Pulmonary Health Hub

Sleep is an issue for many patients with cystic fibrosis, but noninvasive measures can ease at least some of the problem, according to Dr. Eliot Katz of Harvard Medical School, Boston.

A host of factors can disrupt sleep for patients with CF, including chronic cough, hypoventilation, musculoskeletal pain, gastrointestinal reflux, abdominal discomfort, depression, and the need for frequent defecation, Dr. Katz noted. Children with CF may also have obstructive sleep apnea caused by factors such as adenotonsillar hypertrophy and chronic rhinosinusitis. Some patients also take medications that disrupt sleep or struggle to sleep because they receive overnight enteral feeding, he added (Clin. Chest. Med. 2014 [doi:10.1016/j.ccm.2014.06.005]).

Patients also may develop nocturnal hypercapnia and hypoxemia during sleep. Although nocturnal hypoxemia is most common in patients with advanced lung disease (FEV₁ less than 65%), it can also affect patients with milder lung disease, Dr. Katz said. "Hypoxemia is not usually associated with arousal from sleep and, therefore, may be unrecognized," he noted.

As their lung disease progresses, patients with CF develop hypercapnia and subsequent dyspnea, which can be relieved, at least in the short term, by noninvasive ventilation to increase tidal volume and minute ventilation during sleep, Dr. Katz said. He noted that in a study of patients with advanced lung disease, minute ventilation was 22% lower during REM sleep than when patients were awake breathing room air, but was only 14% lower when sleeping patients received noninvasive ventilation (Am. J. Respir. Crit. Care. Med. 2001;163;129-34).

Dr. Katz reported no funding sources and had no disclosures.

Sleep is an issue for many patients with cystic fibrosis, but noninvasive measures can ease at least some of the problem, according to Dr. Eliot Katz of Harvard Medical School, Boston.

A host of factors can disrupt sleep for patients with CF, including chronic cough, hypoventilation, musculoskeletal pain, gastrointestinal reflux, abdominal discomfort, depression, and the need for frequent defecation, Dr. Katz noted. Children with CF may also have obstructive sleep apnea caused by factors such as adenotonsillar hypertrophy and chronic rhinosinusitis. Some patients also take medications that disrupt sleep or struggle to sleep because they receive overnight enteral feeding, he added (Clin. Chest. Med. 2014 [doi:10.1016/j.ccm.2014.06.005]).

Patients also may develop nocturnal hypercapnia and hypoxemia during sleep. Although nocturnal hypoxemia is most common in patients with advanced lung disease (FEV₁ less than 65%), it can also affect patients with milder lung disease, Dr. Katz said. "Hypoxemia is not usually associated with arousal from sleep and, therefore, may be unrecognized," he noted.

As their lung disease progresses, patients with CF develop hypercapnia and subsequent dyspnea, which can be relieved, at least in the short term, by noninvasive ventilation to increase tidal volume and minute ventilation during sleep, Dr. Katz said. He noted that in a study of patients with advanced lung disease, minute ventilation was 22% lower during REM sleep than when patients were awake breathing room air, but was only 14% lower when sleeping patients received noninvasive ventilation (Am. J. Respir. Crit. Care. Med. 2001;163;129-34).

Dr. Katz reported no funding sources and had no disclosures.

Sleep is an issue for many patients with cystic fibrosis, but noninvasive measures can ease at least some of the problem, according to Dr. Eliot Katz of Harvard Medical School, Boston.

A host of factors can disrupt sleep for patients with CF, including chronic cough, hypoventilation, musculoskeletal pain, gastrointestinal reflux, abdominal discomfort, depression, and the need for frequent defecation, Dr. Katz noted. Children with CF may also have obstructive sleep apnea caused by factors such as adenotonsillar hypertrophy and chronic rhinosinusitis. Some patients also take medications that disrupt sleep or struggle to sleep because they receive overnight enteral feeding, he added (Clin. Chest. Med. 2014 [doi:10.1016/j.ccm.2014.06.005]).

Patients also may develop nocturnal hypercapnia and hypoxemia during sleep. Although nocturnal hypoxemia is most common in patients with advanced lung disease (FEV₁ less than 65%), it can also affect patients with milder lung disease, Dr. Katz said. "Hypoxemia is not usually associated with arousal from sleep and, therefore, may be unrecognized," he noted.

As their lung disease progresses, patients with CF develop hypercapnia and subsequent dyspnea, which can be relieved, at least in the short term, by noninvasive ventilation to increase tidal volume and minute ventilation during sleep, Dr. Katz said. He noted that in a study of patients with advanced lung disease, minute ventilation was 22% lower during REM sleep than when patients were awake breathing room air, but was only 14% lower when sleeping patients received noninvasive ventilation (Am. J. Respir. Crit. Care. Med. 2001;163;129-34).

Dr. Katz reported no funding sources and had no disclosures.

The rate of secondary transmission to household members of patients with Middle East respiratory syndrome coronavirus (MERS-CoV) is 4%, a study has shown.

The researchers studied 26 symptomatic index patients in Saudi Arabia along with 280 of their household contacts, and found only 12 with laboratory evidence of infection. The report was published online Aug. 27 in the New England Journal of Medicine.

Courtesy of Maureen Metcalfe/Azaibi Tamin

Dr. Christian Drosten of the University of Bonn (Germany) Medical Center and colleagues found the 12 contacts to have laboratory evidence of MERS-CoV infection a median of 17.5 days from onset of symptoms in the index patients they lived with. Two of the infected household contacts reported having had contact with camels. All 280 contacts were screened via RT-PCR assays on RNA from throat swabs along with serologic testing that included enzyme-linked immunosorbent assays (ELISAs), and immunofluorescence assays.

Of the 12 with evidence of infection, 7 carried MERS-CoV in their upper respiratory tract, generally in low levels. Nonetheless, "positive RT-PCR findings in persons with subclinical infection who are tested soon after exposure should be complemented by serologic analysis," the investigators wrote.

The median age of the household contacts in the study was 29, and of the 12 infected, only one developed symptoms, which were mild. "Persons in the first few decades of life without coexisting illnesses may be able to carry low levels of MERS-CoV RNA without obvious symptoms," the researchers wrote (N. Engl. J. Med. 2014 Aug. 27 [doi:10.1056/NEJMoa1405858]).

The investigators cited as a weakness of their study the fact that only 44 of the 280 contacts originally tested provided follow-up samples. This was because the first round of testing was obligatory in Saudi Arabia, and the second, voluntary. The lack of follow-up testing meant that "we cannot determine whether we may have missed contacts who had delayed seroconversion," they wrote.

Dr. Drosten’s research was funded by the European Commission and German government grants. One coauthor reported receiving payment from the Institute for Experimental Immunology affiliated with EuroIMMUN, a maker of reagents for diagnostics, and another reported support from EuroIMMUN as well as a pending patent related to human betacoronavirus lineage.

The rate of secondary transmission to household members of patients with Middle East respiratory syndrome coronavirus (MERS-CoV) is 4%, a study has shown.

The researchers studied 26 symptomatic index patients in Saudi Arabia along with 280 of their household contacts, and found only 12 with laboratory evidence of infection. The report was published online Aug. 27 in the New England Journal of Medicine.

Courtesy of Maureen Metcalfe/Azaibi Tamin

Dr. Christian Drosten of the University of Bonn (Germany) Medical Center and colleagues found the 12 contacts to have laboratory evidence of MERS-CoV infection a median of 17.5 days from onset of symptoms in the index patients they lived with. Two of the infected household contacts reported having had contact with camels. All 280 contacts were screened via RT-PCR assays on RNA from throat swabs along with serologic testing that included enzyme-linked immunosorbent assays (ELISAs), and immunofluorescence assays.

Of the 12 with evidence of infection, 7 carried MERS-CoV in their upper respiratory tract, generally in low levels. Nonetheless, "positive RT-PCR findings in persons with subclinical infection who are tested soon after exposure should be complemented by serologic analysis," the investigators wrote.

The median age of the household contacts in the study was 29, and of the 12 infected, only one developed symptoms, which were mild. "Persons in the first few decades of life without coexisting illnesses may be able to carry low levels of MERS-CoV RNA without obvious symptoms," the researchers wrote (N. Engl. J. Med. 2014 Aug. 27 [doi:10.1056/NEJMoa1405858]).

The investigators cited as a weakness of their study the fact that only 44 of the 280 contacts originally tested provided follow-up samples. This was because the first round of testing was obligatory in Saudi Arabia, and the second, voluntary. The lack of follow-up testing meant that "we cannot determine whether we may have missed contacts who had delayed seroconversion," they wrote.

Dr. Drosten’s research was funded by the European Commission and German government grants. One coauthor reported receiving payment from the Institute for Experimental Immunology affiliated with EuroIMMUN, a maker of reagents for diagnostics, and another reported support from EuroIMMUN as well as a pending patent related to human betacoronavirus lineage.

The rate of secondary transmission to household members of patients with Middle East respiratory syndrome coronavirus (MERS-CoV) is 4%, a study has shown.

The researchers studied 26 symptomatic index patients in Saudi Arabia along with 280 of their household contacts, and found only 12 with laboratory evidence of infection. The report was published online Aug. 27 in the New England Journal of Medicine.

Courtesy of Maureen Metcalfe/Azaibi Tamin

Dr. Christian Drosten of the University of Bonn (Germany) Medical Center and colleagues found the 12 contacts to have laboratory evidence of MERS-CoV infection a median of 17.5 days from onset of symptoms in the index patients they lived with. Two of the infected household contacts reported having had contact with camels. All 280 contacts were screened via RT-PCR assays on RNA from throat swabs along with serologic testing that included enzyme-linked immunosorbent assays (ELISAs), and immunofluorescence assays.

Of the 12 with evidence of infection, 7 carried MERS-CoV in their upper respiratory tract, generally in low levels. Nonetheless, "positive RT-PCR findings in persons with subclinical infection who are tested soon after exposure should be complemented by serologic analysis," the investigators wrote.

The median age of the household contacts in the study was 29, and of the 12 infected, only one developed symptoms, which were mild. "Persons in the first few decades of life without coexisting illnesses may be able to carry low levels of MERS-CoV RNA without obvious symptoms," the researchers wrote (N. Engl. J. Med. 2014 Aug. 27 [doi:10.1056/NEJMoa1405858]).

The investigators cited as a weakness of their study the fact that only 44 of the 280 contacts originally tested provided follow-up samples. This was because the first round of testing was obligatory in Saudi Arabia, and the second, voluntary. The lack of follow-up testing meant that "we cannot determine whether we may have missed contacts who had delayed seroconversion," they wrote.

Dr. Drosten’s research was funded by the European Commission and German government grants. One coauthor reported receiving payment from the Institute for Experimental Immunology affiliated with EuroIMMUN, a maker of reagents for diagnostics, and another reported support from EuroIMMUN as well as a pending patent related to human betacoronavirus lineage.

Adenotonsillectomy and CPAP achieve similar improvements in apnea-hypopnea index among children with obstructive sleep apnea and Down syndrome or mucopolysaccharidoses, although the benefits from continuous positive airway pressure are more immediate, researchers said.

Dr. Shyam Sudhakar Sudarsan and colleagues from the Madras ENT Research Foundation in Chennai, India, performed a prospective, randomized comparative study in 124 syndromic children aged 6-12 years.

©DenKuvaiev/thinkstockphotos.com

They found that children in both arms of the study achieved a mean apnea-hypopnea index of just over 1 at 12 months after randomization, with no statistically significant difference between CPAP and adenotonsillectomy.

"A striking observation from values of CPAP group was that, the child, if tolerant of a nasal mask/CPAP, showed statistically significant improvement by 6 months itself and this was maintained over a period of time," the authors wrote (Int. J. Pediatr. Otorhinolaryngol. 2014;78:1526-33).

"But in T&A [adenotonsillectomy] group, the improvement was gradual and statistically significant over a period of time," the authors said, suggesting that adenotonsillectomy in this group of high-risk children should be viewed as "beneficial rather than uniformly curative" for obstructive sleep apnea.

There were no conflicts of interest declared.

Adenotonsillectomy and CPAP achieve similar improvements in apnea-hypopnea index among children with obstructive sleep apnea and Down syndrome or mucopolysaccharidoses, although the benefits from continuous positive airway pressure are more immediate, researchers said.

Dr. Shyam Sudhakar Sudarsan and colleagues from the Madras ENT Research Foundation in Chennai, India, performed a prospective, randomized comparative study in 124 syndromic children aged 6-12 years.

©DenKuvaiev/thinkstockphotos.com

They found that children in both arms of the study achieved a mean apnea-hypopnea index of just over 1 at 12 months after randomization, with no statistically significant difference between CPAP and adenotonsillectomy.

"A striking observation from values of CPAP group was that, the child, if tolerant of a nasal mask/CPAP, showed statistically significant improvement by 6 months itself and this was maintained over a period of time," the authors wrote (Int. J. Pediatr. Otorhinolaryngol. 2014;78:1526-33).

"But in T&A [adenotonsillectomy] group, the improvement was gradual and statistically significant over a period of time," the authors said, suggesting that adenotonsillectomy in this group of high-risk children should be viewed as "beneficial rather than uniformly curative" for obstructive sleep apnea.

There were no conflicts of interest declared.

Adenotonsillectomy and CPAP achieve similar improvements in apnea-hypopnea index among children with obstructive sleep apnea and Down syndrome or mucopolysaccharidoses, although the benefits from continuous positive airway pressure are more immediate, researchers said.

Dr. Shyam Sudhakar Sudarsan and colleagues from the Madras ENT Research Foundation in Chennai, India, performed a prospective, randomized comparative study in 124 syndromic children aged 6-12 years.

©DenKuvaiev/thinkstockphotos.com

They found that children in both arms of the study achieved a mean apnea-hypopnea index of just over 1 at 12 months after randomization, with no statistically significant difference between CPAP and adenotonsillectomy.

"A striking observation from values of CPAP group was that, the child, if tolerant of a nasal mask/CPAP, showed statistically significant improvement by 6 months itself and this was maintained over a period of time," the authors wrote (Int. J. Pediatr. Otorhinolaryngol. 2014;78:1526-33).

"But in T&A [adenotonsillectomy] group, the improvement was gradual and statistically significant over a period of time," the authors said, suggesting that adenotonsillectomy in this group of high-risk children should be viewed as "beneficial rather than uniformly curative" for obstructive sleep apnea.

There were no conflicts of interest declared.

Clinicians should measure dim light melatonin onset before treating patients with circadian rhythm sleep disorders, according to Dr. Henry Keijzer of the University Maastricht (the Netherlands) and his associates.

The test enables clinicians to assess patients’ individual circadian timing, the reviewers said. At least 17 of the 90 scientific studies they reviewed support the use of the test in this context, and it can be performed by collecting saliva at home if in-clinic testing is not feasible, they added.

© Wjeger/Thinkstockphotos.com

Although patients are often told to take exogenous melatonin 1-2 hours before bedtime, this generalized approach can lead to adverse phase-shifting effects, the reviewers said (Sleep Med. Rev. 2014;18:333-9).

"Therefore, we believe that the use of melatonin in patients with chronic sleep problems should occur only after their baseline circadian timing information is known, and should be supervised by a health care professional who is familiar with melatonin and its phase-dependent effects," they wrote.

The authors expressed concern that "melatonin is increasingly recommended for patients with insomnia or used by such patients as an over-the-counter self-care medicine."

The investigators reported no funding sources or conflicts of interest.

Clinicians should measure dim light melatonin onset before treating patients with circadian rhythm sleep disorders, according to Dr. Henry Keijzer of the University Maastricht (the Netherlands) and his associates.

The test enables clinicians to assess patients’ individual circadian timing, the reviewers said. At least 17 of the 90 scientific studies they reviewed support the use of the test in this context, and it can be performed by collecting saliva at home if in-clinic testing is not feasible, they added.

© Wjeger/Thinkstockphotos.com

Although patients are often told to take exogenous melatonin 1-2 hours before bedtime, this generalized approach can lead to adverse phase-shifting effects, the reviewers said (Sleep Med. Rev. 2014;18:333-9).

"Therefore, we believe that the use of melatonin in patients with chronic sleep problems should occur only after their baseline circadian timing information is known, and should be supervised by a health care professional who is familiar with melatonin and its phase-dependent effects," they wrote.

The authors expressed concern that "melatonin is increasingly recommended for patients with insomnia or used by such patients as an over-the-counter self-care medicine."

The investigators reported no funding sources or conflicts of interest.

Clinicians should measure dim light melatonin onset before treating patients with circadian rhythm sleep disorders, according to Dr. Henry Keijzer of the University Maastricht (the Netherlands) and his associates.

The test enables clinicians to assess patients’ individual circadian timing, the reviewers said. At least 17 of the 90 scientific studies they reviewed support the use of the test in this context, and it can be performed by collecting saliva at home if in-clinic testing is not feasible, they added.

© Wjeger/Thinkstockphotos.com

Although patients are often told to take exogenous melatonin 1-2 hours before bedtime, this generalized approach can lead to adverse phase-shifting effects, the reviewers said (Sleep Med. Rev. 2014;18:333-9).

"Therefore, we believe that the use of melatonin in patients with chronic sleep problems should occur only after their baseline circadian timing information is known, and should be supervised by a health care professional who is familiar with melatonin and its phase-dependent effects," they wrote.

The authors expressed concern that "melatonin is increasingly recommended for patients with insomnia or used by such patients as an over-the-counter self-care medicine."

The investigators reported no funding sources or conflicts of interest.

Care of critically ill or injured patients during Hurricane Sandy, the 2010 earthquake in Haiti, and the H1N1 influenza pandemic in Mexico City played a role in shaping new recommendations from the American College of Chest Physicians.

The 14-part consensus statement from the College’s Task Force for Mass Critical Care updates and expands on the task force’s previous recommendations from 2008, which did not address pediatrics, trauma, subspecialty critical care, or critical care during disasters in the developing world, among other topics.

Courtesy National Institute for Occupational Safety and Health

Although there is some overlap with the 2008 recommendations, "by and large the specific suggestions are all new or have been updated since the 2008 guidelines, based upon lessons learned from pandemics and disasters that have occurred in the interval," Dr. Jeffrey R. Dichter said in an interview.

If history is any guide, clinicians will want to incorporate the 2014 recommendations as a matter of routine instead of placing them on a shelf only to be retrieved in times of crisis, said Dr. Dichter, a member of the task force. He is medical director for intensive care at Unity Hospital, Fridley, Minn., and a past president of the Society of Hospital Medicine.

The task force heard from colleagues that the 2008 document helped them plan to scale up ICU capacity and manage ventilated patients during the 2009 Mexican influenza epidemic – plans that they did not need to implement but that gave them reassurance nonetheless.

Triage guidelines in the 2008 document helped Bellevue Hospital in New York plan for allocating scarce resources such as electricity from backup generators during 2012’s Hurricane Sandy, a hospital physician reported at the College’s 2013 annual meeting. "Simply knowing they had an approach in place to make those decisions if required allowed the staff to focus on dealing with the situation at hand effectively rather than being distracted by the uncertainty of what would happen if the generators failed," Dr. Dichter said.

The 2014 document’s attention to evacuation of critically ill and injured patients should be of particular interest. "We have seen the challenge related to evacuating ICUs, particularly during the New York hurricane," he said.

Another highlight is a focus on developing the capacity to increase health care personnel and supplies when needed (also known as "surge response") to meet disasters of various sizes – small, medium, or large. The previous recommendations covered only the largest, "crisis" care.

The document provides advice for everyone from individual doctors to hospital administrators, regional health systems, and national governments. "While it is important for all health care workers to have a broad understanding of the issues of emergency preparedness, readers can focus on the areas more relevant to them by consulting the tables in each document" that identify the people for whom those recommendations are most relevant, he said.

The recommendations are based on expert consensus because there is no research to support evidence-based guidelines, the task force stated. That should change by the time the recommendations are updated again in the future, Dr. Dichter said. Groups such as the International Forum for Acute Care Trialists and the International Severe Acute Respiratory and Emerging Infection Consortium are starting to conduct research during pandemics and disasters.

And, of course, more crises will occur, providing experience that will help improve planning for the next inevitable disaster.

Dr. Dichter reported having no financial disclosures.

sboschert@frontlinemedcom.com

On Twitter @sherryboschert

Care of critically ill or injured patients during Hurricane Sandy, the 2010 earthquake in Haiti, and the H1N1 influenza pandemic in Mexico City played a role in shaping new recommendations from the American College of Chest Physicians.

The 14-part consensus statement from the College’s Task Force for Mass Critical Care updates and expands on the task force’s previous recommendations from 2008, which did not address pediatrics, trauma, subspecialty critical care, or critical care during disasters in the developing world, among other topics.

Courtesy National Institute for Occupational Safety and Health

Although there is some overlap with the 2008 recommendations, "by and large the specific suggestions are all new or have been updated since the 2008 guidelines, based upon lessons learned from pandemics and disasters that have occurred in the interval," Dr. Jeffrey R. Dichter said in an interview.

If history is any guide, clinicians will want to incorporate the 2014 recommendations as a matter of routine instead of placing them on a shelf only to be retrieved in times of crisis, said Dr. Dichter, a member of the task force. He is medical director for intensive care at Unity Hospital, Fridley, Minn., and a past president of the Society of Hospital Medicine.

The task force heard from colleagues that the 2008 document helped them plan to scale up ICU capacity and manage ventilated patients during the 2009 Mexican influenza epidemic – plans that they did not need to implement but that gave them reassurance nonetheless.

Triage guidelines in the 2008 document helped Bellevue Hospital in New York plan for allocating scarce resources such as electricity from backup generators during 2012’s Hurricane Sandy, a hospital physician reported at the College’s 2013 annual meeting. "Simply knowing they had an approach in place to make those decisions if required allowed the staff to focus on dealing with the situation at hand effectively rather than being distracted by the uncertainty of what would happen if the generators failed," Dr. Dichter said.

The 2014 document’s attention to evacuation of critically ill and injured patients should be of particular interest. "We have seen the challenge related to evacuating ICUs, particularly during the New York hurricane," he said.

Another highlight is a focus on developing the capacity to increase health care personnel and supplies when needed (also known as "surge response") to meet disasters of various sizes – small, medium, or large. The previous recommendations covered only the largest, "crisis" care.

The document provides advice for everyone from individual doctors to hospital administrators, regional health systems, and national governments. "While it is important for all health care workers to have a broad understanding of the issues of emergency preparedness, readers can focus on the areas more relevant to them by consulting the tables in each document" that identify the people for whom those recommendations are most relevant, he said.

The recommendations are based on expert consensus because there is no research to support evidence-based guidelines, the task force stated. That should change by the time the recommendations are updated again in the future, Dr. Dichter said. Groups such as the International Forum for Acute Care Trialists and the International Severe Acute Respiratory and Emerging Infection Consortium are starting to conduct research during pandemics and disasters.

And, of course, more crises will occur, providing experience that will help improve planning for the next inevitable disaster.

Dr. Dichter reported having no financial disclosures.

sboschert@frontlinemedcom.com

On Twitter @sherryboschert

Care of critically ill or injured patients during Hurricane Sandy, the 2010 earthquake in Haiti, and the H1N1 influenza pandemic in Mexico City played a role in shaping new recommendations from the American College of Chest Physicians.

The 14-part consensus statement from the College’s Task Force for Mass Critical Care updates and expands on the task force’s previous recommendations from 2008, which did not address pediatrics, trauma, subspecialty critical care, or critical care during disasters in the developing world, among other topics.

Courtesy National Institute for Occupational Safety and Health

Although there is some overlap with the 2008 recommendations, "by and large the specific suggestions are all new or have been updated since the 2008 guidelines, based upon lessons learned from pandemics and disasters that have occurred in the interval," Dr. Jeffrey R. Dichter said in an interview.

If history is any guide, clinicians will want to incorporate the 2014 recommendations as a matter of routine instead of placing them on a shelf only to be retrieved in times of crisis, said Dr. Dichter, a member of the task force. He is medical director for intensive care at Unity Hospital, Fridley, Minn., and a past president of the Society of Hospital Medicine.

The task force heard from colleagues that the 2008 document helped them plan to scale up ICU capacity and manage ventilated patients during the 2009 Mexican influenza epidemic – plans that they did not need to implement but that gave them reassurance nonetheless.

Triage guidelines in the 2008 document helped Bellevue Hospital in New York plan for allocating scarce resources such as electricity from backup generators during 2012’s Hurricane Sandy, a hospital physician reported at the College’s 2013 annual meeting. "Simply knowing they had an approach in place to make those decisions if required allowed the staff to focus on dealing with the situation at hand effectively rather than being distracted by the uncertainty of what would happen if the generators failed," Dr. Dichter said.

The 2014 document’s attention to evacuation of critically ill and injured patients should be of particular interest. "We have seen the challenge related to evacuating ICUs, particularly during the New York hurricane," he said.

Another highlight is a focus on developing the capacity to increase health care personnel and supplies when needed (also known as "surge response") to meet disasters of various sizes – small, medium, or large. The previous recommendations covered only the largest, "crisis" care.

The document provides advice for everyone from individual doctors to hospital administrators, regional health systems, and national governments. "While it is important for all health care workers to have a broad understanding of the issues of emergency preparedness, readers can focus on the areas more relevant to them by consulting the tables in each document" that identify the people for whom those recommendations are most relevant, he said.

The recommendations are based on expert consensus because there is no research to support evidence-based guidelines, the task force stated. That should change by the time the recommendations are updated again in the future, Dr. Dichter said. Groups such as the International Forum for Acute Care Trialists and the International Severe Acute Respiratory and Emerging Infection Consortium are starting to conduct research during pandemics and disasters.

And, of course, more crises will occur, providing experience that will help improve planning for the next inevitable disaster.

Dr. Dichter reported having no financial disclosures.

sboschert@frontlinemedcom.com

On Twitter @sherryboschert

Adding bedaquiline to a five-drug background regimen for multidrug-resistant pulmonary tuberculosis significantly accelerated the time at which sputum cultures showed clearance of Mycobacterium tuberculosis in a phase IIb clinical trial, which was published online Aug. 21 in the New England Journal of Medicine.

The addition of 6 months of oral bedaquiline – a diarylquinoline that inhibits mycobacterial ATP synthase and depletes cellular energy stores – also significantly increased the number of patients who achieved such culture conversion (a surrogate for clinical cure), compared with adding placebo, in this industry-sponsored study. Bedaquiline "is the first antituberculosis drug with a new mechanism of action to be approved for use in multidrug-resistant TB in 40 years," said Dr. Andreas H. Diacon of the National Research Foundation Centre of Excellence for Biomedical Tuberculosis Research at Stellenbosch University in Cape Town, South Africa, and his associates.

©CDC/ Elizabeth

Bedaquiline was approved in 2012 under the Food and Drug Administration’s accelerated-approval regulations for drugs that provide meaningful therapeutic benefit over existing therapies for serious or life-threatening conditions. The drug is approved only for patients for whom an effective treatment regimen cannot be constructed without it, a population in whom the benefits outweigh the risks.

In the trial, 160 adults with multidrug-resistant pulmonary TB were randomly assigned to receive either oral bedaquiline (79 patients) or matching placebo tablets (81 patients) for 24 weeks at medical centers in Brazil, India, Latvia, Peru, the Philippines, Russia, South Africa, and Thailand, in addition to the five-drug background regimen of antituberculosis drugs preferred at each location. They continued the background therapy for a further 96 weeks and had a final follow-up exam at the conclusion of that treatment. Sixty participants (38%) left the study prematurely, usually because of withdrawal of consent, adverse effects, nonadherence, loss to follow-up, and pregnancy. The number of and reasons for these discontinuations were similar between the two study groups.

The primary endpoint of the study was the median time to sputum conversion. This was significantly faster in the intervention group (83 days) than in the control group (125 days) in both the modified intention-to-treat analysis and the full intention-to-treat analysis. Moreover, more patients in the intervention group (79%) than in the placebo group (58%) showed culture conversion at 24 weeks, as well as at 120 weeks (62% vs 44%). And according to the World Health Organization definition of "cure," nearly twice as many patients in the bedaquiline group (58%) were cured as in the placebo group (32%) at 120 weeks, Dr. Diacon and his associates said (N. Engl. J. Med. 2014;371:723-32 [doi:10.1056/NEJMoa1313865]).

Fewer patients taking bedaquiline (2) than taking placebo (16) developed new resistance to at least one antituberculosis agent during the study. Rates, types, and severity of adverse events were comparable between the two study groups. However, mortality was significantly higher with bedaquiline (10 patients, 13% mortality) than with placebo (2 patients, 2% mortality), for reasons that are not yet understood but do not appear to be related to the study drug.

"A planned phase III study will enroll a larger number of patients, including HIV-positive patients receiving antiretroviral therapy," the investigators noted.

This study was funded by Janssen Pharmaceuticals. Dr. Diacon reported no financial conflicts of interest. His associates reported ties to Janssen; to its parent company, Johnson & Johnson; and to Quintiles.

Adding bedaquiline to a five-drug background regimen for multidrug-resistant pulmonary tuberculosis significantly accelerated the time at which sputum cultures showed clearance of Mycobacterium tuberculosis in a phase IIb clinical trial, which was published online Aug. 21 in the New England Journal of Medicine.

The addition of 6 months of oral bedaquiline – a diarylquinoline that inhibits mycobacterial ATP synthase and depletes cellular energy stores – also significantly increased the number of patients who achieved such culture conversion (a surrogate for clinical cure), compared with adding placebo, in this industry-sponsored study. Bedaquiline "is the first antituberculosis drug with a new mechanism of action to be approved for use in multidrug-resistant TB in 40 years," said Dr. Andreas H. Diacon of the National Research Foundation Centre of Excellence for Biomedical Tuberculosis Research at Stellenbosch University in Cape Town, South Africa, and his associates.

©CDC/ Elizabeth

Bedaquiline was approved in 2012 under the Food and Drug Administration’s accelerated-approval regulations for drugs that provide meaningful therapeutic benefit over existing therapies for serious or life-threatening conditions. The drug is approved only for patients for whom an effective treatment regimen cannot be constructed without it, a population in whom the benefits outweigh the risks.

In the trial, 160 adults with multidrug-resistant pulmonary TB were randomly assigned to receive either oral bedaquiline (79 patients) or matching placebo tablets (81 patients) for 24 weeks at medical centers in Brazil, India, Latvia, Peru, the Philippines, Russia, South Africa, and Thailand, in addition to the five-drug background regimen of antituberculosis drugs preferred at each location. They continued the background therapy for a further 96 weeks and had a final follow-up exam at the conclusion of that treatment. Sixty participants (38%) left the study prematurely, usually because of withdrawal of consent, adverse effects, nonadherence, loss to follow-up, and pregnancy. The number of and reasons for these discontinuations were similar between the two study groups.

The primary endpoint of the study was the median time to sputum conversion. This was significantly faster in the intervention group (83 days) than in the control group (125 days) in both the modified intention-to-treat analysis and the full intention-to-treat analysis. Moreover, more patients in the intervention group (79%) than in the placebo group (58%) showed culture conversion at 24 weeks, as well as at 120 weeks (62% vs 44%). And according to the World Health Organization definition of "cure," nearly twice as many patients in the bedaquiline group (58%) were cured as in the placebo group (32%) at 120 weeks, Dr. Diacon and his associates said (N. Engl. J. Med. 2014;371:723-32 [doi:10.1056/NEJMoa1313865]).

Fewer patients taking bedaquiline (2) than taking placebo (16) developed new resistance to at least one antituberculosis agent during the study. Rates, types, and severity of adverse events were comparable between the two study groups. However, mortality was significantly higher with bedaquiline (10 patients, 13% mortality) than with placebo (2 patients, 2% mortality), for reasons that are not yet understood but do not appear to be related to the study drug.

"A planned phase III study will enroll a larger number of patients, including HIV-positive patients receiving antiretroviral therapy," the investigators noted.

This study was funded by Janssen Pharmaceuticals. Dr. Diacon reported no financial conflicts of interest. His associates reported ties to Janssen; to its parent company, Johnson & Johnson; and to Quintiles.

Adding bedaquiline to a five-drug background regimen for multidrug-resistant pulmonary tuberculosis significantly accelerated the time at which sputum cultures showed clearance of Mycobacterium tuberculosis in a phase IIb clinical trial, which was published online Aug. 21 in the New England Journal of Medicine.

The addition of 6 months of oral bedaquiline – a diarylquinoline that inhibits mycobacterial ATP synthase and depletes cellular energy stores – also significantly increased the number of patients who achieved such culture conversion (a surrogate for clinical cure), compared with adding placebo, in this industry-sponsored study. Bedaquiline "is the first antituberculosis drug with a new mechanism of action to be approved for use in multidrug-resistant TB in 40 years," said Dr. Andreas H. Diacon of the National Research Foundation Centre of Excellence for Biomedical Tuberculosis Research at Stellenbosch University in Cape Town, South Africa, and his associates.

©CDC/ Elizabeth

Bedaquiline was approved in 2012 under the Food and Drug Administration’s accelerated-approval regulations for drugs that provide meaningful therapeutic benefit over existing therapies for serious or life-threatening conditions. The drug is approved only for patients for whom an effective treatment regimen cannot be constructed without it, a population in whom the benefits outweigh the risks.

In the trial, 160 adults with multidrug-resistant pulmonary TB were randomly assigned to receive either oral bedaquiline (79 patients) or matching placebo tablets (81 patients) for 24 weeks at medical centers in Brazil, India, Latvia, Peru, the Philippines, Russia, South Africa, and Thailand, in addition to the five-drug background regimen of antituberculosis drugs preferred at each location. They continued the background therapy for a further 96 weeks and had a final follow-up exam at the conclusion of that treatment. Sixty participants (38%) left the study prematurely, usually because of withdrawal of consent, adverse effects, nonadherence, loss to follow-up, and pregnancy. The number of and reasons for these discontinuations were similar between the two study groups.

The primary endpoint of the study was the median time to sputum conversion. This was significantly faster in the intervention group (83 days) than in the control group (125 days) in both the modified intention-to-treat analysis and the full intention-to-treat analysis. Moreover, more patients in the intervention group (79%) than in the placebo group (58%) showed culture conversion at 24 weeks, as well as at 120 weeks (62% vs 44%). And according to the World Health Organization definition of "cure," nearly twice as many patients in the bedaquiline group (58%) were cured as in the placebo group (32%) at 120 weeks, Dr. Diacon and his associates said (N. Engl. J. Med. 2014;371:723-32 [doi:10.1056/NEJMoa1313865]).

Fewer patients taking bedaquiline (2) than taking placebo (16) developed new resistance to at least one antituberculosis agent during the study. Rates, types, and severity of adverse events were comparable between the two study groups. However, mortality was significantly higher with bedaquiline (10 patients, 13% mortality) than with placebo (2 patients, 2% mortality), for reasons that are not yet understood but do not appear to be related to the study drug.

"A planned phase III study will enroll a larger number of patients, including HIV-positive patients receiving antiretroviral therapy," the investigators noted.

This study was funded by Janssen Pharmaceuticals. Dr. Diacon reported no financial conflicts of interest. His associates reported ties to Janssen; to its parent company, Johnson & Johnson; and to Quintiles.

Among infants presenting to an emergency department with mild to moderate bronchiolitis, those whose pulse oximetry readings were artificially elevated by 3 percentage points were significantly less likely to be hospitalized than were comparable patients whose pulse oximetry readings were unaltered, according to a report published online Aug. 19 in JAMA.

The accuracy of most oxygen-saturation monitors is approximately plus or minus 2%, and oximetry readings are subject to multiple sources of error, so "the actual physiological difference between the true and altered oximetry measurements in our study was of minor importance. Yet this difference had significant implications for hospitalization," said Dr. Suzanne Schuh, a pediatrician at the Hospital for Sick Children, Toronto, and her associates.

Their findings indicate that clinicians are relying too heavily on tiny differences in a single laboratory parameter – the pulse oximetry reading – to make clinical decisions in this patient population. The results of their experiment further suggest that the monitoring of oxygen saturation in this setting may need to be reevaluated, Dr. Schuh and her colleagues wrote (JAMA 2014;312:712-8).

The introduction and routine use of pulse oximetry in infants with mild to moderate bronchiolitis in the 1980s and 1990s coincided with more than a doubling of hospitalization rates for the disorder. Moreover, the somewhat arbitrary cutoff point of 90% oxygen saturation, which triggers the use of supplemental oxygen, has never been shown to correlate with bronchiolitis progression, yet many mildly ill infants are hospitalized solely because of that reading. Even expert opinion "cautions against overreliance on oximetry and argues for the use of clinical judgment when making disposition determinations," the investigators noted.

They performed this prospective, randomized, double-blind trial to determine whether artificially raising the pulse oximetry reading displayed to emergency department (ED) clinicians by an amount of "minor importance" would lead to fewer unnecessary hospitalizations in 213 otherwise healthy infants (aged 4-12 months) presenting to a single tertiary care pediatric ED during a 5-year period. The 13 physicians who cared for these patients were blinded to the study protocol and ordered supplemental oxygen and pharmacotherapy at their own discretion.

All the infants had a true oxygen saturation of 88% or higher, as well as comparable clinical characteristics and Respiratory Disease Assessment Instrument scores. The oxygen saturation reading was accurately displayed to treating clinicians in the 108 infants who were randomly assigned to "true" oximetry. In the other 105 infants, the oxygen saturation reading was increased by 3 points and displayed to treating clinicians.

All the infants in the study underwent concealed continuous oximetry for safety reasons. These hidden monitors were programmed to sound an alarm if oxygen saturation dropped to less than 92%, which would prompt a thorough clinical reassessment.

The primary outcome of the study was hospitalization for bronchiolitis within 72 hours of enrollment due to concerns about respiratory distress. This occurred in 41% of infants in the true-oximetry group, compared with only 25% of those whose oximetry reading was artificially increased – a significant 16% difference. Yet the medical outcomes of the two study groups were comparable, Dr. Schuh and her associates reported.

"Our results suggest an even lower cutoff might be appropriate and that among children with saturation levels of 88% and higher, disposition determination should be based primarily on the degree of respiratory distress and hydration status, rather than on a particular saturation value," they said.

This study was supported by the Thrasher Research Fund and the Physicians’ Services Incorporated Foundation; Masimo provided the oximeters but played no role in the design or conduct of the study. Dr. Schuh and her associates reported that they had no financial conflicts of interest.

Among infants presenting to an emergency department with mild to moderate bronchiolitis, those whose pulse oximetry readings were artificially elevated by 3 percentage points were significantly less likely to be hospitalized than were comparable patients whose pulse oximetry readings were unaltered, according to a report published online Aug. 19 in JAMA.

The accuracy of most oxygen-saturation monitors is approximately plus or minus 2%, and oximetry readings are subject to multiple sources of error, so "the actual physiological difference between the true and altered oximetry measurements in our study was of minor importance. Yet this difference had significant implications for hospitalization," said Dr. Suzanne Schuh, a pediatrician at the Hospital for Sick Children, Toronto, and her associates.

Their findings indicate that clinicians are relying too heavily on tiny differences in a single laboratory parameter – the pulse oximetry reading – to make clinical decisions in this patient population. The results of their experiment further suggest that the monitoring of oxygen saturation in this setting may need to be reevaluated, Dr. Schuh and her colleagues wrote (JAMA 2014;312:712-8).

The introduction and routine use of pulse oximetry in infants with mild to moderate bronchiolitis in the 1980s and 1990s coincided with more than a doubling of hospitalization rates for the disorder. Moreover, the somewhat arbitrary cutoff point of 90% oxygen saturation, which triggers the use of supplemental oxygen, has never been shown to correlate with bronchiolitis progression, yet many mildly ill infants are hospitalized solely because of that reading. Even expert opinion "cautions against overreliance on oximetry and argues for the use of clinical judgment when making disposition determinations," the investigators noted.

They performed this prospective, randomized, double-blind trial to determine whether artificially raising the pulse oximetry reading displayed to emergency department (ED) clinicians by an amount of "minor importance" would lead to fewer unnecessary hospitalizations in 213 otherwise healthy infants (aged 4-12 months) presenting to a single tertiary care pediatric ED during a 5-year period. The 13 physicians who cared for these patients were blinded to the study protocol and ordered supplemental oxygen and pharmacotherapy at their own discretion.

All the infants had a true oxygen saturation of 88% or higher, as well as comparable clinical characteristics and Respiratory Disease Assessment Instrument scores. The oxygen saturation reading was accurately displayed to treating clinicians in the 108 infants who were randomly assigned to "true" oximetry. In the other 105 infants, the oxygen saturation reading was increased by 3 points and displayed to treating clinicians.

All the infants in the study underwent concealed continuous oximetry for safety reasons. These hidden monitors were programmed to sound an alarm if oxygen saturation dropped to less than 92%, which would prompt a thorough clinical reassessment.

The primary outcome of the study was hospitalization for bronchiolitis within 72 hours of enrollment due to concerns about respiratory distress. This occurred in 41% of infants in the true-oximetry group, compared with only 25% of those whose oximetry reading was artificially increased – a significant 16% difference. Yet the medical outcomes of the two study groups were comparable, Dr. Schuh and her associates reported.

"Our results suggest an even lower cutoff might be appropriate and that among children with saturation levels of 88% and higher, disposition determination should be based primarily on the degree of respiratory distress and hydration status, rather than on a particular saturation value," they said.

This study was supported by the Thrasher Research Fund and the Physicians’ Services Incorporated Foundation; Masimo provided the oximeters but played no role in the design or conduct of the study. Dr. Schuh and her associates reported that they had no financial conflicts of interest.

Among infants presenting to an emergency department with mild to moderate bronchiolitis, those whose pulse oximetry readings were artificially elevated by 3 percentage points were significantly less likely to be hospitalized than were comparable patients whose pulse oximetry readings were unaltered, according to a report published online Aug. 19 in JAMA.

The accuracy of most oxygen-saturation monitors is approximately plus or minus 2%, and oximetry readings are subject to multiple sources of error, so "the actual physiological difference between the true and altered oximetry measurements in our study was of minor importance. Yet this difference had significant implications for hospitalization," said Dr. Suzanne Schuh, a pediatrician at the Hospital for Sick Children, Toronto, and her associates.

Their findings indicate that clinicians are relying too heavily on tiny differences in a single laboratory parameter – the pulse oximetry reading – to make clinical decisions in this patient population. The results of their experiment further suggest that the monitoring of oxygen saturation in this setting may need to be reevaluated, Dr. Schuh and her colleagues wrote (JAMA 2014;312:712-8).

The introduction and routine use of pulse oximetry in infants with mild to moderate bronchiolitis in the 1980s and 1990s coincided with more than a doubling of hospitalization rates for the disorder. Moreover, the somewhat arbitrary cutoff point of 90% oxygen saturation, which triggers the use of supplemental oxygen, has never been shown to correlate with bronchiolitis progression, yet many mildly ill infants are hospitalized solely because of that reading. Even expert opinion "cautions against overreliance on oximetry and argues for the use of clinical judgment when making disposition determinations," the investigators noted.

They performed this prospective, randomized, double-blind trial to determine whether artificially raising the pulse oximetry reading displayed to emergency department (ED) clinicians by an amount of "minor importance" would lead to fewer unnecessary hospitalizations in 213 otherwise healthy infants (aged 4-12 months) presenting to a single tertiary care pediatric ED during a 5-year period. The 13 physicians who cared for these patients were blinded to the study protocol and ordered supplemental oxygen and pharmacotherapy at their own discretion.

All the infants had a true oxygen saturation of 88% or higher, as well as comparable clinical characteristics and Respiratory Disease Assessment Instrument scores. The oxygen saturation reading was accurately displayed to treating clinicians in the 108 infants who were randomly assigned to "true" oximetry. In the other 105 infants, the oxygen saturation reading was increased by 3 points and displayed to treating clinicians.

All the infants in the study underwent concealed continuous oximetry for safety reasons. These hidden monitors were programmed to sound an alarm if oxygen saturation dropped to less than 92%, which would prompt a thorough clinical reassessment.

The primary outcome of the study was hospitalization for bronchiolitis within 72 hours of enrollment due to concerns about respiratory distress. This occurred in 41% of infants in the true-oximetry group, compared with only 25% of those whose oximetry reading was artificially increased – a significant 16% difference. Yet the medical outcomes of the two study groups were comparable, Dr. Schuh and her associates reported.

"Our results suggest an even lower cutoff might be appropriate and that among children with saturation levels of 88% and higher, disposition determination should be based primarily on the degree of respiratory distress and hydration status, rather than on a particular saturation value," they said.

This study was supported by the Thrasher Research Fund and the Physicians’ Services Incorporated Foundation; Masimo provided the oximeters but played no role in the design or conduct of the study. Dr. Schuh and her associates reported that they had no financial conflicts of interest.

Mortality in patients with cystic fibrosis fell by almost 2% per year in the United States between 2000 and 2010, authors of a registry-based study reported online August 18 in Annals of Internal Medicine.

Based on the analyses, patients born and diagnosed in 2010 can expect to live almost 40 years if the state of CF care remains static, and about 56 years if treatments progress at the current rate, said Todd MacKenzie, Ph.D., of Dartmouth School of Medicine in Hanover, N.H., and his associates.

© CTRPhotos / ThinkStockPhotos.com

The study included 110 Cystic Fibrosis Foundation–accredited care centers in the United States. Mortality fell by 1.8% per year between 2000 and 2010 (95% confidence interval, 0.5%-2.7%), and males had a 19% lower risk of death than females (95% CI, 13%-24%), the investigators found. The estimated median survival for children born and diagnosed in 2010 was 39 years overall (95% CI, 38-40 years), 37 years for females (95% CI, 35-39 years), and 40 years for males (95% CI, 39-42 years), they reported (Ann. Int. Med. 2014 Aug. 18 [doi:10.7326/M13-0636]).

The results apply only to patients diagnosed in the first year of life, as patients diagnosed later are likely pancreatic-sufficient and therefore have a better prognosis, Dr. MacKenzie and associates noted. Improved survival could partially reflect the increasing diagnosis of patients with less severe phenotypes, they said.

The Cystic Fibrosis Foundation funded the study. Dr. MacKenzie reported no conflicts of interest. Three coauthors reported grant support from the Cystic Fibrosis Foundation.

Mortality in patients with cystic fibrosis fell by almost 2% per year in the United States between 2000 and 2010, authors of a registry-based study reported online August 18 in Annals of Internal Medicine.

Based on the analyses, patients born and diagnosed in 2010 can expect to live almost 40 years if the state of CF care remains static, and about 56 years if treatments progress at the current rate, said Todd MacKenzie, Ph.D., of Dartmouth School of Medicine in Hanover, N.H., and his associates.

© CTRPhotos / ThinkStockPhotos.com

The study included 110 Cystic Fibrosis Foundation–accredited care centers in the United States. Mortality fell by 1.8% per year between 2000 and 2010 (95% confidence interval, 0.5%-2.7%), and males had a 19% lower risk of death than females (95% CI, 13%-24%), the investigators found. The estimated median survival for children born and diagnosed in 2010 was 39 years overall (95% CI, 38-40 years), 37 years for females (95% CI, 35-39 years), and 40 years for males (95% CI, 39-42 years), they reported (Ann. Int. Med. 2014 Aug. 18 [doi:10.7326/M13-0636]).

The results apply only to patients diagnosed in the first year of life, as patients diagnosed later are likely pancreatic-sufficient and therefore have a better prognosis, Dr. MacKenzie and associates noted. Improved survival could partially reflect the increasing diagnosis of patients with less severe phenotypes, they said.

The Cystic Fibrosis Foundation funded the study. Dr. MacKenzie reported no conflicts of interest. Three coauthors reported grant support from the Cystic Fibrosis Foundation.

Mortality in patients with cystic fibrosis fell by almost 2% per year in the United States between 2000 and 2010, authors of a registry-based study reported online August 18 in Annals of Internal Medicine.

Based on the analyses, patients born and diagnosed in 2010 can expect to live almost 40 years if the state of CF care remains static, and about 56 years if treatments progress at the current rate, said Todd MacKenzie, Ph.D., of Dartmouth School of Medicine in Hanover, N.H., and his associates.

© CTRPhotos / ThinkStockPhotos.com

The study included 110 Cystic Fibrosis Foundation–accredited care centers in the United States. Mortality fell by 1.8% per year between 2000 and 2010 (95% confidence interval, 0.5%-2.7%), and males had a 19% lower risk of death than females (95% CI, 13%-24%), the investigators found. The estimated median survival for children born and diagnosed in 2010 was 39 years overall (95% CI, 38-40 years), 37 years for females (95% CI, 35-39 years), and 40 years for males (95% CI, 39-42 years), they reported (Ann. Int. Med. 2014 Aug. 18 [doi:10.7326/M13-0636]).

The results apply only to patients diagnosed in the first year of life, as patients diagnosed later are likely pancreatic-sufficient and therefore have a better prognosis, Dr. MacKenzie and associates noted. Improved survival could partially reflect the increasing diagnosis of patients with less severe phenotypes, they said.

The Cystic Fibrosis Foundation funded the study. Dr. MacKenzie reported no conflicts of interest. Three coauthors reported grant support from the Cystic Fibrosis Foundation.