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Biomedical subjects

Andrew F Shorr

Publications and source records attributed to Andrew F Shorr.

69 records · Page 4Linked to original sources
PubMed2003

New choices for central venous catheters: potential financial implications.

OBJECTIVE: To determine the cost-effectiveness of the newer antiseptic and antibiotic-impregnated central venous catheters (CVCs) relative to uncoated CVCs and to each other. DESIGN: Decision model analysis of the cost and efficacy of CVCs coated with either chlorhexidine silver sulfadiazine (CSS) or rifampin-minocycline (RM) at preventing catheter-related bloodstream infections (CRBSIs). The primary outcome is the incremental cost (or savings) to prevent one additional CRBSI. Model estimates are derived from prospective trials of the CSS and RM CVCs and from other studies describing the costs of CRBSIs. SETTING AND PATIENTS: Hypothetical cohort of 1,000 patients requiring placement of a CVC. INTERVENTIONS: In the model, patients were managed with either an uncoated CVC, CSS CVC, or RM CVC. MEASUREMENTS AND MAIN RESULTS: The incremental cost-effectiveness of the treated CVCs was calculated as the savings resulting from CRBSIs averted less the additional costs of the newer devices. Sensitivity analysis of the effect of the major clinical inputs was performed. For the base case analysis, we assumed the incidence of CRBSIs was 3.3% with traditional catheters and that the CSS and RM CVC conferred a relative risk reduction for the development of CRBSIs of 60% and 85%, respectively. Despite their significantly higher cost than older catheters, both novel CVCs yield significant savings. Employing either of the treated CVCs saves approximately $10,000 per CRBSI prevented (relative to standard catheters). Comparing the RM CVC to the CSS CVC revealed the RM product to be economically superior, saving nearly $9,600 per CRBSI averted and $81 per patient in the cohort. For sensitivity analysis, we adjusted all model variables by 50% individually and then simultaneously. This demonstrated the model to be most sensitive to the cost of a CRBSI; however, with all inputs skewed by 50% against both the CSS CVC and the RM CVC, these devices remained economically attractive. Under this scenario, use of either treated device was less costly. CONCLUSIONS: Utilization of antiseptic and antibiotic-impregnated CVCs represent an attractive alternative for the prevention of CRBSIs and may lead to significant savings. Of the two newer, coated devices, the RM CVC performs better financially. These observations hold over a range of estimates for our model inputs.

Bacteremia↗
PubMed2003

Predicting mortality in patients with sarcoidosis awaiting lung transplantation.

OBJECTIVES: To identify factors associated with mortality in patients with sarcoidosis listed for lung transplantation, and to create a model for predicting intermediate-term mortality in these individuals. DESIGN: Retrospective cohort study of patients with sarcoidosis listed for lung transplant in the United States between 1995 and 2000. After identifying important risk factors for death, we developed a mortality prediction model based on an inception cohort of 75% of the subjects. The remaining 25% of the individuals served as a validation cohort for determining the validity of the model. SETTING AND PATIENTS: All patients with sarcoidosis in the United States irrespective of referral center listed for lung transplantation between 1995 and 2000. MEASUREMENTS AND MAIN RESULTS: Adequate follow-up data were available for 405 patients, and 111 patients (27.4%) died while awaiting lung transplantation. Neither patient age nor gender correlated with mortality. Survivors and nonsurvivors did not differ based on the results of spirometric testing. African Americans faced a significantly increased risk of death, which persisted after controlling for other confounders (odds ratio, 2.5). The amount of supplemental oxygen used and the mean pulmonary artery pressure were the only other variables predictive of mortality. The mean (+/- SD) pulmonary artery pressure in those who survived was 31.7 +/- 11.5 mm Hg, compared to 41.4 +/- 14.4 mm Hg in nonsurvivors (p < 0.01). Survivors required 2.2 +/- 2.0 L/min of oxygen vs 2.9 +/- 1.7 L/min in those who died awaiting transplant (p < 0.01). Differences in pulmonary artery pressures did not reflect differences in cardiac status, as the pulmonary capillary wedge pressure and the cardiac index were similar in survivors and nonsurvivors. The final mortality prediction model included three variables: race, amount of supplemental oxygen needed, and mean pulmonary artery pressure. Based on the validation cohort, the concordance of the model for death within 2 years of listing was 0.61 (95% confidence interval, 0.47 to 0.76), indicating only moderate explanatory power. CONCLUSIONS: Race, pulmonary hypertension, and oxygen use are important factors indicative of mortality in this population. Specific guidelines for determining time of referral for transplantation in advanced sarcoidosis should be developed. Recommendations extrapolated from data for other types of interstitial lung disease may not be applicable in sarcoidosis. The independent effect of race on outcome is troubling.

Adult↗
PubMed2002

Sarcoidosis involving the musculoskeletal system.

Although sarcoidosis can affect virtually any organ, musculoskeletal involvement is infrequent. Early in the course of the disease, acute polyarthritis may be observed in up to 40% of patients, but this is often self-limited. Chronic or recurrent sarcoid arthritis is rare, affecting only 1 to 4% of patients. Asymptomatic involvement of muscles has been reported in 25 to 75% of patients in small series, but symptomatic involvement of muscles is rare. Although prospective studies assessing the prevalence of muscle involvement in sarcoidosis have not been done, several large retrospective studies suggest that symptomatic muscle involvement occurs in < 0.5% of patients with sarcoidosis. Patterns of sarcoid muscle involvement include chronic, progressive myopathy; nodular or tumorous sarcoidosis affecting muscles; and an acute polymyositis-like syndrome. Corticosteroid therapy is usually efficacious for the acute myositis variant but is less consistently helpful in the other forms (e.g., chronic myopathy or nodules). Similarly, clinically significant involvement of bone is rare (< 2-5%), and is often associated with chronic multisystemic disease, lupus pernio, and chronic uveitis. Unfortunately, osseous sarcoidosis is often unresponsive to therapy. In this review, we discuss the prevalence, clinical features, and management of sarcoidosis involving muscle, joints, and bones.

Journal Article↗
PubMed2002

An update on cost-effectiveness analysis in critical care.

Critical care providers are under increasing pressure to be attentive to cost concerns. The ICU consumes a significant amount of resources and, as such, is a frequently identified target of efforts to limit escalating healthcare costs. Attempts to reduce costs need not progress in a haphazard fashion. Rather, they can proceed in a logical, systematic manner with the assistance of formal economic studies. Cost-effectiveness analysis is one tool for these projects-it allows physicians to compare the financial consequences of different approaches to resource allocation. ICU physicians, therefore, must become familiar with the basic concepts that underlie cost-effectiveness analysis. Cost-effectiveness analyses that address many different aspects of critical care delivery are now commonly found in the critical care literature. With a framework for evaluating these studies, clinicians can better apply their findings to their own institutions.

Cost Control↗
PubMed2002

D-dimer correlates with proinflammatory cytokine levels and outcomes in critically ill patients.

STUDY OBJECTIVES: To determine the relationship between d-dimer (DD) and both proinflammatory and anti-inflammatory cytokine levels, and to confirm the association between DD status and outcomes in critically ill patients. DESIGN: Prospective observational study. SETTING: Medical ICU (MICU) of a tertiary care, academic medical center. PATIENTS: Individuals admitted to the MICU. INTERVENTIONS: Within 24 h of MICU admission, patients had DD status determined and interleukin (IL) levels (IL-6, IL-8, and IL-10) and tumor necrosis factor (TNF)-alpha measured. The strength of the DD level was also noted. Subjects were then monitored prospectively to determine mortality rate and the incidence of organ failure. MEASUREMENT AND RESULTS: The study cohort included 79 patients (mean age, 65.2 years; 54.5% male patients). DD was present in 53.2% of subjects. The DD reaction was weak (1+) in 15 patients and strong (2+) in 27 patients. The TNF-alpha, IL-6, and IL-8 levels all increased in parallel with the increasing strength of the DD level. IL-10 levels did not differ based on DD status. Similarly, the severity of illness as measured by the APACHE (acute physiology and chronic health evaluation) II score was highest among those with higher DD levels: 24.7 +/- 6.2 for those with 2+ DD vs 17.2 +/- 3.1 and 11.5 +/- 2.7 for those with 1+ DD and no circulating DD, respectively (p < 0.001). For patients lacking DD, the mortality rate was 8.1%, compared to 13.3% and 55.6% for those with 1+ and 2+ DD levels, respectively (p < 0.001). No patient without DD had multisystem organ failure (MSOF) develop, while the incidence of MSOF also increased with increasing DD levels. As a screening test for mortality, the DD performed as well as the APACHE II system. CONCLUSIONS: The coagulation system is active in critically ill patients, and DD levels correlate with activation of the proinflammatory cytokine cascade. The absence of a relationship between DD and anti-inflammatory cytokines (IL-10) suggests that the presence of DD may reflect the imbalance between proinflammatory and anti-inflammatory cytokines. DD identifies patients at increased risk for both MSOF and death.

APACHE↗
PubMed2002

Ethical assessment of industry-sponsored clinical trials: a case analysis.

The rapid growth of clinical trials sponsored by the pharmaceutical industry and conducted by community physicians raises concerns about the scientific quality of this research and the adequacy of protections for research participants. In this article, we present an in-depth ethical analysis of a recent industry-sponsored placebo-controlled study for treatment of asthma. The ethical analysis uses a proposed ethical framework for evaluating clinical research focusing on seven ethical requirements: (1) scientific value, (2) scientific validity, (3) fair subject selection, (4) favorable risk/benefit ratio, (5) independent review, (6) informed consent, and (7) respect for enrolled subjects.

Administration, Inhalation↗
PubMed2002

Outcomes for patients with sarcoidosis awaiting lung transplantation.

STUDY OBJECTIVES: To describe the population of patients with sarcoidosis listed for orthotopic lung transplantation (OLT) in the United States, and to determine outcomes for these subjects relative to persons awaiting OLT for idiopathic pulmonary fibrosis (IPF). DESIGN: Retrospective analysis of the United Network for Organ Sharing transplant database over the period between January 1995 and December 2000. PATIENTS: All patients listed for OLT with an underlying diagnosis of either sarcoidosis or IPF. MEASUREMENTS AND RESULTS: During the study period, 427 patients with sarcoidosis and 2,115 patients with IPF were registered on the list for OLT. Demographically, the patients with sarcoidosis were younger and more likely to be female African Americans than were patients with IPF. Pulmonary function was worse in patients with sarcoidosis. The mean FVC was 42.6% of predicted, as compared to 45.0% of predicted in patients with IPF (p = 0.0044). The FEV(1) also differed between the populations (36.0% vs 46.0% of predicted for patients with sarcoidosis and IPF, respectively; p < 0.0001). Only 30.1% of patients with sarcoidosis and 32.4% of patients with IPF lacked functional limitations. For the subset of patients with hemodynamic data available, the mean pulmonary artery pressure was significantly higher in the sarcoidosis population (34.4 mm Hg vs 25.6 mm Hg, respectively; p < 0.0001). Neither the pulmonary capillary wedge pressure nor the cardiac index differed between the groups. Patients with sarcoidosis were less likely to receive a transplant. Approximately 30% of patients with sarcoidosis underwent OLT, compared to 37.3% of IPF patients (p = 0.0102). For those who did undergo transplantation, the median wait until OLT was 803 days for patients with sarcoidosis compared to 555 days for patients with IPF (p < 0.0001). Mortality rates were similar in both groups. In the sarcoidosis group, 28.1% of patients died, compared to 31.1% of patients with IPF (p = not significant). CONCLUSIONS: Patients with sarcoidosis are at as high a risk for mortality as patients with IPF while awaiting transplantation. Nonetheless, patients with sarcoidosis are less likely to undergo OLT. Pulmonary hypertension is a major concern in patients with advanced sarcoidosis awaiting transplantation.

Confidence Intervals↗
PubMed2002

Fludarabine-related pulmonary toxicity: a distinct clinical entity in chronic lymphoproliferative syndromes.

BACKGROUND: Little is known about lung injury caused by fludarabine therapy. OBJECTIVES: To establish a case definition, to describe management, and to identify risk factors for fludarabine-related pulmonary toxicity. DESIGN: Case-control study. SETTING: Tertiary-care US Army teaching hospital. PATIENTS: Individuals treated with fludarabine at our institution between January 1989 and June 2000. MEASUREMENTS: Cases of fludarabine-related pulmonary toxicity were defined as follows: dyspnea, fever, hypoxemia, and radiographic infiltrates seen in a patient treated with fludarabine; cases were excluded if there was evidence of pulmonary infection or progression of underlying lymphoproliferative disease affecting the lungs. For each case, demographic data, medical history, radiographic information, available bronchoscopy and pathology data, and details of treatment were reviewed. Cases were compared with fludarabine-treated control subjects to identify potential risk factors. Comparisons were made with regard to age, gender, history of underlying lung disease, lymphoproliferative diagnosis, prior chemotherapy, fludarabine treatment regimen, and pretreatment chest radiograph. RESULTS: During the study period, 105 patients were treated with fludarabine. The incidence of fludarabine-related pulmonary toxicity using our definition was 8.6% (95% confidence interval [CI], 3.2 to 13.9%). One patient died before this entity was suspected; the remainder of the patients underwent bronchoscopy to exclude infection. Patients were treated with corticosteroids with subjective and objective benefits. One patient later died of apparent infection during steroid therapy. One patient was retreated with fludarabine and symptoms of lung toxicity developed again. Patients (n = 9) were similar to control subjects (n = 96) with respect to age, gender, history of underlying lung disease, previous chemotherapy, and fludarabine regimen. Patients with chronic lymphocytic leukemia were 13.3 (95% CI, 1.6 to 300.6) times more likely to have toxicity develop than patients treated with fludarabine for other diagnoses. There was a trend toward an increased incidence in patients with interstitial infiltrates apparent on prefludarabine chest radiographs. CONCLUSIONS: A variety of lung conditions arise in patients treated with fludarabine; however, this agent seems to cause direct pulmonary toxicity. After performing an appropriate evaluation to exclude infection, corticosteroids are an effective therapy. The relative frequency of this condition and potential for mortality underscore the need for increased clinician awareness of fludarabine-related pulmonary toxicity and its risk factors.

Aged↗
PubMedDate not supplied

Interferon gamma-1b as therapy for idiopathic pulmonary fibrosis. An intrapatient analysis.

BACKGROUND: The only proven therapeutic option for idiopathic pulmonary fibrosis (IPF) is lung transplantation. It is biologically plausible that interferon gamma-1b (G-IFN) may halt or even reverse the disease process and therefore prove to be an effective medical therapy. We report our results using this medication in a cohort of patients with a wide range of severity of IPF. OBJECTIVES: To determine the impact of G-IFN therapy on the progression of disease in patients with IPF. METHODS: We performed a retrospective analysis of patients' pulmonary function tests (PFTs), specifically the forced vital capacity (FVC) and the single breath diffusing capacity for carbon dioxide (DLCO). Comparisons of these parameters prior to and after the implementation of therapy were made by generating regression slopes by least-squares equations. RESULTS: Twenty-two patients qualified for the analysis. For the FVC, comparison of pre- and post-therapy best-fit regression lines demonstrated a significant difference in favor of G-IFN (p<0.015). For the DLCO, a significant difference in favor of gamma interferon therapy was detected in the advanced group (p<0.03). Seventy percent of the patients showed either stabilization or regression of disease in both their FVCs and their DLCO. CONCLUSION: G-IFN appears to be an effective new therapy for patients with IPF. Salutary effects on the rate of change in the FVC and DLCO were most apparent in patients with advanced disease. With slowing or reversal in loss of lung function, G-IFN may improve longevity and may have utility as a bridge to lung transplantation in those patients who are appropriate candidates.

Cohort Studies↗
PubMedDate not supplied

Potential limitations of clinical criteria for the diagnosis of idiopathic pulmonary fibrosis/cryptogenic fibrosing alveolitis.

BACKGROUND: The need to perform surgical lung biopsy (SLB) in all cases of suspected idiopathic pulmonary fibrosis/cryptogenic fibrosing alveolitis (IPF/CFA) is controversial. The American Thoracic Society (ATS) and the European Respiratory Society (ERS) recently endorsed explicit clinical criteria for the diagnosis of IPF/CFA in the absence of SLB. Prior studies evaluating clinical criteria for the diagnosis of IPF/CFA have been limited in that either they were performed by clinicians with expertise in the diagnosis of IPF/CFA or they did not utilize explicit diagnostic criteria. We investigated the accuracy of the ATS/ERS criteria when applied in a general pulmonary medicine setting. OBJECTIVES: To determine the interobserver variability of clinical criteria for the diagnosis of IPF/CFA. METHODS: This was a retrospective, blinded evaluation by three board certified pulmonary physicians without extensive experience in the evaluation of IPF/CFA performed at a United States Army tertiary care academic medical center. Patients referred for surgical lung biopsy as part of a diagnostic evaluation of interstitial lung disease (ILD) were evaluated. The physicians reviewed high-resolution computed tomography scans of the chest (HRCT) and clinical data for each patient. The physicians were blinded to all other data and to the opinions of other study participants. Employing the histologic presence of usual interstitial pneumonia (UIP) coupled with appropriate clinical findings as the gold standard for a diagnosis of IPF/CFA we determined the accuracy and interobserver variability for a diagnosis of IPF/CFA based on HRCT alone and based on the ATS/ERS clinical criteria. RESULTS: The sensitivity and positive predictive value for a HRCT diagnosis of IPF/CFA were 71% each while specificity and negative predictive value were 67% each. For the ATS/ERS criteria sensitivity, specificity, positive predictive value and negative predictive value were 71, 75, 77 and 69%, respectively. The interobserver variability, expressed as a kappa coefficient, for HRCT and the ATS/ERS criteria were 0.59 and 0.53, respectively. CONCLUSIONS: Both HRCT and the ATS/ERS clinical criteria may lead to misdiagnosis of patients with ILD. Further studies are needed to fully characterize the accuracy of these tests when applied in a routine pulmonary medicine practice setting.

Adult↗