Asthma morbidity measures across Black ethnic subgroups.

BACKGROUND: Black adults are disproportionately affected by asthma and are often considered a homogeneous group in research studies despite cultural and ancestral differences. OBJECTIVE: We sought to determine if asthma morbidity differs across adults in Black ethnic subgroups. METHODS: Adults with moderate-severe asthma were recruited across the continental United States and Puerto Rico for the PREPARE (PeRson EmPowered Asthma RElief) trial. Using self-identifications, we categorized multiethnic Black (ME/B) participants (n = 226) as Black Latinx participants (n = 146) or Caribbean, continental African, or other Black participants (n = 80). African American (AA/B) participants (n = 518) were categorized as Black participants who identified their ethnicity as being American. Baseline characteristics and retrospective asthma morbidity measures (self-reported exacerbations requiring systemic corticosteroids [SCs], emergency department/urgent care [ED/UC] visits, hospitalizations) were compared across subgroups using multivariable regression. RESULTS: Compared with AA/B participants, ME/B participants were more likely to be younger, residing in the US Northeast, and Spanish speaking and to have lower body mass index, health literacy, and <1 comorbidity, but higher blood eosinophil counts. In a multivariable analysis, ME/B participants were significantly more likely to have ED/UC visits (incidence rate ratio [IRR] = 1.34, 95% CI = 1.04-1.72) and SC use (IRR = 1.27, 95% CI = 1.00-1.62) for asthma than AA/B participants. Of the ME/B subgroups, Puerto Rican Black Latinx participants (n = 120) were significantly more likely to have ED/UC visits (IRR = 1.64, 95% CI = 1.22-2.21) and SC use for asthma (IRR = 1.43, 95% CI = 1.06-1.92) than AA/B participants. There were no significant differences in hospitalizations for asthma among subgroups. CONCLUSIONS: ME/B adults, specifically Puerto Rican Black Latinx adults, have higher risk of ED/UC visits and SC use for asthma than other Black subgroups.

The number and function of T regulatory cells in obese atopic female asthmatics.

BACKGROUND: Mechanisms underlying the association between asthma and obesity remain poorly understood. Obesity appears to be a risk factor for asthma, and obese asthmatics fare poorly compared to lean asthmatics. OBJECTIVES: To explore the possibility that reduced regulatory T cell (Treg) number and function contribute to the obesity-asthma association. We concentrated on obese females with childhood-onset asthma, since Treg may be involved in this phenotype. METHODS: We recruited 64 women (ages 18-50) into four groups: lean (BMI 18-25 kg/m2) controls (n = 17) and asthmatics (n = 13), and obese (BMI ≥ 35 kg/m2) controls (n = 17) and asthmatics (n = 17). Asthmatics had atopy and childhood-diagnosed asthma. We assessed lung function, asthma control and quality of life. Peripheral blood CD4+/CD25+/FoxP3+ Treg cells were identified and counted by flow cytometry and expressed as % total CD4+ T cells. We assessed Treg cell function by the ability of CD4+/CD25+ Treg cells to suppress autologous CD4+/CD25- responder T cell (Tresp) proliferation and measured as % suppression of Tresp cell proliferation. RESULTS: Obese asthmatics had worse lung function, asthma control, and quality of life compared to lean asthmatics. Compared to lean or obese control groups, the number of Treg cells in the obese asthmatics was approximately 1.58- or 1.73-fold higher. The ability of Treg cells from obese-asthmatics to suppress Tresp cell proliferation was reduced. CONCLUSIONS: Obese, atopic women with childhood diagnosed asthma demonstrate increased Treg cell number and mildly decreased Treg cell function. Our data do not support the view that reduced Treg cell number contributes to this obese-asthma phenotype.

Efficacy of nasal mometasone for the treatment of chronic sinonasal disease in patients with inadequately controlled asthma.

BACKGROUND: Chronic sinonasal disease is common in asthmatic patients and associated with poor asthma control; however, there are no long-term trials addressing whether chronic treatment of sinonasal disease improves asthma control. OBJECTIVE: We sought to determine whether treatment of chronic sinonasal disease with nasal corticosteroids improves asthma control, as measured by the Childhood Asthma Control Test and Asthma Control Test in children and adults, respectively. METHODS: A 24-week multicenter, randomized, placebo-controlled, double-blind trial of placebo versus nasal mometasone in adults and children with inadequately controlled asthma was performed. Treatments were randomly assigned, with concealment of allocation. RESULTS: Two hundred thirty-seven adults and 151 children were randomized to nasal mometasone versus placebo, and 319 participants completed the study. There was no difference in the Childhood Asthma Control Test score (difference in change with mometasone - change with placebo [ΔM - ΔP], -0.38; 95% CI, -2.19 to 1.44; P = .68; age 6-11 years) or the Asthma Control Test score (ΔM - ΔP, 0.51; 95% CI, -0.46 to 1.48; P = .30; age ≥12 years) in those assigned to mometasone versus placebo. In children and adolescents (age 6-17 years) there was no difference in asthma or sinus symptoms but a decrease in episodes of poorly controlled asthma defined by a decrease in peak flow. In adults there was a small difference in asthma symptoms measured by using the Asthma Symptom Utility Index (ΔM - ΔP, 0.06; 95% CI, 0.01 to 0.11; P < .01) and in nasal symptoms (sinus symptom score ΔM - ΔP, -3.82; 95% CI, -7.19 to -0.45; P = .03) but no difference in asthma quality of life, lung function, or episodes of poorly controlled asthma in adults assigned to mometasone versus placebo. CONCLUSIONS: Treatment of chronic sinonasal disease with nasal corticosteroids for 24 weeks does not improve asthma control. Treatment of sinonasal disease in asthmatic patients should be determined by the need to treat sinonasal disease rather than to improve asthma control.

Association of nesfatin-1 and fat mass in cystic fibrosis.

BACKGROUND: The mechanisms of fat mass (FM) loss in cystic fibrosis (CF) are poorly understood but could represent complex pathways involving dysregulation of appetite-modulating peptides and an amplified inflammatory response. Nesfatin-1 is a newly described peptide that decreases food intake and FM but has not been studied in CF. OBJECTIVES: We hypothesized that changes in the appetite-suppressing hormone nesfatin-1 would be physiological, and levels would be lower in advanced CF patients with lower FM compared to those with milder disease and healthy controls. We determined the levels of the cytokines TNF-α, IL-1ß, and IL-6 as they have been associated with weight loss in disease states. METHODS: Fifty-four adult CF subjects, i.e. 17 with severe, 22 with moderate, and 15 with mild disease, as well as 18 controls were recruited. PFT and body composition analysis (via bioelectrical impedance) were performed. Nesfatin-1 and cytokine levels were determined by ELISA. RESULTS: Contrary to our proposed hypothesis, nesfatin-1 levels were highest in CF patients with severe disease and the lowest FM. A significant negative correlation between nesfatin-1 levels and FM was found only in the severe CF group (r = -0.7, p = 0.003). In forward stepwise regression analysis, only FM was significantly associated with nesfatin-1 levels. Levels of TNF-α and IL-6 were elevated in the severe CF group, but there was no association with either FM or nesfatin-1. CONCLUSION: In advanced CF and low FM, nesfatin-1 plasma levels are significantly increased and inversely correlated with the FM. Our results further suggest that nesfatin-1 exerts its effects independently of TNF-α or IL-6.

Finding an alternative diagnosis does not justify increased use of CT-pulmonary angiography.

BACKGROUND: The increased use of computed tomography pulmonary angiography (CTPA) is often justified by finding alternative diagnoses explaining patients' symptoms. However, this has not been rigorously examined. METHODS: We retrospectively reviewed CTPA done at our center over an eleven year period (2000 - 2010) in patients with suspected pulmonary embolus (PE). We then reviewed in detail the medical records of a representative sample of patients in three index years - 2000, 2005 and 2008. We determined whether CTPA revealed pulmonary pathology other than PE that was not readily identifiable from the patient's history, physical examination and prior chest X-ray. We also assessed whether the use of pre-test probability guided diagnostic strategy for PE. RESULTS: A total of 12,640 CTPA were performed at our center from year 2000 to 2010. The number of CTPA performed increased from 84 in 2000 to 2287 in 2010, a 27 fold increase. Only 7.6 percent of all CTPA and 3.2 percent of avoidable CTPAs (low or intermediate pre-test probability and negative D-dimer) revealed previously unknown findings of any clinical significance. When we compared 2008 to 2000 and 2005, more CTPAs were performed in younger patients (mean age (years) for 2000: 67, 2005: 63, and 2008: 60, (p=0.004, one-way ANOVA)). Patients were less acutely ill with fewer risk factors for PE. Assessment of pre-test probability of PE and D-dimer measurement were rarely used to select appropriate patients for CTPA (pre-test probability of PE documented in chart (% total) in year 2000: 4.1%, 2005: 1.6%, 2008: 3.1%). CONCLUSIONS: Our data do not support the argument that increased CTPA use is justified by finding an alternative pulmonary pathology that could explain patients' symptoms. CTPA is being increasingly used as the first and only test for suspected PE.

A return to 1992: Using the "blowhole" technique for diffuse subcutaneous emphysema caused by a broncho-pleural fistula.

A bronchopleural fistula (BPF) is an abnormal communication between the bronchial tree and pleural space resulting in a high risk for morbidity and mortality. We describe a case highlighting the management of a BPF with subcutaneous and mediastinal air resulting in dysphagia and dysphonia using a technique that was first described in a 1992 CHEST article. The "Blowhole" technique may be utilized for patients that are poor surgical candidates requiring rapid correction and prevention of detrimental consequences such as pneumomediastinum, tension pneumothorax, upper airway compromise and pneumopericardium.

Interactions and clinical implications of serological and respiratory variables 3 months after acute COVID-19.

Medical follow-up of symptomatic patients after acute Coronavirus Disease 2019 (COVID-19) results in major burdens on patients and healthcare systems. The value of serological markers as part of this follow-up remains undetermined. We aimed to evaluate the clinical implications of serological markers for follow-up of acute COVID-19. For this purpose, we conducted an observational cohort study of patients 3 months after acute COVID-19. Participants visited a respiratory-clinic between October 2020 and March 2021, and completed pulmonary function tests (PFTs), serological tests, symptom-related questionnaires, and chest CT scans. Overall, 275 patients were included at a median of 82 days (IQR 64-111) post infection. 162 (59%) patients had diffusing capacity for carbon monoxide corrected for hemoglobin (DLCOc) below 80%, and 69 (25%) had bilateral chest abnormalities on CT scan. In multivariate analysis, anti-S levels were an independent predictor for DLCOc (ß = - 0.14, p = 0.036). Anti-S levels were also associated with severe COVID-19 and older age, and correlated with anti-nucleocapsid (r = 0.30, p < 0.001) and antibodies to receptor binding domain (RBD, r = 0.37, p < 0.001). Other serological variables were not associated with clinical outcomes. In conclusion, symptomatic patients 3-months after COVID-19 had high respiratory symptomatic burden, in which anti-S levels were significantly associated with previous severe COVID-19 and DLCOc.

Nocturnal asthma.

PURPOSE OF REVIEW: The aim is to review pathophysiological mechanisms and treatment of nocturnal asthma. RECENT FINDINGS: Physiologic changes accompanying sleep, as well as the nocturnal phase of circadian rhythms, may have an adverse effect on asthma control. Chronotherapeutic principles, which consider circadian variation in relevant biologic rhythms, may improve asthma outcomes. Administration of long-acting bronchodilators and inhaled corticosteroids which achieve maximum efficacy at night may improve nocturnal asthma. Comorbid conditions that may contribute to nocturnal asthma should be considered. The prevalence of obstructive sleep apnea is greater in a cohort of patients with severe asthma than in moderate asthma and in BMI and age matched nonasthmatic controls, suggesting a link between these diseases. A large trial concluded that esomeprazole did not improve asthma control even with comorbid acid reflux, questioning the importance of acid reflux in asthma. The role of polymorphisms of the ß2-adrenergic receptor and their relationship with nocturnal asthma remain controversial. SUMMARY: Sleep is a time of vulnerability to respiratory compromise, especially in asthma patients experiencing nocturnal exacerbations. This asthma phenotype is associated with poorer control, reduced sleep quality, daytime somnolence and increased morbidity and mortality. Nocturnal asthma is a common but under-recognized problem.

The Madison Avenue effect: how drug presentation style influences adherence and outcome in patients with asthma.

BACKGROUND: Little is known about how drug presentation influences medication adherence. OBJECTIVE: To examine the effect of an educational program aimed at increasing expectations of treatment benefit on medication adherence. METHODS: Data are analyzed from 99 participants who underwent electronic drug monitoring during the Trial of Asthma Patient Education, a randomized, placebo-controlled, multicenter trial. Participants with suboptimally controlled asthma were randomized to placebo or montelukast in conjunction with a presentation mode that was either neutral or designed to increase outcome expectancy. Adherence was monitored electronically over 4 weeks and was defined as ≥ 80% use of prescribed doses. Outcome expectancy, peak expiratory flow, prebronchodilator FEV1, asthma control (Juniper asthma control questionnaire), and asthma-related quality of life were assessed at baseline and at the 4-week follow-up. RESULTS: Average electronic medication adherence was 69.9%. There was a significant interaction between presentation mode and drug assignment, with participants in the enhanced/montelukast group having a higher change in outcome expectancy (Δ 2.1 points; P < .001) and better medication adherence (odds ratio, 4.0; 95% CI, 1.1-14.3) compared with those in the neutral/placebo group. There was no difference in asthma symptoms, quality of life, or clinical outcomes on the basis of presentation mode. Rather, increased outcome expectancy was associated with modest improvements in asthma symptoms after adjusting for presentation mode, drug assignment, and medication adherence. CONCLUSION: The use of an enhanced presentation aimed at increasing outcome expectancy may lead to improved medication adherence.

Nebulizer Use by Black and Latinx Adults with Moderate to Severe Asthma.

BACKGROUND: Generally, a short-acting beta-2 agonist (SABA) delivered via metered-dose inhaler (MDI) is recommended for quick relief of asthma symptoms. However, in the PeRson EmPowered Asthma RElief (PREPARE) pragmatic trial, 67% of patients reported having used a nebulizer for SABA administration. OBJECTIVE: To understand preferences, experiences, and decision making regarding the use of nebulizers in Black and Latinx adults with uncontrolled asthma. METHODS: We interviewed 40 of the 1,201 PREPARE patients employing a matrix analysis. Those interviewed were Black (n = 20) and Latinx (n = 20) adults with uncontrolled asthma seeking primary or specialty care in clinics throughout the United States. Data were analyzed used a Rapid Assessment Procedures qualitative methodology, informed by grounded theory. RESULTS: Substudy participants, on average, reported using a nebulizer 3.5 times/wk. Daily use was common, and frequency ranged from less than daily to up to 6 times daily. Nearly all participants reported a longstanding history of nebulizer use. Participants tended to use their nebulizer at home, and some shared it with others in the home. Many reported preferring a nebulizer over an MDI for relief of severe symptoms and to avoid emergency room visits or hospitalizations. The extent to which cost affected nebulizer use varied among participants. CONCLUSIONS: Despite asthma guideline recommendations that MDIs be used rather than nebulizers for SABA administration, nebulizer use was common among PREPARE study participants. Clinicians should explore patients' history and experiences with nebulizer use as part of evaluation of asthma control.

Relationship of adipokines with immune response and lung function in obese asthmatic and non-asthmatic women.

BACKGROUND: Obesity is a risk factor for asthma. Studies in mice suggest that the adipokines leptin and adiponectin affect asthmatic responses. The purpose of this study was to determine if adipokines associated with obesity are (1) altered in obese women with asthma compared to controls and (2) associated with increased cytokines and chemokines involved in allergic inflammation. METHODS: We performed a cross-sectional study of asthmatic and non-asthmatic obese premenopausal women. Participants answered questionnaires and performed lung function tests. Serum and peripheral blood mononuclear cells (PBMCs) were collected for analysis of cytokines and adipokines. RESULTS: A total of 22 asthmatic (mean body mass index 40.0 ± 5.1 kg/m(2)) and 20 non-asthmatic women (mean body mass index 41.3 ± 5.6 kg/m(2)) participated. We found no difference in serum adipokine concentrations between asthmatics and non-asthmatics. Serum adiponectin correlated positively with PBMC eotaxin (r(s) = 0.55, p = .0003) and RANTES (regulated upon activation, normal T-cell expressed, and secreted) (r(s) = 0.36, p = .03), whereas serum leptin correlated negatively with PBMC eotaxin (r(s) = -0.34, p = .04). There was a negative correlation between serum adiponectin and PBMC interferon-γ (r(s) = -0.41, p = .01). CONCLUSIONS: Perturbations of adipokines that occur in obesity were correlated with decreased cytokine production typically associated with allergic responses in PBMC of obese premenopausal women. This study suggests that although obese asthmatics may have elements of Th2-mediated inflammation, adipokine derangements in obesity are associated with Th1 rather than Th2 bias. Obesity has complex effects on allergic inflammation and is likely to be important modifier of the pathogenesis of airway disease in asthma.

Effects of obstructive sleep apnea and gastroesophageal reflux disease on asthma control in obesity.

BACKGROUND: Obesity is a risk factor for asthma. Obese asthmatics often have poor asthma control and respond poorly to therapy. It has been suggested that co-morbidities associated with obesity, such as reflux and obstructive sleep apnea, could be important factors contributing to poor asthma control in obese patients. OBJECTIVES: The purpose of this study was to determine if (1) reflux and/or (2) symptoms of sleep apnea contribute to poor asthma control in obesity. METHODS: We studied asthmatic subjects participating in a trial of reflux treatment. Participants underwent baseline evaluation of asthma symptoms and lung function. Overall 304 participants underwent esophageal pH probe testing; 246 participants were evaluated for obstructive sleep apnea symptoms. RESULTS: Of 402 participants in this trial, 51% were obese. Role of reflux in asthma control. Those with higher body mass index (BMI) reported a higher prevalence of reflux symptoms, but the prevalence of pH probe acid reflux was similar in all groups. Reflux was not associated with measures of asthma control in obese patients. Role of obstructive sleep apnea in asthma control. Symptoms and self-report of obstructive sleep apnea were more common with increasing BMI and associated with worse asthma control as measured by the Juniper Asthma Control questionnaire and Asthma Symptom Utility Index. CONCLUSIONS: Our data suggest that obstructive sleep apnea, but not gastroesophageal reflux disease, may contribute significantly to poor asthma control in obese patients.

Ghrelin receptor expression in lymphocytes isolated from adult cystic fibrosis patients.

BACKGROUND: To explore mechanisms of weight loss in cystic fibrosis (CF), we studied ghrelin receptor expression on isolated lymphocytes from CF subjects with different body mass indices (BMIs). Eating behavior is influenced by hormone peptides such as ghrelin, a potent appetite stimulator. However, studies on ghrelin plasma levels in CF showed it to be increased in cachectic subjects, the expected physiological response. OBJECTIVES: (1) To compare ghrelin receptor expression between clinically stable CF subjects with normal BMI, CF subjects with cachexia and healthy controls. (2) To investigate ghrelin receptor expression in the same CF subjects before and after treatment for an acute exacerbation. METHODS: Lymphocytes were isolated from CF patients with normal BMI and low BMI and from controls. Ghrelin receptor quantification was determined via flow cytometry. Body composition was determined by bioelectrical impedance, and plasma levels of ghrelin, TNF-alpha, IL-1 and IL-6 were determined. RESULTS: CF subjects with low BMI had increased inflammation evidenced by increased plasma cytokines and showed decreased lymphocytic ghrelin receptor expression. Ghrelin receptor expression in the CF group with normal BMI was similar to controls; it decreased during an acute exacerbation associated with weight loss and returned to baseline following treatment and recovery of the weight loss. CONCLUSIONS: Differences exist in ghrelin receptor expression in lymphocytes isolated from stable CF patients with different BMIs. These changes may be due to a disordered pathological response to weight loss.

Randomized trial of the effect of drug presentation on asthma outcomes: the American Lung Association Asthma Clinical Research Centers.

BACKGROUND: Information that enhances expectations about drug effectiveness improves the response to placebos for pain. Although asthma symptoms often improve with placebo, it is not known whether the response to placebo or active treatment can be augmented by increasing expectation of benefit. OBJECTIVE: The study objective was to determine whether response to placebo or a leukotriene antagonist (montelukast) can be augmented by messages that increase expectation of benefit. METHODS: A randomized 20-center controlled trial enrolled 601 asthmatic patients with poor symptom control who were assigned to one of 5 study groups. Participants were randomly assigned to one of 4 treatment groups in a factorial design (ie, placebo with enhanced messages, placebo with neutral messages, montelukast with enhanced messages, or montelukast with neutral messages) or to usual care. Assignment to study drug was double masked, assignment to message content was single masked, and usual care was not masked. The enhanced message aimed to increase expectation of benefit from the drug. The primary outcome was mean change in daily peak flow over 4 weeks. Secondary outcomes included lung function and asthma symptom control. RESULTS: Peak flow and other lung function measures were not improved in participants assigned to the enhanced message groups versus the neutral messages groups for either montelukast or placebo; no differences were noted between the neutral placebo and usual care groups. Placebo-treated participants had improved asthma control with the enhanced message but not montelukast-treated participants; the neutral placebo group did have improved asthma control compared with the usual care group after adjusting for baseline difference. Headaches were more common in participants provided messages that mentioned headache as a montelukast side effect. CONCLUSIONS: Optimistic drug presentation augments the placebo effect for patient-reported outcomes (asthma control) but not lung function. However, the effect of montelukast was not enhanced by optimistic messages regarding treatment effectiveness.

Plasma ghrelin and leptin in adult cystic fibrosis patients.

BACKGROUND: Weight loss in cystic fibrosis (CF) may be associated with altered levels of appetite stimulating peptide ghrelin and the appetite decreasing peptide leptin. However, prior data on leptin in CF are conflicting, while the data on ghrelin are scarce. We hypothesized that weight loss in CF is associated with low levels ghrelin and elevated levels of leptin. METHODS: Plasma ghrelin, leptin, TNF-alpha, IL-1 and IL-6, BMI, fat free mass (FFM), fat mass (FM) were measured in 74 CF adults and 20 controls. CF subjects were divided into 3 groups based on lung disease: mild (n=19), moderate (n=30) and severe (n=25). RESULTS: Severe CF patients (% predicted FEV1 27+/-7; median BMI 21 kg/m2) had significantly elevated ghrelin and decreased leptin compared to controls and other CF subjects. Ghrelin correlated (r value, p value) with BMI (-0.35,<0.001), FFM (-0.22,<0.05), FM (-0.41,<0.0001), FEV1 (-0.62,<0.001), TNF-alpha (0.51,<0.0001), IL-1 (0.56,<0.0001), and IL-6 (0.33,<0.01). Leptin correlated (r value, p value) with BMI (0.40,<0.0001), FM (0.56,<0.0001), FEV1 (0.34,<0.05), IL-1 (-0.51,<0.05) and TNF-alpha (-0.43,<0.0001). BMI and FEV1 were independent predictors of ghrelin (-0.35,<0.05;-0.59,<0.001). FM was a predictor of leptin (0.56,<0.0001). Cytokines were elevated only in severe CF (severe CF vs. controls, pg/ml): TNF-alpha (3.4+/-0.6 vs. 1.2+/-0.4), IL-1 (3.5+/-1 vs. 0.2+/-0.1), IL-6 (17.4+/-4 vs. 2.4+/-2). CONCLUSIONS: Elevated ghrelin and decreased leptin levels are a consequence rather than a cause of weight loss in advanced CF.

Lean Methodology in Health Care.

To improve the delivery of patient care, governments and health-care institutions adopted quality improvement methods that had been developed decades earlier in manufacturing industries. Many health-care practitioners are either unaware or are inexperienced about what these practices entail and whether they are successful in health care. This article reviews Lean, an improvement philosophy made famous by the Toyota Motor Company. Lean uses a set of instruments and incorporates a long-term vision aiming for continuous improvement. It focuses on eliminating waste as perceived by the patient, thereby maximizing quality and safety for the patient. However, the effort required for the attainment of Lean's goals is often not appreciated. Indeed, successful and sustainable implementation requires immense institutional culture change combined with innovative leadership and motivated frontline health-care professionals.

Early in-hospital clinical deterioration is not predicted by severity of illness, functional status, or comorbidity.

BACKGROUND: Prior studies concentrated on unplanned intensive care unit (ICU) transfer to gauge deterioration occurring shortly following hospital admission. However, examining only ICU transfers is not ideal since patients could stabilize with treatment, refuse ICU admission, or not require ICU evaluation. To further explore etiologies of early clinical deterioration, we used rapid response team (RRT) activation within 48 hours of admission as an index of early clinical worsening. METHODS: A retrospective analysis of prospectively gathered admissions from the emergency department in an academic medical center was done. Data were reviewed independently by two physicians. We assessed severity of illness, functional status, comorbidity, the frequency of ICU and palliative care consultations, and changes in advance health care directives. RESULTS: Of 655 rapid responses (RRs) within the study period, 24.6% occurred within 48 hours of admission. Disease trajectory was the most frequent perceived reason for RRs (55.6% and 58.9%, reviewer 1 and 2, respectively) followed by medical error (15.6% and 15.2%). Acute physiology and chronic health evaluation II (APACHE-II) and modified early warning scores (MEWS) were higher at the time of RR compared to admission (p<0.0001). However, admission APACHE-II, MEWS, functional status, and comorbidity scores did not predict early RRs. One third of RRs resulted in ICU consultation and 95% were accepted. Palliative care consults were requested for 15%, the majority (65%) after RR and all resulting in advance directive change. CONCLUSION: Disease trajectory accounted for most clinical deterioration and medical error contributed to 15%. Our data suggest that it is difficult to predict early clinical deterioration as none of the measured parameters were associated with RRT activation.

CF healthcare workers feel unprepared in providing suitable end of life care and desire more education: Results of a nationwide survey.

INTRODUCTION: Little is known about the depth of knowledge and preparedness of CF caregivers in delivering end of life and palliative care to CF patients and families. METHOD: Nationwide survey questionnaires for CF care providers using the CF Foundation Listserv electronic web-based tool. RESULTS: The majority of non-physician CF care providers (55%) had more than 15 years of experience in their discipline and 84% of physician had greater than 15 years of experience. The majority reported that they felt "somewhat" or "very" involved in palliative or end of life care in their current role. Yet, when asked whether they felt adequately prepared to deliver palliative and end of life care, only 18% reported that they were "fully prepared" and 45% felt that they were only "minimally" or "not" prepared. Further, only one third of respondents received more than 10h of education in general palliative or end-of-life care, while only 10% had received more than 10h of education specific to CF end of life care. The majority (73%) of CF healthcare providers preferred more education specific to CF end of life care. CONCLUSION: CF healthcare providers are involved in CF end of life issues but a fair number did not understand their role and felt inadequately prepared in delivering suitable end of life and palliative care. Many desired more education in the provision of such care.