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Pulmonary Journal Club

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May 2017 Phoenix Pulmonary/Critical Care Journal Club
October 2015 Phoenix Pulmonary Journal Club: Lung Volume Reduction
September 2015 Tucson Pulmonary Journal Club: Genomic Classifier
   for Lung Cancer
April 2015 Phoenix Pulmonary Journal Club: Endo-Bronchial Ultrasound in
   Diagnosing Tuberculosis
February 2015 Tucson Pulmonary Journal Club: Fibrinolysis for PE
January 2015 Tucson Pulmonary Journal Club: Withdrawal of Inhaled
    Glucocorticoids in COPD
January 2015 Phoenix Pulmonary Journal Club: Noninvasive Ventilation In 
   Acute Respiratory Failure
September 2014 Tucson Pulmonary Journal Club: PANTHEON Study
June 2014 Tucson Pulmonary Journal Club: Pirfenidone in Idiopathic
   Pulmonary Fibrosis
September 2014 Phoenix Pulmonary Journal Club: Inhaled Antibiotics
August 2014 Phoenix Pulmonary Journal Club: The Use of Macrolide
   Antibiotics in Chronic Respiratory Disease
June 2014 Phoenix Pulmonary Journal Club: New Therapies for IPF
   and EBUS in Sarcoidosis
March 2014 Phoenix Pulmonary Journal Club: Palliative Care
February 2014 Phoenix Pulmonary Journal Club: Smoking Cessation
January 2014 Pulmonary Journal Club: Interventional Guidelines
December 2013 Tucson Pulmonary Journal Club: Hypothermia
December 2013 Phoenix Pulmonary Journal Club: Lung Cancer
   Screening
November 2013 Tucson Pulmonary Journal Club: Macitentan
November 2013 Phoenix Pulmonary Journal Club: Pleural Catheter
   Infection
October 2013 Tucson Pulmonary Journal Club: Tiotropium Respimat 
October 2013 Pulmonary Journal Club: Pulmonary Artery
   Hypertension
September 2013 Pulmonary Journal Club: Riociguat; Pay the Doctor
August 2013 Pulmonary Journal Club: Pneumococcal Vaccine
   Déjà Vu
July 2013 Pulmonary Journal Club
June 2013 Pulmonary Journal Club
May 2013 Pulmonary Journal Club
March 2013 Pulmonary Journal Club
February 2013 Pulmonary Journal Club
January 2013 Pulmonary Journal Club
December 2012 Pulmonary Journal Club
November 2012 Pulmonary Journal Club
October 2012 Pulmonary Journal Club
September 2012 Pulmonary Journal Club
August 2012 Pulmonary Journal Club
June 2012 Pulmonary Journal Club
June 2012 Pulmonary Journal Club
May 2012 Pulmonary Journal Club
April 2012 Pulmonary Journal Club
March 2012 Pulmonary Journal Club
February 2012 Pulmonary Journal Club
January 2012 Pulmonary Journal Club
December 2011 Pulmonary/Sleep Journal Club
October, 2011 Pulmonary Journal Club
September, 2011 Pulmonary Journal Club
August, 2011 Pulmonary Journal Club
July 2011 Pulmonary Journal Club
May, 2011 Pulmonary Journal Club
April, 2011 Pulmonary Journal Club
February 2011 Pulmonary Journal Club 
January 2011 Pulmonary Journal Club 
December 2010 Pulmonary Journal Club

 

Both the Phoenix Good Samaritan/VA and the Tucson University of Arizona fellows previously had a periodic pulmonary journal club in which current or classic pulmonary articles were reviewed and discussed. A brief summary was written of each discussion describing thearticle and the strengths and weaknesses of each article.

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Entries in myocardial injury (2)

Thursday
Feb262015

February 2015 Tucson Pulmonary Journal Club: Fibrinolysis for PE

Meyer G, Vicaut E, Danays T, et al. Fibrinolysis for patients with intermediate-risk pulmonary embolism. N Engl J Med. 2014;370(15):1402-11. [CrossRef] [PubMed]

The role of fibrinolytic therapy among patients with intermediate-risk pulmonary embolism (PE) is controversial (1). When right ventricular dysfunction and myocardial injury are associated with PE, there is an increased risk of adverse events (2). However, the risk of bleeding with fibrinolytic therapy has previously been thought to outweigh the benefits among patients without overt hemodynamic collapse.

The Pulmonary Embolism Thrombolysis (PEITHO) trial was a multi-center, double-blind, placebo-controlled randomized trial designed to investigate the efficacy and safety of single-bolus injection with tenecteplase plus heparin anticoagulation versus heparin anticoagulation alone among normotensive patients with intermediate risk PE (3). The study included 1005 adult patients who were randomized within fifteen days of symptom onset; randomization occurred when both right ventricular dysfunction (echocardiography or spiral computed tomography) and myocardial injury (troponin I or T) were present. All patients were followed for 30 days. The primary outcome was death or hemodynamic collapse within 7 days of randomization. Safety outcomes included major extra cranial and intracranial hemorrhage within 7 days.

Fibrinolytic therapy was associated with less frequent hemodynamic collapse or death within 7 days of treatment (2.6% vs 5.6%, p=0.02). The result was primarily driven by fewer instances of hemodynamic collapse in tenecteplase group (1.6% vs 5.0%, p=0.002). At 30 days, there was no difference in mortality from any cause between the tenecteplase and usual care groups, 2.5% versus 3.2%, respectively (p=0.42). However, tenecteplase therapy was associated with higher risk of major bleeding and stroke than usual care, 11.5% versus 2.4% (p<0.001) and 2.4% versus 0.2% (p=0.003), respectively. Subgroup analysis showed a trend towards increased bleeding in patients older than 75 years though this was not significant (p=0.09).

PEITHO is a relatively large, expensive, randomized controlled trial that provides little guidance on the optimal care of patients with intermediate risk PE. While improvement in the composite outcome of death or hemodynamic decompensation was significant (Odds Ratio 0.44, CI95% 0.23-0.87), the benefit was primarily driven by less frequent hemodynamic compromise. Furthermore, any treatment benefit must be weighed against a substantially increased risk of major bleeding (Odds Ratio 5.55, CI95% 2.3-13.39) or stroke (Odds Ratio 12.10, CI95% 1.57-93.39). Given that follow-up is limited to 30 days and no patient-reported/patient-centered outcomes are available, it is difficult to provide patients or clinicians with the evidence they need to weigh the risks and benefits. Until better data are available, thrombolytic therapy for intermediate risk PE still remains weakly supported due to unclear efficacy and high risks of major bleeding or stroke, particularly among older patients.

Aarthi Ganesh MD, Christian Bime MD, and Joe Gerald PhD

University of Arizona

Tucson, AZ

References

  1. Konstantinides S, Goldhaber SZ. Pulmonary embolism: risk assessment and management. Eur Heart J. 2012;33:3014-22. [CrossRef] [PubMed]
  2. Konstantinides S. Acute pulmonary embolism. N Engl J Med. 2008;359:2804-13. [CrossRef] [PubMed]
  3. Meyer G, Vicaut E, Danays T, et al; PEITHO Investigators. Fibrinolysis for patients with intermediate-risk pulmonary embolism. N Engl J Med. 2014;370(15):1402-11. [CrossRef] [PubMed] 

Reference as: Ganesh A, Bime C, Gerald J. February 2015 Tucson pulmonary journal club: fibrinolysis for PE. Southwest J Pulm Crit Care. 2015;10(2):97-8. doi: http://dx.doi.org/10.13175/swjpcc028-15 PDF

Monday
Jan282013

January 2013 Pulmonary Journal Club

Kartalija M, Ovrutsky AR, Bryan CL, Pott GB, Fantuzzi G, Thomas J, Strand MJ, Bai X, Ramamoorthy P, Rothman MS, Nagabhushanam V, McDermott M, Levin AR, Frazer-Abel A, Giclas PC, Korner J, Iseman MD, Shapiro L, Chan ED. Patients with nontuberculous mycobacterial lung disease exhibit unique body and immune phenotypes. Am J Respir Crit Care Med. 2013;187(2):197-205. Abstract

Among patients with nontuberculous mycobacterial (NTM) lung disease is a subset of previously healthy women with a slender body morphotype, often with scoliosis and/or pectus excavatum. The authors enrolled 103 patients with NTM and 101 uninfected control subjects of similar demographics. Patients with

NTM had significantly lower body mass index and body fat and were significantly taller than control subjects. Scoliosis, pectus excavatum and gastroesophageal reflux were significantly more prevalent in patients with NTM. The normal relationships between the adipokines and body fat were lost and IFN-g and IL-10 levels were significantly suppressed in stimulated whole blood of patients with NTM.

The description in this article extends the description of the “Lady Windermere syndrome” first described in the early 1990’s by Reich and Johnson (1). They described 6 elderly women who were immunocompetent, had no significant smoking history or underlying pulmonary disease, and developed Mycobacterium avium complex (MAC). They hypothesized that these women could have had the habit of voluntary suppression of cough, responsible for the inability to clear secretions from the lung. However, it is now known that the adiopectins have immunomodulatory functions and the findings suggest that the underlying pathophysiology may be an immune deficit.

Søyseth V, Bhatnagar R, Holmedahl NH, Neukamm A, Høiseth AD, Hagve TA, Einvik G, Omland T. Acute exacerbation of COPD is associated with fourfold elevation of cardiac troponin T. Heart. 2013;99(2):122-6. Abstract

The authors investigated if acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is associated with myocardial injury, expressed as elevated cardiac troponin T (Trop). In a cross-sectional study, Trops in patients hospitalized for AECOPD were compared with COPD patients in their stable state. Mean Trops were elevated in the AECOPD group (25.8 ng/l) compared to the reference group (4.55 ng/l).  Higher Trops were associated with the presence of pathological q-waves (p=0.012) and electrocardiographic left ventricular hypertrophy (p=0.039), long-term oxygen treatment (p=0.002) and decreasing forced expiratory volume in 1 s (p=0.014).

Slight elevations of Trops in patients admitted to the hospital are common, including AECOPD patients. This study suggests that elevated Trops do no necessarily indicate underlying cardiac disease and that cardiac consultation and/or workup is not necessarily indicated in every AECOPD patient with a slight elevation in Trops. Clinical judgment as to whether a cardiac condition coexists with the AECOPD must be used.

Richard A. Robbins, MD

References

1. Reich JM, Johnson RE. Mycobacterium avium complex pulmonary infection presenting as isolated lingular or middle lobe pattern: the lady Windermere Syndrome. Chest 1992;101:1605-9.

Referece as: Robbins RA. January 2013 pulmonary journal club. Southwest J Pulm Crit Care 2013:6(1):41-42. PDF