Annals of the American Thoracic Society
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Indwelling Pleural Catheter Drainage Strategy for Malignant Effusion: A Cost-Effectiveness Analysis.
Rationale: The likelihood of achieving pleurodesis after indwelling pleural catheter (IPC) placement for malignant pleural effusion varies with the specific drainage strategy used: symptom-guided drainage, daily drainage, or talc instillation through the IPC (IPC + talc). The relative cost-effectiveness of one strategy over the other is unknown. Objectives: We performed a decision tree model-based analysis to ascertain the cost-effectiveness of each IPC drainage strategy from a healthcare system perspective. ⋯ Daily drainage was not cost effective in any scenario, including for patients with nonexpandable lung, in whom it had an ICER of $2,474,612/QALY over symptom-guided drainage. Conclusions: For patients with malignant pleural effusion and an expandable lung, IPC + talc may be cost effective relative to symptom-guided drainage, although considerable uncertainty exists around this estimation. Daily IPC drainage is not a cost-effective strategy under any circumstance.
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Rationale: Even though idiopathic pulmonary fibrosis (IPF) is a disease with high morbidity and mortality and no cure, palliative care is rarely implemented, leading to high symptom burden and unmet care needs. In 2012, we implemented a multidisciplinary collaborative (MDC) care model linking clinic and community multidisciplinary teams to provide an early integrated palliative approach, focusing on early symptom management and advance care planning. Objectives: To evaluate the differences in resource use and associated costs of end-of-life care between patients with IPF who received early integrated palliative care and patients with IPF who received conventional treatment. ⋯ Conclusions: An integrated palliative approach in IPF is associated with improvements in the quality of end-of-life care and reduction in costs. Transformation of care models is required to deliver palliative care for patients with IPF. MDC teams within such models can address the high burden of unmet needs for symptom management, advance care planning, and community support in this complex population.
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Randomized Controlled Trial
Driving Pressure-Limited Strategy for Patients with Acute Respiratory Distress Syndrome (ARDS): A Pilot Randomized Clinical Trial.
Rationale: Evidence from observational studies suggests that driving pressure is strongly associated with pulmonary injury and mortality, regardless of positive end-expiratory pressure (PEEP) levels, tidal volume, or plateau pressure. Therefore, it is possible that targeting driving pressure may improve the safety of ventilation strategies for patients with acute respiratory distress syndrome (ARDS). However, the clinical effects of a driving pressure-limited strategy for ARDS has not been assessed in randomized controlled trials. ⋯ We did not find statistically significant differences in the incidence of severe acidosis (pH < 7.10) within 7 days (absolute difference -12.1; 95% CI, -41.5 to -17.3) or any clinical secondary endpoint. Conclusions: In patients with ARDS, a trial assessing the effects of a driving pressure-limited strategy using very low tidal volumes versus a conventional ventilation strategy on clinical outcomes is feasible. Clinical trial registered with ClinicalTrials.gov (NCT02365038).
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Randomized Controlled Trial
Sex-Specific Differential Responses of Circulating Biomarkers in Obstructive Sleep Apnea Treatment. A Post Hoc Analysis of a Randomized Controlled Trial.
Rationale: Knowledge of sex-specific changes of cardiovascular biomarkers in response to continuous positive airway pressure (CPAP) therapy for obstructive sleep apnea (OSA) is limited. Objectives: We hypothesized a differential sex-specific cardiovascular biomarker response with CPAP therapy for OSA. Methods: Participants with moderate-severe OSA (apnea-hypopnea index, 15 events/h) were randomized to CPAP versus sham and completed polysomnography and collection of biomarkers of inflammation (myeloperoxidase, fibrinogen, paraoxonase, interleukin [IL]-6, IL-6 soluble receptor, aryl esterase, oxidized low-density lipoprotein, lipoprotein A, plasminogen activator inhibitor 1, and F2-isoprostane urine/creatinine ratio) and vascular measures at baseline and 8 weeks of therapy with either CPAP (n = 72) or sham treatment (n = 70). ⋯ Conclusions: Differential sex-specific responses to CPAP therapy for OSA were observed for circulating inflammatory biomarkers, which persisted after adjustment for confounders. These findings set the stage for validation studies and, if confirmed, biochemical pathway elucidation to inform sex-specific personalized treatment approaches. Clinical trial registered with www.clinicaltrials.gov (NCT00607893).
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Multicenter Study Observational Study
Do Ambient Ozone or Other Pollutants Modify Effects of Controlled Ozone Exposure on Pulmonary Function?
Rationale: In a previous trial (MOSES [Multicenter Ozone Study of oldEr Subjects]), 3 hours of controlled ozone (O3) exposure caused concentration-related reductions in lung function with evidence of airway inflammation and injury, but without convincing evidence of effects on cardiovascular function. However, the subjects' exposures to indoor and outdoor air pollution in the hours and days before each controlled O3 exposure may have modified biomarker responses to the controlled O3 exposures. Objectives: We sought to determine whether personal measures of nitrogen dioxide (NO2) and O3, or ambient concentrations of O3, particulate matter ≤2.5 μm in aerodynamic diameter, NO2, carbon monoxide (CO), and sulfur dioxide (SO2) in the 72 and 96 hours before the exposure visit modified biomarker responses to controlled O3 exposure. ⋯ There was no such modification of the effect of controlled O3 exposure on any other cardiopulmonary outcome group. Conclusions: Reductions in markers of lung function, but not other pathways, by the MOSES controlled O3 exposure were modified by ambient NO2 and CO, and PES NO2, and these reductions were observed only when these pollutant concentrations were elevated in the hours and days before the pre-exposure visit. Clinical trial registered with ClinicalTrials.gov (NCT01487005).