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Bariatric surgery sliced asthma inhaler use
MADRID – Morbidly obese asthmatics may require less inhaler therapy after bariatric surgery, a retrospective chart review and longitudinal cohort study suggests.
Among patients who used any form of inhaler therapy prior to surgery, one or more classes of inhalers were discontinued in 30% (P less than .05), Dr. Randall Schwartz reported at the world congress of the American College of Chest Physicians.
Specifically, short-acting beta agonist (SABA) use decreased significantly by 13.1% from baseline (64.5% to 51.4%; P less than .0001) and long-acting beta agonist/inhaled corticosteroid (LABA/ICS) combinations by 8.1% (40.2% to 32.1%; P = .0034). Fewer patients were on short- or long-acting muscarinic antagonists (SAMA/LAMA), which declined 1.6% (9.4% to 7.8%; P = .305).
The corresponding number need to treat was 8 patients for SABA, 12 for LABA/ICS combinations, and 7 for SAMA/LAMA.
Prior studies have shown a decrease in asthma severity after gastric surgery but haven’t specifically looked at inhaler usage.
Though there was a 30% reduction among those using inhalers, 10% of patients actually required more inhaler therapy after surgery, said Dr. Schwartz, chief internal medicine resident, Cleveland Clinic Florida, Weston.
"Our supposition is that the overwhelming majority of these patients have obesity-related asthma – neutrophilic mediated inflammation; whereas some of those who ended up having to go up in their inhaler therapy might have had classic atopic eosinophilic-mediated asthma," he explained in an interview.
Unfortunately, only 203 of the 505 patients had formal pulmonary function tests (PFT) and only 9 had fractional exhaled nitric oxide measured. "I think nitric oxide would be a really non-invasive and simple thing we could do to follow-up with these patients because PFTs represent a bit of a challenge in this population because of body mechanics," Dr. Schwartz said. "I would bet we’re going to see a disproportionate amount of elevated phenotypes in those who actually had to increase their inhaler usage and probably not significant eosinophilic inflammation in the majority of patients, particularly those who decreased their inhaler usage."
Of those who started a LABA/ICS for the first time after surgery, 72% had already been on a SAMA/LAMA prior to surgery.
Of those starting a SAMA/LAMA for the first time after surgery, 100% were on a SABA or LABA/ICS prior to surgery.
Overall, there was a 20% reduction in postoperative inhaler use, with a number needed to treat of only seven patients, according to the poster presentation (Chest 2014;145:15A [doi:10.1378/chest.1824454]).
Because of the retrospective nature of the study, it was not possible to determine whether type of gastric surgery or amount of weight loss influenced postoperative inhaler use, he said. Other possible factors could be improved body mechanics and decreased inflammation from less adipose tissue.
The mean change in body mass index was –16.2 kg/m2, which occurred at an average of 19 months after surgery.
The review included 716 patients who underwent gastric bypass surgery or sleeve gastrectomy with an accompanying diagnosis of asthma. A total of 211 patients were excluded because of concomitant or suspected chronic obstructive pulmonary disease.
At baseline, the average BMI was 50.7 kg/m2, average forced expiratory volume in 1 second was 79%, and average FEV1/forced vital capacity was 91%.
Going forward, the investigators reported that they hope to perform follow-up testing in the existing cohort and prospectively study post–gastric bypass inhaler use, including asthma severity, fractional exhaled nitric oxide testing, and a cost-benefit analysis.
"Gastric surgery costs about $20,000 and it can cost $3,000-$6,000 a year depending on whether patients are using one or two inhalers to control their asthma," Dr. Schwartz said. "So over the course of a few years, you make up that difference with asthma alone, not to mention the cardiovascular benefits."
The investigators reported having nothing to disclose.
MADRID – Morbidly obese asthmatics may require less inhaler therapy after bariatric surgery, a retrospective chart review and longitudinal cohort study suggests.
Among patients who used any form of inhaler therapy prior to surgery, one or more classes of inhalers were discontinued in 30% (P less than .05), Dr. Randall Schwartz reported at the world congress of the American College of Chest Physicians.
Specifically, short-acting beta agonist (SABA) use decreased significantly by 13.1% from baseline (64.5% to 51.4%; P less than .0001) and long-acting beta agonist/inhaled corticosteroid (LABA/ICS) combinations by 8.1% (40.2% to 32.1%; P = .0034). Fewer patients were on short- or long-acting muscarinic antagonists (SAMA/LAMA), which declined 1.6% (9.4% to 7.8%; P = .305).
The corresponding number need to treat was 8 patients for SABA, 12 for LABA/ICS combinations, and 7 for SAMA/LAMA.
Prior studies have shown a decrease in asthma severity after gastric surgery but haven’t specifically looked at inhaler usage.
Though there was a 30% reduction among those using inhalers, 10% of patients actually required more inhaler therapy after surgery, said Dr. Schwartz, chief internal medicine resident, Cleveland Clinic Florida, Weston.
"Our supposition is that the overwhelming majority of these patients have obesity-related asthma – neutrophilic mediated inflammation; whereas some of those who ended up having to go up in their inhaler therapy might have had classic atopic eosinophilic-mediated asthma," he explained in an interview.
Unfortunately, only 203 of the 505 patients had formal pulmonary function tests (PFT) and only 9 had fractional exhaled nitric oxide measured. "I think nitric oxide would be a really non-invasive and simple thing we could do to follow-up with these patients because PFTs represent a bit of a challenge in this population because of body mechanics," Dr. Schwartz said. "I would bet we’re going to see a disproportionate amount of elevated phenotypes in those who actually had to increase their inhaler usage and probably not significant eosinophilic inflammation in the majority of patients, particularly those who decreased their inhaler usage."
Of those who started a LABA/ICS for the first time after surgery, 72% had already been on a SAMA/LAMA prior to surgery.
Of those starting a SAMA/LAMA for the first time after surgery, 100% were on a SABA or LABA/ICS prior to surgery.
Overall, there was a 20% reduction in postoperative inhaler use, with a number needed to treat of only seven patients, according to the poster presentation (Chest 2014;145:15A [doi:10.1378/chest.1824454]).
Because of the retrospective nature of the study, it was not possible to determine whether type of gastric surgery or amount of weight loss influenced postoperative inhaler use, he said. Other possible factors could be improved body mechanics and decreased inflammation from less adipose tissue.
The mean change in body mass index was –16.2 kg/m2, which occurred at an average of 19 months after surgery.
The review included 716 patients who underwent gastric bypass surgery or sleeve gastrectomy with an accompanying diagnosis of asthma. A total of 211 patients were excluded because of concomitant or suspected chronic obstructive pulmonary disease.
At baseline, the average BMI was 50.7 kg/m2, average forced expiratory volume in 1 second was 79%, and average FEV1/forced vital capacity was 91%.
Going forward, the investigators reported that they hope to perform follow-up testing in the existing cohort and prospectively study post–gastric bypass inhaler use, including asthma severity, fractional exhaled nitric oxide testing, and a cost-benefit analysis.
"Gastric surgery costs about $20,000 and it can cost $3,000-$6,000 a year depending on whether patients are using one or two inhalers to control their asthma," Dr. Schwartz said. "So over the course of a few years, you make up that difference with asthma alone, not to mention the cardiovascular benefits."
The investigators reported having nothing to disclose.
MADRID – Morbidly obese asthmatics may require less inhaler therapy after bariatric surgery, a retrospective chart review and longitudinal cohort study suggests.
Among patients who used any form of inhaler therapy prior to surgery, one or more classes of inhalers were discontinued in 30% (P less than .05), Dr. Randall Schwartz reported at the world congress of the American College of Chest Physicians.
Specifically, short-acting beta agonist (SABA) use decreased significantly by 13.1% from baseline (64.5% to 51.4%; P less than .0001) and long-acting beta agonist/inhaled corticosteroid (LABA/ICS) combinations by 8.1% (40.2% to 32.1%; P = .0034). Fewer patients were on short- or long-acting muscarinic antagonists (SAMA/LAMA), which declined 1.6% (9.4% to 7.8%; P = .305).
The corresponding number need to treat was 8 patients for SABA, 12 for LABA/ICS combinations, and 7 for SAMA/LAMA.
Prior studies have shown a decrease in asthma severity after gastric surgery but haven’t specifically looked at inhaler usage.
Though there was a 30% reduction among those using inhalers, 10% of patients actually required more inhaler therapy after surgery, said Dr. Schwartz, chief internal medicine resident, Cleveland Clinic Florida, Weston.
"Our supposition is that the overwhelming majority of these patients have obesity-related asthma – neutrophilic mediated inflammation; whereas some of those who ended up having to go up in their inhaler therapy might have had classic atopic eosinophilic-mediated asthma," he explained in an interview.
Unfortunately, only 203 of the 505 patients had formal pulmonary function tests (PFT) and only 9 had fractional exhaled nitric oxide measured. "I think nitric oxide would be a really non-invasive and simple thing we could do to follow-up with these patients because PFTs represent a bit of a challenge in this population because of body mechanics," Dr. Schwartz said. "I would bet we’re going to see a disproportionate amount of elevated phenotypes in those who actually had to increase their inhaler usage and probably not significant eosinophilic inflammation in the majority of patients, particularly those who decreased their inhaler usage."
Of those who started a LABA/ICS for the first time after surgery, 72% had already been on a SAMA/LAMA prior to surgery.
Of those starting a SAMA/LAMA for the first time after surgery, 100% were on a SABA or LABA/ICS prior to surgery.
Overall, there was a 20% reduction in postoperative inhaler use, with a number needed to treat of only seven patients, according to the poster presentation (Chest 2014;145:15A [doi:10.1378/chest.1824454]).
Because of the retrospective nature of the study, it was not possible to determine whether type of gastric surgery or amount of weight loss influenced postoperative inhaler use, he said. Other possible factors could be improved body mechanics and decreased inflammation from less adipose tissue.
The mean change in body mass index was –16.2 kg/m2, which occurred at an average of 19 months after surgery.
The review included 716 patients who underwent gastric bypass surgery or sleeve gastrectomy with an accompanying diagnosis of asthma. A total of 211 patients were excluded because of concomitant or suspected chronic obstructive pulmonary disease.
At baseline, the average BMI was 50.7 kg/m2, average forced expiratory volume in 1 second was 79%, and average FEV1/forced vital capacity was 91%.
Going forward, the investigators reported that they hope to perform follow-up testing in the existing cohort and prospectively study post–gastric bypass inhaler use, including asthma severity, fractional exhaled nitric oxide testing, and a cost-benefit analysis.
"Gastric surgery costs about $20,000 and it can cost $3,000-$6,000 a year depending on whether patients are using one or two inhalers to control their asthma," Dr. Schwartz said. "So over the course of a few years, you make up that difference with asthma alone, not to mention the cardiovascular benefits."
The investigators reported having nothing to disclose.
AT CHEST WORLD CONGRESS 2014
Major finding: Bariatric surgery cut use of SABA by 13.1% (P less than .0001), (LABA/ICS) by 8.1% (P = .0034), and SAMA/LAMA antagonists by 1.6% (P = .305).
Data source: A retrospective chart review and longitudinal cohort study of 505 asthmatics.
Disclosures: The investigators reported having nothing to disclose.
Menopause isn’t a culprit behind severe asthma
MADRID – Menopause is blamed for many things, but it’s unlikely to be the reason for the increased risk of severe asthma or worse quality of life in elderly asthmatic women, a study suggests.
"The increased unadjusted asthma severity and need for health care utilization in postmenopausal women are more likely due to other factors like age and other comorbidities rather than menopause per se," Dr. Joe Zein, FCCP, said at CHEST World Congress 2014.
The investigators used a propensity score matching method to analyze the effect of menopause on asthma severity, quality of life, and health care utilization in 166 menopausal and 538 premenopausal women enrolled in the Severe Asthma Research program from 2002 to 2011.
Subsequent multivariate logistic regression analyses were used to adjust for the covariates of age at enrollment, hypertension, gastroesophageal reflux disease (GERD), and hormone therapy, which was used in only 35 menopausal women.
Compared with premenopausal women, menopausal women were older and reported less atopy and more comorbidities, such as higher body mass index, diabetes mellitus, hypertension, GERD, obstructive sleep apnea, sinusitis, and nasal polyps, said Dr. Zein, a pulmonologist at Cleveland Clinic.
Menopausal women also had lower lung function and higher neutrophil percentage in both induced sputum and bronchoalveolar lavage fluid.
Severe asthma was present in 31% (167/538) of premenopausal and 72% (119/166) of menopausal women.
In unadjusted analysis, the risk of severe asthma was almost sixfold higher in menopausal women (odds ratio, 5.62; 95% confidence interval 3.83-8.26), but dropped dramatically in the adjusted analysis (OR, 1.46), 95% C.I. 0.50-4.22),he said.
Menopausal women also had lower average scores than did premenopausal women (4.06 vs. 4.56) on the 7-point Asthma Quality of Life Questionnaire, with 7 being "not impaired at all" and 1 being "severely impaired."
The mean difference between groups pointed to worse quality of life among menopausal women in unadjusted analysis (–0.5),; 95% C.I. -0.71 to -0.27), but again this faded after multivariate adjustment (0.31; 95% C.I. –0.-0.93).
Similar trends were observed for health care utilization including emergency department visits (unadjusted OR, 1.33; adjusted OR, 1.15) and hospitalization (unadjusted OR, 2.93; adjusted OR, 0.70), Dr. Zein said.
Finally, an analysis stratified by menopausal status that looked at the association between enrollment age and the probability of severe asthma suggested a rise in severe asthma among premenopausal women and those in early menopause, followed by a steady decline around age 55 years. Two possible hypotheses are that insulin resistance is higher during the period around menopause and thus may worsen asthma and that estrogen levels initially rise during early menopause before declining and also may increase asthma severity, Dr. Zein said.
"We don’t know exactly, but I think we should not look at menopause as one entity."
Several studies have tried to tease out the effects of menopause and aging on asthma severity, with conflicting results.
A recent study reported that menopausal women in their fifties and sixties are more than twice as likely to be hospitalized for asthma as men the same age (Ann. Allergy Asthma Immunol. 2013;111:176-81).
The Harvard Nurses Health Study, however, found that postmenopausal women who never used hormone therapy had a significantly lower age-adjusted risk of asthma than premenopausal women (Am. J. Respir. Crit. Care Med. 1995;152:1183-8).
The role of estrogen in asthma remains controversial, Dr. Zein observed. The incidence of asthma is twice as high among boys during childhood, but this switches during puberty when girls have a higher incidence of asthma as well as asthma-related hospitalizations and health care utilization, he noted.
Dr. Vera DePalo, FCCP, comments: Asthma severity changes over the spectrum of a lifetime with changing linkage to gender at different ages. During menopause, while there is an increased likelihood of severe asthma, there are several confounding factors, resulting in lower adjusted odds ratios. As we learn more about asthma and its associations, the complexity of its manifestations becomes more evident.
Dr. Vera DePalo, FCCP, comments: Asthma severity changes over the spectrum of a lifetime with changing linkage to gender at different ages. During menopause, while there is an increased likelihood of severe asthma, there are several confounding factors, resulting in lower adjusted odds ratios. As we learn more about asthma and its associations, the complexity of its manifestations becomes more evident.
Dr. Vera DePalo, FCCP, comments: Asthma severity changes over the spectrum of a lifetime with changing linkage to gender at different ages. During menopause, while there is an increased likelihood of severe asthma, there are several confounding factors, resulting in lower adjusted odds ratios. As we learn more about asthma and its associations, the complexity of its manifestations becomes more evident.
MADRID – Menopause is blamed for many things, but it’s unlikely to be the reason for the increased risk of severe asthma or worse quality of life in elderly asthmatic women, a study suggests.
"The increased unadjusted asthma severity and need for health care utilization in postmenopausal women are more likely due to other factors like age and other comorbidities rather than menopause per se," Dr. Joe Zein, FCCP, said at CHEST World Congress 2014.
The investigators used a propensity score matching method to analyze the effect of menopause on asthma severity, quality of life, and health care utilization in 166 menopausal and 538 premenopausal women enrolled in the Severe Asthma Research program from 2002 to 2011.
Subsequent multivariate logistic regression analyses were used to adjust for the covariates of age at enrollment, hypertension, gastroesophageal reflux disease (GERD), and hormone therapy, which was used in only 35 menopausal women.
Compared with premenopausal women, menopausal women were older and reported less atopy and more comorbidities, such as higher body mass index, diabetes mellitus, hypertension, GERD, obstructive sleep apnea, sinusitis, and nasal polyps, said Dr. Zein, a pulmonologist at Cleveland Clinic.
Menopausal women also had lower lung function and higher neutrophil percentage in both induced sputum and bronchoalveolar lavage fluid.
Severe asthma was present in 31% (167/538) of premenopausal and 72% (119/166) of menopausal women.
In unadjusted analysis, the risk of severe asthma was almost sixfold higher in menopausal women (odds ratio, 5.62; 95% confidence interval 3.83-8.26), but dropped dramatically in the adjusted analysis (OR, 1.46), 95% C.I. 0.50-4.22),he said.
Menopausal women also had lower average scores than did premenopausal women (4.06 vs. 4.56) on the 7-point Asthma Quality of Life Questionnaire, with 7 being "not impaired at all" and 1 being "severely impaired."
The mean difference between groups pointed to worse quality of life among menopausal women in unadjusted analysis (–0.5),; 95% C.I. -0.71 to -0.27), but again this faded after multivariate adjustment (0.31; 95% C.I. –0.-0.93).
Similar trends were observed for health care utilization including emergency department visits (unadjusted OR, 1.33; adjusted OR, 1.15) and hospitalization (unadjusted OR, 2.93; adjusted OR, 0.70), Dr. Zein said.
Finally, an analysis stratified by menopausal status that looked at the association between enrollment age and the probability of severe asthma suggested a rise in severe asthma among premenopausal women and those in early menopause, followed by a steady decline around age 55 years. Two possible hypotheses are that insulin resistance is higher during the period around menopause and thus may worsen asthma and that estrogen levels initially rise during early menopause before declining and also may increase asthma severity, Dr. Zein said.
"We don’t know exactly, but I think we should not look at menopause as one entity."
Several studies have tried to tease out the effects of menopause and aging on asthma severity, with conflicting results.
A recent study reported that menopausal women in their fifties and sixties are more than twice as likely to be hospitalized for asthma as men the same age (Ann. Allergy Asthma Immunol. 2013;111:176-81).
The Harvard Nurses Health Study, however, found that postmenopausal women who never used hormone therapy had a significantly lower age-adjusted risk of asthma than premenopausal women (Am. J. Respir. Crit. Care Med. 1995;152:1183-8).
The role of estrogen in asthma remains controversial, Dr. Zein observed. The incidence of asthma is twice as high among boys during childhood, but this switches during puberty when girls have a higher incidence of asthma as well as asthma-related hospitalizations and health care utilization, he noted.
MADRID – Menopause is blamed for many things, but it’s unlikely to be the reason for the increased risk of severe asthma or worse quality of life in elderly asthmatic women, a study suggests.
"The increased unadjusted asthma severity and need for health care utilization in postmenopausal women are more likely due to other factors like age and other comorbidities rather than menopause per se," Dr. Joe Zein, FCCP, said at CHEST World Congress 2014.
The investigators used a propensity score matching method to analyze the effect of menopause on asthma severity, quality of life, and health care utilization in 166 menopausal and 538 premenopausal women enrolled in the Severe Asthma Research program from 2002 to 2011.
Subsequent multivariate logistic regression analyses were used to adjust for the covariates of age at enrollment, hypertension, gastroesophageal reflux disease (GERD), and hormone therapy, which was used in only 35 menopausal women.
Compared with premenopausal women, menopausal women were older and reported less atopy and more comorbidities, such as higher body mass index, diabetes mellitus, hypertension, GERD, obstructive sleep apnea, sinusitis, and nasal polyps, said Dr. Zein, a pulmonologist at Cleveland Clinic.
Menopausal women also had lower lung function and higher neutrophil percentage in both induced sputum and bronchoalveolar lavage fluid.
Severe asthma was present in 31% (167/538) of premenopausal and 72% (119/166) of menopausal women.
In unadjusted analysis, the risk of severe asthma was almost sixfold higher in menopausal women (odds ratio, 5.62; 95% confidence interval 3.83-8.26), but dropped dramatically in the adjusted analysis (OR, 1.46), 95% C.I. 0.50-4.22),he said.
Menopausal women also had lower average scores than did premenopausal women (4.06 vs. 4.56) on the 7-point Asthma Quality of Life Questionnaire, with 7 being "not impaired at all" and 1 being "severely impaired."
The mean difference between groups pointed to worse quality of life among menopausal women in unadjusted analysis (–0.5),; 95% C.I. -0.71 to -0.27), but again this faded after multivariate adjustment (0.31; 95% C.I. –0.-0.93).
Similar trends were observed for health care utilization including emergency department visits (unadjusted OR, 1.33; adjusted OR, 1.15) and hospitalization (unadjusted OR, 2.93; adjusted OR, 0.70), Dr. Zein said.
Finally, an analysis stratified by menopausal status that looked at the association between enrollment age and the probability of severe asthma suggested a rise in severe asthma among premenopausal women and those in early menopause, followed by a steady decline around age 55 years. Two possible hypotheses are that insulin resistance is higher during the period around menopause and thus may worsen asthma and that estrogen levels initially rise during early menopause before declining and also may increase asthma severity, Dr. Zein said.
"We don’t know exactly, but I think we should not look at menopause as one entity."
Several studies have tried to tease out the effects of menopause and aging on asthma severity, with conflicting results.
A recent study reported that menopausal women in their fifties and sixties are more than twice as likely to be hospitalized for asthma as men the same age (Ann. Allergy Asthma Immunol. 2013;111:176-81).
The Harvard Nurses Health Study, however, found that postmenopausal women who never used hormone therapy had a significantly lower age-adjusted risk of asthma than premenopausal women (Am. J. Respir. Crit. Care Med. 1995;152:1183-8).
The role of estrogen in asthma remains controversial, Dr. Zein observed. The incidence of asthma is twice as high among boys during childhood, but this switches during puberty when girls have a higher incidence of asthma as well as asthma-related hospitalizations and health care utilization, he noted.
AT CHEST WORLD CONGRESS 2014
Major finding: The odds ratio for severe asthma was 5.62 for menopausal vs. premenopausal women in unadjusted analysis, but 1.46 after adjustment.
Data source: A retrospective analysis of 166 menopausal and 538 premenopausal asthmatic women.
Disclosures: Dr. Zein reported no financial disclosures; a coauthor reported grant monies from the National Institutes of Health.
A little PT goes a long way in hospitalized COPD patients
MADRID – Adding physical therapy to standard care improved self-reported quality of life in patients hospitalized with an acute exacerbation of chronic obstructive pulmonary disease in a randomized, controlled trial.
Significant gains in health-related quality of life were seen at discharge on all of the EUROQol-5D questionnaire subscales including mobility (mean 2.00 vs. 1.29; P less than .001), self-care (mean 1.76 vs. 1.19; P = .004), usual activities (mean 2.14 vs. 1.43; P = .004), pain/discomfort (mean 1.71 vs. 1.24; P = .014), and anxiety/depression (mean 2.00 vs. 1.38; P less than .001).
Overall health, measured with the EUROQol-5D visual analog scale, also improved significantly from an average score of 57.0 to 74.4 (P = .006), Irene Torres-Sánchez, PT, reported at the world congress of the American College of Chest Physicians.
What stands out is that the average hospital length of stay was just 8.8 days.
The physical therapy protocol included 45 minutes of daily, individualized resistance training targeting the lower limbs and controlled breathing exercises including relaxation exercises, pursed lips breathing, and active expiration, explained Ms. Torres-Sánchez of University of Granada, Spain.
No significant differences were found between the 30 intervention patients and 30 controls at baseline in Saint George\'s Respiratory Questionnaire values (63.95 vs. 63.00). Their average age was 71 years and body mass index was 27.6 kg/m2.
Improvements were seen in the control group, but they were statistically significant, using a P value of less than .05, only for anxiety/depression (mean 1.96 vs. 1.46; P less than .001). Overall health did not improve significantly from baseline (55.42 vs. 58.96; P = .396), according to the poster presentation (Chest 2014;145:372A [doi:10.1378/chest.1823625]).
In two other posters reported during the same session, the investigators showed that adults hospitalized with acute COPD exacerbation walked only 255 steps per day on average (Chest 2014;145:385A [doi:10.1378/chest.1822986]).
Those who took part in the PT program, however, had improved muscle strength and steadiness and muscle endurance, although it was not uniformly significant for both legs (Chest 2014;145:369A [doi:10.1378/chest.1823630]).
The investigators reported no financial disclosures.
Dr. Eric Gartman, FCCP, comments: While further work would be needed in this area to confirm their data and ensure that the effects seen were not just due to the 45 minutes of daily attention the PT group received - it supports other recent studies in our field that the earlier we mobilize and encourage our patients to get out of bed, the better their functionality and outcomes. In addition to the benefit to patients, if such interventions were also shown to reduce COPD readmissions, formal implementation of these resources would become very attractive to health care teams and hospital administrators alike.
Dr. Eric Gartman, FCCP, comments: While further work would be needed in this area to confirm their data and ensure that the effects seen were not just due to the 45 minutes of daily attention the PT group received - it supports other recent studies in our field that the earlier we mobilize and encourage our patients to get out of bed, the better their functionality and outcomes. In addition to the benefit to patients, if such interventions were also shown to reduce COPD readmissions, formal implementation of these resources would become very attractive to health care teams and hospital administrators alike.
Dr. Eric Gartman, FCCP, comments: While further work would be needed in this area to confirm their data and ensure that the effects seen were not just due to the 45 minutes of daily attention the PT group received - it supports other recent studies in our field that the earlier we mobilize and encourage our patients to get out of bed, the better their functionality and outcomes. In addition to the benefit to patients, if such interventions were also shown to reduce COPD readmissions, formal implementation of these resources would become very attractive to health care teams and hospital administrators alike.
MADRID – Adding physical therapy to standard care improved self-reported quality of life in patients hospitalized with an acute exacerbation of chronic obstructive pulmonary disease in a randomized, controlled trial.
Significant gains in health-related quality of life were seen at discharge on all of the EUROQol-5D questionnaire subscales including mobility (mean 2.00 vs. 1.29; P less than .001), self-care (mean 1.76 vs. 1.19; P = .004), usual activities (mean 2.14 vs. 1.43; P = .004), pain/discomfort (mean 1.71 vs. 1.24; P = .014), and anxiety/depression (mean 2.00 vs. 1.38; P less than .001).
Overall health, measured with the EUROQol-5D visual analog scale, also improved significantly from an average score of 57.0 to 74.4 (P = .006), Irene Torres-Sánchez, PT, reported at the world congress of the American College of Chest Physicians.
What stands out is that the average hospital length of stay was just 8.8 days.
The physical therapy protocol included 45 minutes of daily, individualized resistance training targeting the lower limbs and controlled breathing exercises including relaxation exercises, pursed lips breathing, and active expiration, explained Ms. Torres-Sánchez of University of Granada, Spain.
No significant differences were found between the 30 intervention patients and 30 controls at baseline in Saint George\'s Respiratory Questionnaire values (63.95 vs. 63.00). Their average age was 71 years and body mass index was 27.6 kg/m2.
Improvements were seen in the control group, but they were statistically significant, using a P value of less than .05, only for anxiety/depression (mean 1.96 vs. 1.46; P less than .001). Overall health did not improve significantly from baseline (55.42 vs. 58.96; P = .396), according to the poster presentation (Chest 2014;145:372A [doi:10.1378/chest.1823625]).
In two other posters reported during the same session, the investigators showed that adults hospitalized with acute COPD exacerbation walked only 255 steps per day on average (Chest 2014;145:385A [doi:10.1378/chest.1822986]).
Those who took part in the PT program, however, had improved muscle strength and steadiness and muscle endurance, although it was not uniformly significant for both legs (Chest 2014;145:369A [doi:10.1378/chest.1823630]).
The investigators reported no financial disclosures.
MADRID – Adding physical therapy to standard care improved self-reported quality of life in patients hospitalized with an acute exacerbation of chronic obstructive pulmonary disease in a randomized, controlled trial.
Significant gains in health-related quality of life were seen at discharge on all of the EUROQol-5D questionnaire subscales including mobility (mean 2.00 vs. 1.29; P less than .001), self-care (mean 1.76 vs. 1.19; P = .004), usual activities (mean 2.14 vs. 1.43; P = .004), pain/discomfort (mean 1.71 vs. 1.24; P = .014), and anxiety/depression (mean 2.00 vs. 1.38; P less than .001).
Overall health, measured with the EUROQol-5D visual analog scale, also improved significantly from an average score of 57.0 to 74.4 (P = .006), Irene Torres-Sánchez, PT, reported at the world congress of the American College of Chest Physicians.
What stands out is that the average hospital length of stay was just 8.8 days.
The physical therapy protocol included 45 minutes of daily, individualized resistance training targeting the lower limbs and controlled breathing exercises including relaxation exercises, pursed lips breathing, and active expiration, explained Ms. Torres-Sánchez of University of Granada, Spain.
No significant differences were found between the 30 intervention patients and 30 controls at baseline in Saint George\'s Respiratory Questionnaire values (63.95 vs. 63.00). Their average age was 71 years and body mass index was 27.6 kg/m2.
Improvements were seen in the control group, but they were statistically significant, using a P value of less than .05, only for anxiety/depression (mean 1.96 vs. 1.46; P less than .001). Overall health did not improve significantly from baseline (55.42 vs. 58.96; P = .396), according to the poster presentation (Chest 2014;145:372A [doi:10.1378/chest.1823625]).
In two other posters reported during the same session, the investigators showed that adults hospitalized with acute COPD exacerbation walked only 255 steps per day on average (Chest 2014;145:385A [doi:10.1378/chest.1822986]).
Those who took part in the PT program, however, had improved muscle strength and steadiness and muscle endurance, although it was not uniformly significant for both legs (Chest 2014;145:369A [doi:10.1378/chest.1823630]).
The investigators reported no financial disclosures.
AT CHEST WORLD CONGRESS 2014
Key clinical point: Prescribing PT may reduce anxiety and depression in hospitalized COPD patients as well as improve muscle strength and steadiness.
Major finding: Overall health on the EUROQol-5D visual analog scale improved from 57.0 to 74.4 at discharge (P = .006).
Data source: A randomized, single-blind trial in 60 patients hospitalized with COPD.
Disclosures: The investigators reported no financial disclosures.
Soluble ST2 predicts ARDS ICU mortality
MADRID – Elevated levels of the soluble ST2 protein were associated with higher intensive care unit mortality in patients with acute respiratory distress syndrome in a prospective pilot study.
Among 62 patients, median soluble ST2 levels were significantly higher among ICU nonsurvivors than survivors on day 1 of acute respiratory distress syndrome (ARDS) onset (4,934 pg/mL vs. 1,007 pg/mL) and at day 3 (5,720 pg/mL vs. 823 pg/mL), Dr. Marina Garcia de Acilu reported at CHEST World Congress 2014.
The soluble form of the ST2 [interleukin-1 (IL-1) receptor-like 1] protein, and its ligand, IL-33, have come under increased scrutiny in recent years for their potential role in the pathogenesis of various pulmonary diseases including ARDS.
ST2 concentrations have been reported to be elevated in patients with asthma, pulmonary fibrosis, and eosinophilic pneumonia, and were shown in the PRIDE (ProBNP Investigation of Dyspnea in the Emergency Department) study to predict 1-year survival among acutely dyspneic patients with pulmonary disorders admitted to the emergency department (Am. J. Clin. Pathol. 2008;130:578-584) from September 2012 to September 2013. Their median APACHE II (Acute Physiology and Chronic Health Evaluation II) score was 24 (range 19-29) and their median age was 61 years. ICU mortality was 41%.
No significant differences were seen in IL-33 concentrations on day 1 or 3 between survivors and those who died, reported Dr. Garcia de Acilu of Vall d’Hebron University Hospital, Barcelona.
An ST2 level on day 1 of at least 3,672 pg/mL, however, accurately identified patients who died (area under the operator curve 0.96; P less than .01), and outperformed traditional APACHE and SOFA (Sequential Organ Failure Assessment) scores, with a sensitivity of 86% and specificity of 100%.
Patients with an ST2 level below this threshold on day 1 had significantly higher survival rates in a Kaplan-Meier survival analysis.
In addition, an ST2 level above 3,672 pg/mL on day 1 was the only variable in multivariate analysis associated with ICU mortality, increasing the risk of death more than 14-fold (hazard ratio, 14.7), Dr. Garcia de Acilu reported in the poster presentation.
"In ARDS patients, ST2 may be considered a useful early biomarker for prognosis, by identifying high-risk-of-death patients," the authors concluded. "Further studies, using ST2 clinically, should be performed to assess the added value in specific subpopulations or in the presence of some comorbidities."
ST2 may also prove useful as a therapeutic strategy. A recent study, also out of Barcelona, reported that human mesenchymal stem cells, genetically engineered to produce soluble ST2, further prevented IL-33 induction, but also enhanced IL-10 expression in a murine acute lung injury model. This synergy led to a substantial decrease in lung airspace inflammation and vascular leakage (Am. J. Respir. Cell Mol. Biol. 2013:49:552-62).
"This study also illustrates the potential role for targeting ST2 as a therapy for airway disorders," senior author Dr. Jordi Rello, chief of critical care at Vall d’Hebron University Hospital, said in an interview.
Dr. Garcia de Acilu and her coauthors reported no financial disclosures.
Dr. Eleanor Summerhill, FCCP, comments: A recently discovered
member of the IL-1 superfamily of cytokines, IL-33 has been shown to
have multiple immunomodulatory effects, but predominately induces the
T–helper cell (TH-2) pathway. The soluble isoform of the IL-1 receptor
(ST2) acts as a "decoy receptor" for IL-33, dampening the
pro-inflammatory response. A growing body of evidence suggests that
plasma levels of ST2 may serve as a useful biomarker in cardiac,
rheumatologic, and pulmonary disease, including asthma, pulmonary
fibrosis, eosinophilic pneumonia, and ALI/ARDS.
Dr. Garcia-Acilu
and colleagues recently reported the results of a small, single-center
study evaluating the prognostic value of soluble ST2 levels on day 1 in
patients with ARDS, and found that the use of this biomarker
outperformed both the APACHE II and SOFA scores in predicting mortality.
There is also some evidence in the literature that modulation of
soluble ST2 levels may be useful as a therapeutic modality.
This
is a very exciting new area of investigation with significant potential
impact on the future management of patients with ARDS.
Dr. Eleanor Summerhill, FCCP, comments: A recently discovered
member of the IL-1 superfamily of cytokines, IL-33 has been shown to
have multiple immunomodulatory effects, but predominately induces the
T–helper cell (TH-2) pathway. The soluble isoform of the IL-1 receptor
(ST2) acts as a "decoy receptor" for IL-33, dampening the
pro-inflammatory response. A growing body of evidence suggests that
plasma levels of ST2 may serve as a useful biomarker in cardiac,
rheumatologic, and pulmonary disease, including asthma, pulmonary
fibrosis, eosinophilic pneumonia, and ALI/ARDS.
Dr. Garcia-Acilu
and colleagues recently reported the results of a small, single-center
study evaluating the prognostic value of soluble ST2 levels on day 1 in
patients with ARDS, and found that the use of this biomarker
outperformed both the APACHE II and SOFA scores in predicting mortality.
There is also some evidence in the literature that modulation of
soluble ST2 levels may be useful as a therapeutic modality.
This
is a very exciting new area of investigation with significant potential
impact on the future management of patients with ARDS.
Dr. Eleanor Summerhill, FCCP, comments: A recently discovered
member of the IL-1 superfamily of cytokines, IL-33 has been shown to
have multiple immunomodulatory effects, but predominately induces the
T–helper cell (TH-2) pathway. The soluble isoform of the IL-1 receptor
(ST2) acts as a "decoy receptor" for IL-33, dampening the
pro-inflammatory response. A growing body of evidence suggests that
plasma levels of ST2 may serve as a useful biomarker in cardiac,
rheumatologic, and pulmonary disease, including asthma, pulmonary
fibrosis, eosinophilic pneumonia, and ALI/ARDS.
Dr. Garcia-Acilu
and colleagues recently reported the results of a small, single-center
study evaluating the prognostic value of soluble ST2 levels on day 1 in
patients with ARDS, and found that the use of this biomarker
outperformed both the APACHE II and SOFA scores in predicting mortality.
There is also some evidence in the literature that modulation of
soluble ST2 levels may be useful as a therapeutic modality.
This
is a very exciting new area of investigation with significant potential
impact on the future management of patients with ARDS.
MADRID – Elevated levels of the soluble ST2 protein were associated with higher intensive care unit mortality in patients with acute respiratory distress syndrome in a prospective pilot study.
Among 62 patients, median soluble ST2 levels were significantly higher among ICU nonsurvivors than survivors on day 1 of acute respiratory distress syndrome (ARDS) onset (4,934 pg/mL vs. 1,007 pg/mL) and at day 3 (5,720 pg/mL vs. 823 pg/mL), Dr. Marina Garcia de Acilu reported at CHEST World Congress 2014.
The soluble form of the ST2 [interleukin-1 (IL-1) receptor-like 1] protein, and its ligand, IL-33, have come under increased scrutiny in recent years for their potential role in the pathogenesis of various pulmonary diseases including ARDS.
ST2 concentrations have been reported to be elevated in patients with asthma, pulmonary fibrosis, and eosinophilic pneumonia, and were shown in the PRIDE (ProBNP Investigation of Dyspnea in the Emergency Department) study to predict 1-year survival among acutely dyspneic patients with pulmonary disorders admitted to the emergency department (Am. J. Clin. Pathol. 2008;130:578-584) from September 2012 to September 2013. Their median APACHE II (Acute Physiology and Chronic Health Evaluation II) score was 24 (range 19-29) and their median age was 61 years. ICU mortality was 41%.
No significant differences were seen in IL-33 concentrations on day 1 or 3 between survivors and those who died, reported Dr. Garcia de Acilu of Vall d’Hebron University Hospital, Barcelona.
An ST2 level on day 1 of at least 3,672 pg/mL, however, accurately identified patients who died (area under the operator curve 0.96; P less than .01), and outperformed traditional APACHE and SOFA (Sequential Organ Failure Assessment) scores, with a sensitivity of 86% and specificity of 100%.
Patients with an ST2 level below this threshold on day 1 had significantly higher survival rates in a Kaplan-Meier survival analysis.
In addition, an ST2 level above 3,672 pg/mL on day 1 was the only variable in multivariate analysis associated with ICU mortality, increasing the risk of death more than 14-fold (hazard ratio, 14.7), Dr. Garcia de Acilu reported in the poster presentation.
"In ARDS patients, ST2 may be considered a useful early biomarker for prognosis, by identifying high-risk-of-death patients," the authors concluded. "Further studies, using ST2 clinically, should be performed to assess the added value in specific subpopulations or in the presence of some comorbidities."
ST2 may also prove useful as a therapeutic strategy. A recent study, also out of Barcelona, reported that human mesenchymal stem cells, genetically engineered to produce soluble ST2, further prevented IL-33 induction, but also enhanced IL-10 expression in a murine acute lung injury model. This synergy led to a substantial decrease in lung airspace inflammation and vascular leakage (Am. J. Respir. Cell Mol. Biol. 2013:49:552-62).
"This study also illustrates the potential role for targeting ST2 as a therapy for airway disorders," senior author Dr. Jordi Rello, chief of critical care at Vall d’Hebron University Hospital, said in an interview.
Dr. Garcia de Acilu and her coauthors reported no financial disclosures.
MADRID – Elevated levels of the soluble ST2 protein were associated with higher intensive care unit mortality in patients with acute respiratory distress syndrome in a prospective pilot study.
Among 62 patients, median soluble ST2 levels were significantly higher among ICU nonsurvivors than survivors on day 1 of acute respiratory distress syndrome (ARDS) onset (4,934 pg/mL vs. 1,007 pg/mL) and at day 3 (5,720 pg/mL vs. 823 pg/mL), Dr. Marina Garcia de Acilu reported at CHEST World Congress 2014.
The soluble form of the ST2 [interleukin-1 (IL-1) receptor-like 1] protein, and its ligand, IL-33, have come under increased scrutiny in recent years for their potential role in the pathogenesis of various pulmonary diseases including ARDS.
ST2 concentrations have been reported to be elevated in patients with asthma, pulmonary fibrosis, and eosinophilic pneumonia, and were shown in the PRIDE (ProBNP Investigation of Dyspnea in the Emergency Department) study to predict 1-year survival among acutely dyspneic patients with pulmonary disorders admitted to the emergency department (Am. J. Clin. Pathol. 2008;130:578-584) from September 2012 to September 2013. Their median APACHE II (Acute Physiology and Chronic Health Evaluation II) score was 24 (range 19-29) and their median age was 61 years. ICU mortality was 41%.
No significant differences were seen in IL-33 concentrations on day 1 or 3 between survivors and those who died, reported Dr. Garcia de Acilu of Vall d’Hebron University Hospital, Barcelona.
An ST2 level on day 1 of at least 3,672 pg/mL, however, accurately identified patients who died (area under the operator curve 0.96; P less than .01), and outperformed traditional APACHE and SOFA (Sequential Organ Failure Assessment) scores, with a sensitivity of 86% and specificity of 100%.
Patients with an ST2 level below this threshold on day 1 had significantly higher survival rates in a Kaplan-Meier survival analysis.
In addition, an ST2 level above 3,672 pg/mL on day 1 was the only variable in multivariate analysis associated with ICU mortality, increasing the risk of death more than 14-fold (hazard ratio, 14.7), Dr. Garcia de Acilu reported in the poster presentation.
"In ARDS patients, ST2 may be considered a useful early biomarker for prognosis, by identifying high-risk-of-death patients," the authors concluded. "Further studies, using ST2 clinically, should be performed to assess the added value in specific subpopulations or in the presence of some comorbidities."
ST2 may also prove useful as a therapeutic strategy. A recent study, also out of Barcelona, reported that human mesenchymal stem cells, genetically engineered to produce soluble ST2, further prevented IL-33 induction, but also enhanced IL-10 expression in a murine acute lung injury model. This synergy led to a substantial decrease in lung airspace inflammation and vascular leakage (Am. J. Respir. Cell Mol. Biol. 2013:49:552-62).
"This study also illustrates the potential role for targeting ST2 as a therapy for airway disorders," senior author Dr. Jordi Rello, chief of critical care at Vall d’Hebron University Hospital, said in an interview.
Dr. Garcia de Acilu and her coauthors reported no financial disclosures.
AT CHEST WORLD CONGRESS 2014
Major finding: Median soluble ST2 levels were significantly higher among ICU nonsurvivors than survivors at day 1 (4,934 pg/mL vs. 1,007 pg/mL) and day 3 (5,720 pg/mL vs. 823 pg/mL).
Data source: A prospective study in 62 patients with ARDS
Disclosures: The investigators reported no financial disclosures.
Menopause doesn’t drive severe asthma
MADRID – Menopause is blamed for many things, but it’s unlikely to be the reason for the increased risk of severe asthma or worse quality of life in elderly asthmatic women, a study suggests.
"The increased unadjusted asthma severity and need for health care utilization in postmenopausal women are more likely due to other factors like age and other comorbidities rather than menopause per se," Dr. Joe Zein said at the world congress of the American College of Chest Physicians.
The investigators used a propensity score matching method to analyze the effect of menopause on asthma severity, quality of life, and health care utilization in 166 menopausal and 538 premenopausal women enrolled in the Severe Asthma Research program from 2002 to 2011. Subsequent multivariate logistic regression analyses were used to adjust for the covariates of age at enrollment, hypertension, gastroesophageal reflux disease (GERD), and hormone therapy, which was used in only 35 menopausal women.
Compared with premenopausal women, menopausal women were older and reported less atopy and more comorbidities, such as higher body mass index, diabetes mellitus, hypertension, GERD, obstructive sleep apnea, sinusitis, and nasal polyps, said Dr. Zein, a pulmonologist at Cleveland Clinic.
Menopausal women also had lower lung function and higher neutrophil percentage in both induced sputum and bronchoalveolar lavage fluid.
Severe asthma was present in 31% (167/538) of premenopausal and 72% (119/166) of menopausal women.
In unadjusted analysis, the risk of severe asthma was almost sixfold higher in menopausal women (odds ratio, 5.62; 95% confidence interval 3.83-8.26), but dropped dramatically in the adjusted analysis (OR, 1.46), he said.
Menopausal women also had lower average scores than did premenopausal women (4.06 vs. 4.56) on the 7-point Asthma Quality of Life Questionnaire, with 7 being "not impaired at all" and 1 being "severely impaired." The mean difference between groups pointed to worse quality of life among menopausal women in unadjusted analysis (–0.5), but again this faded after multivariate adjustment (0.31; 95% C.I. –0.30 to 0.93).
Similar trends were observed for health care utilization including emergency department visits (unadjusted OR, 1.33; adjusted OR, 1.15) and hospitalization (unadjusted OR, 2.93; adjusted OR, 0.70), Dr. Zein said.
Finally, an analysis stratified by menopausal status that looked at the association between enrollment age and the probability of severe asthma, suggested a rise in severe asthma among premenopausal women and those in early menopause, followed by a steady decline around age 55 years. Two possible hypotheses are that insulin resistance is higher during the period around menopause and thus may worsen asthma and that estrogen levels initially rise during early menopause before declining and also may increase asthma severity, Dr. Zein said.
"We don’t know exactly, but I think we should not look at menopause as one entity."
Several studies have tried to tease out the effects of menopause and aging on asthma severity, with conflicting results.
A recent study reported that menopausal women in their fifties and sixties are more than twice as likely to be hospitalized for asthma as men the same age (Ann. Allergy Asthma Immunol. 2013;111:176-81).
The Harvard Nurses Health Study, however, found that postmenopausal women who never used hormone therapy had a significantly lower age-adjusted risk of asthma than premenopausal women (Am. J. Respir. Crit. Care Med. 1995;152:1183-8).
The role of estrogen in asthma remains controversial, Dr. Zein observed. The incidence of asthma is twice as high among boys during childhood, but this switches during puberty when girls have a higher incidence of asthma as well as asthma-related hospitalizations and health care utilization, he noted.
Dr. Zein reported no financial disclosures; a coauthor reported grant monies from the National Institutes of Health.
MADRID – Menopause is blamed for many things, but it’s unlikely to be the reason for the increased risk of severe asthma or worse quality of life in elderly asthmatic women, a study suggests.
"The increased unadjusted asthma severity and need for health care utilization in postmenopausal women are more likely due to other factors like age and other comorbidities rather than menopause per se," Dr. Joe Zein said at the world congress of the American College of Chest Physicians.
The investigators used a propensity score matching method to analyze the effect of menopause on asthma severity, quality of life, and health care utilization in 166 menopausal and 538 premenopausal women enrolled in the Severe Asthma Research program from 2002 to 2011. Subsequent multivariate logistic regression analyses were used to adjust for the covariates of age at enrollment, hypertension, gastroesophageal reflux disease (GERD), and hormone therapy, which was used in only 35 menopausal women.
Compared with premenopausal women, menopausal women were older and reported less atopy and more comorbidities, such as higher body mass index, diabetes mellitus, hypertension, GERD, obstructive sleep apnea, sinusitis, and nasal polyps, said Dr. Zein, a pulmonologist at Cleveland Clinic.
Menopausal women also had lower lung function and higher neutrophil percentage in both induced sputum and bronchoalveolar lavage fluid.
Severe asthma was present in 31% (167/538) of premenopausal and 72% (119/166) of menopausal women.
In unadjusted analysis, the risk of severe asthma was almost sixfold higher in menopausal women (odds ratio, 5.62; 95% confidence interval 3.83-8.26), but dropped dramatically in the adjusted analysis (OR, 1.46), he said.
Menopausal women also had lower average scores than did premenopausal women (4.06 vs. 4.56) on the 7-point Asthma Quality of Life Questionnaire, with 7 being "not impaired at all" and 1 being "severely impaired." The mean difference between groups pointed to worse quality of life among menopausal women in unadjusted analysis (–0.5), but again this faded after multivariate adjustment (0.31; 95% C.I. –0.30 to 0.93).
Similar trends were observed for health care utilization including emergency department visits (unadjusted OR, 1.33; adjusted OR, 1.15) and hospitalization (unadjusted OR, 2.93; adjusted OR, 0.70), Dr. Zein said.
Finally, an analysis stratified by menopausal status that looked at the association between enrollment age and the probability of severe asthma, suggested a rise in severe asthma among premenopausal women and those in early menopause, followed by a steady decline around age 55 years. Two possible hypotheses are that insulin resistance is higher during the period around menopause and thus may worsen asthma and that estrogen levels initially rise during early menopause before declining and also may increase asthma severity, Dr. Zein said.
"We don’t know exactly, but I think we should not look at menopause as one entity."
Several studies have tried to tease out the effects of menopause and aging on asthma severity, with conflicting results.
A recent study reported that menopausal women in their fifties and sixties are more than twice as likely to be hospitalized for asthma as men the same age (Ann. Allergy Asthma Immunol. 2013;111:176-81).
The Harvard Nurses Health Study, however, found that postmenopausal women who never used hormone therapy had a significantly lower age-adjusted risk of asthma than premenopausal women (Am. J. Respir. Crit. Care Med. 1995;152:1183-8).
The role of estrogen in asthma remains controversial, Dr. Zein observed. The incidence of asthma is twice as high among boys during childhood, but this switches during puberty when girls have a higher incidence of asthma as well as asthma-related hospitalizations and health care utilization, he noted.
Dr. Zein reported no financial disclosures; a coauthor reported grant monies from the National Institutes of Health.
MADRID – Menopause is blamed for many things, but it’s unlikely to be the reason for the increased risk of severe asthma or worse quality of life in elderly asthmatic women, a study suggests.
"The increased unadjusted asthma severity and need for health care utilization in postmenopausal women are more likely due to other factors like age and other comorbidities rather than menopause per se," Dr. Joe Zein said at the world congress of the American College of Chest Physicians.
The investigators used a propensity score matching method to analyze the effect of menopause on asthma severity, quality of life, and health care utilization in 166 menopausal and 538 premenopausal women enrolled in the Severe Asthma Research program from 2002 to 2011. Subsequent multivariate logistic regression analyses were used to adjust for the covariates of age at enrollment, hypertension, gastroesophageal reflux disease (GERD), and hormone therapy, which was used in only 35 menopausal women.
Compared with premenopausal women, menopausal women were older and reported less atopy and more comorbidities, such as higher body mass index, diabetes mellitus, hypertension, GERD, obstructive sleep apnea, sinusitis, and nasal polyps, said Dr. Zein, a pulmonologist at Cleveland Clinic.
Menopausal women also had lower lung function and higher neutrophil percentage in both induced sputum and bronchoalveolar lavage fluid.
Severe asthma was present in 31% (167/538) of premenopausal and 72% (119/166) of menopausal women.
In unadjusted analysis, the risk of severe asthma was almost sixfold higher in menopausal women (odds ratio, 5.62; 95% confidence interval 3.83-8.26), but dropped dramatically in the adjusted analysis (OR, 1.46), he said.
Menopausal women also had lower average scores than did premenopausal women (4.06 vs. 4.56) on the 7-point Asthma Quality of Life Questionnaire, with 7 being "not impaired at all" and 1 being "severely impaired." The mean difference between groups pointed to worse quality of life among menopausal women in unadjusted analysis (–0.5), but again this faded after multivariate adjustment (0.31; 95% C.I. –0.30 to 0.93).
Similar trends were observed for health care utilization including emergency department visits (unadjusted OR, 1.33; adjusted OR, 1.15) and hospitalization (unadjusted OR, 2.93; adjusted OR, 0.70), Dr. Zein said.
Finally, an analysis stratified by menopausal status that looked at the association between enrollment age and the probability of severe asthma, suggested a rise in severe asthma among premenopausal women and those in early menopause, followed by a steady decline around age 55 years. Two possible hypotheses are that insulin resistance is higher during the period around menopause and thus may worsen asthma and that estrogen levels initially rise during early menopause before declining and also may increase asthma severity, Dr. Zein said.
"We don’t know exactly, but I think we should not look at menopause as one entity."
Several studies have tried to tease out the effects of menopause and aging on asthma severity, with conflicting results.
A recent study reported that menopausal women in their fifties and sixties are more than twice as likely to be hospitalized for asthma as men the same age (Ann. Allergy Asthma Immunol. 2013;111:176-81).
The Harvard Nurses Health Study, however, found that postmenopausal women who never used hormone therapy had a significantly lower age-adjusted risk of asthma than premenopausal women (Am. J. Respir. Crit. Care Med. 1995;152:1183-8).
The role of estrogen in asthma remains controversial, Dr. Zein observed. The incidence of asthma is twice as high among boys during childhood, but this switches during puberty when girls have a higher incidence of asthma as well as asthma-related hospitalizations and health care utilization, he noted.
Dr. Zein reported no financial disclosures; a coauthor reported grant monies from the National Institutes of Health.
AT CHEST WORLD CONGRESS 2014
Major finding: The odds ratio for severe asthma was 5.62 for menopausal vs. premenopausal women in unadjusted analysis, but 1.46 after adjustment.
Data source: A retrospective analysis of 166 menopausal and 538 premenopausal asthmatic women.
Disclosures: Dr. Zein reported no financial disclosures; a coauthor reported grant monies from the National Institutes of Health.
A little PT goes a long way in hospitalized COPD patients
MADRID – Adding physical therapy to standard care improved self-reported quality of life in patients hospitalized with an acute exacerbation of chronic obstructive pulmonary disease in a randomized, controlled trial.
Significant gains in health-related quality of life were seen at discharge on all of the EUROQol-5D questionnaire subscales including mobility (mean 2.00 vs. 1.29; P less than .001), self-care (mean 1.76 vs. 1.19; P = .004), usual activities (mean 2.14 vs. 1.43; P = .004), pain/discomfort (mean 1.71 vs. 1.24; P = .014), and anxiety/depression (mean 2.00 vs. 1.38; P less than .001).
Overall health, measured with the EUROQol-5D visual analog scale, also improved significantly from an average score of 57.0 to 74.4 (P = .006), Irene Torres-Sánchez, PT, reported at the world congress of the American College of Chest Physicians.
What stands out is that the average hospital length of stay was just 8.8 days.
The physical therapy protocol included 45 minutes of daily, individualized resistance training targeting the lower limbs and controlled breathing exercises including relaxation exercises, pursed lips breathing, and active expiration, explained Ms. Torres-Sánchez of University of Granada, Spain.
No significant differences were found between the 30 intervention patients and 30 controls at baseline in Saint George's Respiratory Questionnaire values (63.95 vs. 63.00). Their average age was 71 years and body mass index was 27.6 kg/m2.
Improvements were seen in the control group, but they were statistically significant, using a P value of less than .05, only for anxiety/depression (mean 1.96 vs. 1.46; P less than .001). Overall health did not improve significantly from baseline (55.42 vs. 58.96; P = .396), according to the poster presentation (Chest 2014;145:372A [doi:10.1378/chest.1823625]).
In two other posters reported during the same session, the investigators showed that adults hospitalized with acute COPD exacerbation walked only 255 steps per day on average (Chest 2014;145:385A [doi:10.1378/chest.1822986]).
Those who took part in the PT program, however, had improved muscle strength and steadiness and muscle endurance, although it was not uniformly significant for both legs (Chest 2014;145:369A [doi:10.1378/chest.1823630]).
The investigators reported no financial disclosures.
MADRID – Adding physical therapy to standard care improved self-reported quality of life in patients hospitalized with an acute exacerbation of chronic obstructive pulmonary disease in a randomized, controlled trial.
Significant gains in health-related quality of life were seen at discharge on all of the EUROQol-5D questionnaire subscales including mobility (mean 2.00 vs. 1.29; P less than .001), self-care (mean 1.76 vs. 1.19; P = .004), usual activities (mean 2.14 vs. 1.43; P = .004), pain/discomfort (mean 1.71 vs. 1.24; P = .014), and anxiety/depression (mean 2.00 vs. 1.38; P less than .001).
Overall health, measured with the EUROQol-5D visual analog scale, also improved significantly from an average score of 57.0 to 74.4 (P = .006), Irene Torres-Sánchez, PT, reported at the world congress of the American College of Chest Physicians.
What stands out is that the average hospital length of stay was just 8.8 days.
The physical therapy protocol included 45 minutes of daily, individualized resistance training targeting the lower limbs and controlled breathing exercises including relaxation exercises, pursed lips breathing, and active expiration, explained Ms. Torres-Sánchez of University of Granada, Spain.
No significant differences were found between the 30 intervention patients and 30 controls at baseline in Saint George's Respiratory Questionnaire values (63.95 vs. 63.00). Their average age was 71 years and body mass index was 27.6 kg/m2.
Improvements were seen in the control group, but they were statistically significant, using a P value of less than .05, only for anxiety/depression (mean 1.96 vs. 1.46; P less than .001). Overall health did not improve significantly from baseline (55.42 vs. 58.96; P = .396), according to the poster presentation (Chest 2014;145:372A [doi:10.1378/chest.1823625]).
In two other posters reported during the same session, the investigators showed that adults hospitalized with acute COPD exacerbation walked only 255 steps per day on average (Chest 2014;145:385A [doi:10.1378/chest.1822986]).
Those who took part in the PT program, however, had improved muscle strength and steadiness and muscle endurance, although it was not uniformly significant for both legs (Chest 2014;145:369A [doi:10.1378/chest.1823630]).
The investigators reported no financial disclosures.
MADRID – Adding physical therapy to standard care improved self-reported quality of life in patients hospitalized with an acute exacerbation of chronic obstructive pulmonary disease in a randomized, controlled trial.
Significant gains in health-related quality of life were seen at discharge on all of the EUROQol-5D questionnaire subscales including mobility (mean 2.00 vs. 1.29; P less than .001), self-care (mean 1.76 vs. 1.19; P = .004), usual activities (mean 2.14 vs. 1.43; P = .004), pain/discomfort (mean 1.71 vs. 1.24; P = .014), and anxiety/depression (mean 2.00 vs. 1.38; P less than .001).
Overall health, measured with the EUROQol-5D visual analog scale, also improved significantly from an average score of 57.0 to 74.4 (P = .006), Irene Torres-Sánchez, PT, reported at the world congress of the American College of Chest Physicians.
What stands out is that the average hospital length of stay was just 8.8 days.
The physical therapy protocol included 45 minutes of daily, individualized resistance training targeting the lower limbs and controlled breathing exercises including relaxation exercises, pursed lips breathing, and active expiration, explained Ms. Torres-Sánchez of University of Granada, Spain.
No significant differences were found between the 30 intervention patients and 30 controls at baseline in Saint George's Respiratory Questionnaire values (63.95 vs. 63.00). Their average age was 71 years and body mass index was 27.6 kg/m2.
Improvements were seen in the control group, but they were statistically significant, using a P value of less than .05, only for anxiety/depression (mean 1.96 vs. 1.46; P less than .001). Overall health did not improve significantly from baseline (55.42 vs. 58.96; P = .396), according to the poster presentation (Chest 2014;145:372A [doi:10.1378/chest.1823625]).
In two other posters reported during the same session, the investigators showed that adults hospitalized with acute COPD exacerbation walked only 255 steps per day on average (Chest 2014;145:385A [doi:10.1378/chest.1822986]).
Those who took part in the PT program, however, had improved muscle strength and steadiness and muscle endurance, although it was not uniformly significant for both legs (Chest 2014;145:369A [doi:10.1378/chest.1823630]).
The investigators reported no financial disclosures.
AT CHEST WORLD CONGRESS 2014
Key clinical point: Prescribing PT may reduce anxiety and depression in hospitalized COPD patients as well as improve muscle strength and steadiness.
Major finding: Overall health on the EUROQol-5D visual analog scale improved from 57.0 to 74.4 at discharge (P = .006).
Data source: A randomized, single-blind trial in 60 patients hospitalized with COPD.
Disclosures: The investigators reported no financial disclosures.
Blacks balk at life-saving early lung cancer therapy
MADRID – Blacks may need additional guidance from clinicians to use radiotherapy for potentially curable lung cancer, a retrospective population-based study suggests.
Among 6,628 patients diagnosed with early-stage nonsquamous non–small cell lung cancer (NSCLC), primary radiation therapy doubled median survival from 11 months to 22.6 months for cases not receiving surgery (Log rank P value less than .0001).
Despite the survival advantage, blacks were significantly more likely than whites were to skip radiotherapy for stage IA NSCLC (46% vs. 37.5%; P = .02), Dr. Eric Flenaugh, chief of pulmonary and critical care medicine and vice chair of the department of medicine at Morehouse School of Medicine, Atlanta, reported at the world congress of the American College of Chest Physicians.
A subgroup analysis of nonsurgical stage IA cases in which surgery was not recommended or was contraindicated showed that 61% of whites went on to radiotherapy, compared with 47% of blacks (P = .007). When surgical resection was recommended but not performed, radiotherapy use was similar between races.
"What this basically says is that if they [blacks] chose not to have surgery, then they weren’t going to have anything," Dr. Flenaugh said in an interview. "We have to look at our approach to discussing with African Americans who have curable-stage cancer, particularly the IAs, that if you’re not a surgical candidate or choose not to have surgery, there are other options like radiotherapy that can improve your survival."
The data did not allow the investigators to determine patients’ chemotherapy status or which factors drove the lower uptake of radiotherapy, but prior research has shown that blacks undergo surgery for lung cancer less often than whites, even after access to care has been demonstrated (J. Clin. Oncol. 2006;24:413-8).
The current analysis, led by internal medicine resident Srinadh Annangi, MBBS, used data from the National Cancer Institute’s SEER (Surveillance, Epidemiology, and End Results) database for 6,628 patients diagnosed with NSCLC between 2004 and 2010, of which 4,210 did not receive surgery. NSCLC was staged as IA, IB, IIA, and IIB according to AJCC (American Joint Committee on Cancer) 6th edition classifications.
A little more than half of the 5,915 whites and 713 African-Americans were male, with a median age of 78 years and 67.5 years, respectively.
The proportion of tumors less than 2 cm in size for stages IA and IIA and less than 5 cm for stages IB and IIB was not significantly different between races, according to the poster presentation.
No significant racial disparities were seen for nonsurgical stage IB, IIA, and IIB cancers.
Among operable NSCLC cases, whites were significantly more likely to have surgery than were blacks (37% vs. 32%; P = .0004), whereas blacks were significantly more likely to have surgery recommended but refused or not performed (9% vs. 6%; P = .012).
Importantly, the proportion of blacks undergoing their recommended surgery was lower for both stage IA (78.3% vs. 86%; P less than .05) and IB cancers (74.6% vs. 81.3%; P less than .05).
The authors note that surgical resection remains the preferred treatment approach for operable stage I and II NSCLC, but conclude that eliminating the racial disparities in radiotherapy for early-stage NSCLC deemed inoperable or where surgery is refused can improve survival in the African American population.
Dr. Flenaugh and his coauthors reported no financial disclosures.
MADRID – Blacks may need additional guidance from clinicians to use radiotherapy for potentially curable lung cancer, a retrospective population-based study suggests.
Among 6,628 patients diagnosed with early-stage nonsquamous non–small cell lung cancer (NSCLC), primary radiation therapy doubled median survival from 11 months to 22.6 months for cases not receiving surgery (Log rank P value less than .0001).
Despite the survival advantage, blacks were significantly more likely than whites were to skip radiotherapy for stage IA NSCLC (46% vs. 37.5%; P = .02), Dr. Eric Flenaugh, chief of pulmonary and critical care medicine and vice chair of the department of medicine at Morehouse School of Medicine, Atlanta, reported at the world congress of the American College of Chest Physicians.
A subgroup analysis of nonsurgical stage IA cases in which surgery was not recommended or was contraindicated showed that 61% of whites went on to radiotherapy, compared with 47% of blacks (P = .007). When surgical resection was recommended but not performed, radiotherapy use was similar between races.
"What this basically says is that if they [blacks] chose not to have surgery, then they weren’t going to have anything," Dr. Flenaugh said in an interview. "We have to look at our approach to discussing with African Americans who have curable-stage cancer, particularly the IAs, that if you’re not a surgical candidate or choose not to have surgery, there are other options like radiotherapy that can improve your survival."
The data did not allow the investigators to determine patients’ chemotherapy status or which factors drove the lower uptake of radiotherapy, but prior research has shown that blacks undergo surgery for lung cancer less often than whites, even after access to care has been demonstrated (J. Clin. Oncol. 2006;24:413-8).
The current analysis, led by internal medicine resident Srinadh Annangi, MBBS, used data from the National Cancer Institute’s SEER (Surveillance, Epidemiology, and End Results) database for 6,628 patients diagnosed with NSCLC between 2004 and 2010, of which 4,210 did not receive surgery. NSCLC was staged as IA, IB, IIA, and IIB according to AJCC (American Joint Committee on Cancer) 6th edition classifications.
A little more than half of the 5,915 whites and 713 African-Americans were male, with a median age of 78 years and 67.5 years, respectively.
The proportion of tumors less than 2 cm in size for stages IA and IIA and less than 5 cm for stages IB and IIB was not significantly different between races, according to the poster presentation.
No significant racial disparities were seen for nonsurgical stage IB, IIA, and IIB cancers.
Among operable NSCLC cases, whites were significantly more likely to have surgery than were blacks (37% vs. 32%; P = .0004), whereas blacks were significantly more likely to have surgery recommended but refused or not performed (9% vs. 6%; P = .012).
Importantly, the proportion of blacks undergoing their recommended surgery was lower for both stage IA (78.3% vs. 86%; P less than .05) and IB cancers (74.6% vs. 81.3%; P less than .05).
The authors note that surgical resection remains the preferred treatment approach for operable stage I and II NSCLC, but conclude that eliminating the racial disparities in radiotherapy for early-stage NSCLC deemed inoperable or where surgery is refused can improve survival in the African American population.
Dr. Flenaugh and his coauthors reported no financial disclosures.
MADRID – Blacks may need additional guidance from clinicians to use radiotherapy for potentially curable lung cancer, a retrospective population-based study suggests.
Among 6,628 patients diagnosed with early-stage nonsquamous non–small cell lung cancer (NSCLC), primary radiation therapy doubled median survival from 11 months to 22.6 months for cases not receiving surgery (Log rank P value less than .0001).
Despite the survival advantage, blacks were significantly more likely than whites were to skip radiotherapy for stage IA NSCLC (46% vs. 37.5%; P = .02), Dr. Eric Flenaugh, chief of pulmonary and critical care medicine and vice chair of the department of medicine at Morehouse School of Medicine, Atlanta, reported at the world congress of the American College of Chest Physicians.
A subgroup analysis of nonsurgical stage IA cases in which surgery was not recommended or was contraindicated showed that 61% of whites went on to radiotherapy, compared with 47% of blacks (P = .007). When surgical resection was recommended but not performed, radiotherapy use was similar between races.
"What this basically says is that if they [blacks] chose not to have surgery, then they weren’t going to have anything," Dr. Flenaugh said in an interview. "We have to look at our approach to discussing with African Americans who have curable-stage cancer, particularly the IAs, that if you’re not a surgical candidate or choose not to have surgery, there are other options like radiotherapy that can improve your survival."
The data did not allow the investigators to determine patients’ chemotherapy status or which factors drove the lower uptake of radiotherapy, but prior research has shown that blacks undergo surgery for lung cancer less often than whites, even after access to care has been demonstrated (J. Clin. Oncol. 2006;24:413-8).
The current analysis, led by internal medicine resident Srinadh Annangi, MBBS, used data from the National Cancer Institute’s SEER (Surveillance, Epidemiology, and End Results) database for 6,628 patients diagnosed with NSCLC between 2004 and 2010, of which 4,210 did not receive surgery. NSCLC was staged as IA, IB, IIA, and IIB according to AJCC (American Joint Committee on Cancer) 6th edition classifications.
A little more than half of the 5,915 whites and 713 African-Americans were male, with a median age of 78 years and 67.5 years, respectively.
The proportion of tumors less than 2 cm in size for stages IA and IIA and less than 5 cm for stages IB and IIB was not significantly different between races, according to the poster presentation.
No significant racial disparities were seen for nonsurgical stage IB, IIA, and IIB cancers.
Among operable NSCLC cases, whites were significantly more likely to have surgery than were blacks (37% vs. 32%; P = .0004), whereas blacks were significantly more likely to have surgery recommended but refused or not performed (9% vs. 6%; P = .012).
Importantly, the proportion of blacks undergoing their recommended surgery was lower for both stage IA (78.3% vs. 86%; P less than .05) and IB cancers (74.6% vs. 81.3%; P less than .05).
The authors note that surgical resection remains the preferred treatment approach for operable stage I and II NSCLC, but conclude that eliminating the racial disparities in radiotherapy for early-stage NSCLC deemed inoperable or where surgery is refused can improve survival in the African American population.
Dr. Flenaugh and his coauthors reported no financial disclosures.
AT CHEST WORLD CONGRESS 2014
Major finding: Blacks were significantly less likely than were whites to receive radiotherapy for stage IA NSCLC (P = .02).
Data source: A population-based cohort study in 6,628 patients with lung cancer.
Disclosures: Dr. Flenaugh and his coauthors reported no financial disclosures.
Cracking the gray ceiling with bevacizumab
MADRID – Results from a small study challenge the long-standing practice of shutting superannuated patients out of phase III trials.
Patients aged 75 years and older are common in everyday clinical practice and comprised almost 10% (8.6%) of 382 nonsquamous non–small cell lung cancer patients who were candidates for bevacizumab (Avastin) between 2001 and 2012, Dr. Andriani Charpidou said in a late-breaking session at the world congress of the American College of Chest Physicians.
Among these 33 patients, 19 had stable cardiovascular disease, 10 had other comorbidities, and 2 had hemoptysis. All patients were Eastern Cooperative Oncology Group (ECOG) performance status 0 or 1 and received a mean of 5.8 cycles (range, 1-21) of bevacizumab.
In all, 26 patients (78.8%) experienced an adverse event, but no AEs were fatal and only 5 patients (15%) discontinued therapy because of toxicities (3 hemoptysis, 1 hematoma, and 1 neutropenia), said Dr. Charpidou, a chest physician with the oncology unit, University of Athens.
Superannuated patients, however, had a higher probability for bleeding events (40%) than reported in the literature.
"There were no thromboembolic events and no worsening of preexisting stable CVD [cardiovascular disease]," she said.
When the investigators compared patients younger than 80 years with those 80 years and older, there were no significant differences in AEs (19 patients vs. 7 patients; P = .652), AEs greater than grade 3 (7 patients vs. 3 patients; P = .673), or discontinuation due to toxicities (5 patients vs. 3 patients; P = .366).
Partial response occurred in 19% and stable disease in 42%, according to the study (Chest 2014;145(3 Suppl):350B).
Once again, no significant differences were observed between the old and superold with regard to progression-free survival (6 months vs. 4 months; P = .660) or overall survival (6.8 months vs. 7.1 months; P = .557), Dr. Charpidou said.
"Taking in mind the limitation of a small sample size, we suggest that superannuated patients should not be excluded from the use of antiangiogenic factors based only on annual age," she said. "Nevertheless, larger cohort studies are needed."
During an interview, session moderator Dr. Mark J. Rosen, medical director with the American College of Chest Physicians, agreed that larger studies are needed, but added, "Every piece of evidence that says ‘Let’s not exclude people because they’re old,’ will push the ball a little further. I think it’s inevitable. Trials are getting more inclusive rather than less so."
During a discussion of the results, CHEST Congress cochair Dr. Joan Soriano of Hospital Universitari Son Espases, Palma de Mallorca, Spain, said that chronic obstructive pulmonary disease trials are being enriched with superannuated patients following the 2012 validation of the Global Lung Function Initiative spirometric prediction equations in patients aged up to 95 years (Eur. Respir. J. 2012;40:1324-43).
"This has reshuffled the clinical trial inclusion criteria, and now some companies already include patients up to 95," he said in an interview. "There aren’t many patients, but at least it’s not an exclusion criterion.
"The populations are aging, so in theory, all these new drugs for cancer, bronchodilators, or anti-inflammatories will be used in the very elderly. So, I’m sure we will see many more superannuated patients in phase III trials."
Dr. Charpidou reported no financial disclosures.
MADRID – Results from a small study challenge the long-standing practice of shutting superannuated patients out of phase III trials.
Patients aged 75 years and older are common in everyday clinical practice and comprised almost 10% (8.6%) of 382 nonsquamous non–small cell lung cancer patients who were candidates for bevacizumab (Avastin) between 2001 and 2012, Dr. Andriani Charpidou said in a late-breaking session at the world congress of the American College of Chest Physicians.
Among these 33 patients, 19 had stable cardiovascular disease, 10 had other comorbidities, and 2 had hemoptysis. All patients were Eastern Cooperative Oncology Group (ECOG) performance status 0 or 1 and received a mean of 5.8 cycles (range, 1-21) of bevacizumab.
In all, 26 patients (78.8%) experienced an adverse event, but no AEs were fatal and only 5 patients (15%) discontinued therapy because of toxicities (3 hemoptysis, 1 hematoma, and 1 neutropenia), said Dr. Charpidou, a chest physician with the oncology unit, University of Athens.
Superannuated patients, however, had a higher probability for bleeding events (40%) than reported in the literature.
"There were no thromboembolic events and no worsening of preexisting stable CVD [cardiovascular disease]," she said.
When the investigators compared patients younger than 80 years with those 80 years and older, there were no significant differences in AEs (19 patients vs. 7 patients; P = .652), AEs greater than grade 3 (7 patients vs. 3 patients; P = .673), or discontinuation due to toxicities (5 patients vs. 3 patients; P = .366).
Partial response occurred in 19% and stable disease in 42%, according to the study (Chest 2014;145(3 Suppl):350B).
Once again, no significant differences were observed between the old and superold with regard to progression-free survival (6 months vs. 4 months; P = .660) or overall survival (6.8 months vs. 7.1 months; P = .557), Dr. Charpidou said.
"Taking in mind the limitation of a small sample size, we suggest that superannuated patients should not be excluded from the use of antiangiogenic factors based only on annual age," she said. "Nevertheless, larger cohort studies are needed."
During an interview, session moderator Dr. Mark J. Rosen, medical director with the American College of Chest Physicians, agreed that larger studies are needed, but added, "Every piece of evidence that says ‘Let’s not exclude people because they’re old,’ will push the ball a little further. I think it’s inevitable. Trials are getting more inclusive rather than less so."
During a discussion of the results, CHEST Congress cochair Dr. Joan Soriano of Hospital Universitari Son Espases, Palma de Mallorca, Spain, said that chronic obstructive pulmonary disease trials are being enriched with superannuated patients following the 2012 validation of the Global Lung Function Initiative spirometric prediction equations in patients aged up to 95 years (Eur. Respir. J. 2012;40:1324-43).
"This has reshuffled the clinical trial inclusion criteria, and now some companies already include patients up to 95," he said in an interview. "There aren’t many patients, but at least it’s not an exclusion criterion.
"The populations are aging, so in theory, all these new drugs for cancer, bronchodilators, or anti-inflammatories will be used in the very elderly. So, I’m sure we will see many more superannuated patients in phase III trials."
Dr. Charpidou reported no financial disclosures.
MADRID – Results from a small study challenge the long-standing practice of shutting superannuated patients out of phase III trials.
Patients aged 75 years and older are common in everyday clinical practice and comprised almost 10% (8.6%) of 382 nonsquamous non–small cell lung cancer patients who were candidates for bevacizumab (Avastin) between 2001 and 2012, Dr. Andriani Charpidou said in a late-breaking session at the world congress of the American College of Chest Physicians.
Among these 33 patients, 19 had stable cardiovascular disease, 10 had other comorbidities, and 2 had hemoptysis. All patients were Eastern Cooperative Oncology Group (ECOG) performance status 0 or 1 and received a mean of 5.8 cycles (range, 1-21) of bevacizumab.
In all, 26 patients (78.8%) experienced an adverse event, but no AEs were fatal and only 5 patients (15%) discontinued therapy because of toxicities (3 hemoptysis, 1 hematoma, and 1 neutropenia), said Dr. Charpidou, a chest physician with the oncology unit, University of Athens.
Superannuated patients, however, had a higher probability for bleeding events (40%) than reported in the literature.
"There were no thromboembolic events and no worsening of preexisting stable CVD [cardiovascular disease]," she said.
When the investigators compared patients younger than 80 years with those 80 years and older, there were no significant differences in AEs (19 patients vs. 7 patients; P = .652), AEs greater than grade 3 (7 patients vs. 3 patients; P = .673), or discontinuation due to toxicities (5 patients vs. 3 patients; P = .366).
Partial response occurred in 19% and stable disease in 42%, according to the study (Chest 2014;145(3 Suppl):350B).
Once again, no significant differences were observed between the old and superold with regard to progression-free survival (6 months vs. 4 months; P = .660) or overall survival (6.8 months vs. 7.1 months; P = .557), Dr. Charpidou said.
"Taking in mind the limitation of a small sample size, we suggest that superannuated patients should not be excluded from the use of antiangiogenic factors based only on annual age," she said. "Nevertheless, larger cohort studies are needed."
During an interview, session moderator Dr. Mark J. Rosen, medical director with the American College of Chest Physicians, agreed that larger studies are needed, but added, "Every piece of evidence that says ‘Let’s not exclude people because they’re old,’ will push the ball a little further. I think it’s inevitable. Trials are getting more inclusive rather than less so."
During a discussion of the results, CHEST Congress cochair Dr. Joan Soriano of Hospital Universitari Son Espases, Palma de Mallorca, Spain, said that chronic obstructive pulmonary disease trials are being enriched with superannuated patients following the 2012 validation of the Global Lung Function Initiative spirometric prediction equations in patients aged up to 95 years (Eur. Respir. J. 2012;40:1324-43).
"This has reshuffled the clinical trial inclusion criteria, and now some companies already include patients up to 95," he said in an interview. "There aren’t many patients, but at least it’s not an exclusion criterion.
"The populations are aging, so in theory, all these new drugs for cancer, bronchodilators, or anti-inflammatories will be used in the very elderly. So, I’m sure we will see many more superannuated patients in phase III trials."
Dr. Charpidou reported no financial disclosures.
AT CHEST WORLD CONGRESS 2014
Major finding: No adverse events were fatal, and only five patients (15%) discontinued therapy because of toxicities.
Data source: A retrospective study of 33 NSCLC patients, aged 75 years and older.
Disclosures: Dr. Charpidou reported no financial disclosures.
Lung transplants in HIV-positive gaining momentum
MADRID – Evidence is mounting that lung transplantation is feasible in highly select patients positive for human immunodeficiency virus.
A retrospective analysis of three patients revealed no long-term resurgence of HIV viremia or profound complications of overt immune suppression. CD4 counts decreased initially in one patient, but recovered after about 1 year with antiretroviral therapy (ART). All patients were adequately controlled on combination ART, had no HIV viremia for 2 years prior to surgery, and had no resistance to standard antiretrovirals.
"Not all HIV-positive patients would be candidates," Dr. Harish Seethamraju said during a late-breaking abstract session at the world congress of the American College of Chest Physicians. "You want to ensure compliance; and an ability to manage complex medication regimens would be the challenge for any person. So, people who have an in-depth knowledge about their disease and are able to manage their HIV well for a prolonged period of time would be ideal candidates."
As with other solid-organ transplants, acute rejection remains a concern and was reported in patient 1, who underwent bilateral transplant for HIV-associated pulmonary arterial hypertension. The patient experienced three episodes of rejection, including bronchiolitis obliterans syndrome and rejection with respiratory syncytial virus pneumonia requiring admission at 15 months, which tipped her course dramatically and resulted in loss of most of her lung function by post-transplant 43 months, he said.
Mild acute rejection occurred in patients 2 and 3, who were transplanted for idiopathic pulmonary fibrosis, but they remain free of acute rejection and are actively employed 15 months and 41 months after transplant.
Surgeons at Houston Methodist Hospital and the University of California, San Francisco, where the transplants were performed, also learned that ART has to be initiated very early on post-transplant, said Dr. Seethamraju, now medical director of the lung transplant program, University of Kentucky, Lexington.
"In patient 2, we found a resurgence of HIV viremia within 10 days, but we just stopped the medication for the first 4 days and that’s all it took for the virus to come back," he said.
The study findings should provide guidance for clinicians considering transplantation in the wake of the recently approved HIV Organ Policy Equity (HOPE) Act, which made it legal in the United States now to transplant HIV-positive organs in HIV-positive patients. HIV patients are often referred for lung transplant because of an increased incidence of pulmonary hypertension and infections, but their HIV status has traditionally been taken as a contraindication due to the potential risks of added immunosuppression, said Dr. Seethamraju. Only one case report has been published of an HIV and hepatitis B virus coinfected patient with cystic fibrosis who underwent successful double lung transplant, he said.
During a discussion of the study, CHEST Congress cochair Dr. Joan Soriano, of Hospital Universitari Son Espases, Palma de Mallorca, Spain, asked whether any of the centers would consider lung transplantation in HIV-positive patients with chronic obstructive pulmonary disease (COPD).
Dr. Seethamraju replied that COPD is the second-most-common indication for transplant after idiopathic pulmonary fibrosis and interstitial lung disease, but that the United Network for Organ Sharing 2005 lung allocation scores are very low for COPD patients, and thus organs would be hard to obtain for this specific group of HIV patients. "But it would be a great candidate for us," he added. "We would definitely do a transplant in that group of patients, irrespective of their HIV status."
Dr. Seethamraju and his coauthors reported no relevant disclosures.
MADRID – Evidence is mounting that lung transplantation is feasible in highly select patients positive for human immunodeficiency virus.
A retrospective analysis of three patients revealed no long-term resurgence of HIV viremia or profound complications of overt immune suppression. CD4 counts decreased initially in one patient, but recovered after about 1 year with antiretroviral therapy (ART). All patients were adequately controlled on combination ART, had no HIV viremia for 2 years prior to surgery, and had no resistance to standard antiretrovirals.
"Not all HIV-positive patients would be candidates," Dr. Harish Seethamraju said during a late-breaking abstract session at the world congress of the American College of Chest Physicians. "You want to ensure compliance; and an ability to manage complex medication regimens would be the challenge for any person. So, people who have an in-depth knowledge about their disease and are able to manage their HIV well for a prolonged period of time would be ideal candidates."
As with other solid-organ transplants, acute rejection remains a concern and was reported in patient 1, who underwent bilateral transplant for HIV-associated pulmonary arterial hypertension. The patient experienced three episodes of rejection, including bronchiolitis obliterans syndrome and rejection with respiratory syncytial virus pneumonia requiring admission at 15 months, which tipped her course dramatically and resulted in loss of most of her lung function by post-transplant 43 months, he said.
Mild acute rejection occurred in patients 2 and 3, who were transplanted for idiopathic pulmonary fibrosis, but they remain free of acute rejection and are actively employed 15 months and 41 months after transplant.
Surgeons at Houston Methodist Hospital and the University of California, San Francisco, where the transplants were performed, also learned that ART has to be initiated very early on post-transplant, said Dr. Seethamraju, now medical director of the lung transplant program, University of Kentucky, Lexington.
"In patient 2, we found a resurgence of HIV viremia within 10 days, but we just stopped the medication for the first 4 days and that’s all it took for the virus to come back," he said.
The study findings should provide guidance for clinicians considering transplantation in the wake of the recently approved HIV Organ Policy Equity (HOPE) Act, which made it legal in the United States now to transplant HIV-positive organs in HIV-positive patients. HIV patients are often referred for lung transplant because of an increased incidence of pulmonary hypertension and infections, but their HIV status has traditionally been taken as a contraindication due to the potential risks of added immunosuppression, said Dr. Seethamraju. Only one case report has been published of an HIV and hepatitis B virus coinfected patient with cystic fibrosis who underwent successful double lung transplant, he said.
During a discussion of the study, CHEST Congress cochair Dr. Joan Soriano, of Hospital Universitari Son Espases, Palma de Mallorca, Spain, asked whether any of the centers would consider lung transplantation in HIV-positive patients with chronic obstructive pulmonary disease (COPD).
Dr. Seethamraju replied that COPD is the second-most-common indication for transplant after idiopathic pulmonary fibrosis and interstitial lung disease, but that the United Network for Organ Sharing 2005 lung allocation scores are very low for COPD patients, and thus organs would be hard to obtain for this specific group of HIV patients. "But it would be a great candidate for us," he added. "We would definitely do a transplant in that group of patients, irrespective of their HIV status."
Dr. Seethamraju and his coauthors reported no relevant disclosures.
MADRID – Evidence is mounting that lung transplantation is feasible in highly select patients positive for human immunodeficiency virus.
A retrospective analysis of three patients revealed no long-term resurgence of HIV viremia or profound complications of overt immune suppression. CD4 counts decreased initially in one patient, but recovered after about 1 year with antiretroviral therapy (ART). All patients were adequately controlled on combination ART, had no HIV viremia for 2 years prior to surgery, and had no resistance to standard antiretrovirals.
"Not all HIV-positive patients would be candidates," Dr. Harish Seethamraju said during a late-breaking abstract session at the world congress of the American College of Chest Physicians. "You want to ensure compliance; and an ability to manage complex medication regimens would be the challenge for any person. So, people who have an in-depth knowledge about their disease and are able to manage their HIV well for a prolonged period of time would be ideal candidates."
As with other solid-organ transplants, acute rejection remains a concern and was reported in patient 1, who underwent bilateral transplant for HIV-associated pulmonary arterial hypertension. The patient experienced three episodes of rejection, including bronchiolitis obliterans syndrome and rejection with respiratory syncytial virus pneumonia requiring admission at 15 months, which tipped her course dramatically and resulted in loss of most of her lung function by post-transplant 43 months, he said.
Mild acute rejection occurred in patients 2 and 3, who were transplanted for idiopathic pulmonary fibrosis, but they remain free of acute rejection and are actively employed 15 months and 41 months after transplant.
Surgeons at Houston Methodist Hospital and the University of California, San Francisco, where the transplants were performed, also learned that ART has to be initiated very early on post-transplant, said Dr. Seethamraju, now medical director of the lung transplant program, University of Kentucky, Lexington.
"In patient 2, we found a resurgence of HIV viremia within 10 days, but we just stopped the medication for the first 4 days and that’s all it took for the virus to come back," he said.
The study findings should provide guidance for clinicians considering transplantation in the wake of the recently approved HIV Organ Policy Equity (HOPE) Act, which made it legal in the United States now to transplant HIV-positive organs in HIV-positive patients. HIV patients are often referred for lung transplant because of an increased incidence of pulmonary hypertension and infections, but their HIV status has traditionally been taken as a contraindication due to the potential risks of added immunosuppression, said Dr. Seethamraju. Only one case report has been published of an HIV and hepatitis B virus coinfected patient with cystic fibrosis who underwent successful double lung transplant, he said.
During a discussion of the study, CHEST Congress cochair Dr. Joan Soriano, of Hospital Universitari Son Espases, Palma de Mallorca, Spain, asked whether any of the centers would consider lung transplantation in HIV-positive patients with chronic obstructive pulmonary disease (COPD).
Dr. Seethamraju replied that COPD is the second-most-common indication for transplant after idiopathic pulmonary fibrosis and interstitial lung disease, but that the United Network for Organ Sharing 2005 lung allocation scores are very low for COPD patients, and thus organs would be hard to obtain for this specific group of HIV patients. "But it would be a great candidate for us," he added. "We would definitely do a transplant in that group of patients, irrespective of their HIV status."
Dr. Seethamraju and his coauthors reported no relevant disclosures.
AT CHEST WORLD CONGRESS 2014
Major finding: Mild acute rejection occurred in two HIV-positive patients who were transplanted for idiopathic pulmonary fibrosis; they have remained free of acute rejection and are actively employed 15 months and 41 months after transplant.
Data source: A retrospective analysis of lung transplantation in three HIV-positive patients.
Disclosures: Dr. Seethamraju and his coauthors reported no relevant disclosures.
Practice-based asthma navigators trim asthma symptoms, HC utilization
MADRID – Use of practice-based asthma navigators significantly reduced symptoms and emergency room and inpatient visits among inner-city children with moderate to severe asthma in a prospective, case-matched study.
"We’ve seen with our home-visit studies that we’re able to reduce asthma morbidity, but what we hear from the parents all the time is that they feel their communication with providers is lacking, and that they really needed someone to help them navigate the clinical system," Dr. Tyra Bryant-Stephens, founder and director of the Community Asthma Prevention Program at Children’s Hospital of Philadelphia (CHOP), said in an interview.
To overcome this hurdle, CHOP began integrating community health workers as asthma navigators into the clinical team at its inner-city asthma clinics. Key tasks are to teach caregivers about the Asthma Care Plan and proper use of controller medications, facilitate appointment scheduling and set up reminders, contact and share asthma care plans with school nurses, work with social workers to identify appropriate resources for families, and set care coordination goals.
The study enrolled children, aged 2-17 years, on at least two asthma control medications. The participants had been hospitalized or had at least two emergency department (ED) visits in the past year. Their average age was 4.6 years.
After 12 months in the navigator program, preliminary data on 99 children revealed a clear 2- to 3-day reduction over the past 14 days in days using rescue asthma medications (5.28 vs. 3.07; P less than .01), days with symptoms (6.93 to 3.8; P less than .01), and nights with symptoms (6.11 to 3.34; P less than .01), Dr. Bryant-Stephens reported at the world congress of the American College of Chest Physicians.
Compared with baseline, the number of days not taking asthma medications at 12 months was not significantly different (1.48 vs. 1.22) nor was the number of days during which activities had to be slowed (4.41 vs. 3.73).
Enrollment in the navigator program, however, lowered the number of school days missed (16 vs. 2; P less than .05), workdays missed (9.11 vs. 1.13; P less than .01), unscheduled visits to the doctor (2.5 vs. 0.5; P less than .05), ED visits (3.65 vs. 1.31; P less than .01), and hospitalizations (1.73 vs. 0.4; P less than .01).
Although the final analysis comparing participants with matched controls receiving usual care is not yet complete, the data so far show a definite reduction in health care utilization by participants, despite controls being less sick at baseline, Dr. Bryant-Stephens said. This is particularly encouraging because earlier studies at CHOP showed that roughly 50% of asthmatic children never made it back to their primary care physician for follow-up between ED visits.
Making appointments for and keeping follow-up visits were listed by 146 of 157 (93%) caregivers as one of the most important care coordination goals, and were achieved by 80% at 12 months with the assistance of phone calls from the asthma navigator, transportation tokens, and insurance cotransportation, according to the poster presentation.
Success among the other top five caregiver goals was 92% for learning how to properly use asthma medications (126/136 caregivers), 98% for reducing asthma triggers (154/157), 54% for stopping smoking in the house and car (23/42), and 94% for the surprising goal of losing weight in hopes it would reduce asthma symptoms (34/36).
There is no "magic bullet," or single component of the navigator program responsible for the results, but "I think what the navigators have been most effective at is bringing them back to the office. It’s unbelievable compared with the control group," Dr. Bryant-Stephens said at the meeting.
Ultimately, the goal is to make the program self-sufficient, with a pilot program currently underway in which Pennsylvania’s largest Medicaid provider, Keystone First, will pay CHOP to have their clients assigned an asthma navigator when they enroll at an asthma clinic.
Dr. Bryant-Stephens reported funding from the Merck Childhood Asthma Network.
MADRID – Use of practice-based asthma navigators significantly reduced symptoms and emergency room and inpatient visits among inner-city children with moderate to severe asthma in a prospective, case-matched study.
"We’ve seen with our home-visit studies that we’re able to reduce asthma morbidity, but what we hear from the parents all the time is that they feel their communication with providers is lacking, and that they really needed someone to help them navigate the clinical system," Dr. Tyra Bryant-Stephens, founder and director of the Community Asthma Prevention Program at Children’s Hospital of Philadelphia (CHOP), said in an interview.
To overcome this hurdle, CHOP began integrating community health workers as asthma navigators into the clinical team at its inner-city asthma clinics. Key tasks are to teach caregivers about the Asthma Care Plan and proper use of controller medications, facilitate appointment scheduling and set up reminders, contact and share asthma care plans with school nurses, work with social workers to identify appropriate resources for families, and set care coordination goals.
The study enrolled children, aged 2-17 years, on at least two asthma control medications. The participants had been hospitalized or had at least two emergency department (ED) visits in the past year. Their average age was 4.6 years.
After 12 months in the navigator program, preliminary data on 99 children revealed a clear 2- to 3-day reduction over the past 14 days in days using rescue asthma medications (5.28 vs. 3.07; P less than .01), days with symptoms (6.93 to 3.8; P less than .01), and nights with symptoms (6.11 to 3.34; P less than .01), Dr. Bryant-Stephens reported at the world congress of the American College of Chest Physicians.
Compared with baseline, the number of days not taking asthma medications at 12 months was not significantly different (1.48 vs. 1.22) nor was the number of days during which activities had to be slowed (4.41 vs. 3.73).
Enrollment in the navigator program, however, lowered the number of school days missed (16 vs. 2; P less than .05), workdays missed (9.11 vs. 1.13; P less than .01), unscheduled visits to the doctor (2.5 vs. 0.5; P less than .05), ED visits (3.65 vs. 1.31; P less than .01), and hospitalizations (1.73 vs. 0.4; P less than .01).
Although the final analysis comparing participants with matched controls receiving usual care is not yet complete, the data so far show a definite reduction in health care utilization by participants, despite controls being less sick at baseline, Dr. Bryant-Stephens said. This is particularly encouraging because earlier studies at CHOP showed that roughly 50% of asthmatic children never made it back to their primary care physician for follow-up between ED visits.
Making appointments for and keeping follow-up visits were listed by 146 of 157 (93%) caregivers as one of the most important care coordination goals, and were achieved by 80% at 12 months with the assistance of phone calls from the asthma navigator, transportation tokens, and insurance cotransportation, according to the poster presentation.
Success among the other top five caregiver goals was 92% for learning how to properly use asthma medications (126/136 caregivers), 98% for reducing asthma triggers (154/157), 54% for stopping smoking in the house and car (23/42), and 94% for the surprising goal of losing weight in hopes it would reduce asthma symptoms (34/36).
There is no "magic bullet," or single component of the navigator program responsible for the results, but "I think what the navigators have been most effective at is bringing them back to the office. It’s unbelievable compared with the control group," Dr. Bryant-Stephens said at the meeting.
Ultimately, the goal is to make the program self-sufficient, with a pilot program currently underway in which Pennsylvania’s largest Medicaid provider, Keystone First, will pay CHOP to have their clients assigned an asthma navigator when they enroll at an asthma clinic.
Dr. Bryant-Stephens reported funding from the Merck Childhood Asthma Network.
MADRID – Use of practice-based asthma navigators significantly reduced symptoms and emergency room and inpatient visits among inner-city children with moderate to severe asthma in a prospective, case-matched study.
"We’ve seen with our home-visit studies that we’re able to reduce asthma morbidity, but what we hear from the parents all the time is that they feel their communication with providers is lacking, and that they really needed someone to help them navigate the clinical system," Dr. Tyra Bryant-Stephens, founder and director of the Community Asthma Prevention Program at Children’s Hospital of Philadelphia (CHOP), said in an interview.
To overcome this hurdle, CHOP began integrating community health workers as asthma navigators into the clinical team at its inner-city asthma clinics. Key tasks are to teach caregivers about the Asthma Care Plan and proper use of controller medications, facilitate appointment scheduling and set up reminders, contact and share asthma care plans with school nurses, work with social workers to identify appropriate resources for families, and set care coordination goals.
The study enrolled children, aged 2-17 years, on at least two asthma control medications. The participants had been hospitalized or had at least two emergency department (ED) visits in the past year. Their average age was 4.6 years.
After 12 months in the navigator program, preliminary data on 99 children revealed a clear 2- to 3-day reduction over the past 14 days in days using rescue asthma medications (5.28 vs. 3.07; P less than .01), days with symptoms (6.93 to 3.8; P less than .01), and nights with symptoms (6.11 to 3.34; P less than .01), Dr. Bryant-Stephens reported at the world congress of the American College of Chest Physicians.
Compared with baseline, the number of days not taking asthma medications at 12 months was not significantly different (1.48 vs. 1.22) nor was the number of days during which activities had to be slowed (4.41 vs. 3.73).
Enrollment in the navigator program, however, lowered the number of school days missed (16 vs. 2; P less than .05), workdays missed (9.11 vs. 1.13; P less than .01), unscheduled visits to the doctor (2.5 vs. 0.5; P less than .05), ED visits (3.65 vs. 1.31; P less than .01), and hospitalizations (1.73 vs. 0.4; P less than .01).
Although the final analysis comparing participants with matched controls receiving usual care is not yet complete, the data so far show a definite reduction in health care utilization by participants, despite controls being less sick at baseline, Dr. Bryant-Stephens said. This is particularly encouraging because earlier studies at CHOP showed that roughly 50% of asthmatic children never made it back to their primary care physician for follow-up between ED visits.
Making appointments for and keeping follow-up visits were listed by 146 of 157 (93%) caregivers as one of the most important care coordination goals, and were achieved by 80% at 12 months with the assistance of phone calls from the asthma navigator, transportation tokens, and insurance cotransportation, according to the poster presentation.
Success among the other top five caregiver goals was 92% for learning how to properly use asthma medications (126/136 caregivers), 98% for reducing asthma triggers (154/157), 54% for stopping smoking in the house and car (23/42), and 94% for the surprising goal of losing weight in hopes it would reduce asthma symptoms (34/36).
There is no "magic bullet," or single component of the navigator program responsible for the results, but "I think what the navigators have been most effective at is bringing them back to the office. It’s unbelievable compared with the control group," Dr. Bryant-Stephens said at the meeting.
Ultimately, the goal is to make the program self-sufficient, with a pilot program currently underway in which Pennsylvania’s largest Medicaid provider, Keystone First, will pay CHOP to have their clients assigned an asthma navigator when they enroll at an asthma clinic.
Dr. Bryant-Stephens reported funding from the Merck Childhood Asthma Network.
AT CHEST WORLD CONGRESS 2014
Major finding: After 12 months in the asthma navigator program, children had fewer unscheduled visits to the doctor (2.5 vs. 0.5; P less than .05), emergency department visits (3.65 vs. 1.31; P less than .01), and hospitalizations (1.73 vs. 0.4; P less than .01).
Data source: A prospective case-matched study in 99 children with moderate to severe asthma.
Disclosures: Dr. Bryant-Stephens reported funding from the Merck Childhood Asthma Network.
