The greatest human cost of the rapidly moving pandemic of SARS-CoV-2 may be due to its impact on the response to other diseases. One such other disease is tuberculosis (TB). All indications suggest ...that COVID-19-related diversions of healthcare resources and disruptions to public health programming will exacerbate the slower moving pandemic of TB. This is expected to set back TB elimination efforts by years. This is a prediction that is especially relevant to Canada, which has repeatedly failed to meet pre-set targets for the elimination of TB even before the COVID-19 pandemic began. A collaborative approach to achieve TB elimination, one that engages all care providers, has recently been emphasized by the STOP-TB Partnership. Among TB elimination strategies, frontline providers (e.g., family physicians, emergency room physicians, and others) are well positioned to identify candidates for the treatment of latent TB infection, and make the diagnosis of infection-spreading cases of TB in a timely manner, thereby interrupting forward-moving chains of transmission. Electronic medical records offer the promise of automating these processes. In this commentary, we promote broader engagement of the workforce across multiple sectors of medicine to reduce TB associated morbidity and mortality, interrupt transmission, and shrink the reservoir of latent TB infection.
Long-term noninvasive positive airway pressure (PAP) treatment is effective treatment for sleep-related breathing disorders and chronic hypercarbic respiratory failure secondary to chronic ...obstructive pulmonary disease (COPD). PAP treatment may be delivered as continuous positive airway pressure or noninvasive ventilation. Success in initiating PAP treatment and barriers to its use in adult patients with COPD are largely unknown. This systematic review aims to identify the acceptance of and adherence to PAP treatment prescribed for long-term use in adult patients with COPD and to summarize variables associated with these measures.
Seven online electronic databases will be searched by an experienced medical librarian to identify records containing the concepts "obstructive airways disease" and "noninvasive positive airway pressure" and "acceptance" or "adherence". Randomized and non-randomized studies of interventions will be included. Citation lists from relevant articles will be reviewed, and experts will be contacted regarding unpublished studies. Abstracts from key conferences between 2018-2023 and Google Scholar search results will be reviewed for inclusion. Titles, abstracts and full texts will be reviewed independently for inclusion by two reviewers. Data extraction will be completed by one author using a pre-established form and primary outcomes confirmed by a second author. Methodological quality will be evaluated. If sufficient data are available for meta-analysis, a pooled summary statistic for the primary outcome will be calculated using a random-effects generic inverse-variance meta-analysis, weighted proportion or weighted medians-based approach. Subgroup analysis will explore clinically meaningful sources of heterogeneity. Variables that are associated with acceptance and adherence will be described.
Long-term PAP treatment is a complex intervention prescribed to patients with COPD for several indications. Synthesis of the evidence on success with PAP treatment and variables associated with acceptance or adherence will inform program and policy development for supporting patients with COPD who are prescribed this therapy.
Systematic review registration: This protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) on July 13, 2021 (registration number CRD42021259262), with revisions submitted on April 17, 2023.
The management of patients with syncope in the emergency department (ED) is challenging because no robust risk tool available has been recommended for clinical use.
To validate the Canadian Syncope ...Risk Score (CSRS) in a new cohort of patients with syncope to determine its ability to predict 30-day serious outcomes not evident during index ED evaluation.
This prospective multicenter cohort study conducted at 9 EDs across Canada included patients 16 years and older who presented to EDs within 24 hours of syncope. Patients were enrolled from March 2014 to April 2018.
Baseline characteristics, CSRS predictors, and 30-day adjudicated serious outcomes, including arrhythmic (arrhythmias, interventions for arrhythmia, or unknown cause of death) and nonarrhythmic (myocardial infarction, structural heart disease, pulmonary embolism, or hemorrhage) serious outcomes, were collected. Calibration and discrimination characteristics for CSRS validation were calculated.
A total of 3819 patients were included (mean SD age 53.9 22.8 years; 2088 54.7% female), of whom 139 (3.6%) experienced 30-day serious outcomes, including 13 patients (0.3%) who died. In the validation cohort, there were no differences between the predicted and observed risk, the calibration slope was 1.0, and the area under the receiver operating characteristic curve was 0.91 (95% CI, 0.88-0.93). The empirical probability of a 30-day serious outcome during validation was 3.64% (95% CI, 3.09%-4.28%) compared with the model-predicted probability of 3.17% (95% CI, 2.66%-3.77%; P = .26). The proportion of patients with 30-day serious outcomes increased from 3 of 1631 (0.3%) in the very-low-risk group to 40 of 78 (51.3%) in the very-high-risk group (Cochran-Armitage trend test P < .001). There was a similar significant increase in the serious outcome subtypes with increasing CSRS risk category. None of the very-low-risk and low-risk patients died or experienced ventricular arrhythmia. At a threshold score of -1 (2145 of 3819 patients), the CSRS sensitivity and specificity were 97.8% (95% CI, 93.8%-99.6%) and 44.3% (95% CI, 42.7%-45.9%), respectively.
The CSRS was successfully validated and its use is recommended to guide ED management of patients when serious causes are not identified during index ED evaluation. Very-low-risk and low-risk patients can generally be discharged, while brief hospitalization can be considered for high-risk patients. We believe CSRS implementation has the potential to improve patient safety and health care efficiency.
Emergency Department (ED) crowding is a pervasive problem, yet there have been few comparisons of the extent of, and contributors to, crowding among different types of EDs. The study quantifies and ...compares crowding metrics for 16 high volume regional, urban and academic EDs in one Canadian province.
The National Ambulatory Care Reporting System (NACRS) provided ED presentations by adults to 16 high volume Alberta EDs during April 2010 to March 2015 for this retrospective cohort study. Time to physician initial assessment (PIA), length of stay (LOS) for discharges and admissions were grouped by start hour of presentation and facility. Multiple crowding metrics were created by taking the means, medians (PIA-M, LOS-M), and 90th percentiles of the hourly, ED-specific values. Similarly, proportion left against medical advice (LAMA) and proportion left without being seen (LWBS) were day and ED aggregated. Calculated based on the start of the presentation and the facility and for PIA and LOS. The mean, median, and 90th percentiles for the date and time ED-specific metrics for PIA and LOS were obtained. Summary statistics were used to describe crowding metrics.
There were 3,925,457 presentations by 1,420,679 adults. The number of presentations was similar for each sex and the mean age was 46 years. Generally, the three categories of EDs had similar characteristics; however, urban and academic/teaching EDs had more urgent triage scores and a higher percentage of admissions than regional EDs. The median of the PIA-M metric was 1 h23m across all EDs. For discharges, the median of the LOS-M metric was 3h21m whereas the median of the LOS-M metric for admissions was 10h08m. Generally, regional EDs had shorter times than urban and academic/teaching EDs. The median daily LWBS was 3.4% and the median daily LAMA was about 1%.
Emergency presentations have increased over time, and crowding metrics vary considerably among EDs and over the time of day. Academic/teaching EDs generally have higher crowding metrics than other EDs and urgent action is required to mitigate the well-known consequences of ED crowding.
Background
Influenza vaccination is recommended for asthmatic patients in many countries as observational studies have shown that influenza infection can be associated with asthma exacerbations. ...However, influenza vaccination has the potential to cause wheezing and adversely affect pulmonary function. While an overview concluded that there was no clear benefit of influenza vaccination in patients with asthma, this conclusion was not based on a systematic search of the literature.
Objectives
The objective of this review was to assess the efficacy and safety of influenza vaccination in children and adults with asthma.
Search methods
We searched the Cochrane Airways Group trials register and reviewed reference lists of articles. The latest search was carried out in November 2012.
Selection criteria
We included randomised trials of influenza vaccination in children (over two years of age) and adults with asthma. We excluded studies involving people with chronic obstructive pulmonary disease.
Data collection and analysis
Inclusion criteria and assessment of trial quality were applied by two review authors independently. Data extraction was done by two review authors independently. Study authors were contacted for missing information.
Main results
Nine trials were included in the first published version of this review, and nine further trials have been included in four updates. The included studies cover a wide diversity of people, settings and types of influenza vaccination, and we pooled data from the studies that employed similar vaccines.
Protective effects of inactivated influenza vaccine during the influenza season
A single parallel‐group trial, involving 696 children, was able to assess the protective effects of influenza vaccination. There was no significant reduction in the number, duration or severity of influenza‐related asthma exacerbations. There was no difference in the forced expiratory volume in one second (FEV1) although children who had been vaccinated had better symptom scores during influenza‐positive weeks. Two parallel‐group trials in adults did not contribute data to these outcomes due to very low levels of confirmed influenza infection.
Adverse effects of inactivated influenza vaccine in the first two weeks following vaccination
Two cross‐over trials involving 1526 adults and 712 children (over three years old) with asthma compared inactivated trivalent split‐virus influenza vaccine with a placebo injection. These trials excluded any clinically important increase in asthma exacerbations in the two weeks following influenza vaccination (risk difference 0.014; 95% confidence interval ‐0.010 to 0.037). However, there was significant heterogeneity between the findings of two trials involving 1104 adults in terms of asthma exacerbations in the first three days after vaccination with split‐virus or surface‐antigen inactivated vaccines. There was no significant difference in measures of healthcare utilisation, days off school/symptom‐free days, mean lung function or medication usage.
Effects of live attenuated (intranasal) influenza vaccination
There were no significant differences found in exacerbations or measures of lung function following live attenuated cold recombinant vaccine versus placebo in two small studies on 17 adults and 48 children. There were no significant differences in asthma exacerbations found for the comparison live attenuated vaccine (intranasal) versus trivalent inactivated vaccine (intramuscular) in one study on 2229 children (over six years of age).
Authors' conclusions
Uncertainty remains about the degree of protection that vaccination affords against asthma exacerbations that are related to influenza infection. Evidence from more recently published randomised trials of inactivated split‐virus influenza vaccination indicates that there is no significant increase in asthma exacerbations immediately after vaccination in adults or children over three years of age. We were unable to address concerns regarding possible increased wheezing and hospital admissions in infants given live intranasal vaccination.
Background Differentiating asthma from other causes of chronic airflow limitation, such as chronic obstructive pulmonary disease (COPD), can be difficult in a typical outpatient setting. The ...inflammation of asthma typically is different than that of COPD, and the degree of inflammation and cellular damage varies with asthma severity. Metabolomics is the study of molecules created by cellular metabolic pathways. Objectives We hypothesized that the metabolic activity of adults with asthma would differ from that of adults with COPD. Furthermore, we hypothesized that nuclear magnetic resonance spectroscopy (NMR) would measure such differences in urine samples. Methods Clinical and urine-based NMR data were collected on adults meeting the criteria of asthma and COPD before and after an exacerbation (n = 133 and 38, respectively) and from patients with stable asthma or COPD (n = 54 and 23, respectively). Partial least-squares discriminant analysis was performed on the NMR data to create models of separation (86 metabolites were measured per urine sample). Some subjects' metabolomic data were withheld from modeling to be run blindly to determine diagnostic accuracy. Results Partial least-squares discriminant analysis of the urine NMR data found unique differences in select metabolites between patients with asthma and those with COPD seen in the emergency department and even in follow-up after exacerbation. By using these select metabolomic profiles, the model could correctly diagnose blinded asthma and COPD with greater than 90% accuracy. Conclusion This is the first report showing that metabolomic analysis of human urine samples could become a useful clinical tool to differentiate asthma from COPD.
We determine the frequency of elevated blood pressure (BP) readings in the emergency department (ED), the proportion of patients with prior or subsequent diagnosis of hypertension assigned in other ...settings, and the association between ED BP levels and cardiovascular outcomes after ED discharge.
This was a retrospective cohort study using electronic medical records for all adults treated and released from a large-volume ED in 2016 that were linked to administrative records for all health care encounters in the province for 2 years before and after the index ED visit. The primary outcome measure was a composite of stroke or transient ischemic attack, acute coronary syndrome, new heart failure, or death.
Of 30,278 adults treated and released from the ED, 14,717 (48.6%) had elevated BP readings; 10,732 (72.9%) had no prior diagnosis of hypertension. Of the 3,480 patients with no prior diagnosis of hypertension but an ED BP greater than or equal to 160/100 mm Hg, 907 (26.1%) subsequently received a diagnosis of chronic hypertension or were prescribed antihypertensive therapy in other settings within 2 years. Among patients without a history of hypertension, those with an ED BP greater than or equal to 160/100 mm Hg were more likely to meet the composite outcome (stroke, transient ischemic attack, acute coronary syndrome, heart failure, or death) in the subsequent year (3.3% versus 2.5%) or 2 years (5.9% versus 3.8%) than those with ED BPs 120 to 139/80 to 89 mm Hg; however, after adjusting for age, sex, diabetes, atrial fibrillation, and prior cardiovascular disease, their risk was not elevated (adjusted hazard ratio 0.84; 95% confidence interval 0.71 to 1.004 during 2 years).
Elevated BP readings in the ED are common and are often the first time hypertension is detected; however, they were not associated with adverse cardiovascular outcomes within 2 years of the visit.
A COPD discharge bundle is a set of evidence-based practices aimed at improving patient outcomes after discharge from acute care settings following an exacerbation. We conducted a systematic review ...on the effectiveness of COPD discharge bundles and summarised their individual care elements.
Biomedical electronic databases and clinical trial registries were searched from database inception through April 2016 to identify experimental studies evaluating care bundles offered to patients with COPD at discharge. Random-effects meta-analyses of clinical trials data were conducted for hospital readmissions, mortality, and quality of life (QoL).
The review included 14 studies (5 clinical trials, 7 uncontrolled trials, and 2 interrupted time series). A total of 26 distinct elements of care were included in the bundles of individual studies. Evidence from four clinical trials with moderate-to-high risk of bias showed that COPD discharge bundles reduced hospital readmissions (pooled risk ratio (RR): 0.80; 95% CI 0.65 to 0.99). There was insufficient evidence that care bundles influence long-term mortality (RR: 0.74; 95% CI 0.43 to 1.28; four trials) or QoL (mean difference in St. George's Respiratory Questionnaire: 1.84; 95% CI -2.13 to 5.8).
Discharge bundles for patients with COPD led to fewer readmissions but did not significantly improve mortality or QoL. Future studies should employ higher quality research methods, fully report care bundle elements, implementation strategies and intervention fidelity to better evaluate the effectiveness of packaging evidence-based interventions together to improve outcomes of patients with COPD discharged from acute care settings.
Abstract Background Patients with frequent asthma exacerbations resulting in emergency department (ED) visits are at increased risk for future exacerbations. We examined the ability of 1 dose of ...benralizumab, an investigational antiinterleukin 5 receptor α monoclonal antibody, to reduce recurrence after acute asthma exacerbations. Methods In this randomized, double-blind, placebo-controlled study, eligible subjects presented to the ED with an asthma exacerbation, had partial response to treatment, and greater than or equal to 1 additional exacerbation within the previous year. Subjects received 1 intravenous infusion of placebo (n = 38) or benralizumab (0.3 mg/kg, n = 36 or 1.0 mg/kg, n = 36) added to outpatient management. The primary outcome was the proportion of subjects with greater than or equal to 1 exacerbation at 12 weeks in placebo vs the combined benralizumab groups. Other outcomes included the time-weighted rate of exacerbations at week 12, adverse events, blood eosinophil counts, asthma symptom changes, and health care resource utilization. Results The proportion of subjects with greater than or equal to 1 asthma exacerbation at 12 weeks was not different between placebo and the combined benralizumab groups (38.9% vs 33.3%; P = .67). However, compared with placebo, benralizumab reduced asthma exacerbation rates by 49% (3.59 vs 1.82; P = .01) and exacerbations resulting in hospitalization by 60% (1.62 vs 0.65; P = .02) in the combined groups. Benralizumab reduced blood eosinophil counts but did not affect other outcomes, while demonstrating an acceptable safety profile. Conclusions When added to usual care, 1 dose of benralizumab reduced the rate and severity of exacerbations experienced over 12 weeks by subjects who presented to the ED with acute asthma.
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