Effects of early enteral feeding on the outcome of critically ill mechanically ventilated medical patients.

STUDY OBJECTIVES: To determine the impact of early enteral feeding on the outcome of critically ill medical patients. DESIGN: Retrospective analysis of a prospectively collected large multi-institutional ICU database. PATIENTS: A total of 4,049 patients requiring mechanical ventilation for > 2 days. MEASUREMENTS AND RESULTS: Patients were classified according to whether or not they received enteral feeding within 48 h of mechanical ventilation onset. The 2,537 patients (63%) who did receive enteral feeding were labeled as the "early feeding group," and the remaining 1,512 patients (37%) were labeled as the "late feeding group." The overall ICU and hospital mortality were lower in the early feeding group (18.1% vs 21.4%, p = 0.01; and 28.7% vs 33.5%, p = 0.001, respectively). The lower mortality rates in the early feeding group were most evident in the sickest group as defined by quartiles of severity of illness scores. Three separate models were done using each of the different scores (acute physiology and chronic health evaluation II, simplified acute physiology score II, and mortality prediction model at time 0). In all models, early enteral feeding was associated with an approximately 20% decrease in ICU mortality and a 25% decrease in hospital mortality. We also analyzed the data after controlling for confounding by matching for propensity score. In this analysis, early feeding was again associated with decreased ICU and hospital mortality. In all adjusted analysis, early feeding was found to be independently associated with an increased risk of ventilator-associated pneumonia (VAP) developing. CONCLUSION: Early feeding significantly reduces ICU and hospital mortality based mainly on improvements in the sickest patients, despite being associated with an increased risk of VAP developing. Routine administration of such therapy in medical patients receiving mechanical ventilation is suggested, especially in patients at high risk of death.

Evaluation of the causes for racial disparity in surgical treatment of early stage lung cancer.

STUDY OBJECTIVES: Black patients undergo surgical treatment for early stage lung cancer less often than whites. We wanted to determine the causes for the racial difference in resection rates. DESIGN: We studied a retrospective cohort of patients who presented to our institution with potentially resectable lung cancer (stage I or II) between the years 1995 and 1998, inclusive. SETTING: A tertiary-referral hospital and clinic with a cancer database of all lung cancer patients seen. PATIENTS: A total of 281 patients were included: 97 black patients (35%) and 184 white patients (65%). MEASUREMENTS AND RESULTS: The surgical rate was significantly lower in blacks than in whites (56 of 97 patients [58%] vs 137 of 184 patients [74%], p = 0.004). We could not find evidence that the rate at which surgical treatment was offered was different between the two racial groups (68 of 97 black patients [70%] and 145 of 184 white patients [79%], p = 0.11). After controlling for preoperative pulmonary function, tumor stage, history of smoking, and significant comorbidities, we were unable to show that race was a predictor of being offered surgical treatment (odds ratio, 0.46; 95% confidence interval, 0.18 to 1.14; p = 0.09). The difference in surgical rates was mainly due to the fact that blacks were found to decline surgical treatment more often than their white counterparts (12 of 68 patients [18%] vs 7 of 145 patients [5%], p = 0.002). CONCLUSIONS: Our analysis suggests that the lower surgical rate among black patients with early stage lung cancer is mainly due to low rates of acceptance of surgical treatment.

Endobronchial cryptococcosis: a rare cause of lung collapse.

We encountered a 46-year-old immunocompetent male patient who presented with a right upper lobe collapse on a chest x-ray. A flexible bronchoscopic examination revealed an endobronchial mass emanating from the right upper lobe and obstructing the right mainstem bronchus. Bronchial washings and biopsy of the lesion were consistent with cryptococcal infection. The response to oral diflucan therapy was suboptimal. Subsequently, the patient underwent a successful bronchoscopic resection of this mass with the placement of an endobronchial stent. We report this rare case of endobronchial cryptococcal infection treated with a combination of an antifungal agent and bronchoscopic debulking.

Update in screening of lung cancer.

In the USA, lung cancer is the leading cause of cancer death. Earlier studies of CXR and sputum cytology screening conducted in the 1970s showed no mortality benefit. Accordingly, mass screening for lung cancer was abandoned and is not currently recommended. Recently, interest in lung cancer screening has been revived due to various reports showing an advantage of low-dose CT over CXR in detecting smaller size tumours and at an earlier stage. Although these reports generated much enthusiasm for screening among clinicians and the general public, the effectiveness of low-dose CT in reducing lung cancer-specific mortality rates has not been demonstrated. Large-scale randomized controlled trials are currently in progress to determine the efficacy of CXR and low-dose CT screening. This review highlights the advantages and limitations of current modalities for lung cancer screening. The cases for and against screening with currently available modalities are examined. Additional new screening modalities are also discussed.

Cancer and interstitial lung disease.

PURPOSE OF REVIEW: This review assesses the contribution of various conditions that cause interstitial lung disease to the development of cancer. RECENT FINDINGS: Interstitial lung diseases for which the available evidence suggests an increased risk of lung cancer include idiopathic pulmonary fibrosis, systemic sclerosis, and certain forms of pneumoconioses. The pathogenesis of lung cancer remains unclear, and the available data on inflammation-induced pulmonary fibrosis as a risk factor for lung cancer are summarized. There is inadequate evidence for any conclusions about the risk of solid tumors and hematologic malignancies in patients with sarcoidosis, rheumatoid arthritis, and systemic lupus erythematosus. An increased incidence of lymphoma is detected in Sjögren's syndrome. For patients with dermatomyositis and polymyositis, there is a well-documented association with a wide range of cancers. SUMMARY: Further studies are needed to clarify the cause(s) and the mechanisms that link various interstitial lung diseases and cancer.