Alpha-1 Asthma Overlap Syndrome: a Clinical Overview.

PURPOSE OF REVIEW: Alpha-1 antitrypsin deficiency (AATD) is one of the most common genetic diseases that is associated with severe complications and yet remains underdiagnosed. The pulmonary symptoms of both AATD and asthma include cough, excessive sputum production, dyspnea, and wheezing. These symptoms overlap significantly leading to difficulty distinguishing between these two conditions and suspicion that there may be an overlap syndrome. We aim to discuss the pathophysiology, clinical manifestations, and treatment of both alpha-1 antitrypsin and asthma and how they may overlap. RECENT FINDINGS: Recent literature suggests that there is an association between asthma and AATD. This association has been hypothesized to be secondary to an imbalance of elastase and anti-elastase leading to a pro-inflammatory state in patients with AATD. This review serves to overview the pathophysiology, clinical manifestations, and treatment of alpha-1 antitrypsin, asthma, and the increasingly recognized intersection of the two, AATD-asthma overlap syndrome.

Will Remotely Based Pulmonary Rehabilitation Water Down Its Effectiveness?

Despite numerous benefits, traditional Pulmonary Rehabilitation (PR) as a resource remains underutilized in chronic lung disease. Less than 3% of eligible candidates for PR attend one or more sessions after hospitalization due to many barriers, including the ongoing COVID-19 pandemic. Emerging alternative models of PR delivery such as home-based PR, tele-rehabilitation, web-based PR, or hybrid models could help address these barriers. Numerous studies have tested the feasibility, safety, and efficacy of these methods, but there is wide variability across studies and methods. We conducted a literature review to help determine if these alternative delivery methods watered down the effectiveness of PR. To evaluate the effectiveness of remotely based PR, the authors performed a literature search for randomized controlled trials (RCTs), cohort studies, and case series using PubMed, CINAHL, and Medline to identify relevant articles through 1 May 2021. Twenty-six applicable studies were found in which 11 compared tele-rehabilitation to conventional clinic-based PR; 11 evaluated tele-rehabilitation using the patient's baseline status as control; and four compared tele-rehabilitation to no rehabilitation. Despite the different technologies used across studies, tele-rehabilitation was found to be both a feasible and an efficacious option for select patients with lung disease. Outcomes across these studies demonstrated similar benefits to traditional PR programs. Thus the existing data does not show that remotely based PR waters down the effectiveness of conventional PR. Use of remotely based PR is a feasible and effective option to deliver PR, especially for patients with significant barriers to conventional clinic-based PR. Additional, well-conducted RCTs are needed to answer the questions regarding its efficacy, safety, cost-effectiveness and who, among patients with COPD and other lung diseases, will derive the maximum benefit.

Impact of Adjuvant Anticonvulsant Medications on Benzodiazepine Use and Delirium in Alcohol Withdrawal Syndrome.

Objective: To assess the benefits of anticonvulsant medications on benzodiazepine (BZD) use and delirium in patients with alcohol dependence at risk of alcohol withdrawal and admitted to the hospital without delirium.Methods: This was a resident-led retrospective study of prospectively collected data for patients admitted to the monitored unit of a general medical ward between June 2016 and March 2017 for a variety of medical conditions. Patients were assigned to the usual care group (BZD as needed) or the intervention group (scheduled anticonvulsants and BZD as needed) based on admission census and order of arrival. Of 75 patients, 44 were assigned to the usual care group and 31 to the intervention group.Results: Significantly lower BZD dosage (P = .0002) and lower Clinical Institute Withdrawal Assessment for Alcohol Scale-Revised scores were observed in the intervention group. Delirium occurred significantly less in the intervention group (0 versus 7 in the usual care group; P = .037).Conclusions: Adjuvant anticonvulsant medications for alcohol withdrawal were efficacious in reducing BZD use, severity of symptoms of alcohol withdrawal, and occurrence of delirium in patients admitted to the general medical ward without delirium for reasons other than alcohol detoxification.

Anticoagulation in Pulmonary Arterial Hypertension: Do We Know the Answer?

The shear stress and hypoxia in the pulmonary artery in patients with pulmonary arterial hypertension(PAH) causes endothelial dysfunction, smooth muscle proliferation and activation of thrombotic pathways leading to in situ thrombosis. Targeting the thrombotic pathways is a proposed mechanism to slow disease progression and improve survival. Over the years, the survival in patients with PAH has improved due to multiple factors with the increased use of anticoagulation as one of them. Both European Respiratory Society/European Society of Cardiology and American College of Cardiology/American Heart Association guidelines make grade II recommendations for using anticoagulation in PAH. The guidelines are based on weak observational studies with high risk of bias which have only studied warfarin as the choice of anticoagulation. In this article, we review the pathophysiology, rationale and the current literature investigating the role of anticoagulation in PAH.

An internal medicine residency's response to the COVID-19 crisis: caring for our residents while caring for our patients.

BACKGROUND: In response to the COVID-19 pandemic, internal medicine residencies have had to develop new teaching strategies and attend to wellness concerns. Providing front-line care for patients in a time of widespread crisis while maintaining attention to training has created unprecedented challenges. OBJECTIVE: Our large community hospital based internal medicine residency sought to develop and evaluate a crisis response to the demands of the COVID-19 pandemic to meet our residents' educational and wellness needs. METHODS: In March 2020, our residency developed a crisis plan for functioning during the COVID-19 pandemic. A brief survey was sent via email to our 149 residents to obtain their evaluation of how well their needs were being met by this response. RESULTS: 92 (62%) residents completed the survey. 88% indicated their well-being needs were well met. Other components were also rated as successful: effective communication (86%), scheduling/staffing (78%), preparing residents for clinical service (77%), and educational needs (76%). CONCLUSIONS: Our residency crisis response to the COVID-19 pandemic was favorably evaluated by our residents in meeting their training and well-being needs. In future work we plan to seek longer-term and more objective measures to assess how residents fare during these challenging times, and to use lessons learned to prepare for future crisis situations.

Participant retention in trauma intensive care unit (ICU) follow-up studies: a post-hoc analysis of a previous scoping review.

BACKGROUND: The study aimed to synthesize participant retention-related data for longitudinal follow-up studies of survivors from trauma intensive care units (ICUs). METHODS: Within a published scoping review evaluating ICU patient outcomes after hospital discharge, two screeners independently searched for trauma ICU survivorship studies. RESULTS: There were 11 trauma ICU follow-up studies, all of which were cohort studies. Twelve months (range: 1-60 months) was the most frequent follow-up time point for assessment (63% of studies). Retention rates ranged from 54% to 94% across time points and could not be calculated for two studies (18%). Pooled retention rates at 3, 6, and 12 months were 75%, 81%, and 81%, respectively. Mean patient age (OR 0.85 per 1-year increase, 95% CI 0.73 to 0.99, p=0.036), percent of men (OR 1.07, 95% CI 1.04 to 1.10, p=0.002), and publication year (OR 0.89 per 1-year increase, 95% CI 0.82 to 0.95, p=0.007) were associated with retention rates. Early (3-month) versus later (6-month, 12-month) follow-up time point was not associated with retention rates. DISCUSSION: Pooled retention rates were >75%, at 3-month, 6-month, and 12-month time points, with wide variability across studies and time points. There was little consistency with reporting participant retention methodology and related data. More detailed reporting guidelines, with better author adherence, will help improve reporting of participant retention data. Utilization of existing research resources may help improve participant retention. LEVEL OF EVIDENCE: Level III: meta-analyses (post-hoc analyses) of a prior scoping review.

High Scan Volume with Low Positive Scan Rate in Highest Utilizers: Computed Tomography Pulmonary Angiography in the Emergency Department.

BACKGROUND: We examined utilization patterns and predictors of computed tomography pulmonary angiography (CTPA) results in the emergency department (ED). OBJECTIVES: We retrospectively determined ED CTPA positive scan rate (PSR) among ED attendings based on a system that grouped attendings into scan quantity categories through >100. METHODS: We manually reviewed all scans ordered in 2017 in EDs in a multisite medical system. RESULTS: Of 10,032 ED CTPAs, 6168 were ordered by 153 ED attendings. Most attendings (123/153; 80%) ordered 60 or fewer scans with relatively high PSR (259/2927, PSR 8.8%; 95% confidence interval 7.8-9.9%). Of the ED attendings, 13 (3%) ordered more than 100 scans each (1981 scans; 32% of all scans), with PSR of 5.5% (95% confidence interval 4.5-6.5%). CONCLUSION: Most ED attendings were low- to mid-volume utilizers of CTPA and had a relatively high PSR. However, the small percentage of attendings who ordered more than 100 scans each accounted for a large percentage of the total scan volume and had a relatively low PSR. These findings suggest that sharing of performance feedback and best practices in the highest utilizers could help to improve CTPA PSR in the ED.

Impact of traumatic brain injury on sleep: an overview.

Traumatic brain injury (TBI) is a global health problem that affects millions of civilians, athletes, and military personnel yearly. Sleeping disorders are one of the underrecognized sequalae even though they affect 46% of individuals with TBI. After a mild TBI, 29% of patients have insomnia, 25% have sleep apnea, 28% have hypersomnia, and 4% have narcolepsy. The type of sleep disturbance may also vary according to the number of TBIs sustained. Diffuse axonal injury within the sleep regulation system, disruption of hormones involved in sleep, and insults to the hypothalamus, brain stem, and reticular activating system are some of the proposed theories for the pathophysiology of sleep disorders after TBI. Genetic and anatomical factors also come to play in the development and severity of these sleeping disorders. Untreated sleep disturbances following TBI can lead to serious consequences with respect to an individual's cognitive functioning. Initial management focuses on conservative measures with progression to more aggressive options if necessary. Future research should attempt to establish the effectiveness of the treatments currently used, as well as identify manageable co-existing factors that could be exacerbating sleep disorders.