Effectiveness of one-on-one coaching in improving pressurized metered dose inhaler (pMDI) technique among COPD patients: a prospective clinical study.

BACKGROUND: Incorrect use of inhalers among asthma and COPD patients is very prevalent. Yet, no single intervention is considered standard of care. We aimed to conduct a COPD-specific investigation of active one-on-one coaching as the educational intervention to improve pressurized metered dose inhaler (pMDI) technique and COPD symptoms management. METHODS: COPD patients who have pMDI in their treatment regimen were enrolled in this prospective study using the Global Initiative for Chronic Obstructive Lung Disease criteria. After rapid cognitive screen, inhaler technique was assessed and an active one-on-one coaching was provided utilizing the 12-step American Thoracic Society instructions. Patients' inhaler technique was assessed and scored again at their regular follow-up visits. RESULTS: One hundred and one patients participated in the study. The percentage of pMDI misuse decreased from 43.5% pre-teaching to 12.9% post-teaching (binomial test p value < 0.001). The mean number of errors decreased from 3.1 errors pre-teaching to 1.7 errors post-teaching (paired t-test p value < 0.001). The number needed to treat was 3.3 patients to prevent one misuse. Patients with an impaired cognitive function were more likely to have inhaler misuse in general and less likely to improve their technique when provided training. CONCLUSIONS: This study reveals that many COPD patients have incorrect pMDI techniques that can be improved with a short training in the clinic. TRIAL REGISTRATION: Not applicable.

Changes in pulmonary artery systolic pressure and right ventricular function in patients with end-stage renal disease on maintenance dialysis.

AIM: Pulmonary hypertension is common in patients with end-stage renal disease, and portends a poor prognosis. There are little data in this population, and previous studies have not evaluated quantitative changes in haemodynamics over time while on maintenance dialysis. This study sought to estimate changes in pulmonary artery systolic pressure (PASP) and right ventricular function over time, and to predict PASP change using clinical variables routinely available at time of initial measurement, in patients on maintenance dialysis. METHODS: We retrospectively studied patients with end-stage renal disease at a university-affiliated dialysis centre who had two separate echocardiograms 1-4 years apart. RESULTS: Seventy-six patients (65 haemodialysis, 11 peritoneal dialysis) were included. PASP was estimated by echocardiography. Baseline PASP was predicted by left-sided valvular disease, anaemia, COPD, left-ventricular mass index, and haemodialysis modality (P = 0.07 for modality). Average increase in PASP was 2.41 mmHg per year. Higher rates of PASP change were predicted by E/e' ratio by tissue doppler on echocardiogram, diabetes mellitus, low LV mass, and left-sided valvular heart disease (P = 0.07 for valvular disease). Patients with higher PASP had higher incidence of new-onset right ventricular dysfunction. CONCLUSION: In patients with end-stage renal disease, PASP increases over time. Changes are moderately predictable. Higher PASP predicted development of right ventricular dysfunction.

Transfusion Requirements in ESRD Patients Admitted with GI Hemorrhage Undergoing Inpatient Endoscopy.

OBJECTIVES: To date there are no studies evaluating the utilization of blood products in patients with end-stage renal disease (ESRD) with gastrointestinal (GI) hemorrhage. This study estimated transfusion needs and determined predictors available at the time of admission for patients with ESRD admitted to a university hospital with GI bleeding requiring inpatient endoscopy. METHODS: A retrospective chart review was performed on all patients with ESRD who underwent inpatient endoscopy for suspected GI bleeding between 2009 and 2015. RESULTS: Ninety-nine hospital admissions from 76 patients met the inclusion criteria. Patients received mean 2.9 ± 2.6 red blood cell (RBC) units. In the multivariate analysis, increased prothrombin time, low initial hemoglobin, admission to intensive care unit, congestive heart failure, white race (P = 0.08), and syncope (P = 0.09) were independent predictors of RBC transfusion. A total of 28% received fresh frozen plasma and 8% received platelets. Prolonged prothrombin time was the only independent predictor of fresh frozen plasma transfusion (P < 0.001). Platelet transfusion was predicted by thrombocytopenia at platelet counts <100,000/mm3 (P < 0.001) and white race. Coronary artery disease was associated with reduced platelet transfusion. Other baseline comorbidities, bleeding source, and active/recent hemorrhage on endoscopy did not predict transfusion. Desmopressin use was not associated with reduced RBC needs, even after adjusting for other covariates. Ninety-seven percent of patients survived to discharge. CONCLUSIONS: Patients with ESRD admitted to the hospital with GI bleeding have high blood transfusion requirements, which are predicted by variables available at the time of admission. Rockall score and most other predictors of mortality did not predict transfusion.

Tocilizumab Versus Baricitinib in Patients Hospitalized With COVID-19 Pneumonia and Hypoxemia: A Multicenter Retrospective Cohort Study.

In patients hospitalized with COVID-19 pneumonia, both tocilizumab and baricitinib have been shown to have clinical benefit compared with placebo. To date, there are few data comparing the two treatments, and their relative benefits and harms are unknown. This study aims to evaluate the effectiveness of tocilizumab versus baricitinib in patients hospitalized with COVID-19 pneumonia and hypoxemia. DESIGN: Retrospective cohort study. SETTING: Seven inpatient acute-care hospitals in Wisconsin. PARTICIPANTS: Patients hospitalized with COVID-19, hypoxemia, and Pao2-to-Fio2 ratio less than or equal to 300 mm Hg, who received either tocilizumab or baricitinib. INTERVENTIONS: Electronic chart review. MEASUREMENTS AND MAIN RESULTS: Patients were divided into tocilizumab and baricitinib cohorts based on actual medication received. The primary outcome was hospital discharge alive and free from mechanical ventilation within 60 days, assessed by logistic regression. Three hundred eighty-two patients were included: 194 in the tocilizumab cohort and 188 in the baricitinib cohort. Most baseline characteristics in the two cohorts were similar. All patients received dexamethasone. Two patients were lost to follow-up. In the remaining 380 patients, probability of successful discharge in the two cohorts was quantitatively similar in unadjusted, multivariate-adjusted, and propensity score-matched analyses. Hospital length of stay, rates of thromboembolic events, and rates of hospital-acquired infections were all similar in the two cohorts. CONCLUSIONS: In patients hospitalized with COVID-19 pneumonia and hypoxemia who receive dexamethasone, treatment with tocilizumab or baricitinib appears to result in similar outcomes.

Ultrasound-guided estimation of internal jugular vein collapsibility index in patients with shock in emergency department.

OBJECTIVE: To correlate ultrasound-guided estimation of Internal Jugular Vein Collapsibility Index (IJV-CI) with inferior vena cava CI (IVC-CI) and invasively monitored central venous pressure (CVP) in patients with shock in the emergency medicine department. METHODS: A prospective observational study was done in the emergency department (ED). The study was conducted over 15 months (November 2019 to April 2021). It included patients more than 18 years presenting to the ED in shock. The IJV and IVC diameter and cross-sectional area were measured using ultrasound. The corresponding collapsibility indexes were then calculated and correlated with the invasively monitored CVP of the patient. Data were then analyzed using the Statistical Package for the Social Science (SPSS): Version 23 for windows. Pearson's correlation was used between CVP and collapsibility indexes. RESULTS: The mean (±standard deviation) age of the patients was 49.01 (±15.6). There was a 47 (64%) male predominance which outnumbered females 26 (36%). The correlation coefficient was statistically significant between CVP and the collapsibility indices for various IJV and IVC parameters. The highest correlation (r = -0.541, P = 0.005) was seen between IVC-CI (CI 5) and CVP. This was followed by a correlation seen at a 30° position for IJV CI (cross-sectional area) with CVP (r = -0.453, P = 0.001). Similarly, the correlation between IJV CI (AP diameter) and CVP, followed (r = -0.412, P = 0.008) was statistically significant. CONCLUSION: Both IJV and IVC collapsibility indices correlated significantly with invasively measured CVP. Hence, they present as an effective tool in fluid resuscitation in patients with shock in ED.

Effect of Very Low-Dose Hydrocortisone on Shock Reversal in Patients With Septic Shock.

In patients with septic shock, hydrocortisone 200-400 mg/d has been shown to reverse shock compared with placebo. Lower doses of hydrocortisone have not previously been studied, and there are no previous studies comparing two different doses of hydrocortisone. At our institution, some clinicians routinely prescribe doses less than 200 mg/d. This study aims to compare the effect of lower doses of hydrocortisone to standard doses on shock reversal and adverse events in septic shock. DESIGN: Retrospective cohort study. SETTING: Single-center medical ICU. SUBJECTS: Patients who received hydrocortisone for septic shock. INTERVENTIONS: Electronic chart review. MEASUREMENTS AND MAIN RESULTS: Patients were divided into low-dose hydrocortisone (75-150 mg/d) and standard-dose hydrocortisone (200-400 mg/d) cohorts based on initial prescribed hydrocortisone dose. Rates of shock reversal and adverse events in the two cohorts were compared. Two-hundred thirteen patients were included-41 in low-dose and 172 in standard-dose cohorts. Baseline characteristics including initial vasopressor requirement and Sequential Organ Failure Assessment scores were similar. Average rates of change in vasopressor needs, conditional hazard rate for vasopressor withdrawal, and cumulative probability for vasopressor withdrawal were all quantitatively similar for low-dose and standard-dose hydrocortisone. Insulin requirement (particularly in those with diabetes mellitus), blood glucose in those with diabetes mellitus, and frequency of secondary infections seemed to be lower in the low-dose hydrocortisone cohort. Mortality and other secondary outcomes were similar. CONCLUSIONS: In septic shock, hydrocortisone dosed 75-150 mg/d appears to reverse shock as effectively 200-400 mg/d and may cause a lower frequency of adverse events.

Anaphylaxis with elevated serum tryptase after administration of intravenous ferumoxytol.

Ferumoxytol is a newly approved preparation of intravenous iron with a modified dextran shell that is thought to confer upon it a low immunogenic potential. Serious adverse reactions have been very uncommon in clinical studies, but these studies excluded patients with prior adverse reactions to other preparations of intravenous iron. Furthermore, the reactions were classified clinically. We report on a patient with a history of hypersensitivity to iron dextran who experienced an anaphylactic reaction after receiving ferumoxytol. Laboratory testing revealed an elevated serum tryptase level, confirming mast cell activation. This is the first laboratory-proven case of anaphylaxis related to ferumoxytol.