Optimizing routine screening for cardiac sarcoidosis through use of commonly available studies.

BACKGROUND: Sarcoidosis is a multisystem granulomatous disorder with unclear etiology. Morbidity and mortality vary based on organ involvement, with cardiac sarcoidosis (CS) associated with higher mortality; despite this, CS remains underdiagnosed. The Heart Rhythm Society (HRS) expert consensus statement recommends screening sarcoidosis patients for CS utilizing a symptom screen, EKG, and echocardiogram (TTE), while the American Thoracic Society (ATS) guideline recommends only EKG and symptom screening. These recommendations, however, are based on limited data with recommendations for further studies. RESEARCH QUESTION: The purpose is to evaluate the prevalence of abnormal screening tests in patients with sarcoidosis and the correlation of these tests with the subsequent diagnosis of CS. A specific emphasis was placed on evaluating the sensitivity of the recommendations versus the sensitivity of a modified criteria. STUDY DESIGN: and Methods: This study retrospectively evaluated a database of prospectively enrolled patients from a tertiary military academic center. All patients who underwent imaging with cardiac MRI and/or FDG-PET were identified. These results were correlated with screening studies (symptom screen, EKG, TTE, and ambulatory rhythm monitoring (ARM)) and used to calculate sensitivity, specificity, and positive and negative predictive values for each test. Using a clinical diagnosis of CS as the reference standard, the sensitivity and specificity of the HRS criteria were calculated and compared to a modified screening rubric developed a priori, consisting of minor changes to the criteria and the addition of ARM. RESULTS: This study evaluated 114 patients with sarcoidosis with 132 advanced imaging events, leading to a diagnosis of CS in 36 patients. Utilizing HRS screening recommendations, the sensitivity for CS was 63.9%, while the modified criteria increased sensitivity to 94.4%. INTERPRETATION: This study suggests that the HRS guidelines lack sensitivity to effectively screen for CS and that a modified screening model which includes ARM may be more effective.

Clinical Evaluation of Deployed Military Personnel With Chronic Respiratory Symptoms: Study of Active Duty Military for Pulmonary Disease Related to Environmental Deployment Exposures (STAMPEDE) III.

BACKGROUND: Chronic respiratory symptoms are frequently reported after Southwest Asia deployment in support of combat operations. The full spectrum of clinical lung diseases related to these deployments is not well characterized. METHODS: Military personnel with chronic symptoms, primarily exertional dyspnea, underwent a standardized cardiopulmonary evaluation at two tertiary medical centers. Pulmonary function testing consisted of spirometry, lung volume, diffusing capacity, impulse oscillometry, and bronchodilator testing. Further testing included methacholine challenge, exercise laryngoscopy, high-resolution CT scan, ECG, and transthoracic echocardiography. RESULTS: A total of 380 participants with a mean age of 38.5 ± 8.4 years completed testing. Asthma was the most common diagnosis in 87 patients (22.9%) based on obstructive spirometry/impulse oscillometry and evidence of airway hyperreactivity, whereas another 57 patients (15.0%) had reactivity with normal spirometry. Airway disorders included 25 (6.6%) with laryngeal disorders and 16 (4.2%) with excessive dynamic airway collapse. Interstitial lung disease was identified in six patients (1.6%), whereas 11 patients (2.9%) had fixed obstructive lung disorders. Forty patients (10.5%) had isolated pulmonary function abnormalities and 16 (4.2%) had miscellaneous disorders. The remaining 122 patients (32.1%) with normal studies were classified as undiagnosed exertional dyspnea. Significant comorbidities identified included elevated BMI > 30 kg/m2 (34.2%), smoking (36.4%), positive allergy testing (43.7%), sleep apnea (38.5%), and esophageal reflux (13.6%). Mental health disorders and posttraumatic stress disorder were likewise common. CONCLUSIONS: Postdeployment pulmonary evaluation should focus on common diseases, such as asthma and airway hyperreactivity, and include testing for upper airway disorders. Diffuse lung diseases were rarely diagnosed, whereas numerous comorbidities were common.

Lung function abnormalities among service members returning from Iraq or Afghanistan with respiratory complaints.

BACKGROUND: Service members deploying to Afghanistan (OEF) and Iraq (OIF) often return with respiratory symptoms. We sought to determine prevalence of lung function abnormalities following OEF/OIF. METHODS: We identified OEF/OIF patients who had unexplained respiratory symptoms evaluated using lung function testing. Lung function data were summarized and analyzed for associations with demographic and deployment characteristics. RESULTS: We found 267 patients with unexplained cough or dyspnea, lung function testing and a history of OEF/OIF deployment. All patients had basic spirometry performed and 82 had diffusion capacity for carbon dioxide (DLCO) measured. The median (IQR) number of deployments and total days deployed were 1 (1-2) and 352.0 (209-583), respectively. There were 83 (36.6%) patients with abnormal spirometry, 53 (63.9%) of whom had an abnormal FEV1/FVC. Only one (1.2%) patient had an abnormal DLCO adjusted for alveolar volume. Of 104 patients who had post bronchodilator (BD) testing performed, six (5.8%) had a positive response by ATS criteria. We found no relationships between lung function and time in theater, deployment location, deployment frequency, or land based-deployment. Dyspnea and enlisted rank were associated with tobacco use and lower FEV1, and cough was associated with total number of deployments. CONCLUSIONS: Service members with respiratory complaints following OEF/OIF have a high prevalence of abnormalities on spirometry. Tobacco use, enlisted rank and total number of deployments were associated with symptoms or spirometric abnormalities.

Invasive approaches to the diagnosis of ventilator-associated pneumonia: a meta-analysis.

OBJECTIVE: Ventilator-associated pneumonia remains a major challenge in the intensive care unit. The role for invasive diagnostic methods (e.g., bronchoscopy) remains unclear. We hypothesized that invasive testing would alter antibiotic management in patients with ventilator-associated pneumonia but would not necessarily alter mortality. DESIGN: Meta-analysis of randomized, controlled trials of invasive diagnostic strategies in suspected ventilator-associated pneumonia and a separate pooled analysis of prospective, observational studies of the effect of invasive cultures on antibiotic utilization in ventilator-associated pneumonia. SETTING: NA. PATIENTS: Subjects enrolled in the various clinical trials identified. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We identified four randomized, controlled trials that included 628 patients. The overall quality of these studies was moderate (median Jadad score of 5) and there was both clinical and statistical heterogeneity among these trials. Ventilator-associated pneumonia was confirmed bronchoscopically in 44-69% of participants, with Pseudomonas aeruginosa and Staphylococcus aureus being the most frequently isolated pathogens. Most subjects (90.3%) received adequate antibiotics; however, in one trial there was a significant difference between the invasive and noninvasive arms with respect to this factor. Overall, an invasive approach did not alter mortality (odds ratio 0.89, 95% confidence interval 0.56-1.41). Invasive testing, though, affected antibiotic utilization (odds ratio for change in antibiotic management after invasive sampling, 2.85, 95% confidence interval 1.45-5.59). Five prospective observational studies examined invasive testing and included 635 subjects. These reports confirm that invasive sampling leads to modifications in the antibiotic regimen in more than half of patients (pooled estimate for rate of alteration in antibiotic prescription, 50.3%, 95% confidence interval 35.9-64.6%). CONCLUSIONS: Few trials have systematically examined the impact of diagnostic techniques on outcomes for patients suspected of suffering from ventilator-associated pneumonia. Invasive strategies do not alter mortality. Invasive approaches to ventilator-associated pneumonia affect antibiotic use and prescribing.

Preoperative risk stratification using electron beam computed tomography in elective vascular surgery: relationship to clinical risk prediction and postoperative complications.

We studied the utility of electron beam computed tomography as a screening test for the cardiovascular risk of elective vascular surgery. In 45 patients undergoing principally carotid and aortic surgical procedures, coronary artery calcification was prevalent and severe, and related to the clinically predicted cardiovascular risk of the procedure. However, only the clinically predicted surgical risk, and not coronary artery calcification, was related to the incidence of perioperative cardiovascular complications.