Disease Management plus Recommended Care versus Recommended Care Alone for Ambulatory Patients with Chronic Obstructive Pulmonary Disease.

Rationale: The efficacy of disease management programs in the treatment of patients with chronic obstructive pulmonary disease (COPD) remains uncertain.Objectives: To study the effect of disease management (DM) added to recommended care (RC) in ambulatory patients with COPD.Measurements and Main Results: In this trial, 1,202 patients with COPD (age, ≥40 yr), with moderate to very severe airflow limitation were randomly assigned either to DM plus RC (study intervention) or to RC alone (control intervention). RC included follow-up by pulmonologists, inhaled long-acting bronchodilators and corticosteroids, smoking cessation intervention, nutritional advice and psychosocial support when indicated, and supervised physical activity sessions. DM, delivered by trained nurses during patients' visits to the designated COPD centers and by remote contacts with the patients between these visits, included patient self-care education, monitoring patients' symptoms and adherence to treatment, provision of advice in case of acute disease exacerbation, and coordination of care vis-à-vis other healthcare providers. The primary composite endpoint was first hospital admission for respiratory symptoms or death from any cause. During 3,537 patient-years, 284 patients (47.2%) in the control group and 264 (44.0%) in the study intervention group had a primary endpoint event. The median (range) time elapsed until a primary endpoint event was 1.0 (0-4.0) years among patients assigned to the study intervention and 1.1 (0-4.1) years among patients assigned to the control intervention; adjusted hazard ratio, 0.92 (95% confidence interval, 0.77-1.08).Conclusions: DM added to RC was not superior to RC alone in delaying first hospital admission or death among ambulatory patients with COPD.

Long-term reflux-related symptoms after bariatric surgery: comparison of sleeve gastrectomy versus laparoscopic adjustable gastric banding.

BACKGROUND: Long-term pulmonary reflux-related symptoms following laparoscopic adjustable gastric banding (LAGB) and laparoscopic sleeve gastrectomy (LSG) have not been reported. METHODS: We designed a retrospective analysis of consecutive patients who underwent LAGB or LSG between January 2000 and December 2010. All patients provided detailed history and physical examination. We assessed both early and late reflux-related symptoms. All patients underwent spirometry and chest X-ray (CXR). RESULTS: The analysis included 307 patients who underwent either LAGB (n = 193) or LSG (n = 114). Mean age was 43 ± 12 and 46 ± 11 years, respectively; 144 (76.6 %) and 83 (73 %) were female, respectively. Similar rates of previous pulmonary disease were noted in both LAGB and LSG groups (10.9 vs. 10.5 %, respectively). However, more patients with sleep apnea were in the LSG group (13.2 vs. 6.2 %, p = 0.03). The mean interval between surgery and the onset of pulmonary symptoms was longer in patients who underwent LAGB (72 ± 22 months) than for those who had LSG (36 ± 24 months; p = 0.03). The overall complication rate was higher in the LAGB (7.3 %) than in LSG (4.4 %) group. LSG patients had significantly lower rates of morning cough (12.3 vs. 59.6 %, p = 0.001) and postprandial cough (10.5 vs. 58 %, p = 0.001) compared to the LAGB patients. Two cases of pneumonia occurred in each group. The mortality rate was zero in both groups. CONCLUSION: Both surgeries are considered safe and without major reflux-related symptoms. There is a lower incidence of cough with LSG than with LAGB.

[Pleural effusion in chronic obstructive pulmonary medicine (COPD) patients in a medical intensive care unit: characteristics and clinical implications].

BACKGROUND: Pleural effusions are common among patients admitted to an Intensive-Care Unit (ICU). AIM: To retrospectively assess the role of pleural effusions in chronic obstructive pulmonary disease (COPD) patients admitted to a Medical ICU (MICU). PATIENTS AND METHODS: We reviewed records of patients admitted over 12-months to the MICU with a diagnosis of COPD. We colLected clinical and laboratory data for their entire MICU stay. A radiologist reviewed all chest radiographs to determine the presence and estimated volume of pleural effusions. RESULTS: A total of 100 consecutive patients with COPD admitted to the MICU were included; 32 (32%) developed pleural effusions. COPD exacerbations were more common among patients without pleural effusion. Congestive heart failure (CHF) exacerbations were more common among patients with pleural effusions (p=0.001 and p=0.006, respectively). The length of stay was significantly longer among COPD patients with a pleural effusion (19 +/- 8 days) than those without it (14 +/- 3 days, p=0.001). The mortality rate was similar (40%) in both groups. Only patients with a large or unexplained effusion (19%) underwent thoracocentesis. In all cases, the pleural fluids were transudate and confirmed the diagnosis of CHF. CONCLUSIONS: Pleural effusion is common among COPD patients admitted to a MICU. Most are due to CHF and parapneumonic effusions and respond well to treatment of the underlying problem.

Pulmonary complications following laparoscopic adjustable gastric banding.

Laparoscopic adjustable silicone banding (LAP-BAND) has rapidly gained acceptance and is now considered the most common bariatric operation. The accumulated experience with LAP-BAND has established this surgical method as safe and effective. However, no data have been issued concerning pulmonary complications following the procedure. We have recently experienced 3 cases of pulmonary complications following LAP-BAND surgery: 1 patient with pulmonary cavitation and 2 with bronchiectasis. Pulmonary physicians should be aware of the possibility of long-term pulmonary complications in patients who have undergone LAP-BAND surgery.

First experience with the home-care management system for respiratory patients in Israel.

BACKGROUND: Ventilator-dependent patients represent an increasing clinical logistic and economic burden. An alternative solution might be monitored home care with high-tech ventilatory support systems. OBJECTIVES: To explore the implications of such home care management, such as its impact on quality of life and its cost-effectiveness, and to assess the practical feasibility of this mode of home care in Israel. METHODS: We surveyed 25 partly or fully home-ventilated patients (17 males and 8 females), average age 37.6 years (range 1-72), who were treated through a home care provider during a 2 year period. RESULTS: Most patients (n = 18) had a neuromuscular respiratory disorder. The average hospital stay of these patients prior to entry into the home care program was 181.2 days/per patient. The average home care duration was 404.9 days/per patient (range 60-971) with a low hospitalization rate of 3.3 +/- 6.5 days/per patient. The monthly expenditure for home care of these patients was one-third that of the hospital stay cost ($3.546.9 vs. $11.000, per patient respectively). The patients reported better quality of life in the home care environment, as assessed by the Sickness impact Profile questionnaire. CONCLUSIONS: Home ventilation of patients in Israel by home care providers is a practical and attractive treatment modality in terms of economic benefits and quality of life.