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Biomedical subjects

Andrew F Shorr

Publications and source records attributed to Andrew F Shorr.

At least 55 records · Page 3Linked to original sources
PubMed2004

Acute eosinophilic pneumonia among US Military personnel deployed in or near Iraq.

CONTEXT: Acute eosinophilic pneumonia (AEP) is a rare disease of unknown etiology characterized by respiratory failure, radiographic infiltrates, and eosinophilic infiltration of the lung. OBJECTIVES: To describe a case series of AEP, illustrate the clinical features of this syndrome, and report the results of an epidemiologic investigation. DESIGN, SETTING, AND PARTICIPANTS: Epidemiologic investigation of cases of AEP identified both retrospectively and prospectively from March 2003 through March 2004 among US military personnel deployed in or near Iraq. Survivors were offered a follow-up evaluation. MAIN OUTCOME MEASURE: Morbidity and mortality related to AEP. RESULTS: There were 18 cases of AEP identified among 183,000 military personnel deployed in or near Iraq during the study period, yielding an AEP incidence of 9.1 per 100,000 person-years (95% confidence interval, 4.3-13.3). The majority of patients (89%) were men and the median age was 22 (range, 19-47) years. All patients used tobacco, with 78% recently beginning to smoke. All but 1 reported significant exposure to fine airborne sand or dust. Known causes of pulmonary eosinophilia (eg, drug exposures or parasitic disease) were not identified. Epidemiologic investigation revealed no evidence of a common source exposure, temporal or geographic clustering, person-to-person transmission, or an association with recent vaccination. Six patients underwent bronchoalveolar lavage (median eosinophilia of 40.5%). All patients developed peripheral eosinophilia (range, 8%-42%). Mechanical ventilation was required in 67% for a median of 7 (range, 2-16) days. Two soldiers died; the remainder responded to corticosteroids and/or supportive care. Twelve individuals were reevaluated a median of 3 months after diagnosis. At that point, 3 patients reported mild dyspnea and 1 reported wheezing. All patients had finished treatment and had either normal or nearly normal spirometry results. None had recurrent eosinophilia. CONCLUSIONS: AEP occurred at an increased rate among this deployed military population and resulted in 2 deaths. Failure to consider AEP in the differential diagnosis of respiratory failure in military personnel can result in missing this syndrome and possibly death. The etiology of AEP remains unclear, but the association with new-onset smoking suggests a possible link.

Acute Disease↗
PubMed2004

Meta-analysis: outcomes in patients with suspected pulmonary embolism managed with computed tomographic pulmonary angiography.

BACKGROUND: Spiral computed tomographic pulmonary angiography (CTPA) is increasingly being used in the evaluation of patients with clinically suspected pulmonary embolism (PE). However, CTPA as a definitive diagnostic test may be limited by inadequate sensitivity, especially in instances of isolated subsegmental emboli. PURPOSE: To assess the safety of withholding anticoagulation in patients with suspected PE and negative results on CTPA. DATA SOURCES: All relevant studies identified in MEDLINE (1966 to March 2004) and EMBASE (1974 to 2004) and in bibliographies of key articles. The search was not limited to the English language. STUDY SELECTION: The authors selected all published studies that used CTPA to evaluate suspected PE and reported at least 3 months of follow-up in patients not receiving anticoagulation on the basis of a negative CTPA result. DATA EXTRACTION: Two reviewers independently rated study quality on the basis of predetermined criteria. Data were extracted on participants, CTPA technique, diagnostic studies performed, prevalence of PE, number of patients with negative or indeterminate CTPA results who were followed, and subsequent rates of venous thromboembolism and fatal PE. DATA SYNTHESIS: Twenty-three studies reported on 4657 patients with negative CTPA results who did not receive anticoagulation. The 3-month rate of subsequent venous thromboembolic events was 1.4% (95% CI, 1.1% to 1.8%), and the 3-month rate of fatal PE was 0.51% (CI, 0.33% to 0.76%). LIMITATIONS: The CTPA technology used varied across studies and was not applied uniformly in the same step of diagnostic algorithms. Only 1 study used CTPA as the sole diagnostic test. CONCLUSION: The rate of subsequent venous thromboembolism after negative results on CTPA is similar to that seen after negative results on conventional pulmonary angiography. It appears to be safe to withhold anticoagulation after negative CTPA results.

Angiography↗
PubMed2004

Practical utility of clinical prediction rules for suspected acute pulmonary embolism in a large academic institution.

INTRODUCTION: In an attempt to standardize clinicians' approach to the determination of pretest probability (PTP) in pulmonary embolism (PE), two simplified scoring models have recently been proposed. We sought to determine the utility of these algorithms in patients with suspected PE in a large, tertiary, academic medical center. METHODS: We performed a retrospective analysis of 295 inpatients and outpatients from our institution who were evaluated for suspected PE. Pretest probability (PTP) was calculated using two previously formulated scoring systems by Wells et al. (Canadian score) and Wicki et al. (Geneva score). Our primary endpoint was the prevalence of PE within each strata of PTP. RESULTS: The prevalence of pulmonary embolism in our cohort was 30%. The prevalence of PE in the low, intermediate and high PTP groups using the Canadian score was 15.3% (95% CI 9.5-23.7%), 34.8% (95% CI 27.9-42.4%), and 47.2% (95% CI 32.0-63.0), respectively. When compared with the low PTP group, the odds ratios of the likelihood of PE was 2.95 (95% CI 1.56-5.59) in the intermediate PTP group and 4.95 (95% CI 2.11-11.64) in the high PTP. The Wicki analysis was divided into "Geneva pure" and "Geneva presumed", where the fractional inspired oxygen concentration was known and presumed to have been sampled on room air, respectively. Neither of the Geneva scores showed statistical significance in the prevalence of PE among the PTP groups. CONCLUSIONS: The Wells' clinical prediction score is easily applied and meaningfully risk stratifies patients with suspected PE. In our population, the Geneva score was less useful.

Academic Medical Centers↗
PubMed2004

Cost-minimization analysis of two algorithms for diagnosing acute pulmonary embolism.

INTRODUCTION: Pulmonary embolism is a common disorder that often requires extensive diagnostic testing. We hypothesized that an algorithmic approach to diagnosis of pulmonary embolism based upon clinical risk stratification and D-dimer testing would be less costly than a standard approach. MATERIALS AND METHODS: We constructed a decision tree based upon two published algorithms for diagnosing acute pulmonary embolism. Branch point probabilities were obtained from the best available published literature. Costs were based upon Medicare charges. From this we obtained a base-case analysis and conducted sensitivity analysis. RESULTS: Our base-case analysis revealed that the cost-per-patient for diagnostic testing were US$216.52 for the algorithm based upon pre-test probability and D-dimer testing and US$538.62 for the standard algorithm. The cost difference per patient evaluated was US$322.10. One- and two-way sensitivity analyses did not reveal any instances in which the clinical risk algorithm was more costly than the standard algorithm. Two-way sensitivity analysis revealed several scenarios in which the standard algorithm would be less costly; however, the conditions required for these scenarios are rarely encountered in clinical practice. CONCLUSIONS: Costs of testing using an algorithm based on clinical pre-test probability and D-dimer testing are less than with a standard approach for evaluating suspected acute pulmonary embolism. This new algorithm has previously been shown to be safe and has the potential for large cost savings if widely applied.

Algorithms↗
PubMed2004

Linezolid for treatment of ventilator-associated pneumonia: a cost-effective alternative to vancomycin.

OBJECTIVES: To determine the incremental cost-effectiveness of linezolid compared with vancomycin for treatment of ventilator-associated pneumonia due to Staphylococcus aureus. DESIGN: Decision model analysis of the cost and efficacy of linezolid vs. vancomycin for treatment of ventilator-associated pneumonia. The primary outcome was the incremental cost-effectiveness of linezolid in terms of cost per added quality-adjusted life-year gained. Other outcomes were the marginal costs per hospital survivor and per year of life saved generated by using linezolid. Model estimates were derived from prospective trials of linezolid for ventilator-associated pneumonia and from other studies describing the costs and outcomes for ventilator-associated pneumonia. SETTING AND PATIENTS: Hypothetical cohort of 1,000 patients diagnosed with ventilator-associated pneumonia. INTERVENTIONS: In the model, patients received either linezolid or vancomycin. MEASUREMENTS AND MAIN RESULTS: The incremental cost-effectiveness of linezolid was calculated as the additional quality-adjusted life-years resulting from therapy with linezolid divided by the sum of the incremental costs arising because of use of linezolid (e.g., higher direct costs for linezolid, costs per in-hospital care of survivors, and posthospitalization costs). Despite its higher cost, linezolid was cost-effective for treatment of ventilator-associated pneumonia. The cost per quality-adjusted life-year equals approximately 30,000 dollars. The model was moderately sensitive to the estimated efficacy of linezolid over vancomycin. Nonetheless, even with all inputs simultaneously skewed against, linezolid remains a cost-effective option (cost per quality-adjusted life-year approximately 100,000 dollars). Based on Monte Carlo simulation, the results of our analysis are robust across a range of model inputs and assumptions (95% confidence interval for cost per quality-adjusted life-year ranges from 23,637 dollars to 42,785 dollars). CONCLUSIONS: Linezolid is a cost-effective alternative to vancomycin for the treatment of ventilator-associated pneumonia.

Acetamides↗
PubMed2004

Red blood cell transfusion and ventilator-associated pneumonia: A potential link?

OBJECTIVE: To determine the relationship between packed red blood cell transfusion practice and the development of ventilator-associated pneumonia (VAP). DESIGN: Secondary analysis of a multicentered, prospective observational study of transfusion practice in intensive care units in the United States. SETTING: A total of 284 intensive care units in the United States were studied from August 2000 to April 2001. PATIENTS: Patients without pneumonia at intensive care unit admission and who then required at least 48 hrs of mechanical ventilation were considered at risk for VAP. MEASUREMENTS AND MAIN RESULTS: VAP was diagnosed based on prospectively defined clinical criteria and represented the primary study end point. Late-onset VAP (VAP arising after > or =5 days of mechanical ventilation) represented a secondary end point. Transfusions given during the intensive care unit stay and before the onset of VAP were tracked prospectively. Of 4,892 subjects in the original cohort, 1,518 received mechanical ventilation of > or =48 hrs and did not have preexisting pneumonia. VAP was diagnosed in 311 (20.5%) patients. Multivariate analysis revealed that transfusion independently increased the risk for VAP (odds ratio, 1.89; 95% confidence interval [CI], 1.33-2.68). Other factors increasing the risk for VAP included male sex (odds ratio, 1.54; 95% CI, 1.15-2.07), admission after trauma (odds ratio, 1.68; 95% CI, 1.15-2.47), use of continuous sedation (odds ratio, 1.43; 95% CI, 1.07-1.92), and type of nutritional support (e.g., early enteral nutrition: odds ratio, 2.65; 95% CI, 1.93-3.63; total parenteral nutrition: odds ratio, 3.27; 95% CI, 2.24-4.75). The effect of transfusion on late-onset VAP was more pronounced (odds ratio, 2.16; 95% CI, 1.27-3.66) and demonstrated a positive dose-response relationship (p =.0223 for trend test). CONCLUSIONS: Transfusion of packed red blood cells increases the risk of developing VAP. Avoiding the unnecessary use of packed red blood cell transfusions may decrease the occurrence of VAP.

Cross Infection↗
PubMed2004

Mortality from time of listing for transplantation as an indicator of candidate outcomes.

CONTEXT: Survival after transplantation has traditionally been the statistic most closely scrutinized as to the efficacy of the procedure and a program's performance. We propose that mortality from the time of listing is a more significant outcome measure for potential transplant candidates. We present our lung transplant program's outcomes using this measure. METHODS: An analysis was performed on all patients listed for lung transplantation at our institution between 1997 and 2002. Kaplan-Meier analyses of survival at 1, 2, and 3 years after listing were assessed. RESULTS: One hundred forty-eight patients qualified for the analysis; of these, 96 received transplants. The median time to transplantation was 142 days. Twenty-five of the patients died while waiting for a transplant. The median time to death for these patients was 311 days. Of the 27 transplant recipients who died, the median time from listing to death was 547 days. The 1-, 2-, and 3-year mortality rates after being listed were 20.0%, 32.4%, and 39.7%, respectively, for all patients. CONCLUSIONS: Mortality after listing is a more relevant statistic for prospective transplant candidates. Intraprogram comparisons of listed nontransplant survival to listed transplant survival may facilitate the acceptance of sicker patients for transplant consideration. It may also help foster the development of an "alternate" list for transplantation and prove useful in helping determine organ prioritization.

Bias↗
PubMed2004

Pulmonary infiltrates in the non-HIV-infected immunocompromised patient: etiologies, diagnostic strategies, and outcomes.

Pulmonary complications remain a major cause of both morbidity and mortality in immunocompromised patients. When such individuals present with radiographic infiltrates, the clinician faces a diagnostic challenge. The differential diagnosis in this setting is broad and includes both infectious and noninfectious processes. Rarely are the radiographic findings classic for one disease, and most potential etiologies have overlapping clinical and radiographic appearances. In recent years, several themes have emerged in the literature on this topic. First, an aggressive approach to identifying a specific etiology is necessary; as a corollary, diagnostic delay increases the risk for mortality. Second, the evaluation of these infiltrates nearly always entails bronchoscopy. Bronchoscopy allows identification of some etiologies with certainty, and often allows for the exclusion of infectious agents even if the procedure is otherwise unrevealing. Third, early use of CT scanning regularly demonstrates lesions missed by plain radiography. Despite these advances, initial therapeutic interventions include the use of broad-spectrum antibiotics and other anti-infectives in order to ensure that the patients is receiving appropriate therapy. With the results of invasive testing, these treatments are then narrowed. Frustratingly, outcomes for immunocompromised patients with infiltrates remain poor.

Bronchoscopy↗
PubMed2004

Sarcoidosis, race, and short-term outcomes following lung transplantation.

BACKGROUND: Patients with sarcoidosis, many of whom are African American, may require lung transplantation (LT). Little is known about survival following LT for sarcoidosis. OBJECTIVE: To determine short-term mortality following LT for sarcoidosis, to evaluate if survival after LT for sarcoidosis is similar to outcomes after LT for other diseases, and to investigate the impact of race on the results of LT. DESIGN: Retrospective review. PATIENTS: All patients who underwent LT, irrespective of diagnosis, in the United States between January 1995 and December 2000. MEASUREMENTS: Vital status at 30 days after LT and cause of death. RESULTS: During the study period, 4,721 LTs were performed; of these 133 LTs (2.8%) were for sarcoidosis. Approximately 83% of patients with sarcoidosis survived following LT compared to 91% of persons undergoing transplantation for other reasons (p = 0.002). In multivariate analysis controlling both for health insurance status and other factors known to affect survival after LT, patients with sarcoidosis were no more likely to die than persons undergoing transplantation for other conditions (adjusted odds ratio for death, 1.45; 95% confidence interval [CI], 0.84 to 2.48). Significant predictors of mortality included the following: undergoing combined heart-lung transplant, need for mechanical ventilation, treatment in an ICU at time of LT, pre-LT FEV(1), need for supplemental oxygen, and donor age. Both recipient race and donor race significantly affected short-term survival. African-American patients were nearly 50% more likely to die (adjusted odds ratio, 1.49; 95% CI, 1.01 to 2.20). This difference based on race persisted after excluding heart-lung recipients and after controlling for recipient-donor racial mismatch. The most frequent cause of death for patients with sarcoidosis was graft failure, while infection was the primary cause of death among other LT patients. CONCLUSIONS: Patients with sarcoidosis do as well as patients undergoing LT for other diseases. Race is an important factor affecting survival after LT.

Black or African American↗
PubMed2004

Depreotide scanning in sarcoidosis: a pilot study.

STUDY OBJECTIVES: To determine whether sarcoidosis results in uptake on (99m)Tc-labeled depreotide (DP) scintigraphy and to generate preliminary data to guide the development of future trials exploring this imaging modality in sarcoidosis patients. DESIGN: Prospective cohort trial among a convenience sample of patients with sarcoidosis. SETTING: Tertiary care medical center pulmonary clinic. PATIENTS: Subjects in whom sarcoidosis has been diagnosed based on a biopsy revealing nonnecrotizing granulomas. INTERVENTIONS: Two hours after IV administration of (99m)Tc-DP, all patients underwent whole-body anterior and posterior planar imaging, followed by thoracic single-photon emission CT scanning. Images were interpreted by two nuclear medicine physicians who were blinded to the patient's clinical status. MEASUREMENTS AND RESULTS: The study cohort included 22 subjects (mean [+/- SD] age, 41.3 +/- 9.3 years; 40% female). Approximately half of the cohort had stage I disease determined by chest radiographs (CXRs). The results of (99m)Tc-DP scintigraphy were positive for sarcoidosis in 18 individuals (81.8%; 95% confidence interval, 59.7 to 94.8%). Of the four persons lacking (99m)Tc-DP uptake, all had normalized their CXRs since the time of presentation. In the entire sample, the intraclass correlation between radiographic stage determined by CXR vs that determined by (99m)Tc-DP scintigraphy was robust (kappa = 0.79; p = 0.0005). Among patients with positive (99m)Tc-DP scan findings, the correlation was stronger (kappa = 0.94; p < 0.0001). Flow rates and lung volumes were lower in patients with parenchymal activity on (99m)Tc-DP scintigraphy (mean FEV(1), 68.6 +/- 13.9% predicted vs 84.5 +/- 10.7% predicted, respectively [p = 0.012]; mean FVC, 74.0 +/- 16.0% predicted vs 88.4 +/- 12.7% predicted [p = 0.041]). (99m)Tc-DP scintigraphy correctly identified all sites of known nonpulmonary visceral involvement with sarcoidosis. CONCLUSIONS: The results of (99m)Tc-DP imaging are often positive in sarcoidosis patients, and correlate with disease stage determined by CXR and pulmonary function. (99m)Tc-DP scintigraphy does not preclude the need for biopsy if this is indicated to confirm the diagnosis of sarcoidosis or to exclude the possibility of malignancy. (99m)Tc-DP scintigraphy merits further study in the evaluation and management of sarcoidosis.

Adult↗
PubMed2003

Linezolid does not increase the risk of thrombocytopenia in patients with nosocomial pneumonia: comparative analysis of linezolid and vancomycin use.

Reports from uncontrolled studies suggest that linezolid is associated with rates of thrombocytopenia higher than those reported in clinical studies. We assessed the risk of thrombocytopenia in 686 patients with nosocomial pneumonia who received linezolid or vancomycin for > or =5 days in 2 randomized, double-blind studies and for whom follow-up platelet counts had been measured. New-onset thrombocytopenia (platelet count of <150x10(9) platelets/L) occurred in 19 (6.4%) of 295 linezolid recipients and 22 (7.7%) of 285 vancomycin recipients with baseline platelet counts of > or =150x10(9) platelets/L; severe thrombocytopenia (platelet count of <50x10(9) platelets/L) occurred in only 1 patient in each group. Platelet counts decreased to less than the baseline level in 4 (6.6%) of 61 linezolid recipients and 5 (11.1%) of 45 vancomycin recipients who had baseline counts of <150x10(9) platelets/L. No patient had a decrease to <20x10(9) platelets/L. There were no statistically significant differences between groups in these or any other platelet assessments. Clinically significant thrombocytopenia was uncommon in our analysis, and linezolid was not associated with a greater risk of thrombocytopenia in seriously ill patients than was vancomycin.

Acetamides↗
PubMed2003

Management of idiopathic pulmonary haemosiderosis in pregnancy: report of two cases.

Idiopathic pulmonary haemosiderosis (IPH) is a rare cause of alveolar haemorrhage. Its management in pregnancy is complicated and little clinical data exist on outcomes or treatment. Two patients with IPH, one with a known diagnosis prior to pregnancy (patient A) and one presenting de novo during pregnancy (patient B) are reported. Both subjects became maximally symptomatic in the third trimester and were treated with corticosteroids. Despite steroid treatment patient A had continued symptoms and was treated with azathioprine. Both patients delivered healthy female infants at 32 weeks and 38 weeks gestation, respectively. Patient B's course was complicated by the development of fatal invasive pulmonary aspergillosis 4 weeks postpartum. With improved care, more patients with IPH survive to childbearing age. Patients become most symptomatic late in pregnancy, underscoring the need for careful third trimester monitoring. These cases demonstrate that steroids are safe and that azathioprine can be used as additional therapy. When considering treatment options it is important to weigh the benefits of these medications against the potential for maternal and foetal harm.

Adult↗
PubMed2003

Is the implementation of research findings in the critically ill hampered by the lack of universal definitions of illness?

In the design of clinical trials, a clear definition of disease is essential for enrollment of a homogeneous study population with a higher likelihood of demonstrating a benefit of an intervention. A definition that is applicable to standard clinical practice enhances the ability of clinicians to apply results of the clinical trial to patient care. Use of a universally accepted definition allows valid comparisons across multiple studies. Sepsis, the acute respiratory distress syndrome, and ventilator-associated pneumonia are examples of conditions for which universal definitions developed by panels of experts have facilitated the design of successful clinical trials. However, implementation of the results of some of these studies has been complicated by a lack of understanding or acceptance of disease definitions or by their overly inclusive nature. For example, the presence of Systemic Inflammatory Response Syndrome (SIRS) will identify most patients with sepsis, however, a significant number of patients with those clinical findings will have other underlying processes. Approved definitions for VAP are cumbersome, and adherence to those definitions in the design of clinical trials is poor. This has led to confusion regarding the accuracy of diagnostic tests and poor acceptance of evidence based guidelines by clinicians. When investigators and clinicians do not adhere to common definitions of disease, results of clinical trials may be applied inappropriately or ignored altogether. More specific identifiers of critical illnesses using specific biochemical or genetic markers are being explored. This approach may also be useful for staging disease.

Critical Illness↗
PubMed2003

Effect of standardized orders and provider education on head-of-bed positioning in mechanically ventilated patients.

OBJECTIVE: Semirecumbent head-of-bed positioning in mechanically ventilated patients decreases the risk of developing ventilator-associated pneumonia (VAP). The purpose of this study was to determine whether the addition of a standardized order followed by the initiation of a provider education program would increase the frequency with which our patients were maintained in the semirecumbent position. DESIGN: Prospective, pre-, and postintervention observational study. SETTING: A tertiary care, U.S. Army teaching hospital. PATIENTS: Mechanically ventilated medical and surgical intensive care unit patients. INTERVENTIONS: The first intervention involved the addition of an order for semirecumbent head-of-bed positioning to our intensive care unit order sets. This was followed 2 months later with a second intervention, which was a nurse and physician education program emphasizing semirecumbent positioning. MEASUREMENTS AND MAIN RESULTS: Data regarding head-of-bed positioning were collected on 100 patient observations at baseline and at 1 and 2 months after each of our interventions. The mean angle of head of bed increased from 24 +/- 9 degrees at baseline to 35 +/- 9 degrees (p <.05) 2 months after the addition of the standard order. The percentage of observations with head of bed >45 degrees increased from 3% to 16% 2 months after the standardized order (p <.05). Two months after our provider education program, the mean angle of the head of bed was 34 +/- 11 degrees and the percentage of patients with head of bed >45 degrees was 29% (p = NS compared with values after the first intervention). Data collected 6 months after completion of our education programs showed that these improvements were maintained. CONCLUSIONS: Standardizing the process of care via the addition of an order specifying head-of-bed position significantly increased the number of patients who were placed in the semirecumbent position. In an era of cost-conscious medicine, interventions that utilize protocols and education programs should be emphasized.

Female↗