Background: Patients with COVID-19 and ARDS on prolonged mechanical ventilation are at risk for developing endotracheal tube (ETT) obstruction that has not been previously described in patients with ARDS due to other causes. The purpose of this report is to describe a case series of patients with COVID-19 and ARDS in which ETT occlusion resulted in significant clinical consequences and to define the pathology of the obstructing material. Methods: Incidents of ETT occlusion during mechanical ventilation of COVID-19 patients were reported by clinicians and retrospective chart review was conducted. Statistical analysis was performed comparing event rates between COVID-19 and non-COVID 19 patients on mechanical ventilation over the predefined period. Specimens were collected and submitted for pathological examination. Findings: Eleven COVID-19 patients experienced endotracheal tube occlusion over a period of 2 months. Average age was 69 (14.3, range 33-85) years. Mean APACHE III score was 73.6 (17.3). All patients had AKI and cytokine storm. Nine exhibited biomarkers for hypercoagulability. Average days on mechanical ventilation before intervention for ETT occlusion was 14 (5.18) days (range of 9 to 23 days). Five patients were discharged from the ICU, and 4 expired. Average documented airway resistance on admission was 14.2 (3.0) cm H2O/L/sec. Airway resistance before tube exchange was 28.1 (8.0) cm H2O /L/sec. No similar events of endotracheal tube occlusion were identified in non-COVID patients on mechanical ventilation during the same time period. Microscopically, the material consisted of mucin admixed with necrotic cell debris, variable numbers of degenerated inflammatory cells, oral contaminants and red blood cells. Interpretation: Patients with COVID-19 and ARDS on prolonged mechanical ventilation are at risk for developing ETT obstruction due to deposition of a thick, tenacious material within the tube that consists primarily of mucin and cellular debris. Clinicians should be aware of this dangerous but treatable complication.
Purpose of review Long-term noninvasive positive pressure ventilation (NIV) used to be a controversial form of therapy for patients with stable hypercapnic chronic obstructive pulmonary disease (SH-COPD). New evidence described in this review defines the optimal settings, timing and target population for NIV utilization in SH-COPD necessary to maximize its benefit. Recent findings NIV, when titrated appropriately, leads to improved clinical outcomes. High inspiratory positive airway pressures aimed at decreasing CO2 levels can ensure NIV success in SH-COPD. NIV initiated when patients remain hypercapnic whereas in a clinical stable state following an acute exacerbation can prolong the time to a readmission. Technological advances in NIV algorithms and remote monitoring have the potential to improve use and titration. NIV and portable NIV improve exercise tolerance and may accentuate the benefits derived from pulmonary rehabilitation alone. Summary Use of high-intensity NIV in SH-COPD is beneficial yet appropriate patient selection and implementation is paramount.
Introduction: Cancer care costs escalated with the introduction of novel therapies. Therefore, cancer-related Cost Utility Analyses (CUAs) are used to guide policy makers. Since numerous methods (criteria) exist to evaluate CUAs, we compared these criteria between CUAs of solid tumors and those of hematological malignancies. Methods:A systemic MEDLINE search of English-language publications between 2001 and 2012 was performed. Strict inclusion criteria were limited to CUAs examining one single intervention and one single study comparator. Standard data of 66 variables, based on the Drummond criteria, were collected to review each CUA for clarity, completeness, and health economic methodological quality.Results: Among 8,515 screened papers on Pubmed, 177 cancer-related CUAs (2%) were eligible. Solid tumors and hematological malignancies CUAs constituted 161(91%) and 16(9%). Among the standardized methods for evaluating CUAs, those of solid tumors reported more frequently the presentation of cost-effectiveness acceptability curve (p=0.02) and the use of threshold value to interpret study results (p=0.024) than those of hematological malignancies. Further, CUAs of solid tumors were more frequently multicenter-based (p=0.014); however, CUAs of hematological malignancies listed differential quality adjusted life year separately more frequently (p=0.02). Outcomes of CUAs of solid tumors were more frequently reported as significant (p=0.014). Conclusions:CUAs of solid tumors abided more frequently with the standardized methods (criteria) than those of hematological malignancies, which may be due in part to their multiple study sites. CUAs of hematological malignancies may warrant more methodological standardization and incorporate more study sites. MethodsA systemic MEDLINE search by the keywords: CUAs and cancer of English-language manuscripts published between 2001 and 2012 was performed. Eligibility criteria consisted of including only CUAs that examined one single intervention and one single study comparator. For example, adding rituximab to fludarabine and cyclophosphamide for the treatment of previously untreated chronic lymphocytic leukemia [15]. Exclusion criteria included CUAs that examined more than one intervention, more than one comparator or more than one study population or type of malignancy. The study population was not limited by age; therefore, CUAs examining children, adult or geriatric populations were included.
Introduction Decitabine (Dec) is not approved in the United States (US) for acute myeloid leukemia (AML) because it did not improve overall survival compared with standard conventional induction treatment. We asked what would be the cost effectiveness of Dec versus conventional induction therapy in AML patients (pts) older than 60 years of age. Methods The standard conventional induction including cytarabine, and daunorubicin, (AD) (N Engl J Med. 2009 361:1235-48) was compared with Dec (Haematologica. 2012 97:393-401) using a semi-Markov model compiling survival and cost data. Survival probabilities were retrieved from the literature. Data accounted for re-induction therapy with IDA-FLAG (idarubicin, fludarabine, cytarabine and granulocyte colony-stimulating factor) and consolidation therapy with high-dose cytarabine (HiDAC) but not for stem cell transplantation. The assumption-based model considered a maximum of 4 cycles of HiDAC and continuing Dec until loss of benefit. Drug costs were derived from the 2012 US market. Hospital costs accrued were evaluated in a diagnosis-related group (DRG) system. Drug dosage was estimated based on a body surface area of 1.85 m2. The quality of life (QoL) was assumed as 1 for healthy individuals; 0 for death; 0.524 for active disease; 0.91 for AML in remission on AD; 0.71 and 0.524 for AML being actively treated with Dec or AD, and 0.81 for AML in remission treated with Dec or HIDAC. QoL data were based on the literature except for pts on consolidation therapy. The latter was the mean of QoL of AML in remission and AML actively being treated. Results Assuming 1,000 pts for each treatment arm in a semi-Markov model over 1 year time horizon, the quality-adjusted life year (QALY) for AD vs. Dec was 0.1754 and 0.5982. The percentage survival for AD and Dec was 45.2% and 50.5%. Their costs were $127,867 and $55,777. The incremental cost-effectiveness ratio (ICER) was -$72,090/0.4228 = -$170,506/year. By sensitivity analysis, Dec was superior to AD to all parameters (Table 1). Conclusion Dec is a more cost-effective therapy for pts older than 60 years of age than conventional induction therapy. Given the economic pressures in the US Health System, one should consider approving Dec for newly diagnosed AML pts older than 60 years of age. Disclosures: No relevant conflicts of interest to declare.
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