Describing results that contrast sharply with those from several prior observational studies by other biomedical scientists, investigators found that, in a large cohort of patients with chronic obstructive pulmonary disease (COPD), there was no significant effect from inhaled corticosteroid use on either patient mortality rate, the number of COPD exacerbations, or COPD-related hospital stays. Researchers presented data from 2,654 COPD patients who were prescribed inhaled corticosteroids for at least 80 percent of a 90-day period during the trial. There were 5,398 COPD patients who never had used inhaled corticosteroids also involved in the analysis. (COPD patients have a persistent obstruction of the airways associated with either severe emphysema or chronic bronchitis. The disease usually results from smoking.) The study authors said that they did not find a significant reduction in mortality for average inhaled steroid use at either a low, medium, or high dose. Nor did they see any association between inhaled corticosteroid use and reduced hospitalizations or exacerbations due to COPD. According to the authors, during a mean follow-up period of 544 days, 1,052 patients of the total included in the study died, 559 were hospitalized for COPD-associated symptoms, and 1,287 made an outpatient visit for a COPD exacerbation. The authors noted that several large prior observational studies had shown that inhaled corticosteorids, as used in clinical practice, were associated with a significant reduction in mortality or exacerbations. They attributed the difference in results to a statistical bias during the prior studies. The research is published in the second issue for December 2003 of the American Thoracic Society's peer-reviewed American Journal of Respiratory and Critical Care Medicine.
DEEP VEIN THROMBOSIS REDUCTION STRATEGY FOR THE CRITICALLY ILL
An ultrasound-based deep vein thrombosis screening strategy performed on critically ill patients who have had a femoral central venous catheter placed in their leg could add to their quality-adjusted life expectancy, prevent a pulmonary embolism, and reduce pulmonary embolism-associated deaths. Investigators developed a decision model to assess the potential cost-effectiveness of routine lower extremity Doppler ultrasound performed on patients with femoral catheters. (The femoral artery is the main artery in the thigh that runs down two-thirds of that leg portion before branching.) The researchers' model was designed to prevent pulmonary embolism-associated deaths. The authors said that almost half of the 16 million patients admitted to U.S. intensive care units annually receive central venous catheters. Femoral vein placement is associated with an incidence of deep vein thrombosis (blood clot) that ranges from 8.5 percent to slightly over 26 percent, as well as to a high risk of catheter-related bloodstream infections. Among those who develop deep vein thrombosis, pulmonary embolism can be shown in about half. (A pulmonary embolism is the closure of the pulmonary artery or one of its branches by a blood clot or other plug.) Because pulmonary embolism mortality increases due to cardiopulmonary derangements, the critically ill patient who requires mechanical ventilation is at special risk. In their model, the researchers analyzed outcomes from 1,000 patients with assumed acute respiratory failure requiring mechanical ventilation. The patients were assumed to have received mechanical ventilation for 7 days, as well as to require an intensive care unit (ICU) stay of 8 days, with additional hospitalization for 8 more days Using direct medical costs, the ultrasound strategy cost $8,688 per quality-adjusted life year gained, $5,305 per pulmonary embolism averted, and $98,286 per pulmonary embolism death averted. By basing anticoagulation therapy on ultrasound results, the researchers found that 263 nonfatal and 14 fatal pulmonary embolisms could be averted at the expense of 14 major episodes of gastrointestinal bleeding and 13 episodes of heparin-induced thrombocytopenia for every 10,000 ultrasound tests performed. The study is published in the second issue for December 2003 of the American Thoracic Society's peer-reviewed American Journal of Respiratory and Critical Care Medicine.
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Journal
American Journal of Respiratory and Critical Care Medicine