Background The increasing global prevalence of pulmonary nontuberculous mycobacteria (NTM) disease has called attention to challenges in NTM diagnosis and management. This study is conducted to understand management and outcomes of patients with pulmonary NTM disease at diverse centers across the US. Methods We conducted a 10-year (2005-2015) retrospective study at seven Vaccine and Treatment Evaluation Units to evaluate pulmonary NTM treatment outcomes in human immunodeficiency virus-negative adults. Demographic and clinical information were abstracted through medical record review. Microbiologic and clinical cure were evaluated using previously defined criteria. Results Of 297 patients diagnosed with pulmonary NTM, the most frequent NTM species were Mycobacterium avium-intracellulare complex (83.2%), M. kansasii (7.7%), and M. abscessus (3.4%). Two hundred forty-five (82.5%) patients received treatment, while 45 (15.2%) were followed without treatment. Eighty-six patients had available drug susceptibility results; of these, >40% exhibited resistance to rifampin, ethambutol, or amikacin. Of the 138 patients with adequate outcome data, 78 (56.5%) experienced clinical and/or microbiologic cure. Adherence to the American Thoracic Society/Infectious Diseases Society of America (ATS/IDSA) treatment guidelines was significantly more common in patients who were cured (odds ratio [OR] 4.5, 95% confidence interval [CI] 2.0-10.4, P < 0.001). Overall mortality was 15.7%. Conclusions Despite ATS/IDSA Guidelines, management of pulmonary NTM disease was heterogeneous and cure rates were relatively low. Further work is required to understand which patients are suitable for monitoring without treatment and the impact of antimicrobial therapy on pulmonary NTM morbidity and mortality.
This randomized, multicentre, parallel-group study assessed the efficacy of epoetin beta in reducing the transfusion frequency in patients ineligible for autologous blood donation prior to surgery. The patients (n = 194) received either epoetin beta (125 or 250 IU/kg, once weekly) or no therapy for 3–4 weeks before surgery. The pre-operation haemoglobin levels were markedly increased in the epoetin beta groups (125 IU/kg: +1.1 g/dl; 250 IU/kg: +1.6 g/dl), but not in the control group. The transfusion frequency was significantly reduced in both epoetin groups as compared with the control group (p = 0.046). Epoetin beta was well tolerated, and no serious adverse events were observed. Low-dose administration of epoetin beta before elective surgery reduces the transfusion frequencies in patients not eligible for autologous blood donation.
RationaleTherapeutic thoracentesis is among the most frequently performed medical procedures. Chest discomfort is a common complication and has been associated with increasingly negative pleural pressure as fluid is withdrawn in the setting of non-expendable lung. Visual analogue scales (VASs) are commonly employed to measure changes in discomfort and dyspnoea related to pleural interventions. The minimal clinically important difference (MCID), defined as the smallest change in VAS score associated with patient report of significant change in a symptom, is required to interpret the results of studies using VAS scores and is used in clinical trial power calculations. The MCID for chest discomfort in patients undergoing pleural interventions has not been determined.MethodsProspectively collected data from two recent randomised trials of therapeutic thoracentesis were used for this investigation. Adult patients with symptomatic pleural effusions referred for therapeutic thoracentesis were enrolled across ten US academic medical centres. Patients were asked to rate their level of chest discomfort on 100 mm VAS before, during and following thoracentesis. Patients then completed a 7-point Likert scale indicating the significance of any change in chest discomfort from preprocedure to postprocedure. The mean difference between discomfort 5 min postprocedure and discomfort just prior to the start of pleural fluid drainage was categorised by Likert scale response.ResultsData from a total of 262 thoracenteses were included in the analysis. Thirty-four of 262 patients experienced a ‘small but significant increase’ or a ‘large or moderate increase’ in discomfort following thoracentesis. The mean increase in VAS score in those reporting a ‘small but significant increase’ in chest discomfort (n=23) was 16 mm (SD 22.44, 95% CI 6.87 to 25.21).ConclusionsThe MCID for thoracentesis-related chest discomfort measured by 100 mm VAS is 16 mm. This MCID specific to discomfort resulting from pleural fluid interventions can inform the design and analysis of future pleural intervention studies.
Rationale Long-term survival for lung transplantation (LT) is poor with a 10-year survival of 27%. Chronic lung allograft dysfunction (CLAD), a well-recognized major cause of morbidity and mortality after LT, affects up to 50% of patients within 5 years. Previous studies have shown that an abnormal FEV1 at 1-year post-LT is associated with increased CLAD risk. The importance of DLCO after LT has not been studied. We hypothesized that an abnormal DLCO at 1 year post-LT is associated with increased CLAD risk. Methods Bilateral LT recipients who had DLCO measurement at 1 year after LT (n=153) were included. Patients who underwent single LT, did not have DLCO data, and those who did not survive 1 year were excluded. Spirometry and DLCO were collected between 1/1/2009 to 8/31/2017. Comparison between continuous variables was assessed using Mann Whitney U testing and between categorial variables by Chi squared testing. Survival was assessed with Cox regression including age, sex, and transplant indication as covariates. Univariable logistic regression was used to assess predictors of abnormal DLCO. Multivariable logistic regression was performed with variables with p<0.05 in univariate analysis. Results The study cohort was 53% male and underwent LT for emphysema (26%), ILD/IPF (32%), CF (25%), PAH (6%), and other (11%). The majority of LT patients (78%) had an abnormal DLCO% (<80% predicted) at 1 year post-LT. DLCO % predicted was mildly reduced (65-79%) in 43 patients, moderately reduced (50-64%) in 47 patients, and severely reduced (<50%) in 31 patients. DLCO<65% predicted was associated with reduced CLAD-free survival (HR 2.40; p=0.008). When controlling for FEV1 and other covariates, this relationship persisted (HR 2.82; 95% CI 1.35-5.89; p=0.006; Panel A). DLCO<65% was associated with increased prevalence of CLAD (HR 2.40; p=0.009). The relationships between DLCO and CLAD-free survival were primarily driven by those patients with DLCO<50% (HR 7.54; p<0.001; Panel B). Conclusions An abnormal DLCO at 1 year post-LT is associated with increased risk of CLAD, independent of FEV1. Given that CLAD portends such a poor prognosis, the identification of these patients for early therapy may improve clinical outcomes.
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