Obstructive Sleep Apnea and Colorectal Cancer: A Systematic Review and Meta-Analysis.

BACKGROUND: Obstructive sleep apnea (OSA), characterised by recurrent episodes of upper airway collapse, intermittent hypoxia (IH) and sleep fragmentation (SF), has been associated with carcinogenesis in pre-clinical models. The relationship between OSA and colorectal cancer (CRC) in clinical studies is controversial. AIM: The objective of this meta-analysis was to assess the association between OSA and CRC. METHODS: Two independent investigators searched studies indexed in CINAHL, MEDLINE, EMBASE, the Cochrane Database and clinicaltrials.gov that were randomised controlled trials (RCT) or observational studies evaluating the relationship between OSA and CRC. Studies were included if they had available odds ratios (OR) and relative risks (RR) or if hazard ratios (HR) with 95% confidence intervals (CI) were available and a reference group composed of participants who did not have OSA. OR and 95% CI were calculated using a random-effect, generic inverse variance method. RESULTS: We included four observational studies out of 85 records, comprising a combined cohort of 5,651,662 identified patients in the data analysis. Three studies used polysomnography to identify OSA. The pooled OR of CRC in patients with OSA was 1.49 (95% CI, 0.75 to 2.97). The statistical heterogeneity was high with I2 of 95%. CONCLUSIONS: Our study is unable to conclusively point towards OSA being a risk factor in the development of CRC, despite the plausible biological mechanisms for this. Further well-designed prospective RCT assessing the risk of CRC in patients with OSA and the impact of OSA treatments on the incidence and prognosis of CRC are needed.

New lung cancer diagnosis after emergency department presentation in a tertiary hospital: patient characteristics and outcomes.

OBJECTIVES: Currently, there are limited data available about patients who are diagnosed with lung cancer following an emergency department (ED) visit. This study sought to define the demographics, symptoms profile, staging, and prognosis of this cohort of patients. METHODS: We conducted a retrospective study of patients diagnosed with a primary lung malignancy at a lung cancer multidisciplinary meeting between January 2018 and January 2020. Medical records were reviewed to collect data around demographics, presenting symptoms, investigations, admission, cancer stage, and mortality. RESULTS: During the study period, 890 patients were diagnosed with a primary lung malignancy of which 209 (23.5%) presented to ED prompting diagnostic work-up. Of these 209 patients, 89% were hospitalized for a median duration of 6 days. Also, 104 (50%) were female and the average age of the cohort was 70 years. Dyspnea (38%) was the most common presenting symptom. Radiological staging and tissue biopsy were performed as an outpatient procedure in 46% and 41% of patients, respectively. A total of 188 patients had non-small cell lung cancer of whom 68% had ztage IV disease. A total of 53 (25%) patients died within 3 months of ED presentation. These patients were older with more advanced disease compared to patients who were alive at 3 months. CONCLUSION: Emergent diagnosed patients are a significant proportion of the lung cancer population, presenting with advanced stage disease and increased short-term mortality. Future research should be directed at interventions, such as lung cancer screening program and/or community education, to reduce the need for patients to present to the ED with disabling lung cancer symptoms.

Vena caval filters for the prevention of pulmonary embolism.

BACKGROUND: Pulmonary emboli (PE), or blood clots in the lungs,can be potentially fatal. Anticoagulation is the first line therapy to prevent PE. In some instances anticoagulation fails to prevent more emboli, or cannot be given because the person has a high risk of bleeding. Inferior vena caval filters (VCFs) are metal alloy devices that mechanically trap fragmented emboli from the deep leg veins en route to the pulmonary circulation. Retrievable filters are designed to be introduced and removed percutaneously. Although their deployment seems of theoretical benefit, their clinical efficacy and adverse event profile is unclear. This is the third update of a Cochrane Review first published in 2007. OBJECTIVES: To assess the evidence for the effectiveness and safety of vena caval filters (VCFs) in preventing pulmonary embolism (PE). SEARCH METHODS: For this review update, the Cochrane Vascular Information Specialist (CIS) searched the Specialised Register (last searched 10 September 2019) and the Cochrane Register of Controlled Trials (CENTRAL) (2019, Issue 8) via the Cochrane Register of Studies Online. The CIS also searched MEDLINE Ovid, EMBASE Ovid, CINAHL, and AMED (1 January 2017 to 10 September 2019) and trials registries to 10 September 2019. SELECTION CRITERIA: We included randomised controlled trials (RCTs) and controlled clinical trials (CCTs) that examined the efficacy of VCFs in preventing PE. DATA COLLECTION AND ANALYSIS: For this update, studies were assessed and data extracted independently. We assessed study quality with Cochrane's 'Risk of bias' tool and used the GRADE approach to assess the overall certainty of the evidence. The outcomes of interest were PE, mortality, lower limb venous thrombosis, filter-related complications and major bleeding. MAIN RESULTS: We identified four new studies for this update, bringing the total to six included studies involving 1388 participants. The six studies were clinically heterogeneous and we were unable to carry out meta-analysis. Only two studies were considered to be both applicable in current clinical settings and of good methodological quality. One was a randomised open-label trial studying the effect of a retrievable inferior vena caval filter plus anticoagulation versus anticoagulation alone on risk of recurrent pulmonary embolism (PE) in 399 participants over three months. There was no evidence of a difference in the rates of PE, death, lower extremity deep vein thrombosis (DVT), or bleeding at three and six months after the intervention (moderate-certainty evidence). A filter was inserted in 193 people, but could only be successfully retrieved from 153. Minor filter complications were noted at six months. The second clinically relevant study was a randomised open-label trial of 240 participants who had sustained multiple traumatic injuries, allocated to a filter or no filter, three days after injury, in conjunction with anticoagulation and intermittent pneumatic compression. Prophylactic anticoagulation was initiated in both groups when it was thought safe to do so. There was no evidence of a difference in symptomatic PE, death, or lower limb venous thrombosis rates (moderate-certainty evidence). The only major filter complication was that one person required surgical removal of the filter. We are unable to draw any conclusions from the remaining four included studies. One study showed an increased incidence of long-term lower extremity DVT at eight years. Three studies are no longer clinically applicable because they utilised permanent filters which are seldom used now, or they did not use routine prophylactic anticoagulation which is current standard practice. The fourth study compared two filter types and was terminated prematurely as one filter group had a higher rate of thrombosis compared to the other filter type. AUTHORS' CONCLUSIONS: Two of the six identified studies were relevant for current clinical settings. One showed no evidence of a benefit of retrievable filters in acute PE for the outcomes of PE, death, DVT and bleeding during the initial three months in people who can receive anticoagulation (moderate-certainty evidence). The other study did not show any benefit for prophylactic filter insertion in people who sustained multiple traumatic injuries, with respect to symptomatic PE, mortality, or lower extremity venous thrombosis (moderate-certainty evidence). We can draw no firm conclusions regarding filter efficacy in the prevention of PE from the remaining four RCTs identified in this review. Further trials are needed to assess vena caval filter effectiveness and safety, and clinical differences between various filter types.

Resilience Factors Important in Health-Related Quality of Life of Subjects With COPD.

BACKGROUND: Common among patients with COPD is declining health-related quality of life (HRQOL). Although results of research identified some factors associated with HRQOL, resilience factors are yet to be fully investigated. METHODS: This study examined resilience and demographic factors associated with HRQOL. Participants >40 y old were recruited from community health programs and hospitals in South East Queensland. Self-administered questionnaires were used to query subjects' HRQOL and levels of resilience. A decision tree examined the factors important to HRQOL in 159 subjects with COPD. RESULTS: Factors of importance in the HRQOL of subjects with COPD were found in 3 domains of the St George Respiratory Questionnaire. Of importance on the breathlessness domain was marital status, defensive coping, coping, number of comorbidities, relationships, decision-making, self-esteem, self-efficacy, and professional support of health and well-being. Of the symptoms domain, self-efficacy, recruitment location, anxiety/depression, decision-making, self-esteem, coping, relationships, professional support of health and well-being, and risks were important. The cough domain found recruitment location, anxiety/depression, professional support of health and well-being, coping, and defensive coping to be important for subjects' HRQOL. CONCLUSIONS: Resilience and confounding factors were of importance in the HRQOL of subjects with COPD. Thus, consultation with a medical professional, especially at discharge, who identifies, encourages, and approves of the patient's disease management abilities will enhance both resilience and HRQOL.

Nontypeable Haemophilus influenzae and chronic obstructive pulmonary disease: a review for clinicians.

Chronic Obstructive Pulmonary Disease (COPD) is a leading cause of morbidity and mortality worldwide. In the lower airways of COPD patients, bacterial infection is a common phenomenon and Haemophilus influenzae is the most commonly identified bacteria. Haemophilus influenzae is divided into typeable and nontypeable (NTHi) strains based on the presence or absence of a polysaccharide capsule. While NTHi is a common commensal in the human nasopharynx, it is associated with considerable inflammation when it is present in the lower airways of COPD patients, resulting in morbidity due to worsening symptoms and increased frequency of COPD exacerbations. Treatment of lower airway NTHi infection with antibiotics, though successful in the short term, does not offer long-term protection against reinfection, nor does it change the course of the disease. Hence, there has been much interest in the development of an effective NTHi vaccine. This review will summarize the current literature concerning the role of NTHi infections in COPD patients and the consequences of using prophylactic antibiotics in patients with COPD. There is particular focus on the rationale, findings of clinical studies and possible future directions of NTHi vaccines in patients with COPD.

Evaluating the appropriateness of hospital doctors' requests for pulmonary function tests beyond basic spirometry: results from a prospective observational study.

OBJECTIVES: Hospitalists request 'complete' pulmonary function tests (PFTs), typically comprising of spirometry, diffusion capacity of the lung for carbon monoxide (DLCO) and absolute lung volumes (ALVs), the results of which assist in the management of patients with respiratory disorders. Recently, concerns have been raised about over-requesting of 'complete' PFTs, but there is a paucity of information on the proportion of requests that can be considered clinically inappropriate. This study prospectively evaluated the 'complete' PFTs requested in a hospital service and assessed the impact of medical review of the requests. METHODS: A six-month prospective study on requests to two teaching hospital PFT laboratories from non-respiratory doctors was undertaken. Requests at one laboratory underwent review by a respiratory doctor ('intervention laboratory') while requests at the second laboratory were not reviewed ('control laboratory'). The appropriateness of requests was measured against pre-specified criteria. RESULTS: PFT requests for 335 subjects were included in the study. In the intervention laboratory, 8 of 110 ALV and 122 of 134 DLCO requests fulfilled pre-specified criteria for appropriate test indications. Fewer ALV (7% vs. 100%, p < 0.001) and DLCO tests (91% vs. 100%, p = 0.031) could have been performed in the intervention laboratory compared to the control laboratory. CONCLUSION: A considerable proportion of 'complete' PFT requests from non-respiratory hospital doctors may be unwarranted. Using a simple screening method, the number of unnecessary PFTs could be reduced, resulting in substantial time and cost savings for hospital PFT laboratories.

Investigating a unilateral pleural effusion: A tale of a medical error and diagnostic delays.

We report the case of an elderly Asian man where a medical error and diagnostic delays obscured the diagnosis of pleural tuberculosis (TB). The patient was hospitalized for evaluation of a unilateral pleural effusion. Initially, the patient was subjected to a pleural aspiration on the wrong side due to a lack of bedside ultrasound guidance. Subsequently, the patient underwent several investigations but not a blind closed pleural biopsy (BCPB) due to a lack of equipment. Furthermore, the patient was deemed to be too sick to undergo a thoracoscopic pleural procedure. Eventually, a bronchoscopy was performed, and washings from the right upper lobe were cultured, which established the diagnosis of TB. This case highlights the need to use bedside ultrasound in the investigation of pleural effusions, the role of BCPB especially in frail patients and finally the utility of bronchoscopy in establishing a diagnosis of pleural TB.

The effects of chronic obstructive pulmonary disease self-management interventions on improvement of quality of life in COPD patients: A meta-analysis.

This article aimed to analyse the outcome of self-management randomised control trials and their impact upon chronic obstructive pulmonary disease patients' health outcomes using meta-analysis approach. PubMed, Scopus, CINAHL, Web of Science databases and Cochrane Library, were searched for articles between 1990 and December 2015 by two researchers. Self-management programs significantly improved patients' quality of life across all domains of the St George Respiratory Questionnaire (SGRQ) (activity -2.21 (95% CI: -3.61 to -0.80), p = 0.002; impact -3.30 (95% CI: -5.28 to -1.32), p = 0.001; symptoms -3.12 (95% CI: -4.94 to -1.03), p = 0.001; total -3.32 (95% CI: -4.60 to -2.04), p < 0.001), the six-minute walk test (-30.50 (95% CI: 3.32 to 57.68), p = 0.028), and across three domains of the chronic obstructive pulmonary disease self-efficacy scale (negative effect -1.22 (95% CI: -2.31 to -0.14), p = 0.027; physical exertion -1.27 (95% CI: -2.52 to -0.02), p = 0.047; behavioural risk factors -0.58 (95% CI: -0.99 to -0.16), p = 0.007). Subgroup analyses revealed that chronic obstructive pulmonary disease education (p < 0.01) was the strongest component with improvements on all aspects of the SGRQ and the six-minute walk test. Providing an exacerbation action plan significantly improved SGRQ activity and impact scores whilst exercise information had a positive effect on activity and symptom scores (p < 0.05). Interventions with a duration of less than five weeks (p < 0.05) significantly improved symptom and activity scores, in addition to the number of patient hospital admissions. Thus, self-management interventions are effective at improving the health outcomes of chronic obstructive pulmonary disease patients, especially when disease education is provided.

Effect of changing from the National Health and Nutritional Examination Survey III spirometry reference range to that of the Global Lung Initiative 2012 at Gold Coast Hospital and Health Service.

The categorisation of lung disease into obstructive ventilatory defect (OVD) and tendency to a restrictive ventilatory defect (TRVD) patterns using spirometry is used to guide both prognostication and treatment. The effectiveness of categorisation depends upon having reference ranges that accurately represent the population they describe. The Global Lung Initiative 2012 (GLI 2012) has spirometry reference ranges drawn from the largest sample size to date. This study aimed to determine whether using spirometry reference ranges from the new GLI 2012 dataset, compared to the previously used National Health and Nutritional Examination Survey III (NHANES III) dataset, resulted in a change in diagnosis between OVD, TRVD and normal ventilatory pattern (NVP). Spirometry data were collected from 301 patients, aged 18-80 years, undergoing investigation at the Gold Coast Hospital and Health Service (GCHHS) throughout February and March 2014. OVD was defined as a forced expiratory volume in 1 second (FEV1) divided by forced vital capacity (FVC) less than lower limit of normal (LLN). TRVD was defined as FEV1/FVC ≥ LLN, FEV1 < LLN, and FVC < LLN. The LLN values were determined by equations from the GLI and NHANES datasets. Spirometry interpreted using the NHANES III equations showed: 102 individuals (33.9%) with normal spirometry, 136 (45.2%) with an OVD pattern, 52 (17.3%) with a TRVD pattern, and 11 (3.7%) with a mixed pattern. When the spirometry data were interpreted using the GLI 2012 equations 2 (0.7%) individuals changed from OVD to NVP, 2 (0.7%) changed from NVP to OVD and 14 (4.7%) changed from TRVD to NVP. Using the GLI 2012 reference range resulted in a change in diagnosis of lung disease in 5.9% of the individuals included in this study. This variance in diagnosis when changing reference ranges should be taken into account by clinicians as it may affect patient management.

Communication of Pulmonary Function Test Results: A Survey of Patient's Preferences.

INTRODUCTION: Physician-patient communication in patients suffering from common chronic respiratory disease should encompass discussion about pulmonary function test (PFT) results, diagnosis, disease education, smoking cessation and optimising inhaler technique. Previous studies have identified that patients with chronic respiratory disease/s often express dissatisfaction about physician communication. Currently there is a paucity of data regarding patient awareness of their PFT results (among those who have undergone PFTs previously) or patient preferences about PFT result communication. METHODS: We undertook a three-month prospective study on outpatients referred to two Pulmonary Function Laboratories. If subjects had undergone PFTs previously, the awareness of their previous test results was evaluated. All subjects were asked about their preferences for PFT result communication. Subjects were determined to have chronic respiratory disease based on their past medical history. RESULTS: 300 subjects (50% male) with a median age (± SD) of 65 (± 14) years participated in the study. 99% of the study participants stated that they were at least moderately interested in knowing their PFT results. 72% (217/300) of the subjects had undergone at least one PFT in the past, 48% of whom stated they had not been made aware of their results. Fewer subjects with chronic respiratory disease preferred that only a doctor discuss their PFT results with them (28% vs. 41%, p = 0.021). CONCLUSION: Our study demonstrates that while almost all subjects want to be informed of their PFT results, this does not occur in a large number of patients. Many subjects are agreeable for their PFT results to be communicated to them by clinicians other than doctors. Further research is required to develop an efficient method of conveying PFT results that will improve patient satisfaction and health outcomes.

Emergency department management of acute exacerbations of chronic obstructive pulmonary disease and factors associated with hospitalization.

BACKGROUND: Currently there is a paucity of information about biomarkers that can predict hospitalization for acute exacerbations of chronic obstructive pulmonary disease (AECOPD) patients presenting to the emergency department (ED). There is limited data on the consistency of ED management of AECOPD with local COPD guidelines. The aim of this study was to identify biomarkers associated with hospitalization in AECOPD patients and to determine if the ED management was concordant with local COPD guidelines. MATERIALS AND METHODS: We performed a retrospective audit of consecutive AECOPD patients presenting to the Gold Coast Hospital ED over a 6-month period. RESULTS: During the study period, 122 AECOPD patients (51% male, mean age (SE) 71 (±11) years) presented to the ED. Ninety-eight (80%) patients were hospitalized. Univariate analysis identified certain factors associated with hospitalization: Older age, former smokers, home oxygen therapy, weekday presentation, SpO2 < 92%, and raised inflammatory markers (white cell count (WCC) and C-reactive protein (CRP)). After adjustment for multiple variable, increased age was significantly associated with hospitalization (odds ratio (OR) 1.09; 95% confidence interval (CI): 1.00-1.18; P = 0.05). Radiology assessment and pharmacological management was in accordance with COPD guidelines. However, spirometry was performed in 17% of patients and 28% of patients with hypercapneic respiratory failure received noninvasive ventilation (NIV). CONCLUSION: We identified several factors on univariate analysis that were associated with hospitalization. Further research is required to determine the utility of these biomarkers in clinical practice. Also, while overall adherence to local COPD guidelines was good, there is scope for improvement in performing spirometry and provision of NIV to eligible patients.

Genomic medicine in non-small cell lung cancer: paving the path to personalized care.

Lung cancer is the commonest cause of cancer-related mortality and non-small cell lung cancer (NSCLC) accounts for 80% of all lung cancer. The prognosis of NSCLC remains poor across all stages, despite advances in staging techniques and treatments. The findings of recent high-throughput mRNA microarray studies have shown potential in refining current NSCLC diagnosis, classification, prognosis and treatment paradigms. Emerging microarray studies of microRNA, DNA copy number and methylation profiles are also providing novel insights into the biology of NSCLC. Currently there are several challenges, such as the reproducibility and cost of microarray platforms that will need to be addressed prior to the implementation of these genomic technologies to routine thoracic oncology practice. In addition, genomic tests (such as prognosis and prediction gene expression signatures) will need to be validated in well designed prospective studies that aim to answer clinically relevant questions. If successful, the integration of microarray-based genomic information with existing clinicopathological models may enhance the ability of clinicians to match the most effective treatment to an individual patient. Such a strategy may improve survival and reduce treatment-related morbidity in NSCLC patients.