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Mycobacterial disease in patients with rheumatic disease.

Nat Clin Pract Rheumatol. 2008 Dec;4(12):649-656

Authors: van Ingen J, Boeree MJ, Dekhuijzen PR, van Soolingen D

This Review focuses on the emergence of mycobacterial disease in patients undergoing treatment for rheumatic disease with four new drug classes-tumor necrosis factor (TNF) inhibitors, human interleukin (IL)-1 receptor antagonists, anti-CD20 antibodies and CD4(+) T-cell costimulation modulators-collectively referred to as biologic agents. Mycobacterial disease is a major cause of severe infection in patients undergoing anti-TNF therapy. Reports are now emerging of an association between mycobacterial infection and antirheumatic treatment with anti-IL-1 or anti-CD20 antibodies. Although tuberculosis is the most common mycobacterial disease, nontuberculous mycobacterial (NTM) disease is an increasingly recognized problem in this setting. Among the antirheumatic drugs currently in development, agents that target IL-17, IL-23, Janus kinase-signal transducers and activators of transcription signaling, and metalloproteinases are likely to confer an increased risk of mycobacterial disease. Although screening and preventive treatments have lowered the incidence of active tuberculosis, these tools are not applicable to patients with NTM disease. All patients receiving drugs associated with an increased risk of mycobacterial disease should be carefully monitored, and suspect lesions should undergo Mycobacterium culture. Further studies are needed to determine the prevalence of NTM disease in this setting, and to evaluate the safety of simultaneous anti-TNF and antimycobacterial treatment.

PMID: 19037226 [PubMed - as supplied by publisher]

A retrospective randomized study of asthma control in the US: results of the CHARIOT study.

Curr Med Res Opin. 2008 Dec;24(12):3443-52

Authors: Marcus P, Arnold RJ, Ekins S, Sacco P, Massanari M, Stanley Young S, Donohue J, Bukstein D

ABSTRACT Background: The third version of the National Asthma Education and Prevention Program (NAEPP) Expert Panel Report (EPR-3): Guidelines on the Diagnosis and Management of Asthma emphasizes the need to use asthma control rather than patient severity to base adjustments to treatment and ultimately improve patient outcomes. The objectives of the current study were to assess control of patients with moderate-to-severe asthma, examine the natural history of the disease, practice patterns and resource utilization in specialty community practices according to recently reviewed NAEPP guidelines. Research design and methods: This analysis represents a retrospective, multicenter, randomized study of 1009 patient charts in sixty United States allergy and pulmonary medicine community practices. The proportion of patients with controlled and uncontrolled asthma over 12 months, prevalence and characteristics of atopy, past asthma history, pulmonary function, medications and treatment patterns, patient and clinical practice characteristics were analyzed. Main outcome measures: The primary outcome of interest was asthma control. Results: A total of 365 male and 644 female patients with moderate-to-severe persistent asthma (mean 43.2 +/- 17.1 years) were enrolled. 81.9% of patients were uncontrolled according to recent NAEPP guidelines. Importantly, a greater percentage of patients with moderate asthma vs. severe persistent asthma were uncontrolled (p < 0.0114). Atopy was detected in 92% of patients. Patients with early onset of asthma were associated with control (p < 0.0433). Atopic symptoms, such as allergic rhinitis (p < 0.0130) and rhinosinusitis (p < 0.0476), were associated with uncontrolled asthma. Uncontrolled patients were also associated with more medications (a mean of 4.05 +/- 1.87 medications) than were controlled patients (a mean of 3.40 +/- 1.37 medications (p < 0.0001), although the temporal relationship of this association was not recorded. Limitations may have included patient and/or study site selection bias and difficulty in the process of operationalizing the definitions of control and disease severity. Since the current study only examined patients from specialty practices, the results may not be generalizable to the overall asthma population. Conclusions: Greater than 80% of asthma patients from specialty practices were uncontrolled with regard to asthma symptoms. Atopic symptoms, such as allergic rhinitis and rhinosinusitis, in addition to a greater number of medications, were associated with uncontrolled asthma. Moreover, patients designated as having asthma of moderate severity were associated with being uncontrolled more than were those with severe asthma (p < 0.0114), which suggests that the former population may not have received adequate assessment of impairment or risk, with subsequent changes in treatment for control of symptoms.

PMID: 19032126 [PubMed - in process]

Fiberoptic bronchoscopy in children an audit from a tertiary care center.

Indian Pediatr. 2008 Nov;45(11):917-9

Authors: Kabra SK, Lodha R, Ramesh P, Sarthi M

A retrospective review of 529 fiberoptic bronchoscopies was done with an aim to identify conditions where it will be most useful. The common indications were persistent/ recurrent pneumonia, persistent collapse, stridor and pulmonary hemorrhage. The diagnostic yield was maximum when it was performed to identify structural abnormalities and the yield was relatively poor in suspected drug resistant tuberculosis, and interstitial lung diseases. Serious complications were seen in children with pulmonary arterial hypertension. Fiberoptic bronchoscopy is an important tool for management of respiratory problems but should be performed with caution in children with pulmonary arterial hypertension.

PMID: 19029566 [PubMed - in process]

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Risk-adjusted 30-day outcomes of carotid stenting and endarterectomy: Results from the SVS Vascular Registry.

J Vasc Surg. 2008 Nov 21;

Authors: Sidawy AN, Zwolak RM, White RA, Siami FS, Schermerhorn ML, Sicard GA,

OBJECTIVE: As the first operational societal registry of carotid procedures, the Outcomes Committee of the Society for Vascular Surgery (SVS) developed the Vascular Registry (VR) in response to the Centers for Medicare and Medicaid Services' (CMS) National Coverage Decision on carotid artery stenting (CAS). Although CMS requires data submission only on CAS, the VR collects similar data on carotid endarterectomy (CEA) to allow comparison of outcomes, as well as potential for expansion to other procedures. METHODS: SVS-VR on-line provider-reported data include baseline through follow-up visits to better understand long-term risks and benefits associated with CAS and CEA. The primary outcomes are combined death, stroke, and myocardial infarction (MI). An independent data coordinating center maintains the database, which is Health Insurance Portability and Accountability (HIPAA)-compliant and auditable. RESULTS: As of December 26, 2007, 6403 procedures with discharge data were entered by 287 providers at 56 centers on 2763 CAS patients (1450 with 30-day outcomes, 52.5%) and 3259 CEA patients (1368 with 30-day outcomes, 42%). Of the total cohort, 98% of CEA and 70.7% of CAS (P < .001) were performed for atherosclerotic disease. Restenosis accounted for 22.3% and post-radiation induced stenosis in 4.5% of CAS patients. Preprocedure lateralizing neurologic symptoms were present in a greater proportion of CAS patients (49.2%) than CEA patients (42.4%, P < .001). CAS patients also had higher preprocedure prevalence of coronary artery disease (CAD), MI, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and cardiac arrhythmia. For CAS, death/stroke/MI at 30 days was 7.13% for symptomatic patients and 4.60% for asymptomatic patients (P = .04). For CEA, death/stroke/MI at 30 days was 3.75% in symptomatic patients and 1.97% in asymptomatic patients (P = .05). After risk-adjustment for age, history of stroke, diabetes, and American Society of Anesthesiologists (ASA) grade (ie, factors found to be significant confounders in outcomes using backwards elimination), logistic regression analysis suggested better outcomes following CEA. There were no statistically significant differences when examining CAS outcomes based on center volume. CAS in atherosclerotic disease had significantly worse outcomes than in nonatherosclerotic stenosis. When CAS and CEA were compared in the treatment of atherosclerotic disease only, the difference in outcomes between the two procedures was more pronounced, with death/stroke/MI 6.42% after CAS vs 2.62% following CEA, P < .0001. CONCLUSION: Following best possible risk adjustment of these unmatched groups, symptomatic and asymptomatic CAS patients had significantly higher 30-day postprocedure incidence of death/stroke/MI when compared with CEA patients. The initial 1.5 years of data collection provide proof of concept that a specialty society based VR can succeed in meeting regulatory and scientific goals. With continued enrollment and follow-up, analysis of SVS-VR will supplement randomized trials by providing real-world comparisons of CAS and CEA with sufficient numbers to serve as an outcome assessment tool of important patient subsets and across the spectrum of peripheral vascular procedures.

PMID: 19028045 [PubMed - as supplied by publisher]