Triple inhaled therapy in COPD patients: determinants of prescription in primary care.
Respir Med. 2019 May 29;154:12-17
Authors: Vetrano DL, Zucchelli A, Bianchini E, Cricelli C, Piraino A, Zibellini M, Ricci A, Onder G, Lapi F
OBJECTIVE: To assess the incidence and determinants of the triple inhaled therapy in chronic obstructive pulmonary disease (COPD) primary care patients.
METHODS: Data derived from the Health Search Database (HSD) gathering information on 700 Italian general practitioners. A cohort of COPD patients, prescribed for the first time with inhaled treatments, was followed-up between January 2002 and December 2014. The outcome was the first incident prescription of a triple inhaled therapy, namely the combination of inhaled corticosteroids (ICS), long-acting beta agonists (LABA), and long-acting muscarinic antagonists (LAMA). Cox regressions were used to test the association (hazard ratios, HR) between candidate determinants and the outcome.
RESULTS: Out of 17589 patients (mean age 71.1 ± 11.3 years; 37.4% females), 3693 (21%) were prescribed with a triple inhaled therapy during follow-up. Older age (HR = 1.79 to 2.61), current and former smoking habit (HR = 1.72 and 1.66), higher GOLD stage (HR = 1.45 to 2.79), the number of moderate and severe COPD exacerbations (HR = 1.10 to 2.63), and heart failure (HR = 1.17) resulted statistically significantly associated with an increased incident prescription of the triple inhaled therapy. Female sex (HR = 0.80) and some comorbidities (HR = 0.21 to 0.87) resulted negatively associated with the outcome. Furthermore, patients initially treated with LAMA (HR = 1.5) and LABA/ICS (HR = 1.23) were more likely to escalate to the triple therapy, than those on LABA. Conversely, patients initially treated with ICS presented a negative hazard (HR = 0.72).
CONCLUSIONS: The knowledge of demographic and clinical determinants of the escalation to the triple inhaled therapy in real-world COPD patients may help clinicians to better personalize respiratory pharmacological treatments of their patients, and inform international societies that issue clinical guidelines.
PMID: 31202120 [PubMed - as supplied by publisher]
Operative Complexity and Prior Endovascular Intervention Negatively Impact Morbidity after Aortobifemoral Bypass in the Modern Era.
Ann Vasc Surg. 2019 Jun 12;:
Authors: DeCarlo C, Boitano LT, Schwartz SI, Lancaster RT, Conrad MF, Eagleton MJ, Brewster DC, Clouse WD
BACKGROUND: Endovascular therapy is first-line treatment for aortoiliac occlusive disease. This shift has altered case volume, patient selection, and risk profile for aortobifemoral bypass (ABF). Given this, we sought to investigate factors influencing morbidity and mortality after ABF in the endovascular era.
METHODS: Data for patients undergoing primary ABF from 2000 to 2017 were queried. Primary endpoints included major complication (unplanned return to OR, life-or-limb-threatening complications, and 30-day readmission or death) and long-term survival. Logistic regression and cox proportional hazards models determined predictors of primary endpoints. Kaplan-Meier analysis estimated long-term survival.
RESULTS: During this 17-years, 256 patients underwent primary ABF. Mean age was 67.9±10.6 years and 51.2% were women. Most had claudication (69.5%); 28.9% had critical ischemia. Sixty-five (25.4%) patients had prior aortoiliac endovascular intervention, 106 (41.4%) required aortic cuff endarterectomy, 111 (43.3%) femoral outflow adjunct, 9 (3.5%) simultaneous lower extremity bypass, and 230 (89.8%) had TASC D lesions. Concomitant renovisceral revascularization was needed in 42 (16.4%) patients. Thirty-day mortality was 2.7%. Major complication occurred in 92 patients (35.9%). Predictors included prior endovascular intervention (OR 2.2, 95% CI: 1.2-4.1; p=0.01), malignancy (OR 2.6, 95%CI: 1.3-5.3; p=0.01), intraoperative complication (OR 3.3, 95%CI: 1.3-9.2; p=0.03), operative blood loss, (OR 1.0 per 100ml, 95%CI: 1.0-1.0; p=0.03), and cuff endarterectomy (OR 1.8, 95%CI: 1.0-3.1; p=0.04). Median follow-up was 5.3 years (interquartile range: 7.2 years). Survival at 1, 3, and 5-years was 94%, 90%, and 82% respectively. Primary patency and freedom from reintervention at 5-years were 76% and 79%, respectively. Predictors of late mortality included malignancy (HR 2.3, 95%CI: 1.3-3.9; p<0.01), COPD (HR 1.8, 95%CI: 1.1-3.1; p=0.02), CHF (HR 2.3, 95%CI: 1.2-4.3; p=0.01), Rutherford's class (HR 1.5, 95%CI: 1.1-2.1; p=0.01), operative blood loss (HR 1.0 per 100ml, 95%CI: 1.0-1.0; p=0.04) and CKD (HR 2.3, 95%CI: 1.2-4.2; p=0.01).
CONCLUSION: Although late outcomes after ABF in the contemporary era remain acceptable, major complications are frequent. Operative complexity and prior endovascular revascularization predict complications. Long-term survival is driven by degree of limb-ischemia and comorbidities. These should be considered in selection for ABF, potentially modifying approach to improve outcomes.
PMID: 31201980 [PubMed - as supplied by publisher]
Factors Associated with Increased Mortality Following Isolated Abdominal Aortic Dissection Repair.
Ann Vasc Surg. 2019 Jun 12;:
Authors: Baldawi M, Baldawi M, Krafcik B, Al-Jubouri M, Markowiak S, Osman M, Brunicardi FC, Nazzal M
OBJECTIVE: Postoperative mortality following open and endovascular repair of thoracic aortic dissection (AD) has been the focus of previous research. However, a little has been published on the far less common Isolated Abdominal Aortic Dissection (IAAD). The aim of our study was to identify risk factors associated with 30-day postoperative mortality in IAAD patients.
METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) was queried for patients who underwent open or endovascular aortic dissection repair from January 2010 to December 2015. Information regarding patient demographics, comorbidities, pre-operative laboratory values, procedure details, and post-operative complications were analyzed, and predictors of 30-day mortality were identified. Risk stratification by the type of aortic repair and surgery setting was performed, and patient characteristics associated with mortality in each setting were determined. We employed Chi-square test, Student's t-test and Mann-Whitney U test for the univariate analysis; while the multivariate analysis was performed using a stepwise binary logistic regression test.
RESULTS: There were 229 patients who met the specified criteria, 15 died within 30 days postoperatively, and 214 survived beyond the same period (mortality rate was 6.5%). Among preoperative factors, a history of chronic obstructive pulmonary disease (COPD), preoperative ventilator dependence, preoperative transfusion of ≥1 unit packed RBCs, emergent operation and advanced American Society of Anesthesiologists (ASA) class were associated with increased risk of mortality. Postoperative complications associated with a higher risk of mortality were acute kidney injury, mechanical ventilation ≥48 hours, unplanned intubation, myocardial infarction, septic shock, and blood transfusion. On multivariate analysis, risk factors independently associated with increased risk of mortality were a history of COPD (AOR, 10.5; p=0.013), postoperative acute renal failure (AOR, 12.8; p=0.003) and septic shock (AOR, 15.3; p=0.014).
CONCLUSION: Multiple preoperative and postoperative factors are associated with a high risk of death following IAAD repair. A better control of COPD and prevention of postoperative acute renal failure and septic shock may result in better outcomes.
PMID: 31201973 [PubMed - as supplied by publisher]
To what extent do the NRS and CRQ capture change in patients' experience of breathlessness in advanced disease? Findings from a mixed-methods double blind randomised feasibility trial.
J Pain Symptom Manage. 2019 Jun 12;:
Authors: Lovell N, Etkind SN, Bajwah S, Maddocks M, Higginson IJ
CONTEXT: Chronic or refractory breathlessness is common and distressing. To evaluate new treatments, outcome measures that capture change in patient experience are needed.
OBJECTIVES: To explore the extent to which the Numerical Rating Scale (NRS) worst and average, and the Chronic Respiratory Questionnaire (CRQ) capture change in patient experience during a trial of mirtazapine for refractory breathlessness.
METHODS: Convergent mixed-methods design embedded within a randomised trial comprising 1) semi-structured qualitative interviews (considered to be the gold standard), and 2) outcome measure data collected pre-and post-intervention. Data were integrated, exploring examples where findings agreed and disagreed. Adults with advanced cancer, chronic obstructive pulmonary disease (COPD), interstitial lung disease (ILD), or chronic heart failure (CHF), with a Modified Medical Research Council Dyspnoea (mMRC) scale grade 3/4 were recruited from three UK sites.
RESULTS: Data was collected for 22 participants. 11 had a diagnosis of COPD, 8 ILD, 2 CHF and 1 cancer. Median age was 71 (56-84) years. 16 were male. Changes in the qualitative data were commonly captured in the NRS (worst and average) and CRQ. The NRS worst captured change most frequently. Improvement in the emotional domain was associated with physical changes, improved confidence and control.
CONCLUSION: This study found that the NRS using the question 'How bad has your breathlessness felt at its worst over the past 24 hours?' captured change across multiple domains, and therefore may be an appropriate primary outcome measure in trials in this population. Future work should confirm the construct validity of this question.
PMID: 31201877 [PubMed - as supplied by publisher]
Urinary Incontinence in Chronic Obstructive Pulmonary Disease: A Common Co-morbidity or a Typical Adverse Effect?
Drugs Aging. 2019 Jun 15;:
Authors: Battaglia S, Benfante A, Principe S, Basile L, Scichilone N
Urinary incontinence (UI) is defined as a loss of bladder control and is characterized by the complaint of any involuntary leakage of urine. Evidence suggests that the prevalence of UI is higher in subjects with chronic obstructive pulmonary disease (COPD) than in age-matched controls in both sexes. UI is classified as stress, urge, and mixed, and has a considerable impact on quality of life. However, the prevalence of UI in individuals with COPD is mostly unexplored in clinical research and often underestimated in clinical practice. Interestingly, although the involuntary leakage of a small amount of urine during coughing (e.g., stress UI) is among the most plausible causes of UI in patients with COPD, its importance has been questioned by some researchers. Moreover, UI as a respiratory drug-related adverse effect is largely overlooked; only a few randomized controlled trials have reported the presence of urinary symptoms, mainly as urinary retention due to anticholinergic agents. In this narrative review, we explored whether, and to what extent, UI occurs in COPD individuals, and what the proposed actions to improve this condition are. We found that the association between UI and COPD is largely unexplored, mostly because UI tends to be attributed to older age. We infer that the prevalence of UI in individuals with chronic respiratory symptoms is often underestimated in clinical practice. The misinterpretation of urinary symptoms as related to the respiratory condition can delay diagnostic and therapeutic approaches. The use of simple self-administered questionnaires to assess the presence of UI is encouraged.
PMID: 31201688 [PubMed - as supplied by publisher]