Chest Medicine (all articles)
RCT: Azithromycin Increases Asthma Remission Rates in Adults With Persistent Uncontrolled Asthma
6 Sep, 2024 | 22:35h | UTCStudy Design and Population: This secondary analysis stems from the Asthma and Macrolides: Azithromycin Efficacy and Safety (AMAZES) trial, a randomized, double-anonymized, placebo-controlled trial. The study involved 335 adults with persistent uncontrolled asthma, who were treated with either azithromycin (500 mg, 3 times weekly) or placebo for 12 months. The goal was to evaluate azithromycin’s impact on asthma remission, defined through clinical and lung function measures.
Main Findings: Azithromycin significantly increased the rate of clinical remission compared to placebo (50.6% vs. 38.9%; P = .032). Clinical remission combined with lung function criteria was also higher in the azithromycin group (50.8% vs. 37.1%; P = .029). Although the complete remission rate (including sputum eosinophil count <3%) trended higher, it did not reach statistical significance (23% vs. 13.7%; P = .058).
Implications for Practice: This secondary analysis suggests that azithromycin, when added to standard asthma therapy, could significantly increase remission rates in adults with persistent uncontrolled asthma, including both eosinophilic and noneosinophilic subtypes.
Retrospective Study: AI Tool Accurately Excludes Pathology in Up to 52.7% of Unremarkable Chest Radiographs with Low Critical Misses – Radiology
24 Aug, 2024 | 16:14h | UTCStudy Design and Population: This retrospective study assessed the effectiveness of a commercial AI tool in correctly identifying unremarkable chest radiographs, thus potentially reducing the workload in radiology departments. The study analyzed 1,961 chest radiographs from adult patients (median age: 72 years) across four Danish hospitals. The radiographs were labeled as remarkable or unremarkable by thoracic radiologists, and the AI tool’s performance was evaluated at varying sensitivity thresholds.
Main Findings: The AI tool demonstrated a specificity of 24.5% to 52.7% at sensitivity thresholds of 99.9% to 98.0%, respectively, effectively excluding pathology in unremarkable chest radiographs. At sensitivities of 95.4% or higher, the AI had equal or lower rates of critical misses compared to radiology reports, with the AI missing only 2.2% of critical findings compared to 1.1% by radiologists at similar sensitivity levels.
Implications for Practice: The results suggest that AI tools could autonomously report up to 52.7% of unremarkable chest radiographs, potentially reducing radiologist workload without compromising patient safety. However, prospective studies are necessary to confirm these findings and optimize AI deployment in clinical practice.
Retrospective Cohort Study: Rheumatoid Arthritis Linked to Over 50% Increased Lung Cancer Risk, with a Three-Fold Risk in RA-Associated Interstitial Lung Disease – Arthritis Rheumatol
18 Aug, 2024 | 18:58h | UTCStudy Design and Population: This retrospective matched cohort study examined the risk of lung cancer in 72,795 patients with rheumatoid arthritis (RA) and 757 patients with RA-associated interstitial lung disease (RA-ILD) from the Veterans Health Administration database, compared with 633,937 non-RA controls. The study spanned from 2000 to 2019, with patients matched on age, gender, and enrollment year.
Main Findings: The study found that RA was associated with a 58% increase in lung cancer risk (adjusted hazard ratio [aHR] 1.58). The risk was significantly higher in RA-ILD patients, with a more than three-fold increase (aHR 3.25) compared to non-RA controls. Even among never smokers, RA patients showed a 65% increased lung cancer risk, indicating that factors beyond smoking contribute to the elevated risk.
Implications for Practice: The study underscores the significant increase in lung cancer risk among patients with RA, particularly those with RA-ILD. While this elevated risk is notable, further research is necessary to determine the most effective strategies for monitoring and managing this risk. Clinicians should be aware of these findings and consider them when evaluating the overall health and risk factors of patients with RA, especially those with additional pulmonary complications like ILD. Enhanced awareness and individualized risk assessments may help in early detection and management of lung cancer in this high-risk population.
Systematic Review: Immune Checkpoint Inhibitors Plus Chemotherapy Improves Survival in NSCLC for Patients Aged 65-75 – Cochrane Database Syst Rev
18 Aug, 2024 | 15:24h | UTCStudy Design and Population: This Cochrane systematic review evaluated the efficacy and safety of immune checkpoint inhibitors (ICIs) combined with platinum-based chemotherapy versus platinum-based chemotherapy alone (with or without bevacizumab) in treatment-naïve older adults with advanced non-small cell lung cancer (NSCLC). The review included 17 randomized controlled trials (RCTs) with a total of 4,276 participants, focusing on three age groups: 65 years and older, 65-75 years, and 75 years and older.
Main Findings: The addition of ICIs to chemotherapy likely improves overall survival (HR 0.78, 95% CI 0.70 to 0.88) and progression-free survival (HR 0.61, 95% CI 0.54 to 0.68) in patients aged 65 years and older. For those aged 65-75, the benefits are more pronounced (HR 0.75 for overall survival; HR 0.64 for progression-free survival), although there may be an increase in treatment-related adverse events (RR 1.47). However, in patients over 75, the benefits in overall survival and progression-free survival are unclear, with a low-certainty evidence suggesting no significant improvement (HR 0.90 and HR 0.83, respectively).
Implications for Practice: The findings support the use of ICIs combined with chemotherapy in older adults aged 65-75 with advanced NSCLC, but caution is advised for those over 75 due to the lack of clear survival benefit and the potential for increased toxicity. Further research is needed to better understand the risks and benefits in the oldest patients.
Innovative Antimicrobial Susceptibility Testing Bypasses Blood Culture, Promising Faster Sepsis Diagnosis – Nature
18 Aug, 2024 | 14:09h | UTCStudy Design and Population: This study introduces a novel ultra-rapid antimicrobial susceptibility testing (AST) method that bypasses the traditional blood culture process, potentially reducing diagnostic time by 40-60 hours. The method was evaluated using a cohort of 190 hospitalized patients in Korea with suspected sepsis, including those with blood cancers.
Main Findings: The new AST method identified bacterial species in all patients with positive blood infections, achieving a 100% match in species identification. For antimicrobial susceptibility, the method demonstrated a 94.9% categorical agreement with conventional AST methods, with a theoretical turnaround time of 13 ± 2.53 hours, significantly faster than current workflows.
Implications for Practice: This method could improve sepsis treatment by providing same-day results, potentially reducing sepsis-related mortality and the use of broad-spectrum antibiotics. However, further validation in a more diverse patient population is necessary to confirm its clinical efficacy and value.
Review: Prevention and Management of Device-Associated Complications in the Intensive Care Unit – The BMJ
17 Aug, 2024 | 20:04h | UTCIntroduction:
This review article, published by experts from the David Geffen School of Medicine at UCLA, focuses on the complications associated with invasive devices commonly used in the Intensive Care Unit (ICU). While these devices are essential for managing critically ill patients, they also pose significant risks, necessitating a thorough understanding of their potential complications and strategies for prevention and management.
Key Points:
1 – Central Venous Catheters (CVCs):
– CVCs are widely used in ICU patients but carry risks like vascular injury, pneumothorax, thrombosis, and infection.
– Use of real-time ultrasound guidance and careful operator technique are crucial for minimizing these risks.
– Prompt removal of unnecessary CVCs is essential to reduce the risk of complications.
2 – Arterial Catheters:
– Commonly used for hemodynamic monitoring, these catheters can lead to complications such as vascular occlusion, nerve injury, and infection.
– Ultrasound guidance is recommended to reduce the risk of complications, and catheters should be discontinued as soon as clinically feasible.
3 – Airway Devices (Endotracheal Tubes and Tracheostomies):
– Complications include laryngeal injury, tracheal stenosis, and tracheomalacia.
– Strategies to reduce these risks include minimizing intubation attempts, ensuring proper tube placement, and managing cuff pressures carefully.
4 – Extracorporeal Membrane Oxygenation (ECMO):
– ECMO is associated with significant complications, including bleeding, thromboembolic events, and neurologic injuries.
– Proper cannulation technique and vigilant monitoring are essential to mitigate these risks.
5 – Infection Control:
– Strict adherence to aseptic techniques and the use of chlorhexidine-impregnated dressings are recommended to prevent device-associated infections.
Conclusion:
This review underscores the importance of judicious use and timely removal of invasive devices in the ICU to minimize complications. Healthcare professionals must remain vigilant and employ best practices to prevent and manage these complications effectively.
RCT: Osimertinib Significantly Extends Progression-Free Survival in Unresectable Stage III EGFR-Mutated NSCLC After Chemoradiotherapy – N Engl J Med
17 Aug, 2024 | 16:30h | UTCStudy Design and Population: This phase 3, double-blind, placebo-controlled trial enrolled 216 patients with unresectable stage III EGFR-mutated non-small-cell lung cancer (NSCLC) who showed no disease progression during or after chemoradiotherapy. Patients were randomly assigned to receive either osimertinib (143 patients) or a placebo (73 patients) until disease progression.
Main Findings: The study found that osimertinib significantly prolonged progression-free survival (PFS) compared to placebo, with a median PFS of 39.1 months versus 5.6 months, respectively. The hazard ratio for disease progression or death was 0.16, indicating a substantial reduction in risk with osimertinib. At 12 months, 74% of patients in the osimertinib group were alive and progression-free, compared to 22% in the placebo group. Interim overall survival data suggested a modest difference favoring osimertinib, though it was not statistically significant.
Implications for Practice: Osimertinib offers a significant survival benefit as a consolidation therapy following chemoradiotherapy in patients with unresectable stage III EGFR-mutated NSCLC. The findings support the use of osimertinib in this setting, despite an increased incidence of adverse events, highlighting its role in improving long-term outcomes.
Study Shows High Prevalence of Solid Lung Nodules in Nonsmoking Adults – Radiology
14 Aug, 2024 | 13:14h | UTCStudy Design and Population: This cohort study examined the prevalence and size distribution of solid lung nodules in a nonsmoking population from the Northern Netherlands. A total of 10,431 participants aged 45 years and older, predominantly nonsmokers, were included in the Imaging in Lifelines (ImaLife) study. The study utilized low-dose chest CT scans to detect and measure lung nodules.
Main Findings: Lung nodules were present in 42% of participants, with a higher prevalence in males (47.5%) than females (37.7%). The prevalence of clinically relevant nodules (≥100 mm³) was 11.1%, and actionable nodules (≥300 mm³) were found in 2.3% of individuals. Both prevalence and nodule size increased with age, and male participants consistently showed a higher prevalence and larger nodule sizes compared to females.
Implications for Practice: While 42% of nonsmoking adults in this Northern European cohort were found to have solid lung nodules, the incidence of lung cancer within this population is notably low. This suggests that many of the clinically relevant and even actionable nodules identified in nonsmokers are likely benign. These findings highlight the need to refine nodule management strategies for individuals at low risk of lung cancer, potentially reducing unnecessary follow-up and interventions in nonsmoking populations. Future research on lung cancer outcomes in this cohort could further inform and optimize guidelines for nodule management in low-risk groups.
RCT: Bisoprolol Does Not Reduce COPD Exacerbations in High-Risk Patients – JAMA
14 Aug, 2024 | 12:31h | UTCStudy Design and Population: The Bisoprolol in COPD Study (BICS) was a double-blind, placebo-controlled randomized clinical trial conducted across 76 sites in the UK, including both primary and secondary care clinics. The study enrolled 515 patients with chronic obstructive pulmonary disease (COPD) who had moderate to severe airflow obstruction and a history of at least two exacerbations in the past year. Participants were randomly assigned to receive either bisoprolol (n=261) or placebo (n=258) and were followed for one year.
Main Findings: The primary outcome, the number of COPD exacerbations requiring treatment with oral corticosteroids, antibiotics, or both, did not differ significantly between the bisoprolol group (mean exacerbations, 2.03 per year) and the placebo group (mean exacerbations, 2.01 per year). The adjusted incidence rate ratio was 0.97 (95% CI, 0.84-1.13; P = .72), indicating no significant reduction in exacerbations with bisoprolol. Additionally, the rates of serious adverse events were similar between the two groups.
Implications for Practice: The findings suggest that bisoprolol does not reduce exacerbations in COPD patients at high risk and should not be recommended for this purpose. This study underscores the need for continued research into effective interventions for preventing COPD exacerbations in high-risk populations.
Meta-Analysis: Inhaled Antibiotics Offer Modest Reductions in Exacerbations and Quality of Life Gains in Bronchiectasis – CHEST
11 Aug, 2024 | 13:12h | UTCStudy Design and Population: This study is an updated systematic review and meta-analysis of 20 randomized controlled trials involving 3,468 adults with bronchiectasis, who were treated with inhaled antibiotics. The trials included in the analysis were selected based on criteria such as a minimum treatment duration of 4 weeks and involved patients diagnosed by CT imaging. The primary endpoint was exacerbation frequency, while secondary endpoints included severe exacerbations, bacterial load, symptoms, quality of life, and FEV1.
Main Findings: The meta-analysis found that inhaled antibiotics modestly reduced the proportion of patients experiencing exacerbations (risk ratio [RR], 0.85) and exacerbation frequency (RR, 0.78). Severe exacerbations were also decreased (RR, 0.48), and there was a slight increase in the time to the first exacerbation (hazard ratio [HR], 0.80). Additionally, quality of life showed modest improvements as measured by the Quality of Life Questionnaire-Bronchiectasis (mean difference, 2.51) and the St. George Respiratory Questionnaire (mean difference, -3.13). Bacterial load was consistently reduced, although FEV1 did not change meaningfully with treatment. The rate of adverse effects was similar to placebo (odds ratio [OR], 0.99), but antibiotic resistance appeared more likely to increase with treatment.
Implications for Practice: Inhaled antibiotics appear to be a beneficial treatment for adults with bronchiectasis, as they can reduce both exacerbation rates and severity while also improving quality of life. However, the increased risk of antibiotic resistance is a concern, indicating the need for careful patient selection and monitoring during treatment. These findings support the use of inhaled antibiotics in appropriate cases, particularly for those at high risk of exacerbations.
Randomized Trials: Tirzepatide Reduces Apnea-Hypopnea Index and Body Weight in Patients with Obstructive Sleep Apnea and Obesity – N Engl J Med
10 Aug, 2024 | 19:38h | UTCStudy Design and Population: This study comprises two phase 3, double-blind, randomized trials involving adults with moderate-to-severe obstructive sleep apnea (OSA) and obesity. Participants were either using or not using positive airway pressure (PAP) therapy at baseline and received tirzepatide or placebo over 52 weeks.
Main Findings: Tirzepatide significantly reduced the apnea-hypopnea index (AHI) by 20-24 events per hour compared to placebo and also lowered body weight, hypoxic burden, and systolic blood pressure.
Implications for Practice: Tirzepatide offers a promising treatment for reducing OSA severity and associated obesity-related complications, but further research is needed to confirm long-term benefits.
RCT: Pantoprazole Reduces GI Bleeding in Mechanically Ventilated ICU Patients – N Engl J Med
3 Aug, 2024 | 18:57h | UTCStudy Design and Population: This international, randomized, double-blind trial involved 4,821 critically ill adults undergoing invasive mechanical ventilation across 68 intensive care units (ICUs). Participants were assigned to receive either intravenous pantoprazole (40 mg daily) or a matching placebo. The primary efficacy outcome was the incidence of clinically significant upper gastrointestinal bleeding within 90 days, and the primary safety outcome was mortality from any cause within the same period.
Main Findings: The trial found that upper gastrointestinal bleeding occurred in 1.0% of patients treated with pantoprazole compared to 3.5% in the placebo group (hazard ratio, 0.30; 95% CI, 0.19 to 0.47; P<0.001). Mortality at 90 days was 29.1% in the pantoprazole group and 30.9% in the placebo group, showing no significant difference (hazard ratio, 0.94; 95% CI, 0.85 to 1.04; P=0.25). There were no significant differences in the rates of ventilator-associated pneumonia or Clostridioides difficile infection between the groups.
Implications for Practice: The study demonstrates that pantoprazole significantly reduces the risk of upper gastrointestinal bleeding in critically ill patients on mechanical ventilation without affecting overall mortality. This suggests that pantoprazole can be considered a safe and effective option for stress ulcer prophylaxis in this high-risk population, potentially improving patient outcomes in the ICU.
Meta-Analysis: Effects of extracorporeal CO2 removal on gas exchange and ventilator settings in critically ill adults – Crit Care
27 May, 2024 | 20:28h | UTCSummary: Study Design and Population: This systematic review and meta-analysis included 49 studies (3 RCTs, 46 observational studies) involving 1672 critically ill adults undergoing extracorporeal carbon dioxide removal (ECCO2R) for respiratory failure between January 2000 and March 2022.
Main Findings: ECCO2R significantly reduced PaCO2, plateau pressure, and tidal volume, while increasing pH across all patient groups. Adverse event rate was 19%. The three RCTs did not show mortality benefits but indicated longer ICU and hospital stays.
Implications for Practice: ECCO2R improves gas exchange and reduces ventilation invasiveness, especially in ARDS and lung transplant patients. However, due to the lack of mortality benefits and increased adverse events, further studies are needed to identify patient groups that could benefit most from ECCO2R.
Reference (link to free full-text):
RCT: Cytisinicline shows promising results in enhancing vaping cessation among adults – JAMA Intern Med
11 May, 2024 | 13:35h | UTCStudy Design and Population: The ORCA-V1 study was a double-blind, placebo-controlled randomized clinical trial conducted across five US clinical sites from July 2022 to February 2023. It enrolled 160 adults who used nicotine e-cigarettes daily and expressed a desire to quit, but were not current cigarette smokers. Participants were predominantly middle-aged (mean age 33.6 years), with a slight female majority (51.9%).
Main Findings: The trial assessed cytisinicline, a plant-based alkaloid, compared to placebo over a 12-week period with follow-up to 16 weeks. Results showed that cytisinicline significantly increased continuous abstinence from e-cigarette use during the last four weeks of treatment (31.8% vs 15.1% with placebo; odds ratio, 2.64; 95% CI, 1.06-7.10; P = .04). The effect was less pronounced but still present during the four weeks post-treatment (23.4% vs 13.2% with placebo; odds ratio, 2.00; 95% CI, 0.82-5.32; P = .15). The medication was well-tolerated, with only 3.8% of the cytisinicline group discontinuing due to adverse events.
Implications for Practice: Cytisinicline offers a promising pharmacotherapy option for adults seeking to quit vaping, demonstrating both efficacy and safety in this trial. Further research in larger populations and over longer periods is needed to confirm these findings and fully establish cytisinicline’s role in treating nicotine e-cigarette dependence.
Reference (link to abstract – $ for full-text):
RCT: No significant benefit of adjuvant prednisone for patients with cystic fibrosis with exacerbations unresponsive to antibiotics – Eur Respir J
6 May, 2024 | 06:32h | UTCThis randomized, double-blind, placebo-controlled trial investigated the effectiveness of adjuvant oral prednisone in enhancing lung function recovery in patients with cystic fibrosis (CF) experiencing pulmonary exacerbations (PExs) unresponsive to initial intravenous (IV) antibiotic treatment. The study involved 173 participants, with 76 not achieving more than 90% of their baseline forced expiratory volume in one second (ppFEV1) by Day 7 of antibiotic treatment and subsequently randomized to receive either oral prednisone (1 mg·kg−1 twice daily, up to 60 mg/day) or placebo for an additional 7 days. Results showed that 50% of the prednisone group and 39% of the placebo group recovered over 90% of their baseline ppFEV1 by Day 14. However, the difference was not statistically significant (11% difference; 95% CI -11, 34%; p=0.34). Additionally, prednisone did not significantly prolong the time to the next exacerbation compared to placebo. This study concludes that adjuvant oral prednisone does not significantly improve lung function recovery or delay subsequent exacerbations in CF patients not responding to initial antibiotic therapy.
Reference (link to abstract – $ for full-text):
RCT: Lack of significant effect of Paxlovid (nirmatrelvir–ritonavir) on symptom alleviation in Covid-19
26 Apr, 2024 | 11:49h | UTCStudy Design and Population:
This phase 2–3 randomized clinical trial investigated the efficacy of nirmatrelvir in combination with ritonavir for treating mild-to-moderate Covid-19 in adults. Participants, both vaccinated and unvaccinated, were enrolled based on their risk factors for severe Covid-19. The study included 1296 adults who had confirmed Covid-19 with symptom onset within the past 5 days. They were randomly assigned to receive either nirmatrelvir–ritonavir or placebo every 12 hours for 5 days.
Main Findings:
The primary endpoint was the time to sustained alleviation of all targeted Covid-19 signs and symptoms. Results showed that the median time to alleviation was 12 days for the treatment group and 13 days for the placebo group, a difference that was not statistically significant (P=0.60). Hospitalizations and deaths were slightly lower in the treatment group (0.8%) compared to the placebo group (1.6%), but this difference was also not statistically significant. Adverse events were similar across both groups, with dysgeusia and diarrhea being the most common in the treatment group.
Implications for Practice:
The findings indicate that nirmatrelvir–ritonavir treatment does not significantly reduce the time to symptom alleviation for Covid-19 compared to placebo among vaccinated or unvaccinated adults. These results suggest that further research is needed to explore the potential benefits of this treatment in specific subpopulations or in combination with other interventions.
Reference (free full-text):
FDA approves antibiotic Zevtera (ceftobiprole medocaril sodium) for three indications
26 Apr, 2024 | 11:39h | UTCThe FDA has granted approval for Zevtera (ceftobiprole medocaril sodium), an antibiotic formulated for injection, targeting three key bacterial infections. This includes treatment for adults with Staphylococcus aureus bloodstream infections (SAB) with or without right-sided infective endocarditis, acute bacterial skin and skin structure infections (ABSSSI), and community-acquired bacterial pneumonia (CABP) in both adults and pediatric patients aged three months to under 18 years.
The approval follows rigorous clinical trials demonstrating Zevtera’s efficacy. In a multicenter study for SAB, Zevtera achieved a 69.8% success rate, slightly outperforming the comparator drug. For ABSSSI, Zevtera showed a 91.3% early clinical response, and for CABP, it had a clinical cure rate of 76.4% in adults. Pediatric efficacy for CABP was extrapolated from adult data and supported by a smaller pediatric trial.
Common side effects include anemia, nausea, and increased liver enzyme levels, with specific reactions varying by infection treated. Contraindications include severe hypersensitivity to ceftobiprole or other cephalosporins. Zevtera also carries warnings about potential hypersensitivity reactions, central nervous system effects, and Clostridioides difficile-associated diarrhea.
This approval, supported by Priority Review and Fast Track designations, offers a new treatment option for clinicians managing these serious infections.
Source: FDA NEWS RELEASE: FDA Approves New Antibiotic for Three Different Uses
Cohort Study: Inappropriate pneumonia diagnoses and associated risks in 17,290 hospitalized adults
26 Apr, 2024 | 11:25h | UTCStudy Design and Population:
This prospective cohort study analyzed medical records and patient interactions from July 2017 to March 2020 across 48 Michigan hospitals. A total of 17,290 adults admitted for general care were retrospectively assessed for community-acquired pneumonia (CAP) treatment, focusing on those who received antibiotics within the first two days of hospitalization.
Main Findings:
The study identified that 12.0% of the patients were inappropriately diagnosed with CAP. Key risk factors for misdiagnosis included older age, presence of dementia, and altered mental status at presentation. Among those misdiagnosed, 87.6% underwent a full course of antibiotics, which did not significantly change the 30-day risk of mortality, readmission, emergency visits, or Clostridioides difficile infections compared to brief treatment but was associated with higher antibiotic-related adverse events.
Implications for Practice:
The findings underscore the prevalence of inappropriate pneumonia diagnosis among hospitalized adults, especially in older patients with specific geriatric conditions. This study highlights the potential harms of unnecessary antibiotic use, suggesting a need for improved diagnostic accuracy and treatment decision-making in hospital settings to mitigate adverse outcomes.
Reference (free full-text):
Nested Case-Control Study: Increased risk of major bleeding in atrial fibrillation patients with concomitant SSRI and oral anticoagulant use
23 Mar, 2024 | 20:48h | UTCStudy Design and Population
This nested case-control study investigated the association between the concomitant use of selective serotonin reuptake inhibitors (SSRIs) and oral anticoagulants (OACs) on the risk of major bleeding among patients with atrial fibrillation. Conducted within the UK’s Clinical Practice Research Datalink, the study included 42,190 cases of major bleeding matched to 1,156,641 controls based on age, sex, cohort entry date, and follow-up duration. Patients initiating OACs between January 2, 1998, and March 29, 2021, were included, with risk-set sampling utilized for control selection.
Main Findings
The study found that concomitant use of SSRIs and OACs was associated with a 33% increased risk of major bleeding compared to OAC use alone, with the highest risk observed within the first 30 days of concurrent use. The increased risk was consistent across different ages, sexes, and patient histories, including those with chronic kidney disease or previous bleeding events. Notably, the elevated risk of bleeding extended up to 6 months of concomitant use but did not vary significantly with the potency of SSRIs or the type of OAC used (direct OACs or vitamin K antagonists).
Implications for Practice
These findings underscore the need for healthcare professionals to closely monitor patients with atrial fibrillation who are prescribed SSRIs in addition to OACs, particularly during the initial months of treatment. This study highlights the importance of managing bleeding risk factors and suggests reconsidering the necessity and duration of concomitant SSRI and OAC use. Future research should focus on strategies to mitigate this bleeding risk and explore alternative treatments for managing depression in patients requiring anticoagulation.
Reference
RCT: Clarithromycin improves early clinical and inflammatory responses in hospitalized community-acquired pneumonia patients
23 Mar, 2024 | 20:25h | UTCStudy Design and Population: The ACCESS trial was a phase 3, prospective, double-blind, randomized controlled trial conducted in 18 Greek hospitals, involving adults hospitalized with community-acquired pneumonia who displayed systemic inflammatory response syndrome, had a Sequential Organ Failure Assessment (SOFA) score of 2 or more, and procalcitonin levels of 0.25 ng/mL or more. Participants were randomly assigned to receive either standard of care with intravenous cephalosporins or β-lactam/β-lactamase inhibitor combinations plus oral clarithromycin (500 mg twice daily for 7 days) or placebo. The trial aimed to evaluate the impact of clarithromycin on early clinical and inflammatory responses.
Main Findings: Among 278 participants allocated to clarithromycin (n=139) or placebo (n=139), the primary composite endpoint—indicating early clinical response and inflammatory burden reduction within 72 hours—was met by 68% of patients in the clarithromycin group compared to 38% in the placebo group, showcasing a significant difference (29.6%, odds ratio 3.40, p<0.0001). Serious treatment-emergent adverse events were slightly lower in the clarithromycin group than in the placebo group, although not statistically significant.
Implications for Practice: The addition of clarithromycin to the standard of care for hospitalized patients with community-acquired pneumonia significantly improves early clinical response and reduces inflammatory burden, potentially through modulation of the immune response. These results support the use of clarithromycin alongside β-lactam antibiotics in the treatment of community-acquired pneumonia, highlighting its role in enhancing patient outcomes by targeting early clinical and inflammatory indicators.
Reference
Prof Evangelos J Giamarellos-Bourboulis, MD et al. (2024). Clarithromycin for early anti-inflammatory responses in community-acquired pneumonia in Greece (ACCESS): a randomised, double-blind, placebo-controlled trial. The Lancet Respiratory Medicine, Volume(Issue), Pages. DOI: https://doi.org/10.1016/S2213-2600(23)00412-5. Access the study here: Link
RCT: Lower oxygenation target improves days alive without life support in severe COVID-19 hypoxemia
21 Mar, 2024 | 13:46h | UTCStudy Design and Population: This multicenter randomized clinical trial investigated the impact of different oxygenation targets on the survival of adult patients with COVID-19 and severe hypoxemia in the ICU. Conducted across 11 European ICUs from August 2020 to March 2023, the study involved 726 patients requiring at least 10 L/min of oxygen or mechanical ventilation. Participants were randomly assigned to receive an oxygenation target of either 60 mm Hg (lower oxygenation group, n=365) or 90 mm Hg (higher oxygenation group, n=361) for up to 90 days.
Main Findings: The primary outcome was the number of days alive without life support at 90 days post-intervention. Patients in the lower oxygenation group achieved a median of 80.0 days alive without life support compared to 72.0 days in the higher oxygenation group, a difference that was statistically significant (P=0.009). Although there was a slight reduction in mortality at 90 days in the lower oxygenation group (30.2% vs 34.7% in the higher group), this was not statistically significant. No significant differences were observed in the proportion of patients with serious adverse events or the number of days alive and out of hospital.
Implications for Practice: Targeting a lower Pao2 of 60 mm Hg in ICU patients with COVID-19 and severe hypoxemia appears to increase the days alive without life support compared to a higher target of 90 mm Hg, without increasing serious adverse events. This finding suggests that a lower oxygenation target could be more beneficial for this patient population, potentially guiding clinical practice in managing oxygen therapy for severe COVID-19 cases.
Reference
Reference: Nielsen FM et al. (2024). Randomized Clinical Trial: Effect of Oxygenation Targets on Survival Without Life Support in COVID-19 Patients with Severe Hypoxemia. JAMA, Published online March 19, 2024. DOI: 10.1001/jama.2024.2934. Access the study here: [Link]
Cohort Study | Mortality risk in anti-MDA5 dermatomyositis linked to rapid ILD progression and anti-Ro52 antibody levels
11 Aug, 2023 | 15:21h | UTC
Commentary on Twitter
High mortality risk predictors in patients with anti-MDA5 dermatomyositis include:
– rapidly progressive interstitial lung disease
– anti-Ro52 antibody
– age > 57 years
(based on study of 126 MDA-5+ DM pts)https://t.co/JLGIgALUip pic.twitter.com/boTTzrixk9— Dr. John Cush (@RheumNow) August 5, 2023
Survival ≠ Recovery | A narrative review of post-intensive care syndrome
11 Aug, 2023 | 15:11h | UTCSurvival ≠ Recovery: A Narrative Review of Post-Intensive Care Syndrome – CHEST Critical Care
Review | Primary ciliary dyskinesia
11 Aug, 2023 | 15:10h | UTCPrimary Ciliary Dyskinesia – CHEST Pulmonary
M-A | Efficacy of vibrotactile positional therapy devices on patients with positional obstructive sleep apnea
9 Aug, 2023 | 15:30h | UTC