 in HIV group. The number of native Irish in these groups was 2001 and 99, while that of Non Irish was 409 and 232. The number of Non Irish patients in HIV was 232(65.9%) from Sub Sahara, 33(9.3%) from Europe, 4(1.1%) from USA and 1(0.28%) from Asia. The number of individual having LTB (positive Montoux test and normal CXR) was 765(31.7%) in normal and 39(11.07) in HIV group. CONCLUSION: The data in our study indicates that a significant proportion of normal healthy population and HIV group had Latent Tuberculosis (LTB). While the incidence of LTB was higher in the normal healthy population, the incidence of clinical TB was higher in HIV group. CHANGE OF IL-12 AND TNF-ALPHA PRODUCTIONS MEASURED BY WHOLE BLOOD CULTURE IN TUBERCULOSIS PATIENTS AFTER TREATMENT Young S. Kim MD* Jin W. Moon MD Chang H. Han MD Shin M. Kang MD Moo S. Park MD Se K. Kim MD Joon Chang MD Sung K. Kim MD Yonsei Univ College of Medicine, Seoul, South Korea PURPOSE: Tuberculosis is one of the leading infectious diseases in adults, causing around 3 million deaths annually. Research on understanding the host defense and immunopathogenesis of tuberculosis is necessary because there is an urgent need for a new vaccine and adjunctive immunotherapy, particularly in patients with drug resistant Mycobacterium tuberculosis infection. Recently, many aspects of cytokine dynamics in patients with active pulmonary tuberculosis have been investigated through ex-vivo studies with specific or crude mycobacterial antigens, or M. tuberculosis. METHODS: We used whole blood culture method in order to evaluate IL-12 and TNF-alpha productions in active TB patients, tuberculin skin test positive and negative healthy controls. We investigated the productions of IL-12, TNF-alpha in response to nonspecific mitogens and M. tuberculosis specific antigens. We used many tuberculous antigens for stimulation. The tuberculous antigens are culture filtrate proteins (CFP), purified protein derivatives (PPD), antigen 85A M. tuberculosis proteins (Ag85A), early secretory antigen target-6 (ESAT-6), 38k Dalton antigen
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TUBERCULOUS LYMPHADENITIS: CLINICAL CHARACTERISTICS AND OUTCOME IN A COMMUNITY HOSPITAL Tapan K. Gayen MD* Ravindra Hanumaiah MD Vijay Rupanagudi MD Karthikeyan Kanagarajan MD Santi Dhar MD Coney Island Hospital, Brooklyn, NY PURPOSE: Tuberculosis (TB) affecting the lymph nodes remain the most common extra pulmonary involvement by Mycobacterium Tuberculosis (MTB). In United States, over the last 35 years, the proportion of Tuberculous lymphatic disease has risen substantially, whereas reductions have been most pronounced in other forms of extra pulmonary TB. The aim of our study is to identify characteristics associated with its presentation, diagnosis and treatment. METHODS: Retrospective review of 50 cases of TB lymphadenitis seen between 1992 to 2005 in a community hospital. Diagnosis of TB
Variable Median age Male: Female Demography Indian subcontinent US born Others PPD positive HIV positive Sputum culture for MTB Lymph node Culture & Sensitivity Culture for MTB Pansensitive Multi drug resistant TB Duration of treatment 6 months 9 months 12 months 18 months 24 months* Adverse reactions Abnormal Liver function tests Skin rash Paradoxical reaction Reasons for prolonged treatment Adverse reactions Non compliance Relapse Drug resistance
Value (%) 39 years 1:1 32 (64%) 8 (16%) 10 (20%) 30 (60%) 7 (14%) 4 (8%) 36 (72%) 35 (70%) 1 (2%) 35 (70%) 6 (12%) 4 (8%) 3 (6%) 2 (4%) 11 (22%) 4 (4%) 4 (8%) 6 (12%) 6 (12%) 2 (4%) 1 (2%)
DISCLOSURE: Tapan Gayen, None. PULMONARY AND PLEURAL TUBERCULOSIS IN EXTREME ELDERLY Eun A Eum MD* Yangjin Jegal MD Moo Cheol Shin MD Kwang Won Seo MD Woon-Jung Kwon MD Jong-Joon Ahn MD Department of Pulmonology and Critical Care Medicine, Ulsan University Hospital, Ulsan, Korea PURPOSE: Several publications about tuberculosis in elderly patients have suggested that their clinical presentation and clinical course might be atypical from those in elderly. This tendency may be more strengthened with advancing years in age. The aim of this study was to compare clinical features of pulmonary and pleural tuberculosis in extreme elderly ( 80 years old) with those in elderly (between 60 and 79). METHODS: Thirty-seven extreme elderly with pulmonary and pleural tuberculosis from Ulsan University hospital between January 2000 and December 2004 were compared with randomly selected fifty-six elderly patients. RESULTS: General weakness was the only symptom that was observed more frequently in extreme elderly than in elderly (p 0.016). Other symptoms such as cough, sputum, fever, weight loss, anorexia and chest pain were not different between two groups. Dyspnea tends to be more frequent, and hemoptysis tends to be less common in extreme elderly although they were not statistically significant (p 0.056, 0.053 respectively). Evolution time before diagnosis and laboratory findings at presentation were not different between two groups. The incidence of comorbid conditions such as chronic obstructive pulmonary disease, diabetes, gastrectomy and malignancies were not different between two groups.
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one way analysis of variance was used to compare the data between the groups. Significant statistical differences were considered for p 0.05. RESULTS: The results are expressed in median (CI 25-75%) and are demonstrated in the table below. CONCLUSION: We do not observe significant differences for IL-1 , TNF and TGF among tuberculosis patients, patients with others pulmonary diseases and control group. CLINICAL IMPLICATIONS: This profile of cytokines do not contribute to differentiate tuberculosis from others pulmonary diseases and must not be used for diagnosis in patients with clinical or radiological suspicion of tuberculosis and negative smear.
Tuberculosis Non-Tuberculosis
7.8 (7.8-7.8) 7.8 (7.8-31.8) 7.8 (7.8-140.2) 0.515 15.6 (15.6-15.6) 24.5 (15.6-41.8) 15.6 (15.6-52.7) 0.213 31.2 (31.2-31.2) 31.2 (31.2-31.2) 31.2 (31.2-65.2) 0.503
DISCLOSURE: Leila Antonangelo, None. INDUCED SPUTUM VERSUS FIBEROPTIC BRONCHOSCOPY IN DIAGNOSIS OF PULMONARY TUBERCULOSIS Amr A. Darwish MD* Ahmed A. Abd el Rahman MD Wafaa A. Zahraan MD Nourane Y. Azab MD Mohammed A. Agha MD Menouffyia University, Menouffyia, Egypt PURPOSE: Tuberculosis (TB) remains one of the deadliest diseases in the world.Cases cant expectorate sputum constitute a major problem especially in developing countries. Therefore, the aim of this study was to compare between sputum induction (SI) using nebulized hypertonic saline and fiberoptic bronchoscopy (FOB) in the diagnosis of pulmonary TB in clinically and radiologically suspected cases. METHODS: This study included 30 patients(17 males and 13 females)with clinical and radiological suspicion of pulmonary TB. They had either dry cough or negative repeated sputum examinations for AFB. Three successive SI using nebulized hypertonic saline and FOB were done for all patients. Ziehl-Neelson stain (Z.N.) and Lowenstein-Jensen media(L.J.) were be used for the diagnosis of tuberculosis. RESULTS: The sensitivity, specificity and accuracy of SI compared with bronchial washing using Z.N. were 80%,100% and 90% respectively.While,using L.J. media the sensitivity, specificity and accuracy of SI compared with bronchial washing were 88%, 100% and 90% respectively.The positive results of SI and post-bronchoscopic sputum were similar 22 cases (66.7%). There was no significant difference (P 0.05) between SI, 20 cases (66.7)and bronchial brushing,23 case (76.7) in diagnising pulmonary TB. The third SI sample is the most significant sample in detecting AFB (19 cases). CONCLUSION: Sputum induction is an easy, effective, cheap and non-invasive procedure for the diagnosis of pulmonary TB compared to FOB. Also, SI is very suitable diagnositic technique where FOB isnot available. CLINICAL IMPLICATIONS: Sputum induction must be done to every patient with clinical and radiological suspecion of pulmonary TB who cant expectorate sputum or their sputum were negative for AFB. Fiberoptic bronchoscopy should be postponed until three induced sputum samples proved to be negative for AFB. DISCLOSURE: Amr Darwish, None. EVALUATING THE DIAGNOSIS OF TUBERCULOSIS IN INDUCED SPUTUM COLLECTION AND BRONCHOALVEOLAR LAVAGE SPECIMENS Rogerio G. Xavier MD* Fabricio L. Savegnago Fernanda Damian Natalia Fernandes Monica Rodrigues Patrcia Passos Paulo Franciscatto Pedro Piccinini Lucelia Henn MD Bronchology Unit, Hospital de Clnicas de Porto Alegre, Porto Alegre, Brazil PURPOSE: Validation of induced sputum (IS) with aerosol hypertonic saline solution followed by bronchoalveolar lavage (BAL) through flexible bronchoscopy (FB) in patients without spontaneous sputum for the diagnosis of pulmonary tuberculosis (TB). METHODS: Sputum was induced after 3 or more unsatisfactory spontaneous collection for acid fast bacilli (AFB). FB was recommended to collect BAL in a series of 99 patients with clinical suspicion of TB that
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DISCLOSURE: Leila Antonangelo, None. CITOKYNES IN BRONCHOALVEOLAR LAVAGE FROM PATIENTS WITH PULMONARY TUBERCULOSIS AND NEGATIVE SPUTUM Leila Antonangelo MD* Milena M. Acencio BS Francisco S. Vargas MD Lisete R. Teixeira MD Marcia Seiscento MD Wilson L. Pedreira Junior MD Gabriela G. Carnevale PharmD Viviane R. Figueiredo MD Pulmonary Division-Heart Institute (InCor) and Department of Pathology, Universi, Sao Paulo, Brazil PURPOSE: To evaluate the IL-1 , TNF- and TGF 1 profile in samples of brochoalveolar lavage obtained from patients with pulmonary tuberculosis and negative smear and culture sputum. METHODS: Samples of bronchoalveolar lavage obtained from 19 patients with pulmonary tuberculosis, 8 patients with others pulmonary diseases and 4 patients without pulmonary disease (control) were evaluated for IL-1 , TNF and TGF by an ELISA assay. The Kruskal -Wallis
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8.5 points Coefficient 6.288 6.456 1.897 8.5 points Coeficient 2.511 1.048 1.482 5.589
A COMPARISON BETWEEN THE INCIDENCE OF TUBERCULOSIS (TBC) IN GREEK POPULATION AND THE POPULATION OF ECONOMICAL EMIGRANTS IN THE COUNTY OF EVIA GREECE Georgios S. Vlachogeorgos MD* Helen Nicolopoulou MD Stylianos Podaras MD General Hospital of Chalkis, Chalkida, Greece PURPOSE: To compare the incidence of TBC between the Greek population and the population of the economical emigrants in the county of Evia Greece. METHODS: All the new cases of TBC in the decade 1994-2003 in the county of Evia Greece were studied yearly. Greek population was studied in contrast with the population of the economical emigrants. The numbers of the populations were considered after the National Statistic Service of Greece. RESULTS: There is a statistical significant difference between the mean incidence in Greeks (3.57) and the economical emigrants (25.75) p 0.002. CONCLUSION: a)For the last 3 studied years the incidence of the TBC in the Greek population has risen in parallel with the rising of the incidence of the disease in the population of economical emigrants b)The economical emigrants may be one of the reasons of the reapperance of the TBC in the developed countries. CLINICAL IMPLICATIONS: The economical emigrants must have free admission to the public health services independent the legal status that they live in the respective country for the general benefit.
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Year 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
POTTS DISEASE THE DILEMMA OF LOW BACK PAIN HIGH RESOLUTION RADIODIAGNOSIS BY COMPUTERISRD SCAN (CT) & MAGNETIC RESONANCE (MRI) MADE POSSIBLE THE DIAGNOSISTIC ACUURACY IN INCONCLUSIVE CASES Mohammad M. Ishaq Khan MD* Imran Khan MD Sameera M. I MD Al-Junaid Hospital, Nowshera, Pakistan PURPOSE: Tuberculous spondylitis, i.e. Potts disease with relentless progress, shares the common clinical presentation with low back ache, seems to be of trivial nature may end in catastrophic complication i.e, paraplegia. METHODS: A total of 45 patients(n 45),age 15-60 years both sex with proven tuberculosis. The clinical and imaging details assessed in all 45 cases. RESULTS: Distribution of tuberculosis lesion in the order of frequency was cervical & cervicodorsal region(n 3,7%)dorsal/dorsolumber region(n 17,37.8%),Lumber(n 19,42%),Lunbosacral & sacral region(n 6,13%). The lamina were most commonly involved (24 patients, 53.3%; 8 bilateral, 16 unilateral) followed by pedicles 10 patients, 22.2%s%; 6 bilateral, 4 unilateral), articular processes (6 patients,13.3%; 3 bilateral, 3 unilateral), spinous process (3Patients,6.7%), and transverse processes (2 cases,4.4%;1 bilateral, 1 unilateral). Bone destruction and marrow changes were seen in all patients. Involvement of the entire posterior arch was seen in six patients. A total of 14 patients revealed extraspinal soft tissue collections.,Intraspinal extradural granulation tissue/ abscess was seen in 11 patients. Spinal cord was either displaced or compressed in 6 patients, and abnormal high signal intensity intrinsic cord changes were seen in eight patients. Gait may be limping with variable degree of muscle wasting. Off & on low grade fever was associated. Laboratory investigations had elevated ESR, relative lymphocytosis low hemoglobin & few with tuberculin reaction conversion detected. Plain x-rays had irregular erosion of the end plate of adjacent vertebral bodies & narrowing of the intervening disk spaces. CT & MRI had revealed the nature of the lesion .With anti tubercular drugs on empirical ground, added diagnostic yield . with following outcome.1.Individuals diagnosed on empirical (ATD), 10-15%2.Diagnosis established on clinical manifestations only (Patients with poor economy could not afford expenses of investigations), 5 - 10 % 3.Financially stable patients, diagnosis established on CT/MRI. 75 -85 %. CONCLUSION: A large tubercular abscess compressing on spinal cord is a medical emergency, may result in irreversible paraphrases. CLINICAL IMPLICATIONS: Patients with Potts disease has characteristic early insomnia from spasm of para spinal muscles, and late insomnia resulting from urinary bladder distension. DISCLOSURE: Mohammad Ishaq Khan, None.
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CYTOKINE CHANGES IN SEVERE PULMONARY TUBERCULOSIS AFTER INITIATION OF TREATMENT: A PILOT STUDY Mariko S. Koh MBBS* E-Shyong Tai MBBS Constance Lo MBBS Kenneth P. Chan MBBS Philip Eng MBBS Singapore General Hospital, Singapore, Singapore PURPOSE: Sudden death occurs in a significant number of patients with pulmonary tuberculosis after the initiation of anti-tuberculous therapy. We postulate that a Jarisch-Herxheimer (JH) type response which is characterized by surge in Interleukin 6 (IL-6), Interleukin- 8 (IL-8) and Tumour necrosis factor alpha (TNF alpha) could be responsible for this phenomenon. METHODS: Five patients admitted to hospital for pulmonary tuberculosis were enrolled in this pilot study. These patients had multi-lobar involvement, were sputum smear positive for acid-fast bacilli and had low haemoglobin and albumin, signifying severe disease. Vital signs, temperature and clinical responses were monitored. Venepuncture was carried out 2, 4, 8, 12, 24, 48 and 72 hours after the first dose of anti-tuberculous therapy. These samples were analyzed to determine the concentrations of IL-6, IL-8 and TNF alpha at the various time points. RESULTS: Several patterns of cytokine changes were noted. In two patients, there was an increase in serum levels of IL-6 between 4 and 8 hours and these returned to baseline levels within 24 hours. Neither of these patients experienced an adverse clinical event. Two patients had relatively high IL-8 levels to start with compared to the other patients and had documented hypotensive episodes between 4 and 8 hours. Radiologically, these patients had more severe disease. CONCLUSION: An increase in IL-6 was observed in 2 patients which may be consistent with Jarisch-Herxheimer reaction. However, this was not accompanied by any clinical sequelae to support the occurrence of such a reaction. In contrast, patients with high IL-8 at baseline did exhibit clinically significant deterioration consistent with previous studies which have found that increased concentration of IL-8 were found in patients who died from tuberculosis compared to those who survived. Further studies should be carried out to clearly document the prognostic significance of serum levels of cytokine at baseline and within the first 24 hours following commencement of anti-tuberculous therapy for pulmonary tuberculosis. CLINICAL IMPLICATIONS: IL-6 and IL-8 levels may have prognostic significance in patients with pulmonary tuberculosis.
POSTER PRESENTATIONS
DISCLOSURE: Rafael Laniado-Laborin, None. TREATMENT OUTCOME OF TUBERCULOSIS UNDER DIRECTLY OBSERVED TREATMENT SHORT COURSE ( DOTS ) IN PATIENTS PRESENTING AT CHEST & TB HOSPITAL, AMRITSAR Vishal Verma MBBS Jorawar Singh MBBS Nirmal Chand MS* J. S. Khalsa MBBS Dept. of Tuberculosis & Respiratory Diseases, Amritsar, India PURPOSE: The present study was undertaken to determine the treatment outcome of DOTS as prescribed under RNTCP. Side effects and radiological improvement was also noted. METHODS: A total of 150 cases of tuberculosis on the basis of history, sputum & radiological examination were selected. They were divided into three categories under RNTCP. All the patients were administered standard regimens of antitubercular drugs as prescribed under DOTS. Sputum of all patients was examined before the start of treatment and then at the end of intensive phase, 4or5or6 months and then at the end of treatment. X-ray was taken before and at the end of treatment. Treatment outcome was determined. RESULTS: 150 patients comprised of 91 males and 59 females. Cough was the major complaint in 70% . Sputum conversion rate was 81% & 85.71% for category I & II. Cure rate was 91% & 71.40% for category I & II. Treatment completion rate was 100% for category III. Overall default rate was 5.33%. Failure rate was 0.67%. Radiological improvement was seen in 73.33%. 60.67% gained weight in the range of 6-10 Kg. Fatigue was major side effect under DOTS in 24% cases. CONCLUSION: DOTS is an effective and economical treatment with successful treatment outcome, sputum conversion and minimal side effects for tuberculosis.
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CHARACTERISTICS AND PROGNOSTIC FACTORS OF PULMONARY SADDLE EMBOLUS Linda M. Lam DO* George Matuschak MD Stephen Trottier MD Saint Louis University, Saint Louis, MO PURPOSE: Pulmonary saddle embolism is a radiographic description of massive embolization implicitly assumed to confer increased mortality. However, supportive data are scant. This is a review of 19 patients with a pulmonary saddle embolus over a 5 year period at a university medical center, hypothesizing that: 1) such patients exhibit increased mortality; and 2) discrete prognostic factors stratify these and other adverse outcomes. METHODS: The medical records of patients between June 1999 and June 2004 were retrieved to identify those with pulmonary saddle embolus on helical CT chest . Data collection included demographic data, APACHE II score, shock defined as requiring vasopressors and/or MAP 60 mmHg, need for mechanical ventilation, PaO2/FIO2 ratio, presence of deep venous thrombosis, echocardiographic findings, and hospital morbidity and mortality. Data was summarized by median calculation, means standard error and evaluated by X2 analysis, and bivariate correlation (SPSS v. 13 .0). RESULTS: Saddle embolism was diagnosed in 6 females and 13 males (total n 19), representing an incidence of 1.2%. Mean age was 58.2 years old /- SD 16.34 and median Apache II score of 9 (range 4-26). Five patients presented with hemodynamic instability, of which 2 patients demonstrated right ventricular systolic dysfunction. RV dilation found in 7/10 patients. Co-existing deep vein thrombosis found in 10 patients and superficial thrombophebitis in 4 patients. Median Pa02/FIO2 ratio found to be 233 (range 53-395). Four patients (22 %) required mechanical ventilation. No patients received thrombolytics. Seventeen (94 %) patients were anticoagulated with heparin infusion. No significant correlation existed among shock, occurrence or type of echocardiographic abnormalities, and degree of hypoxemia. All patients survived. CONCLUSION: Saddle pulmonary embolism is not consistently associated with shock, echocardiographic abnormalities, or hypoxemia in patients surviving the initial embolic event who were treated by standard anticoagulation regimens and/or caval interruption. CLINICAL IMPLICATIONS: Saddle pulmonary embolism is not associated with increase mortality based on shock, hypoxemia, or echcardiographic abnormalities. DISCLOSURE: Linda Lam, None.
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DIABETES MELLITUS IS SIGNIFICANTLY ASSOCIATED WITH PULMONARY EMBOLISM AND PULMONARY HYPERTENSION Mohammad-Reza Movahed MD* Mehrtash Hashemzadeh MA M. Mazen Jamal MD University of California, Irvine Medical Center, Orange, CA PURPOSE: Patients with diabetes mellitus (DM) suffer from hypercoagulable state which may increase their risk for thromboembolism. However, the data about this association is contradictory in the literature. The goal of this study was to evaluate the occurrence of pulmonary embolism and pulmonary hypertension (HTN) in patients with DM after
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MASSIVE PULMONARY EMBOLISM: TRANSCATHETER LYSIS WITH RETEPLASE Jaime Tisnado MD* Muhammad S. Chaudhri MD Ferdinand K. Hui MD MCV Hospitals/VCU Medical Center, Richmond, VA PURPOSE: Massive pulmonary embolism (PE) is a serious and relatively common problem, sometimes very difficult to manage. The conventional treatment (systemic anticoagulation and/or thrombolysis) is associated with significant hemorrhagic and other complications. A new method of therapy is the selective, local, transcatheter infusion of Retavase (Reteplase, recombinant) into the pulmonary arteries. METHODS: Twelve patients (24-70 y.o.) with massive bilateral PE, hemodynamically unstable with severe respiratory compromise, were treated with transcatheter directed thrombolysis with Reteplase infusion at 0.5-1 U/hr. Two catheters were simultaneously inserted into one or both common femoral veins and placed in each one of the two pulmonary arteries. The infusion time lasted from 20 to 48 hours. RESULTS: All patients recovered well. All patients showed significant drops in pulmonary artery systolic pressures ranging from 13-34 mm of Hg. Improvements in pulmonary perfusion with resolution of clot occurred at 24 hours (n 6) and 48 hours (n 6) of infusion. No significant complications occurred despite the severity of the clinical condition of most patients. Concomitant heparin (400-500 U/hr) was given to some patients. CONCLUSION: Bilateral selective pulmonary artery infusion of Retavase is safe, effective and well tolerated for the management of patients with massive PE, especially those who are not candidates for the conventional means of therapy, and those patients being considered for a more aggressive management such as pulmonary embolectomy. CLINICAL IMPLICATIONS: A very serious and potentially lethal condition (massive PE) can be successfully managed with IR methods. Some of these patients would have needed, perhaps, open pulmonary embolectomy, associated with high morbidity and mortality. DISCLOSURE: Jaime Tisnado, None.
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