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Biomedical subjects

Thomas R Gildea

Publications and source records attributed to Thomas R Gildea.

15 recordsLinked to original sources
PubMed2007

Lung volume reduction surgery in patients with emphysema and alpha-1 antitrypsin deficiency.

BACKGROUND: The role of lung volume reduction surgery (LVRS) for individuals with alpha-1 antitrypsin (AAT) deficiency is unclear. METHODS: To assess the role of LVRS in individuals with severe deficiency of AAT, outcomes within the National Emphysema Treatment Trial were analyzed. RESULTS: Of 1218 randomized subjects, 16 (1.3%) had severe AAT deficiency (serum level < 80 mg/dL) and a consistent phenotype (when available). Characteristics of these 16 patients include 87.5% male; median serum AAT level, 55.5 mg/dL; age, 66 years; forced expiratory volume in 1 second (FEV1), 27% predicted; and 50% had upper-lobe-predominant emphysema. All 10 subjects randomized to LVRS underwent the procedure. Although the small number of subjects hampered statistical analysis, 2-year mortality was higher with surgery (20% versus 0%) than with medical treatment. Comparison of outcomes between the 10 AAT-deficient and the 554 AAT-replete subjects undergoing LVRS showed a greater increase in exercise capacity at 6 months in replete subjects and a trend toward lower and shorter duration FEV1 rise in deficient individuals. CONCLUSIONS: This study extends to 49 cases the published experience of LVRS in severe AAT deficiency. Although the small number of subjects precludes firm conclusions, trends of lower magnitude and duration of FEV1 rise after surgery in AAT-deficient versus AAT-replete subjects and higher mortality in deficient individuals randomized to surgery versus medical treatment suggest caution in recommending LVRS in AAT deficiency.

Aged↗
PubMed2006

Electromagnetic navigation diagnostic bronchoscopy: a prospective study.

RATIONALE: Electromagnetic navigation bronchoscopy using superDimension/Bronchus System is a novel method to increase diagnostic yield of peripheral and mediastinal lung lesions. OBJECTIVES: A prospective, open label, single-center, pilot study was conducted to determine the ability of electromagnetic navigation bronchoscopy to sample peripheral lung lesions and mediastinal lymph nodes with standard bronchoscopic instruments and demonstrate safety. METHODS: Electromagnetic navigation bronchoscopy was performed using the superDimension/Bronchus system consisting of electromagnetic board, position sensor encapsulated in the tip of a steerable probe, extended working channel, and real-time reconstruction of previously acquired multiplanar computed tomography images. The final distance of the steerable probe to lesion, expected error based on the actual and virtual markers, and procedure yield was gathered. MEASUREMENTS: 60 subjects were enrolled between December 2004 and September 2005. Mean navigation times were 7 +/- 6 min and 2 +/- 2 min for peripheral lesions and lymph nodes, respectively. The steerable probe tip was navigated to the target lung area in all cases. The mean peripheral lesions and lymph nodes size was 22.8 +/- 12.6 mm and 28.1 +/- 12.8 mm. Yield was determined by results obtained during the bronchoscopy per patient. RESULTS: The yield/procedure was 74% and 100% for peripheral lesions and lymph nodes, respectively. A diagnosis was obtained in 80.3% of bronchoscopic procedures. A definitive diagnosis of lung malignancy was made in 74.4% of subjects. Pneumothorax occurred in two subjects. CONCLUSION: Electromagnetic navigation bronchoscopy is a safe method for sampling peripheral and mediastinal lesions with high diagnostic yield independent of lesion size and location.

Adult↗
PubMed2006

Endobronchial fungal disease: an under-recognized entity.

Most fungi enter the human body via inhalation; however, endobronchial fungal infection (EBFI) seems to be a rare manifestation compared to pulmonary or systemic disease. This presentation seems to be related to environmental factors as well as to the host status. With the increasing popularity of flexible bronchoscopy, it is being recognized with a higher frequency. Bronchoscopic findings in EBFI vary from mild mucosal inflammation to central airway obstruction. We searched English literature related to the topic and found 228 total cases of EBFI: Aspergillus species (121), Coccidioides immitis (38), Zygomycetes (31), Candida species (14) Cryptococcus neoformans (13), and Histoplasma capsulatum (11). We have also included a single case of endobronchial Pseudallescheria boydii infection in a lung transplant recipient that has not been reported previously. Most patients were immunocompromised, exhibited systemic manifestations of the primary infection, and responded to appropriate therapy. EBFI should be included in the differential diagnosis of any form of airway lesions in immunocompromised patients, especially among residents from the endemic areas.

Bronchitis↗
PubMed2006

Extended use of extracorporeal membrane oxygenation after lung transplantation.

OBJECTIVES: Extracorporeal membrane oxygenation (ECMO) for severe graft failure after lung transplantation is accepted immediately postoperatively; extending its use is controversial. We evaluated our post-lung transplant ECMO experience, which included extended indication, to (1) determine its prevalence, risk factors, indications, and timing, (2) compare complications and outcomes of these patients with those not requiring it, and (3) identify risk factors, including indications, for mortality. METHODS: From February 1990 to October 2005, 474 patients underwent lung transplantation; postoperative ECMO support was instituted for severe graft failure 23 times in 22 patients (4.0%). Indications for ECMO and its timing were obtained by reviewing medical records and survival by systematic follow-up. RESULTS: No factor evaluated predicted severe graft failure leading to ECMO. The most common indication for ECMO was early graft failure (13 patients); however, it was also used for pneumonia or sepsis (6) and acute rejection (4). ECMO was initiated at a median arterial oxygen tension/inspired oxygen fraction of 59 at a median of 2 days postoperatively and was maintained for a median of 4 days. The most common complications were renal failure (57%) and bleeding (43%). ECMO was effective in salvaging patients with rejection and early graft failure (survival at 1, 3, 6, and 12 months: 62%, 54%, 49%, and 41%), but ineffective for pneumonia or sepsis (survival at these intervals: 9%, 4%, 4%, and 3%). CONCLUSIONS: ECMO can be extended beyond early severe graft failure to acute rejection and can be considered after the immediate postoperative period. Survival after ECMO in patients with pneumonia or sepsis is poor.

Extracorporeal Membrane Oxygenation↗
PubMed2006

Performance of a self-expanding silicone stent in palliation of benign airway conditions.

INTRODUCTION: The Polyflex stent (Boston Scientific; Boston, MA) is a self-expanding, thin-walled, silicone stent. Its use has been described in the management of patients with malignant airway obstruction, yet reports of its use for treatment of benign airway conditions are rare. STUDY: We report a retrospective review of our experience with the Polyflex stent in the management of benign airway conditions. RESULTS: A total of 16 stents were deployed in 12 patients. The indications for the stent placement included the following: anastomotic stenosis following lung transplantation (LTR) [four patients]; tracheal stenosis (three patients); tracheobronchomalacia (two patients); tracheobronchopathiaosteochondroplastica (one patient); relapsing polychondritis (one patient); and bronchopleural fistula (one patient). Even though immediate palliation was established in most cases (90%), the incidence of complications was 75%. Stent migration was the most common consequence, with time to the event ranging from < 24 h to 7 months. One stent was expectorated within < 24 h. One patient coughed up a portion of the inner lining of the stent 7 months after its placement. Emergent bronchoscopy was required in four patients for mucous impaction. The complication rate was 100% in patients with LTR-related anastomotic stenosis. CONCLUSION: The use of the Polyflex stent for the treatment of benign airway conditions is associated with a high complication rate. We have abandoned its use under such conditions in our practice.

Adult↗
PubMed2005

Short-term deployment of self-expanding metallic stents facilitates healing of bronchial dehiscence.

Bronchial dehiscence after lung transplantation is difficult to treat and associated with high mortality. We describe our experience using self-expanding metallic stents to treat post-lung transplant bronchial dehiscence. From January 1995 to June 2004, 189 single and 118 double lung transplants were performed in our institution, totaling 425 at-risk bronchial anastomoses. Seven (1.6%) incidents of life-threatening bronchial dehiscence were treated with self-expanding metallic stents. The interval between transplant and diagnosis of dehiscence was 29.1 +/- 18.5 days. All patients presented with respiratory distress, and three required mechanical ventilation. Self-expanding metallic stent placement resulted in complete bronchial healing. All three patients with respiratory failure requiring mechanical ventilation were successfully weaned after stent placement. In two later cases, the stents were electively removed after adequate healing of the dehiscence. Complications included stent migration (one patient) and in-stent stenosis (three patients). Two of these patients required repeat stent insertion after removal, due to bronchomalacia. In patients with life-threatening bronchial dehiscence, self-expanding metallic stents offer prospects for a successful outcome. Self-expanding metallic stents are known to be associated with significant granulation tissue formation, and this property provides a platform for healing of dehiscence and, in time, peribronchial soft tissue grows in to cover the defect, allowing stent removal.

Anastomosis, Surgical↗
PubMed2005

Cost-effectiveness of population screening for alpha-1 antitrypsin deficiency: a decision analysis.

The objective was to assess the cost-effectiveness of population screening for alpha-1 antitrypsin (AAT) deficiency. The design was a Markov-based decision analytic model. Hypothetical cohorts were analyzed from birth and followed over time until death using Monte Carlo simulation. The following strategies were compared: 1) screen all newborns, 2) screen all 10-year-old children, and 3) do not screen. Screenees found to have PI*ZZ AAT deficiency received the benefits of lower smoking rates and were offered augmentation therapy. In keeping with reported experience, most (96%) non-screened AAT deficient individuals remained undiagnosed and, therefore, missed these benefits. Under base conditions, screening all newborns cost nearly $422,000 per quality-adjusted life-year (QALY) gained; this estimate fell to $92,135 per QALY when the cost of screening was minimized to $6 in the model. Delaying screening until age 10 decreased the incremental cost-effectiveness ratio (ICER) to nearly $317,000. In sensitivity analysis, when the prevalence of PI*ZZ individuals increased from a baseline of 1.96 to 16 per 10,000, the ICER for newborn screening decreased below $100,000 per QALY. When the cost of screening and augmentation therapy were decreased simultaneously with increasing PI*ZZ prevalence, there were many scenarios in which the ICER decreased below $50,000. While population-based screening for AAT deficiency is not cost-effective under current conditions, cost-effectiveness criteria could be satisfied when case-finding in a high prevalence population is undertaken.

Cost-Benefit Analysis↗
PubMed2005

First case of laryngeal glomangiomyoma.

Glomus tumors are derived from the normal glomus body, which is an arteriovenous confluence involved with thermoregulation. These true glomus tumors are different from the "glomus tumors" derived from the paraganglion system often encountered by the otolaryngologist. Glomus tumors have been reported in a variety of locations including the pancreas, perineum, nasal cavity, and torso; however, most are found in the extremities. We present the first case of a laryngeal glomangiomyoma. Furthermore, this lesion was successfully excised endoscopically with a CO2 laser.

Aged↗
PubMed2004

Removal of self-expandable metallic stents: is it possible?

Self-expandable metallic stents (SEMS) have become an important component of the management of central airway disease. These stents are not, however, without problems and stent-related complications (SRCs) can be more formidable to treat than the original indication for SEMS placement. As use of SEMS has increased, the number of patients returning to hospital for management of SRCs has similarly risen. A small group of these patients will have, as their only therapeutic option, stent removal Thus far limited experience exists with late stent removal. Stent extraction is difficult and requires expertise in a variety of techniques. A multidisciplinary approach to both SEMS placement and extraction is strongly advocated.

Journal Article↗
PubMed2004

Association of an abnormal exercise heart rate recovery with pulmonary function abnormalities.

BACKGROUND: Heart rate recovery (HRR) after exercise correlates with decreased vagal tone and mortality. Patients with COPD may have altered autonomic tone. We sought to determine the association of HRR with spirometry measures of pulmonary function. METHODS: We analyzed 627 patients (mean [+/- SD] age, 58 +/- 12 years; 65% men; mean FEV(1), 2.6 +/- 0.9 L, 80 +/- 20% predicted; patients receiving inhaled beta(2) agonist therapy, 10%; patients receiving inhaled anticholinergic therapy, 3%; patients receiving inhaled steroids, 5%; patients receiving oral prednisone, 4%) who had undergone maximal exercise testing and had undergone pulmonary function tests < 1 year apart. Patients with heart failure, pacemakers, and atrial fibrillation were excluded. Abnormal HRR was defined as a fall in heart rate during the first minute after exercise of <or= 12 beats/min (<or= 18 beats/min with stress echocardiography). Patients were divided into quartiles based on FEV(1) percent predicted. RESULTS: An abnormal HRR was seen in 229 patients (36%). The mean FEV(1) values broken into quartiles 1 to 4 were 54 +/- 11% predicted, 74 +/- 3% predicted, 87 +/- 4% predicted, and 106 +/- 10% predicted. In smokers and nonsmokers, a worsening FEV(1) percent predicted was associated with an abnormal HRR. In a multivariable model accounting for confounding factors including medications and functional capacity, the predictors of an abnormal HRR included FEV(1) percent predicted (adjusted odds ratio for 1 SD decrease, 1.32; 95% confidence interval, 1.07 to 1.65; p = 0.0004), impaired functional capacity, male gender, and age. CONCLUSIONS: Abnormalities found on spirometry are associated with abnormal HRR, which may reflect an altered autonomic tone associated with pulmonary dysfunction, either obstructive or restrictive in nature.

Autonomic Nervous System↗
PubMed2004

Predictors of long-term mortality in patients with cirrhosis of the liver admitted to a medical ICU.

CONTEXT: The long-term survival of patients with cirrhosis of the liver admitted to the ICU has not been described. OBJECTIVE: The main objectives were to determine the 1-year and 5-year mortality rates of a cohort of patients admitted to a medical ICU (MICU), and to identify the risk factors that may predict long-term outcomes. DESIGN: This is a cohort study. We used a model-building (MB) and model validation (MV) procedure that has previously been described to determine the risk factors for overall mortality. SETTINGS: An MICU in a major referral medical center. PATIENTS: Four hundred twenty consecutive patients admitted to the ICU from January 1, 1993, through October 31, 1998, met the inclusion criteria of diagnosis of liver failure, cirrhosis, chronic liver disease, variceal bleeding, hepatic encephalopathy, or hepatorenal syndrome. Patients with acute liver failure who had undergone liver transplantation, or candidates for orthotopic liver transplantation were excluded. INTERVENTION: None. RESULTS: The 1-year mortality rate was 69%, and the 5-year mortality rate was 77%. The median survival time was 1 month. The independent predictors of mortality in patients in the MB group who retained their significance in the MV group were as follows: an acute physiology, age, and chronic health evaluation (APACHE) III score of >/= 90 (hazard ratio [HR], 2.2; 95% confidence interval [CI], 1.6 to 2.8; p < 0.0001), the use of pressors (HR, 2.5; 95% CI, 1.9 to 3.2; p < 0.0001), and jaundice (HR, 1.7; 95% CI, 1.4 to 2.2; p < 0.0001). Patients with all three risk factors (ie, APACHE III score >/= 90, use of pressors, and jaundice) had a 92% 1-month mortality rate compared to 11.2% for patients with no risk factors. CONCLUSIONS: Patients admitted to an MICU with underlying cirrhosis who are not eligible for liver transplantation have a poor long-term prognosis, even if they survive the ICU admission, particularly as the number of risk factors increases.

APACHE↗
PubMed2003

Cost-effectiveness analysis of augmentation therapy for severe alpha1-antitrypsin deficiency.

A Markov-based decision model was created to assess the cost-effectiveness of augmentation therapy (Aug) for severe alpha1-antitrypsin deficiency, comparing strategies of: (1) no Aug, (2) Aug for life, and (3) Aug until FEV1 is below 35% predicted. A hypothetical cohort of 46-year-old patients with FEV1 49% predicted was followed over time using Monte Carlo simulation across five possible health states: (1) FEV1 50 to 79% predicted, (2) FEV1 35 to 49% predicted, (3) FEV1 below 35% predicted, (4) status-post-lung transplantation, and (5) dead. Treatment for life yielded 7.19 quality-adjusted life-years (QALYs) and cost 895,243 dollars. Treating until FEV1 is below 35% predicted cost 511,930 dollars and produced 6.64 QALYs. "No Aug" cost 92,091 dollars with 4.62 QALYs. The incremental cost-effectiveness ratio was 207,841 dollars/QALY for Aug until FEV1 is below 35% predicted and 312,511 dollars/QALY for the "Aug for life" strategy. In all sensitivity analyses, the incremental cost-effectiveness ratio for Aug for life exceeded 100,000 dollars. The cost of Aug needed to be reduced from 54,765 dollars to 4,900 dollars for the "Aug for life" strategy to be considered cost-effective. We conclude that, compared with other conventionally used health interventions, Aug is relatively less cost-effective. These results should encourage the development of more clinically and cost-effective therapies for alpha1-antitrypsin deficiency.

Cost-Benefit Analysis↗
PubMed2003

Treatments and strategies to optimize the comprehensive management of patients with pulmonary arterial hypertension.

The management of pulmonary arterial hypertension (PAH) should aim to provide vasodilation of the pulmonary arteries, treat right ventricular failure, improve functional capacity and quality of life, and improve survival, if possible. Data from right heart catheterization and an estimation of vasoresponsiveness together guide treatment for PAH. The judicious use of calcium channel blockers, prostacyclin analogues, anticoagulation, and endothelin receptor antagonists forms the current basis of therapy. Three drugs-the prostacyclin analogues epoprostenol and treprostinil and the endothelin receptor antagonist bosentan-are currently approved for the primary treatment of PAH and have been clinically shown to improve outcomes. Coumarin derivatives, epoprostenol, and, in selected patients, calcium channel blockers are the only drugs associated with improved survival, and only epoprostenol has been shown to improve survival in a prospective randomized trial. Knowledge of the supportive therapies, indications for surgical intervention, and emerging drug therapies should provide the working armamentarium for clinicians treating this rare but devastating disease.

Antihypertensive Agents↗
PubMed2002

Emphysema in nonsmokers: alpha 1-antitrypsin deficiency and other causes.

Nonsmokers with signs of emphysema at an earlier age than is typical for emphysema deserve a workup for one of the less common causes of emphysema, which include alpha 1-antitrypsin deficiency, connective tissue diseases, hypocomplementemic urticarial vasculitis syndrome, intravenous drug use, human immunodeficiency virus infection, and several rare metabolic disorders.

Age of Onset↗