Pre-existing Pulmonary Disease Research Articles

Thoracic Complications of Bariatric Surgeries: Overlooked Entities.

Bariatric surgeries are increasingly performed to treat obesity worldwide. The currently available literature on these surgeries mainly focuses on their abdominal complications, giving less attention to their thoracic ones. Hence, the present work aimed to highlight the thoracic complications associated with bariatric surgeries. A retrospective descriptive study was performed and involved the review of the medical charts of 390 patients who underwent different bariatric surgeries between January 2014 and January 2017 in our hospital or who were referred to us from other centers after their specific operations. The data of patients who developed thoracic complications and who required further intervention were identified and categorized by the modality of diagnosis, outcome, duration of hospital and ICU stays, and management. Patients with a history of a preexisting pulmonary disease were excluded. Twenty-six patients were observed to have thoracic complications secondary to their bariatric surgeries. Twenty-two patients (84.6%) received post-laparoscopic sleeve gastrectomy (LASG). Nine patients (34.6%) required ICU stays. Twenty patients (76.9) had incidences of pleural effusion in the postoperative period. The mean duration of hospital and ICU stays were 4.4 ± 11.67days and 15 ± 19.36days, respectively. Other reported thoracic complications included esophageal perforations, thoracic empyema, septic pericardial effusion, and pancreaticopleural fistula. Bariatric surgeries are safe procedures in selected patients. There is a significant amount of literature describing abdominal, nutritional, neurological, and even ophthalmic complications after bariatric surgeries. Being that they are relatively rare, thoracic complications are underreported in the literature. The management of thoracic complications after bariatric surgery requires awareness and a high index of suspicion to prevent further morbidities and mortalities.

Docetaxel-Induced Lung Injury: An Under-Recognized Complication of a Commonly Used Chemotherapeutic Agent

Abstract Background: Docetaxel-induced pneumonitis is a rare, but potentially serious complication of a commonly used chemotherapeutic agent. Methods: We performed an audit of patients with suspected docetaxel pneumonitis from the tertiary cancer center. Results: Out of 477 patients who received docetaxel over a 1 year period, eight patients (1.7%) developed lung injury. All patients (median age: 43 years [34–65]) had breast cancer (four metastatic on palliative docetaxel, two were on neoadjuvant, and two were on adjuvant therapy) and had received a median of three cycles of docetaxel 75 mg/m2 in a 3 weekly schedule (7 as single agent and 1 in combination with cyclophosphamide). One patient had the preexisting pulmonary disease (localized bronchiectasis), and four had received prior radiation to the chest wall or dorsal spine. The median time from administration of the last dose was 16 days (8–28). Most (n = 6/8, 75%) required hospitalization. Three patients with CTCAE Grade 3 pneumonitis required oxygen support. Radiology showed a pattern of interstitial pneumonitis in most patients. All the patients responded to steroids and follow-up imaging showed resolution of infiltrates. The median duration of hospital stay was 8.5 days (7–18 days). There was no mortality due to this condition. Conclusions: Drug-induced lung injury should be considered in patients presenting with respiratory symptoms after administration of docetaxel. Timely initiation of steroids could reduce complications.

88 A Retrospective Review of the Use of Airway Pressure Release Ventilation (APRV) in the Burn Operating Room

Airway Pressure Release Ventilation (APRV) is the preferred mode of mechanical ventilation for the initial treatment of inhalation injury at our burn center. APRV improves alveolar recruitment, thus improving oxygenation. However, general anesthesia cannot be administered when patients are on APRV, resulting in frequent interruptions in the circuit and subsequent alveolar derecruitment with prolonged periods of sub-optimal ventilation post-operatively. Total IV anesthesia (TIVA) allows for the continued use of APRV perioperatively. The purpose of this study was to assess the safety and efficacy of APRV during surgery. This was a retrospective chart review of patients that remained on APRV during surgery over a 3-year period. Demographic, injury, ventilator, and outcome data were collected. Pre (PRE) and post-operative (POST) FIO2, Rate (set & spontaneous), Tidal Volume (TV), Minute Volume (MV), P High/Low, T High/Low, and Mean Airway Pressures (MAP) were compared for each surgery. The charts of 55 patients were reviewed, mean age was 45 years, the majority were male (75%) and 9% had pre-existing pulmonary disease. The most common mechanism was flame/flash (67%) with total body surface area (TBSA) burned ranging from 0 - 92% (M 42%). Concomitant inhalation injury was present for 58% of patients. Total ventilator days (M 42.2, ±35.7), total APRV days (M 16, ±12.9). Total number of surgeries (M 9.4, ±7.94), total number of surgeries on APRV (M 3.4, ±2.65). There were 38 patients with complete PRE and POST ventilator data. Surgery 1 on APRV; there were no significant differences for FIO2, Rate, TV, MV, P High/Low, T High, MAP; POST T Low was lower (M 0.8) when compared to PRE (M 0.9), (p=0.0005). Surgery 2 (n=35), POST mean FIO2 requirements were higher; PRE (0.47) vs POST (0.57), (p=.0358). Surgery 3 (n=25) average TV was lower POST-OP; PRE-OP (630) vs POST (523), (p=.005). There were no significant differences between PRE and POST requirements for patients on APRV during surgeries 4 (n=16) and 5 (=13). No patients suffered complications pre, peri or post-operatively when on APRV. Overall inpatient mortality was 35%. Of survivors, 92% required transfer to a post-acute care facility. APRV can be continued intra-operatively with the use of TIVA. This retrospective study demonstrates that TIVA and intra-operative APRV are safe and effective. TIVA allows the continued use of APRV intra-operatively in burn patients requiring aggressive ventilator support.

Pulmonary function abnormalities are common in patients with multiple myeloma and are independently associated with worse outcome.

Pre-existing pulmonary disease may affect treatment choices, toxicity, and survival of patients with multiple myeloma (MM). However, data on the prognostic value of pulmonary function tests (PFTs) in myeloma patients' outcome, at the time of initial assessment of newly diagnosed patients, are scarce. Here, we prospectively performed PFTs in 121 newly diagnosed MM patients, before initiation of treatment, and we evaluated possible associations of lung function with their outcomes. Fifty-four patients (44.63%) had either obstructive or restrictive pulmonary function defects, even among those not reporting a history of lung disease. The survival was significantly worse in those with obstructive pulmonary defect (median OS 32.8months) vs. those with restrictive (median OS 52.5months) or normal lung function (median not reached, 3-year survival 76%) (p= 0.013), independently of other myeloma-related factors. Forced vital capacity (FVC) (lt) (p= 0.012), forced expiratory volume in 1s (FEV1) (lt) (p= 0.018), peak expiratory flow (PEF) (lt/min) (p= 0.008), carbon monoxide diffusion capacity (DLCO) (p= 0.012), and expiratory/inspiratory pressures (Pe) (kPa) (p= 0.032)/(Pi) (kPa) (p= 0.023) were significantly associated with OS. Myeloma-related factors associated with survival included ISS stage (p= 0.008), hypercalcemia (p= 0.064), and high-risk cytogenetics (p= 0.004). In the multivariate analysis, only the presence of high-risk cytogenetics and presence of either or both PEF and DLCO < 65% of predicted were independent prognostic factors. We conclude that PEF and DLCO could be useful in the initial assessment of newly diagnosed MM patients as significant predictors of survival. Further research is needed to evaluate if respiratory screening should be included in the routine initial evaluation of myeloma patients, despite the presence or absence of respiratory symptoms or abnormal clinical respiratory examination.

Perceptions in rib injuries: A multidisciplinary single center survey of clinician differences in risk stratification and management of patients with rib fractures

BackgroundAlthough associated with significant morbidity, there is no universally accepted management of rib fractures. We hypothesized that variations in risk stratification may influence this. MethodsA questionnaire was developed to assess providers’ perceived risk factors and injury stratification of rib fracture patients at a Level 1 trauma center. ResultsThere were 143 responses (36% physician response rate). Hypoxia, age, number of ribs fractured, pre-existing pulmonary disease, and flail chest were identified as the most important risk factors determining morbidity and mortality in blunt chest trauma. While clinicians agreed on predicted mortality for <2 fractured ribs, significant variation for 5–6 and >8 rib fractures was seen. EM and surgery providers significantly differed in assessment of injury severity. ConclusionProviders identified common risk factors for increased morbidity and mortality. However, the difference in perceived severity between providers indicates a need for clinical tools to assist in better standardizing rib fracture management.

Risk factors for opioid-induced respiratory depression in surgical patients: a systematic review and meta-analyses

ObjectiveThis systematic review and meta-analysis aim to evaluate the risk factors associated with postoperative opioid-induced respiratory depression (OIRD).DesignSystematic review and meta-analysis.Data sourcesPubMed-MEDLINE, MEDLINE in-process, EMBASE, Cochrane Central Register of Controlled...

Healthcare utilization and costs associated with COPD among SEER-Medicare beneficiaries with NSCLC

Aim: To estimate the healthcare utilization and costs in elderly lung cancer patients with and without pre-existing chronic obstructive pulmonary disease (COPD).Methods: Using Surveillance, Epidemiology and End Results (SEER)-Medicare data, this study identified patients with lung cancer between 2006–2010, at least 66 years of age, and continuously enrolled in Medicare Parts A and B in the 12 months prior to cancer diagnosis. The diagnosis of pre-existing COPD in lung cancer patients was identified using ICD-9 codes. Healthcare utilization and costs were categorized as inpatient hospitalizations, skilled nursing facility (SNF) use, physician office visits, ER visits, and outpatient encounters for every stage of lung cancer. The adjusted analysis was performed using a generalized linear model for healthcare costs and a negative binomial model for healthcare utilization.Results: Inpatient admissions in the COPD group increased for each stage of non-small cell lung cancer (NSCLC) compared to the non-COPD group per 100 person-months (Stage I: 14.67 vs 9.49 stays, p < .0001; Stage II: 14.13 vs 10.78 stays, p < .0001; Stage III: 28.31 vs 18.91 stays, p < .0001; Stage IV: 49.5 vs 31.24 stays, p < .0001). A similar trend was observed for outpatient visits, with an increase in utilization among the COPD group (Stage I: 1136.04 vs 796 visits, p < .0001; Stage II: 1325.12 vs 983.26 visits, p < .0001; Stage III: 2025.47 vs 1656.64 visits, p < .0001; Stage IV: 2825.73 vs 2422.26 visits, p < .0001). Total direct costs per person-month in patients with pre-existing COPD were significantly higher than the non-COPD group across all services ($54,799.16 vs $41,862.91). Outpatient visits represented the largest cost category across all services in both groups, with higher costs among the COPD group ($41,203 vs $31,140.08).Conclusion: Healthcare utilization and costs among lung cancer patients with pre-existing COPD was ∼2–3-times higher than the non-COPD group.

Immune-checkpoint inhibitors in non-small cell lung cancer: A tool to improve patients' selection.

The identification of reliable predictive biomarkers of efficacy or resistance to immune-oncology (I-O) agents is a major issue for translational research and clinical practice. However, along with PDL1 and molecular features other clinical, radiological and laboratory factors can be considered for the selection of those patients who would not be the best candidate for immune-checkpoint inhibitors (ICPIs). We examined these factors, emerging from the results of currently available studies in non-small cell lung cancer (NSCLC), aiming to provide a useful and manageable tool which can help Oncologists in their everyday clinical practice. A thorough patient evaluation and close clinical monitoring, due to limited, early or inconclusive currently available data, should be deserved for patients with a pre-existing symptomatic chronic obstructive pulmonary disease, age >75 years, Eastern Cooperative Oncology Group (ECOG) performance status (PS) ≥ 1, a time to progression (TTP) < three months and progressive disease (PD) as the best response to the previous treatment, hepatitis or HIV-infections, high neutrophil to lymphocyte ratio (NLR), or on treatment with high-dose steroids, when the use of ICPIs is considered. Limited data are available to consider that ICPIs are safe in patients with interstitial lung disease, bronchiolitis obliterans organizing pneumonia and autommune diseases. Early evidence on steroids, vaccinations and antibiotics suggest their possible interaction with ICPIs and need to be more investigated in clinical trials. Oncogene-addicted NSCLC harboring EGFR-mutations and low tumor-infiltrating T-lymphocytes (TILs) seems not to gain benefit from I-O.

Counseling intervention to improve quality of life in patients with pre-existing acute myocardial infarction (AMI) or chronic obstructive pulmonary disease (COPD): a pilot study.

In the light of diagnostic and therapeutic advances, patients with a previous myocardial infarction or with a diagnosis of chronic obstructive pulmonary disease are vulnerable and need continuous monitoring over time. These pathological frameworks have a strong impact on the economy and on the status of the population and require effective and low-cost solutions. The objective of this clinical trial is to evaluate the efficacy in the short term of a telephone counseling intervention to modify the lifestyles of these two patient populations. In May 2015, all the patients included in the study underwent a questionnaire to evaluate their eating and smoking habits and their quality of life. After randomization in two groups, the intervention group received telephone counseling related to the correct lifestyles. The control group did not undergo any intervention. In September-October 2015, the same initial questionnaire was administered to evaluate changes in patients' behavior. 64 patients were included in the study: 34 were assigned to the intervention group and 30 to the control group. The outcomes evaluated were: quality of life, assessment of eating habits and smoking status. After the telephone counseling, the intervention group (34 persons) showed a significant improvement in the score of adherence to the Mediterranean diet (p = 0.01) and a significant reduction in the percentage of smokers (p = 0.01) compared to the population that did not receive any intervention (30 persons). On the other hand, the changes related to the quality of life questionnaire were not significant. A single telephone counseling intervention is effective in modifying the lifestyles of patients with a previous myocardial infarction or diagnosed with chronic obstructive pulmonary disease in the short term, reducing their risk profile.

Stereotactic body radiotherapy for second primary lung cancer and intra-parenchymal lung metastasis in patients previously treated with surgery: evaluation of indications and predictors of decreased respiratory function

Background The adaptation criteria for administration of stereotactic body radiotherapy (SBRT) to patients with lung cancer who previously underwent surgery and subsequently developed a second primary lung cancer (SPLC) or intra-parenchymal lung metastasis (IPLM) are controversial, unlike the criteria for repeat surgery. We aimed to evaluate the feasibility of SBRT for these patients. Factors associated with decreased respiratory function were also evaluated. Material and methods Sixty-nine patients with 89 lesions who underwent SBRT between 2008 and 2017 were analyzed. Of these, 29 were diagnosed with SPLC while the remaining 40 had IPLM. The distribution of histological types was as follows: squamous cell carcinoma (n = 13 lesions); adenocarcinoma (n = 25); non-small cell carcinoma (n = 1); unknown histological type (n = 49). The prescribed doses to the planning target volume (PTV) were 50 Gy in five fractions for 85 lesions and 60 Gy in 10 fractions for four lesions at PTV mean. Results Over a median follow-up period of 55 months, the 4-year overall survival and local control rates were 50.3% and 87.6%, respectively. Six patients experienced grade 2 radiation pneumonitis and one experienced grade 3. Two patients experienced grade 5 pulmonary fibrosis. Decreased respiratory function was observed in 10 patients (15.1%). On multivariate analysis, the presence of pulmonary disease before SBRT was the only statistically significant factor associated with decreased respiratory function. Conclusions SBRT is safe and feasible in patients with SPLC or IPLM previously treated surgically. Pre-existing pulmonary disease was a predictive factor for decreased respiratory function.

Ambient Air Pollution and Clinical Implications for Susceptible Populations.

Air pollution is associated with a diversity of health effects, and evidence for a causal relationship with specific diseases exists. Exposure to air pollution is ubiquitous and typically beyond the control of the individual; the resulting health burden for the population can be high. Disproportionate effects are seen in individuals who have increased susceptibility to air pollution owing to individual- or community-level characteristics. As studies grow increasingly sophisticated, the understanding of who comprises the susceptible population continuously expands. Characteristics of susceptibility include genetic predisposition; socioeconomic factors; life stage; the presence of preexisting diseases, such as asthma, chronic obstructive pulmonary disease, cystic fibrosis; and the unique population of lung transplant recipients. This review explores how select populations, namely individuals with preexisting pulmonary disease and those living in communities of low socioeconomic status, have an increased susceptibility to the health effects of ambient air pollution. Genetic susceptibility, though a fundamental determinant of risk, is beyond the scope of this review and is not discussed. Strategies designed to mitigate air pollution-related health effects are discussed using a framework that addresses pollution exposure at multiple levels-government, state, community, and the individual. Emission reduction strategies remain the basis for public health protection; however, ancillary harm reduction measures are explored that can be adopted by susceptible communities and individuals.

Effect of Age on Glasgow Coma Scale in Patients with Moderate and Severe Traumatic Brain Injury: An Approach with Propensity Score-Matched Population.

Background: The most widely used methods of describing traumatic brain injury (TBI) are the Glasgow Coma Scale (GCS) and the Abbreviated Injury Scale (AIS). Recent evidence suggests that presenting GCS in older patients may be higher than that in younger patients for an equivalent anatomical severity of TBI. This study aimed to assess these observations with a propensity-score matching approach using the data from Trauma Registry System in a Level I trauma center. Methods: We included all adult patients (aged ≥20 years old) with moderate to severe TBI from 1 January 2009 to 31 December 2016. Patients were categorized into elderly (aged ≥65 years) and young adults (aged 20–64 years). The severity of TBI was defined by an AIS score in the head (AIS 3‒4 and 5 indicate moderate and severe TBI, respectively). We examined the differences in the GCS scores by age at each head AIS score. Unpaired Student’s t- and Mann–Whitney U-tests were used to analyze normally and non-normally distributed continuous data, respectively. Categorical data were compared using either the Pearson chi-square or two-sided Fisher’s exact tests. Matched patient populations were allocated in a 1:1 ratio according to the propensity scores calculated using NCSS software with the following covariates: sex, pre-existing chronic obstructive pulmonary disease, systolic blood pressure, hemoglobin, sodium, glucose, and alcohol level. Logistic regression was used to evaluate the effects of age on the GCS score in each head AIS stratum. Results: The study population included 2081 adult patients with moderate to severe TBI. These patients were categorized into elderly (n = 847) and young adults (n = 1234): each was exclusively further divided into three groups of patients with head AIS of 3, 4, or 5. In the 162 well-balanced pairs of TBI patients with head AIS of 3, the elderly demonstrated a significantly higher GCS score than the young adults (14.1 ± 2.2 vs. 13.1 ± 3.3, respectively; p = 0.002). In the 362 well-balanced pairs of TBI patients with head AIS of 4, the elderly showed a significantly higher GCS score than the young adults (13.1 ± 3.3 vs. 12.2 ± 3.8, respectively; p = 0.002). In the 89 well-balance pairs of TBI patients with head AIS of 5, no significant differences were observed for the GCS scores. Conclusions: This study demonstrated that elderly patients with moderate TBI present higher GCS score than younger patients. This study underscores the importance of determining of TBI severity in this group of elderly patients based on the GCS score alone. A lower threshold of GCS cutoff should be adopted in the management of the elderly patients with TBI.

Effect of pre existing respiratory conditions on survival of lung cancer patients: A nationwide population-based cohort study.

Common diseases with potential to increase the risk of death from lung cancer have so far not been studied in large populations. We did a population-based retrospective cohort study using nationwide health insurance claims data from 2005 to 2012 in Korea including 205403 lung cancer patients. Multivariate-adjusted hazard ratios (aHRs) of lung cancer mortality by presence, time intervals with lung cancer diagnosis and combinations of pre-existing chronic obstructive pulmonary disease (COPD), pneumonia, asthma and tuberculosis were calculated using the Cox-proportional hazards model. The total number of person-years of follow-up was 397780 and 60.2% of patients died (mean survival 23.2 months after lung cancer diagnosis). Lung cancer patients with previous respiratory disease had increased aHR for mortality (COPD, hazard ratio [HR]=1.32, CI 1.29-1.35; pneumonia, HR=1.14, CI 1.08-1.19; and asthma, HR=1.11, CI 1.06-1.16). Risks were positively associated with longer duration of pre-existing disease diagnosis; cases with >5 years since diagnosis compared to <2 years: COPD, HR=2.91, CI 2.82-3.00; pneumonia, HR=1.67, CI 1.51-1.85; asthma, HR=1.56, CI 1.45-1.68; and tuberculosis, HR=2.03, CI 1.90-2.17. Furthermore, elevated HRs of death were found among patients with multiple pre-existing co-morbidities. Hazards of death from lung cancer are significantly increased in cases with pre-existing lung disease, and worse with longer durations, and with multiple combinations before cancer diagnosis. Patients and physicians should be aware of these meaningful risk/prognostic factors for lung cancer when identifying high-risk patient groups.

Surveillance system of severe influenza cases admitted to the regional ICU,2009-2015

ObjectiveThe study aimed at: i) analyses the regional characteristics and riskfactors of severe influenza, taking into account dominant circulatingvirus(es) ii) estimate the regional completeness of the surveillancesystem.IntroductionEvery year, circulating influenza viruses generate a significantnumber of deaths. During the 2009 pandemic influenza A(H1N1),a national non mandatory surveillance system of severe influenzacases admitted to intensive care units(ICU) was set up in France.This surveillance is regionally driven by the regional offices (CIRE)of Santé publique France, the French Public Health Agency. Thisreport provides epidemiologic analysis of the recorded data sincethe implementation of surveillance in the Centre-Val de Loire regionover seasons 2009-10 to 2015-16 in regard of influenza epidemicsdynamics.MethodsSurveillance was carried out each year from October to April.Descriptive and analytic analyses were conducted to comparepopulation characteristics, pre-existing risk factors and the clinicaldata according to influenza season and dominant circulatinginfluenza virus(es). Logistic regressions were performed to identifyfactors associated with an increased risk of acute respiratory distresssyndrome (ARDS) or death. Two capture-recapture analyses wereperformed to establish the completeness of the surveillance systemin the region. The first one was realized on all cases, using two datasources (hospital records/surveillance data) and the second one, onlyon deaths, using three data sources(additional source: medical deathcertificates).ResultsFrom 2009-10 to 2015-16, the outbreak of influenza epidemicswas started more and more late. The number of severe influenzacases reported in the Loire Valley varied from 19 in 2010-11 to 75 in2014-15. Overall, the most affected population was adults, from 41%in 2011-12 to 83% in 2009-10. However seniors (more than 65 yearsold) represented an important part of patients during three epidemics:50% in 2011-12 and around 45% during the two last seasons;during these epidemics, men, (60%-68%), were more affected thanwomen. Patients’ pre-existing risk factors were mainly: being olderthan 65 years old and suffering of cardiac or pulmonary diseases.The comparison by dominant viruses over the seasons revealed thatwhen A(H1N1) virus prevailed, severe influenza occurred mainlyin adults patients with any type of pre-existing risk factors whereaswhen A(H3N2) virus prevailed, seniors with pre-existing pulmonarydisease were the most affected. More than a third of patientsdeclared an ARDS. The overall observed lethality was close to 16%.ARDS occurred more frequently in patients who were middle-aged(45-64 years), immunocompromised or infected with A(H1N1).Pre-existing pulmonary disease was a protective factor. Risk factorsassociated with death were being older than 65 years, male and havingdeclared an ARDS. The completeness of this surveillance system wasestimated by capture-recapture methods at 59% for severe influenzacases and 40% for death cases.ConclusionsThe epidemiology of severe influenza and epidemics dynamics inthe Centre-Val de Loire follow the national trends. Every season ischaracterized by the same dominant virus at national and regionallevels in intensive care units. Influenza epidemics 2009-10 and2014-15 were particularly long and severe, the first dominatedby the A(H1N1)pdm09 virus and the second by the A(H3N2).Our study has demonstrated that the populations at risk of severeinfluenza differ according to the circulating virus(es). Accordingto the obtained estimations, the completeness of the surveillancesystem, based on voluntary report by physicians, can be consideredas satisfactory. Regarding influenza deaths relatively low percentageof completeness may be explained by the fact that two sources arehospital based whereas the third one, medical death certificates,includes all influenzadeaths with no information on the death place.Many patients were not vaccinated or their status was unknown. Mostcases admitted to ICU presented pre-existing risk factors includedin eligibility criteria in influenza vaccination policies. This studyoutlines the importance of vaccination as the first prevention measure.

Preoperative Optimization of Pulmonary Diseases - an Approach

Preoperative identification of patients with an increased risk for perioperative pulmonary complications is crucial for the anesthesiological management. These complications were underestimated in the past, but are associated with an increased morbidity and mortality when occuring. Patients with preexisting pulmonary diseases are at increased risk for perioperative pulmonary complications. In the recent past more emphasis was placed on preoperative optimization of the underlying pulmonary diseases like COPD or Asthma bronchiale. The knowledge of pathophysiology and pharmacological treatment options in this special subset of patients is essential. It has been shown that preventive programs in the preoperative setting were able to reduce pulmonary complications.

Outcomes after oesophageal perforation: a retrospective cohort study of patients with different aetiologies.

The mortality rate after oesophageal perforation is high despite advances in operative and non-operative techniques. In this study, we sought to identify risk factors for hospital mortality after oesophageal perforation treatment. We retrospectively examined patients treated for oesophageal perforation in a university teaching hospital in Hong Kong between January 1997 and December 2013. Their demographic and clinical characteristics, aetiology, management strategies, and outcomes were recorded and analysed. We identified a cohort of 43 patients treated for perforation of the oesophagus (28 men; median age, 66 years; age range, 30-98 years). Perforation was spontaneous in 22 (51.2%) patients (15 with Boerhaave's syndrome and seven with malignant perforation), iatrogenic in 15 (34.9%), and provoked by foreign body ingestion in six (14.0%). Of the patients, 14 (32.6%) had pre-existing oesophageal disease. Perforation occurred in the intrathoracic oesophagus in 30 (69.8%) patients. Emergent surgery was undertaken in 23 patients: 16 underwent primary repair, six surgical drainage or exclusion, and one oesophagectomy. Twenty patients were managed non-operatively, 13 of whom underwent stenting. Two stented patients subsequently required oesophagectomy. Four patients had clinical signs of leak after primary repair: two were treated conservatively and two required oesophagectomy. Overall, six (14.0%) patients required oesophagectomy, one of whom died. Nine other patients also died in hospital; the hospital mortality rate was 23.3%. Pre-existing pulmonary and hepatic disease, and perforation associated with malignancy were significantly associated with hospital mortality (P=0.03, <0.01, and <0.01, respectively). Most oesophageal perforations were spontaneous. Mortality was substantial despite modern therapies. Presence of pre-existing pulmonary disease, hepatic disease, and perforation associated with malignancy were significantly associated with hospital mortality. Salvage oesophagectomy was successful in selected patients.

Novel therapies for perioperative respiratory complications

Postoperative respiratory complications are of paramount clinical importance as they prolong the hospitalization, increase the costs of treatment and contribute to the perioperative mortality. Obesity, preexisting pulmonary disease and advanced age are known risk factors for developing postoperative respiratory complications, which affect exceeding number of patients. Hereby, we present a review on the pathogenesis of post-operative respiratory complications particularly in obese and older patients. We further focus on the standard management and emerging therapies for the post-operative respiratory complications.

Earlier nephrology consultation may not be associated with improved short-term survival of acute kidney injury in very elderly men.

ObjectivesA delayed nephrology consultation (NC) may be associated with a poor prognosis in acute kidney injury (AKI) patients. The aims of this study were to compare the clinical and laboratory characteristics of elderly AKI patients evaluated and not evaluated by nephrologists and to generate a hypothesis regarding the relationship between the timing of the NC and 90-day outcomes.MethodsFrom 2007 to 2015, this study explored associations among the presence and timing of NC with the non-intensive care unit stay and 90-day mortality in elderly AKI patients at the Geriatric Department of the Chinese People’s Liberation Army General Hospital. Early NC and delayed NC were defined as NCs performed before and 2 days after the day of AKI diagnosis, respectively. Multivariable logistic regression was used to adjust for confounding and selection bias.ResultsIn total, 623 patients were included for the final analysis, of whom 162 (26%) were evaluated by nephrologists. The 90-day mortality rate was 33.2%, and dialysis was required in 1.4% of patients (9/623). Multivariable analysis showed that a higher prevalence of preexisting chronic obstructive pulmonary disease, AKI diagnosis time, peak serum creatinine level, blood urea nitrogen level, AKI stage, and mortality was associated with the NC. The NC was delayed (>48 h) in 59 patients (36.4%) (median time to consultation, 4 days). The median AKI diagnosis time, presence of oliguria, uric acid level, and a more severe AKI stage were associated with delayed consultation. Moreover, delayed consultation presented a similar 90-day mortality rate to that of an early NC (50.8% vs 44.7%, respectively, P=0.448).ConclusionIn very elderly AKI patients, those evaluated by nephrologists have more severe AKI and a higher mortality rate than those not evaluated by nephrologists. An earlier NC may not be associated with improved 90-day survival.

Does chronic exposure to high levels of nitrogen dioxide exacerbate the short-term effects of airborne particles?

BackgroundLong-term exposure to air pollutants has been hypothesised as a factor in susceptibility to short-term exposure to particulate matter (PM), but results are not coherent. We studied the short-term effects...

Prevalence of Medication-Related Risks for Falls and Osteoporosis at a Hospital Network: A Post-hoc Analysis

AIM : PRO-OSTEO Extend 1was an osteoporosis management study at a Victorian Healthcare service. This post-hoc analysis examined comorbidities and drug-related risks for falls and osteoporosis, and analysed the accuracy of the medication subcomponent of the falls risk assessment tool used at the service. The secondary aim of this analysis was to evaluate the impact of proton pump inhibitors on the success of anti-osteoporosis therapies. Material and Methods : This analysis was part of a two year retrospective cohort study. The falls risk assessment tool medication subsection results, completed by nursing staff, were compared to scores given by the data collection pharmacist based on medical history notes using Mann-Whitney U test. The impact of proton pump inhibitors use on active osteoporosis therapy in patients admitted after a fall was analysed using the Fisher Exact test. Prevalence of medical and medication-related risk factors for osteoporosis and falls was compared between patients with fractures without osteoporosis treatment at admission and patient who were excluded from the primary study due to active osteoporosis therapy, or admission after a fall without a fracture. RESULTS : The falls risk assessment tool completion rate was approximately 80%, with accuracy below 50% P < 0.001. Medications which increase osteoporosis and falls risk were prevalent, with high use of benzodiazepines, opioids, serotonin reuptake inhibitors antidepressants and proton pump inhibitors. The impact of proton pump inhibitors carried a 14% increased relative risk of a fracture in this cohort (P = 0.218). There was also high prevalence of pre-existing fractures, pulmonary disease, heart failure and strokes in the study population. CONCLUSION : Falls risk assessment in relation to medication use is frequently inaccurate and is not done at all for a significant proportion of patients. The use proton pump inhibitors and medication-related risks for falls and osteoporosis treatment can be improved with potential for hospital pharmacists to contribute to the risk reduction strategies.