Implantable Cardioverter Defibrillators in Patients with Chronic Obstructive Pulmonary Disease.

Chest. 2013 May 16;

Authors: Naksuk N, Kunisaki KM, Benditt DG, Tholakanahalli V, Adabag S

Abstract
ABSTRACT BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a common comorbidity in heart failure. The efficacy of implantable cardioverter-defibrillator (ICD) therapy has not been determined in heart failure patients with COPD. METHODS: We examined the incidence of ICD shocks and mortality in 628 consecutive patients who underwent defibrillator implantation at the Minneapolis Veterans Affairs Medical Center from 2006 to 2010. RESULTS: Mean age of the patients was 67±10 years and 99% were male. Patients with COPD (n=246, 39%) were functionally more limited (p<0.0001) and more likely to have ICD for primary prevention of sudden death (p=0.04) than those without COPD. Over a median 4.1 years [IQR25,75 2.2, 5.7] of follow-up, COPD patients had a higher incidence of appropriate shocks (29% vs.17%; p<0.0001) compared to those without COPD, whereas the incidence of inappropriate shocks was similar (9% vs. 10%, respectively; p=0.61). In multivariable analysis, COPD was associated with a 2-fold increase in the odds of appropriate ICD shock (95% confidence interval 1.3-2.9; p=0.001). Incidence of ICD shocks did not vary with severity of COPD. Although all-cause mortality was higher in COPD patients than those without COPD (29% vs. 21% respectively; p=0.029), one-year mortality (5.3% vs. 2.6%, respectively; p=0.08) and the average time from first appropriate ICD shock to death was comparable (median 2.3 years [IQR25,75 1.2, 4.4] vs. 2.8 years [IQR25,75 1.4, 5.3], respectively, p=0.29). CONCLUSIONS: Patients with COPD have a higher incidence of ICD shocks than those without COPD and appear to benefit from ICD therapy.

PMID: 23681102 [PubMed - as supplied by publisher]

Comprehensive venous thromboembolism prevention programme incorporating mandatory risk assessment reduces the incidence of hospital-associated thrombosis.

Chest. 2013 May 16;

Authors: Roberts LN, Porter G, Barker RD, Yorke R, Bonner L, Patel RK, Arya R

Abstract
ABSTRACT BACKGROUND: Venous thromboembolism (VTE) is a common complication of hospitalisation and is associated with significant morbidity and mortality. The use of appropriate thromboprophylaxis can significantly reduce the risk of VTE but remains underutilised. In England, a comprehensive approach to VTE prevention was launched in 2010. This study aimed to evaluate the impact of the implementation of the national programme in a single centre. METHODS: A prospective quality improvement programme was established at King's College Hospital NHS Foundation Trust in 2010. The multidisciplinary thrombosis team launched mandatory documented VTE risk assessment and updated thromboprophylaxis guidance. Root cause analysis of hospital-associated thrombosis (HAT) was implemented to identify system failures, enable outcome measurement and to facilitate learning to improve VTE prevention practice. The key outcomes were the incidence of HAT and the proportion of events preventable with appropriate thromboprophylaxis. RESULTS: Documented VTE risk assessment improved from less than 40% to >90% in the first nine months. 425 episodes of HAT were identified over two years. A significant reduction in the incidence of HAT was observed following sustained achievement of 90% risk assessment (RR 0.88, 95% CI 0.74 - 0.98; P=0.014). The proportion of HAT attributable to inadequate thromboprophylaxis fell significantly from 37.5% to 22.4% (P=0.005). CONCLUSION: Mandatory VTE risk assessment can significantly reduce preventable HAT and thereby improve patient safety.

PMID: 23681495 [PubMed - as supplied by publisher]

Impact of Age and Comorbidity on Etiology and Outcome in Community-Acquired Pneumonia.

Chest. 2013 May 9;

Authors: Cillóniz C, Polverino E, Ewig S, Aliberti S, Gabarrús A, Menéndez R, Mensa J, Blasi F, Torres A

Abstract
ABSTRACT BACKGROUND: Prolonged life expectancy has currently increased the proportion of the very elderly among patients with community-acquired pneumonia (CAP). The aim of this study was to determine the influence of age and comorbidity on microbial patterns in CAP patients over 65 years of age. METHODS: Prospective observational study of adult CAP patients (excluding nursing home) over a 12-year period. We compared patients aged 65-74 years, 75-84 years and >85 years for potential differences in clinical presentation, comorbidities, severity on admission, microbial investigations, etiologies, antimicrobial treatment, and outcomes. RESULTS: We studied a total of 2149 patients: 759 (35.3%) patients aged 65-74 years, 941 (43.7%) aged 75-84 years, and 449 (20.8%) patients aged >85 years. At least one comorbidity was present in 1710 (79.6%) patients. Streptococcus pneumoniae was the most frequent pathogen in all age groups, regardless of comorbidity. Staphylococcus aureus, Enterobacteriaceae, and Pseudomonas aeruginosa accounted for 9.1% of isolates and Haemophilus influenzae, 6.4%. All these pathogens were isolated only in patients with ≥1 comorbidity. Mortality increased with age (65-74 y, 6.9%; 75-84 y, 8.9%; >85 y, 17.1%; p<0.001) and was associated with increased comorbidities (neurological, OR: 2.1, 95% CI: 1.5-2.1), PSI IV-V (OR: 3.2, 95% CI: 1.8-6.0), bacteremia (OR: 1.7, 95% CI: 1.1-2.7), the presence of a potential MDR pathogen (S. aureus, P. aeruginosa, Enterobacteriaceae; OR: 2.4, 95% CI: 1.3-4.3) and ICU admission (OR: 4.2, 95% CI: 2.9-6.1) on multivariate analysis. CONCLUSIONS: Age does not influence microbial etiology itself, while comorbidities are associated with specific etiologies such as H. influenzae and potential MDR pathogens. Mortality in the elderly is mainly driven by the presence of comorbidities and potential MDR.

PMID: 23670047 [PubMed - as supplied by publisher]