Pulmonary Health Hub

KANSAS CITY, MO. – The use of a socioeconomic-based risk index early in the hospital encounter can identify children at significantly increased risk of asthma readmission and family financial strain, a secondary analysis suggests.

The study of 601 patients with asthma found that children classified at high social risk had more than double the risk of hospital readmission or return emergency department visit within 12 months than did those at low risk, according to Dr. Andrew Beck, a pediatrics fellow at Cincinnati Children’s Hospital Medical Center, and his colleagues.

In addition, patients at high risk had nearly 15-fold increased odds of reporting two or more financial hardships.

Patrice Wendling/Elsevier Global Medical News

Dr. Beck observed that area-based geographic data is used routinely in public health for surveillance, resource allocation, and deprivation assessment but not at the bedside, where electronic medical records can improve data linkages from the moment patients register with their address.

"We don’t routinely use this data to identify patients who may be at increased social risk," he said during the plenary session at Pediatric Hospital Medicine 2011. "Every child receives the same basic, acute-oriented medical care, potentially missing the opportunity to inform other hospital, social, and medical interventions."

To illustrate his point, Dr. Beck pointed to a 20-fold difference in asthma admissions among patients aged 1-17 years and a 10-fold difference in median household income between Cincinnati’s tony, east-side Hyde Park neighborhood and the historic, urban Over-the-Rhine neighborhood. Some Cincinnati neighborhoods have no residents living in poverty, while others have 50% of children living below the poverty line.

The researchers devised a point-of-first-contact (PFC) risk index using the patient’s insurance status and U.S. census tract variables of poverty rate, home value, and education that were geographically coded to the patient’s address and zip code. One point was given if patients were on the "at-risk" side of the national median for each variable and another given if they were publicly insured or uninsured. Race/ethnicity was not included because of the potential for misclassification.

Analyzing the Backgrounds of Asthmatic Children

Based on the index, 117 of the 601 children, aged 1-16 years, in the prospective cohort, were at low risk (0 points), 201 were at medium risk (1-2 points), and 283 at high risk (3-4 points), he said at the meeting, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and Academic Pediatric Association.

A total of 237 children (39%) returned to the ED or were readmitted within 12 months. Overall, 73% of the low-risk group had not returned to the hospital, compared with 64% of the medium-risk and 53% of the high-risk group, he said.

When this association was assessed in a Cox model using the low-risk group as the reference, the risk of reutilization was increased 70% among those at medium risk (hazard ratio, 1.7) and more than double among those at high risk (HR, 2.3).

The researchers then measured family financial strain in face-to-face interviews with caregivers using five validated questions chosen for their likelihood of leading to intervention. In all, 38% of families reported not having enough money to make ends meet, 11% said they did not have enough food to eat, 23% were unable to pay the full rent/mortgage, 39% were unable to pay full utilities, and 13% were forced to move in with others for financial reasons.

Nearly one-third (32%) of the sample answered "yes" to two or more financial strain questions. The odds of reporting two or more financial hardships were 14.8-fold higher for the high-risk group and 7.9-fold higher for the medium-risk group, which was statistically significant (both P value less than .0001), Dr. Beck said. Interestingly, this correlation had a high sensitivity (97%) and negative predictive value (95%), illustrating the index’s value as a screening tool, he added.

"Because the PFC index is based on data available so early on in the admission encounter and triage, we believe it could be used to quickly triage who may and who may not benefit from further assessment and intervention by deriving a risk profile before you even enter the room," Dr. Beck concluded.

The Value in Determining Patient Risk

Session co-moderator Dr. Karen Wilson of the University of Rochester (N.Y.) agreed that the data could be readily available but said more work needs to be done to determine how patients would react if told by an ED physician they were at risk based on where they live.

"It is a novel idea that I think deserves further investigation, but it’s probably not something, just based on our IT system, that is practical to use right now because we don’t have the computer systems to automatically generate that census tract information," she said in an interview.

Fellow comoderator Dr. Mike Dean, chief of pediatric critical care at the University of Utah in Salt Lake City, asked whether it would suffice to simply determine whether patients lived in an area of extreme poverty according to census data rather than using a more complex and completely automated index. Dr. Beck said that approach would be feasible and that a significant effect size was observed even when the variable of extreme poverty was evaluated in isolation

Overall, 57% of children in the analysis lived in a census tract where more than 3.3% of the population lived below the 50% poverty line, 65% lived in a tract with a median home value of $106,700 or less, and 36% lived in a tract where 18% or more of adults lacked a high school education.

A total of 64% of the cohort was male, 53% were black, their mean age was 5.9 years, and 65% had public insurance or no insurance.

Dr. Beck, his coauthors, and Dr. Dean report no relevant financial relationships. Dr. Wilson reports a research grant from Child Health Corp. of America.

KANSAS CITY, MO. – The use of a socioeconomic-based risk index early in the hospital encounter can identify children at significantly increased risk of asthma readmission and family financial strain, a secondary analysis suggests.

The study of 601 patients with asthma found that children classified at high social risk had more than double the risk of hospital readmission or return emergency department visit within 12 months than did those at low risk, according to Dr. Andrew Beck, a pediatrics fellow at Cincinnati Children’s Hospital Medical Center, and his colleagues.

In addition, patients at high risk had nearly 15-fold increased odds of reporting two or more financial hardships.

Patrice Wendling/Elsevier Global Medical News

Dr. Beck observed that area-based geographic data is used routinely in public health for surveillance, resource allocation, and deprivation assessment but not at the bedside, where electronic medical records can improve data linkages from the moment patients register with their address.

"We don’t routinely use this data to identify patients who may be at increased social risk," he said during the plenary session at Pediatric Hospital Medicine 2011. "Every child receives the same basic, acute-oriented medical care, potentially missing the opportunity to inform other hospital, social, and medical interventions."

To illustrate his point, Dr. Beck pointed to a 20-fold difference in asthma admissions among patients aged 1-17 years and a 10-fold difference in median household income between Cincinnati’s tony, east-side Hyde Park neighborhood and the historic, urban Over-the-Rhine neighborhood. Some Cincinnati neighborhoods have no residents living in poverty, while others have 50% of children living below the poverty line.

The researchers devised a point-of-first-contact (PFC) risk index using the patient’s insurance status and U.S. census tract variables of poverty rate, home value, and education that were geographically coded to the patient’s address and zip code. One point was given if patients were on the "at-risk" side of the national median for each variable and another given if they were publicly insured or uninsured. Race/ethnicity was not included because of the potential for misclassification.

Analyzing the Backgrounds of Asthmatic Children

Based on the index, 117 of the 601 children, aged 1-16 years, in the prospective cohort, were at low risk (0 points), 201 were at medium risk (1-2 points), and 283 at high risk (3-4 points), he said at the meeting, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and Academic Pediatric Association.

A total of 237 children (39%) returned to the ED or were readmitted within 12 months. Overall, 73% of the low-risk group had not returned to the hospital, compared with 64% of the medium-risk and 53% of the high-risk group, he said.

When this association was assessed in a Cox model using the low-risk group as the reference, the risk of reutilization was increased 70% among those at medium risk (hazard ratio, 1.7) and more than double among those at high risk (HR, 2.3).

The researchers then measured family financial strain in face-to-face interviews with caregivers using five validated questions chosen for their likelihood of leading to intervention. In all, 38% of families reported not having enough money to make ends meet, 11% said they did not have enough food to eat, 23% were unable to pay the full rent/mortgage, 39% were unable to pay full utilities, and 13% were forced to move in with others for financial reasons.

Nearly one-third (32%) of the sample answered "yes" to two or more financial strain questions. The odds of reporting two or more financial hardships were 14.8-fold higher for the high-risk group and 7.9-fold higher for the medium-risk group, which was statistically significant (both P value less than .0001), Dr. Beck said. Interestingly, this correlation had a high sensitivity (97%) and negative predictive value (95%), illustrating the index’s value as a screening tool, he added.

"Because the PFC index is based on data available so early on in the admission encounter and triage, we believe it could be used to quickly triage who may and who may not benefit from further assessment and intervention by deriving a risk profile before you even enter the room," Dr. Beck concluded.

The Value in Determining Patient Risk

Session co-moderator Dr. Karen Wilson of the University of Rochester (N.Y.) agreed that the data could be readily available but said more work needs to be done to determine how patients would react if told by an ED physician they were at risk based on where they live.

"It is a novel idea that I think deserves further investigation, but it’s probably not something, just based on our IT system, that is practical to use right now because we don’t have the computer systems to automatically generate that census tract information," she said in an interview.

Fellow comoderator Dr. Mike Dean, chief of pediatric critical care at the University of Utah in Salt Lake City, asked whether it would suffice to simply determine whether patients lived in an area of extreme poverty according to census data rather than using a more complex and completely automated index. Dr. Beck said that approach would be feasible and that a significant effect size was observed even when the variable of extreme poverty was evaluated in isolation

Overall, 57% of children in the analysis lived in a census tract where more than 3.3% of the population lived below the 50% poverty line, 65% lived in a tract with a median home value of $106,700 or less, and 36% lived in a tract where 18% or more of adults lacked a high school education.

A total of 64% of the cohort was male, 53% were black, their mean age was 5.9 years, and 65% had public insurance or no insurance.

Dr. Beck, his coauthors, and Dr. Dean report no relevant financial relationships. Dr. Wilson reports a research grant from Child Health Corp. of America.

KANSAS CITY, MO. – The use of a socioeconomic-based risk index early in the hospital encounter can identify children at significantly increased risk of asthma readmission and family financial strain, a secondary analysis suggests.

The study of 601 patients with asthma found that children classified at high social risk had more than double the risk of hospital readmission or return emergency department visit within 12 months than did those at low risk, according to Dr. Andrew Beck, a pediatrics fellow at Cincinnati Children’s Hospital Medical Center, and his colleagues.

In addition, patients at high risk had nearly 15-fold increased odds of reporting two or more financial hardships.

Patrice Wendling/Elsevier Global Medical News

Dr. Beck observed that area-based geographic data is used routinely in public health for surveillance, resource allocation, and deprivation assessment but not at the bedside, where electronic medical records can improve data linkages from the moment patients register with their address.

"We don’t routinely use this data to identify patients who may be at increased social risk," he said during the plenary session at Pediatric Hospital Medicine 2011. "Every child receives the same basic, acute-oriented medical care, potentially missing the opportunity to inform other hospital, social, and medical interventions."

To illustrate his point, Dr. Beck pointed to a 20-fold difference in asthma admissions among patients aged 1-17 years and a 10-fold difference in median household income between Cincinnati’s tony, east-side Hyde Park neighborhood and the historic, urban Over-the-Rhine neighborhood. Some Cincinnati neighborhoods have no residents living in poverty, while others have 50% of children living below the poverty line.

The researchers devised a point-of-first-contact (PFC) risk index using the patient’s insurance status and U.S. census tract variables of poverty rate, home value, and education that were geographically coded to the patient’s address and zip code. One point was given if patients were on the "at-risk" side of the national median for each variable and another given if they were publicly insured or uninsured. Race/ethnicity was not included because of the potential for misclassification.

Analyzing the Backgrounds of Asthmatic Children

Based on the index, 117 of the 601 children, aged 1-16 years, in the prospective cohort, were at low risk (0 points), 201 were at medium risk (1-2 points), and 283 at high risk (3-4 points), he said at the meeting, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and Academic Pediatric Association.

A total of 237 children (39%) returned to the ED or were readmitted within 12 months. Overall, 73% of the low-risk group had not returned to the hospital, compared with 64% of the medium-risk and 53% of the high-risk group, he said.

When this association was assessed in a Cox model using the low-risk group as the reference, the risk of reutilization was increased 70% among those at medium risk (hazard ratio, 1.7) and more than double among those at high risk (HR, 2.3).

The researchers then measured family financial strain in face-to-face interviews with caregivers using five validated questions chosen for their likelihood of leading to intervention. In all, 38% of families reported not having enough money to make ends meet, 11% said they did not have enough food to eat, 23% were unable to pay the full rent/mortgage, 39% were unable to pay full utilities, and 13% were forced to move in with others for financial reasons.

Nearly one-third (32%) of the sample answered "yes" to two or more financial strain questions. The odds of reporting two or more financial hardships were 14.8-fold higher for the high-risk group and 7.9-fold higher for the medium-risk group, which was statistically significant (both P value less than .0001), Dr. Beck said. Interestingly, this correlation had a high sensitivity (97%) and negative predictive value (95%), illustrating the index’s value as a screening tool, he added.

"Because the PFC index is based on data available so early on in the admission encounter and triage, we believe it could be used to quickly triage who may and who may not benefit from further assessment and intervention by deriving a risk profile before you even enter the room," Dr. Beck concluded.

The Value in Determining Patient Risk

Session co-moderator Dr. Karen Wilson of the University of Rochester (N.Y.) agreed that the data could be readily available but said more work needs to be done to determine how patients would react if told by an ED physician they were at risk based on where they live.

"It is a novel idea that I think deserves further investigation, but it’s probably not something, just based on our IT system, that is practical to use right now because we don’t have the computer systems to automatically generate that census tract information," she said in an interview.

Fellow comoderator Dr. Mike Dean, chief of pediatric critical care at the University of Utah in Salt Lake City, asked whether it would suffice to simply determine whether patients lived in an area of extreme poverty according to census data rather than using a more complex and completely automated index. Dr. Beck said that approach would be feasible and that a significant effect size was observed even when the variable of extreme poverty was evaluated in isolation

Overall, 57% of children in the analysis lived in a census tract where more than 3.3% of the population lived below the 50% poverty line, 65% lived in a tract with a median home value of $106,700 or less, and 36% lived in a tract where 18% or more of adults lacked a high school education.

A total of 64% of the cohort was male, 53% were black, their mean age was 5.9 years, and 65% had public insurance or no insurance.

Dr. Beck, his coauthors, and Dr. Dean report no relevant financial relationships. Dr. Wilson reports a research grant from Child Health Corp. of America.

KANSAS CITY, MO. – Just four children experienced radiographic or spirometric abnormalities 6 months after hospitalization for complicated pneumonia in a prospective observational study involving 82 patients.

"Long-term sequelae from this condition are uncommon, and this may be important information for clinicians, patients, and parents in weighing various treatment decisions," study coauthor Dr. Sanjay Mahant said at the Pediatric Hospital Medicine 2011 meeting.

While the best management strategy for complicated pneumonia continues to be debated, there’s been increasing use of procedures, particularly chest tube placement with fibrinolytics such as tissue plasminogen activator and video-assisted thoracoscopic surgery.

The lack of long-term sequelae in the Canadian-based study is particularly remarkable in that 40 children received a chest drain with fibrinolytics and 11 received a chest drain alone, while the remaining were treated only with antibiotics.

"I still think larger studies are needed, but it’s really important when we’re discussing with families up front to explain why we’re doing these interventions," Dr. Mahant said. "We need to add in the mix that long-term outcomes are good regardless of whether we do antibiotics alone or an intervention, and what we’re really focusing on is reducing the short-term morbidity."

Research has focused almost entirely on short-term outcomes, with very few large, prospective studies available on how children with complicated pneumonia do over the long haul.

The current study is novel and important in that it looked not just at long-term lung function in a large prospective cohort, but also quality of life and outcomes relevant to families, session comoderator and pediatric infectious disease specialist Dr. Samir Shah said in an interview. He observed that a large portion of the children experienced short-term clinical phenomena in the study, but that these abnormalities appeared to resolve when followed out to 1 year.

"I think that’s very encouraging and good information to know, and will help inform our short-term treatment decisions, realizing that these kids seem to do well, somewhat or perhaps, no matter what we do," he said. "That may be helpful in prioritizing how invasive we need to be with drainage procedures and surgical procedures."

The study enrolled 82 children between October 2008 and October 2010 who were hospitalized with ultrasound evidence of pleural effusions with loculations. Their median age was 3.6 years and 55% were male.

Their median length of stay was 10 days, eight were admitted to the pediatric ICU, and none died, Dr. Mahant reported on behalf of principal investigator Dr. Eyal Cohen and their colleagues at the Hospital for Sick Children, University of Toronto. Six patients were readmitted within 1 month, of which three required treatment with a chest drain.

At 1 month follow-up, fever was reported in 15 (18%) children and persistent cough in 19 (23%). Failure to thrive was observed in two (2%). Among the 74 children evaluated at 6 months, 12 (16%) had persistent cough and none were feverish or failed to thrive.

A predicted forced expiratory volume in 1 second of 80% or less was reported in 7 (35%) of 20 patients at 1 month and only 1 (3.5%) of 28 patients evaluated at 6 months, he said at the meeting, which was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association. Spirometry results at 1 year in this patient were normal.

Persistent chest radiographic abnormalities, defined as effusion, pneumatocele or abscess, were noted in 24 (29%) of 82 patients at 1 month and 3 (4.6%) of 65 patients at 6 months. Chest x-rays were normal in two of the three children at 1 year, with one child lost to follow-up. A 7-year-old initially treated with a drain and no fibrinolytics required readmission, but he was among those with normal x-rays at 1 year, Dr. Mahant said.

The median time lost from school in the first month was 5 days, with 23% of parents reporting work loss. At 6 months, the median school loss was 2 days and just 9% of parents reported work loss.

Parent- and child-reported total scores on the Pediatric Quality of Life questionnaire were similar at 6 months to healthy controls. In addition, scores were significantly higher in the empyema cohort than in historical asthma controls (P value less than .001), he said.

While the data are encouraging, it is uncertain whether they will be enough to ratchet back the use of more invasive procedures, particularly in the United States. In addition, clinicians worldwide are facing an increasing incidence of complicated pneumonia since the 1990s due in part to pneumococcal serotype shift and antibacterial resistance, Dr. Mahant said.

Dr. Shah of Cincinnati Children’s Hospital Medical Center said the findings will give clinicians pause about whether invasive procedures are needed and the relative timing of these procedures. Moreover, researchers will recognize the importance of measuring long-term outcomes in future trials.

"I think that it’s critical to look at these [outcomes] because ultimately that is what matters," he said. "I think most people would be willing to trade a day or two in the hospital if whatever you’re doing led to fewer long-term symptoms."

Dr. Mahant and his coauthors reported a University of Toronto grant and funding from the SickKids Foundation. Dr. Shah reported no relevant financial disclosures.

KANSAS CITY, MO. – Just four children experienced radiographic or spirometric abnormalities 6 months after hospitalization for complicated pneumonia in a prospective observational study involving 82 patients.

"Long-term sequelae from this condition are uncommon, and this may be important information for clinicians, patients, and parents in weighing various treatment decisions," study coauthor Dr. Sanjay Mahant said at the Pediatric Hospital Medicine 2011 meeting.

While the best management strategy for complicated pneumonia continues to be debated, there’s been increasing use of procedures, particularly chest tube placement with fibrinolytics such as tissue plasminogen activator and video-assisted thoracoscopic surgery.

The lack of long-term sequelae in the Canadian-based study is particularly remarkable in that 40 children received a chest drain with fibrinolytics and 11 received a chest drain alone, while the remaining were treated only with antibiotics.

"I still think larger studies are needed, but it’s really important when we’re discussing with families up front to explain why we’re doing these interventions," Dr. Mahant said. "We need to add in the mix that long-term outcomes are good regardless of whether we do antibiotics alone or an intervention, and what we’re really focusing on is reducing the short-term morbidity."

Research has focused almost entirely on short-term outcomes, with very few large, prospective studies available on how children with complicated pneumonia do over the long haul.

The current study is novel and important in that it looked not just at long-term lung function in a large prospective cohort, but also quality of life and outcomes relevant to families, session comoderator and pediatric infectious disease specialist Dr. Samir Shah said in an interview. He observed that a large portion of the children experienced short-term clinical phenomena in the study, but that these abnormalities appeared to resolve when followed out to 1 year.

"I think that’s very encouraging and good information to know, and will help inform our short-term treatment decisions, realizing that these kids seem to do well, somewhat or perhaps, no matter what we do," he said. "That may be helpful in prioritizing how invasive we need to be with drainage procedures and surgical procedures."

The study enrolled 82 children between October 2008 and October 2010 who were hospitalized with ultrasound evidence of pleural effusions with loculations. Their median age was 3.6 years and 55% were male.

Their median length of stay was 10 days, eight were admitted to the pediatric ICU, and none died, Dr. Mahant reported on behalf of principal investigator Dr. Eyal Cohen and their colleagues at the Hospital for Sick Children, University of Toronto. Six patients were readmitted within 1 month, of which three required treatment with a chest drain.

At 1 month follow-up, fever was reported in 15 (18%) children and persistent cough in 19 (23%). Failure to thrive was observed in two (2%). Among the 74 children evaluated at 6 months, 12 (16%) had persistent cough and none were feverish or failed to thrive.

A predicted forced expiratory volume in 1 second of 80% or less was reported in 7 (35%) of 20 patients at 1 month and only 1 (3.5%) of 28 patients evaluated at 6 months, he said at the meeting, which was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association. Spirometry results at 1 year in this patient were normal.

Persistent chest radiographic abnormalities, defined as effusion, pneumatocele or abscess, were noted in 24 (29%) of 82 patients at 1 month and 3 (4.6%) of 65 patients at 6 months. Chest x-rays were normal in two of the three children at 1 year, with one child lost to follow-up. A 7-year-old initially treated with a drain and no fibrinolytics required readmission, but he was among those with normal x-rays at 1 year, Dr. Mahant said.

The median time lost from school in the first month was 5 days, with 23% of parents reporting work loss. At 6 months, the median school loss was 2 days and just 9% of parents reported work loss.

Parent- and child-reported total scores on the Pediatric Quality of Life questionnaire were similar at 6 months to healthy controls. In addition, scores were significantly higher in the empyema cohort than in historical asthma controls (P value less than .001), he said.

While the data are encouraging, it is uncertain whether they will be enough to ratchet back the use of more invasive procedures, particularly in the United States. In addition, clinicians worldwide are facing an increasing incidence of complicated pneumonia since the 1990s due in part to pneumococcal serotype shift and antibacterial resistance, Dr. Mahant said.

Dr. Shah of Cincinnati Children’s Hospital Medical Center said the findings will give clinicians pause about whether invasive procedures are needed and the relative timing of these procedures. Moreover, researchers will recognize the importance of measuring long-term outcomes in future trials.

"I think that it’s critical to look at these [outcomes] because ultimately that is what matters," he said. "I think most people would be willing to trade a day or two in the hospital if whatever you’re doing led to fewer long-term symptoms."

Dr. Mahant and his coauthors reported a University of Toronto grant and funding from the SickKids Foundation. Dr. Shah reported no relevant financial disclosures.

KANSAS CITY, MO. – Just four children experienced radiographic or spirometric abnormalities 6 months after hospitalization for complicated pneumonia in a prospective observational study involving 82 patients.

"Long-term sequelae from this condition are uncommon, and this may be important information for clinicians, patients, and parents in weighing various treatment decisions," study coauthor Dr. Sanjay Mahant said at the Pediatric Hospital Medicine 2011 meeting.

While the best management strategy for complicated pneumonia continues to be debated, there’s been increasing use of procedures, particularly chest tube placement with fibrinolytics such as tissue plasminogen activator and video-assisted thoracoscopic surgery.

The lack of long-term sequelae in the Canadian-based study is particularly remarkable in that 40 children received a chest drain with fibrinolytics and 11 received a chest drain alone, while the remaining were treated only with antibiotics.

"I still think larger studies are needed, but it’s really important when we’re discussing with families up front to explain why we’re doing these interventions," Dr. Mahant said. "We need to add in the mix that long-term outcomes are good regardless of whether we do antibiotics alone or an intervention, and what we’re really focusing on is reducing the short-term morbidity."

Research has focused almost entirely on short-term outcomes, with very few large, prospective studies available on how children with complicated pneumonia do over the long haul.

The current study is novel and important in that it looked not just at long-term lung function in a large prospective cohort, but also quality of life and outcomes relevant to families, session comoderator and pediatric infectious disease specialist Dr. Samir Shah said in an interview. He observed that a large portion of the children experienced short-term clinical phenomena in the study, but that these abnormalities appeared to resolve when followed out to 1 year.

"I think that’s very encouraging and good information to know, and will help inform our short-term treatment decisions, realizing that these kids seem to do well, somewhat or perhaps, no matter what we do," he said. "That may be helpful in prioritizing how invasive we need to be with drainage procedures and surgical procedures."

The study enrolled 82 children between October 2008 and October 2010 who were hospitalized with ultrasound evidence of pleural effusions with loculations. Their median age was 3.6 years and 55% were male.

Their median length of stay was 10 days, eight were admitted to the pediatric ICU, and none died, Dr. Mahant reported on behalf of principal investigator Dr. Eyal Cohen and their colleagues at the Hospital for Sick Children, University of Toronto. Six patients were readmitted within 1 month, of which three required treatment with a chest drain.

At 1 month follow-up, fever was reported in 15 (18%) children and persistent cough in 19 (23%). Failure to thrive was observed in two (2%). Among the 74 children evaluated at 6 months, 12 (16%) had persistent cough and none were feverish or failed to thrive.

A predicted forced expiratory volume in 1 second of 80% or less was reported in 7 (35%) of 20 patients at 1 month and only 1 (3.5%) of 28 patients evaluated at 6 months, he said at the meeting, which was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association. Spirometry results at 1 year in this patient were normal.

Persistent chest radiographic abnormalities, defined as effusion, pneumatocele or abscess, were noted in 24 (29%) of 82 patients at 1 month and 3 (4.6%) of 65 patients at 6 months. Chest x-rays were normal in two of the three children at 1 year, with one child lost to follow-up. A 7-year-old initially treated with a drain and no fibrinolytics required readmission, but he was among those with normal x-rays at 1 year, Dr. Mahant said.

The median time lost from school in the first month was 5 days, with 23% of parents reporting work loss. At 6 months, the median school loss was 2 days and just 9% of parents reported work loss.

Parent- and child-reported total scores on the Pediatric Quality of Life questionnaire were similar at 6 months to healthy controls. In addition, scores were significantly higher in the empyema cohort than in historical asthma controls (P value less than .001), he said.

While the data are encouraging, it is uncertain whether they will be enough to ratchet back the use of more invasive procedures, particularly in the United States. In addition, clinicians worldwide are facing an increasing incidence of complicated pneumonia since the 1990s due in part to pneumococcal serotype shift and antibacterial resistance, Dr. Mahant said.

Dr. Shah of Cincinnati Children’s Hospital Medical Center said the findings will give clinicians pause about whether invasive procedures are needed and the relative timing of these procedures. Moreover, researchers will recognize the importance of measuring long-term outcomes in future trials.

"I think that it’s critical to look at these [outcomes] because ultimately that is what matters," he said. "I think most people would be willing to trade a day or two in the hospital if whatever you’re doing led to fewer long-term symptoms."

Dr. Mahant and his coauthors reported a University of Toronto grant and funding from the SickKids Foundation. Dr. Shah reported no relevant financial disclosures.

Delayed diagnosis renders dominant hand and wrist useless

A WOMAN HOSPITALIZED WITH RESPIRATORY SYMPTOMS was treated and released 4 days later. She returned by ambulance the next day and was readmitted for chronic obstructive pulmonary disease and respiratory failure. She had a history of tobacco use. It turned out she had suffered a myocardial infarction. After a cardiac consultation, she was started on 3 anticoagulants, including enoxaparin.

When her condition failed to improve after 4 days, she was transferred to another hospital. Before the transfer, bruising and slight swelling were observed on the patient’s left side and chest, and a physician reportedly ordered that the enoxaparin be discontinued. The plaintiff received another dose of enoxaparin just after she arrived at the second hospital and 3 more doses before the drug was discontinued 2 days later. On the day after admission, the patient’s right forearm, her dominant arm, was noted to be swollen, firm, and painful; her torso was bruised. No immediate evaluation was performed.

An orthopedic consultation the following day led to a diagnosis of compartment syndrome. Emergency surgery resulted in loss of muscle and nerves in the arm and chronic pain. The patient also developed anemia, hypovolemic shock, and retroperitoneal hemorrhage requiring a number of blood transfusions. The patient lost almost all function in her right wrist and hand.

PLAINTIFF’S CLAIM The defendants were negligent in failing to promptly diagnose compartment syndrome and subsequent hemorrhaging.

THE DEFENSE No negligence occurred.

VERDICT $1.525 million Ohio verdict.

COMMENT Subtle and nonspecific findings make compartment syndrome a challenging diagnosis. The combination of extremity pain, swelling, and bruising in the context of anticoagulation should trigger consideration of this condition.

Failure to suspect endocarditis ends in heart surgery and memory deficit

GENERAL ACHES, FATIGUE, AND OCCASIONAL FEVER of 102.5°F led a 43-year-old woman to seek treatment at a local clinic. The nurse practitioner who examined her suspected influenza. Six days later the patient returned, complaining that her symptoms were making it difficult to care for her 4 children. She didn’t have a fever at the time. The nurse practitioner suggested that the woman might want to go to the local hospital for an examination; she also said she could prescribe oral antibiotics to see if they helped. The patient chose the antibiotics.

Her symptoms improved over the next week but then reappeared, prompting her to return to the clinic with complaints of headache, muscle aches, fatigue, chest tightening, an unproductive cough, and night sweats so severe she had to wrap herself in a towel to avoid soaking her bed. Although she was still having regular periods, a physician told her she was probably premenopausal. He also told her that overweight people often sweat at night and attributed her fatigue to her 4 children. He prescribed rizatriptan on the theory that the headaches might be migraines. Because the woman didn’t have a fever at the time of the visit and had just finished a course of antibiotics, the physician said he was sure that she didn’t have an infection.

After 6 days with no improvement, the patient went to a hospital emergency department (ED) for a complete checkup because she was planning to drive to Arizona with her family and wanted to make sure she was all right before leaving. The ED physician ordered scans, a spinal tap, and blood tests; he diagnosed a viral infection.

Three days later, the patient went to the clinic, accompanied by her entire family, to find out the results of the blood tests. She still had symptoms and had developed a swollen, tender sternum. The nurse practitioner noted a positive culture result for Streptococcus veridans on the test report; she allegedly told the patient, in the presence of her 10-year-old son, that it must be a skin contaminant. She advised the patient to go on vacation and have additional blood work if she didn’t feel better.

The nurse practitioner gave the patient another pack of oral antibiotics in case she had a lingering low-grade infection. The patient also received another prescription for rizatriptan and an acetaminophen and oxycodone prescription for pain.

The nurse practitioner claimed that she suggested that the patient could stop by the hospital for a blood test before leaving on vacation, but the patient denied that the nurse made the suggestion, and no notes supported the claim. The oral antibiotics relieved the patient’s symptoms only temporarily. The family cut short their vacation so the patient could return to the clinic, where she received another ineffectual antibiotic. When her condition continued to deteriorate, her husband took her to the ED of a larger hospital in the area.

The ED physician diagnosed subacute endocarditis, which was confirmed by subsequent tests. Testing also identified a bicuspid aortic valve, which increased the patient’s susceptibility to endocarditis. She was started on appropriate intravenous antibiotics and improved initially.

The patient subsequently noticed red patches on her hand and forearm. She also experienced problems with mental processing. She returned to the hospital, where a scan showed increased vegetative growth on her aortic valve. Pieces of the growth were breaking off, causing embolic injury to the patient’s brain, hand, and other areas of her body. The patient underwent open heart surgery to replace the aortic valve and prevent further embolic injury. She continues to suffer from significant short-term memory loss and will require warfarin for the rest of her life to prevent blood clotting.

PLAINTIFF’S CLAIM The patient should have been referred earlier for a complete workup, and the nurse practitioner should have taken seriously the culture showing S veridans. The nurse practitioner was mistaken in thinking that S veridans was found on the skin. Had she looked it up, which she should have done, she would have discovered that the organism is the most common bacterial cause of subacute endocarditis.

The patient had the classic symptoms of subacute endocarditis. The delay in diagnosis allowed bacteria to build up on her aortic valve, forming a biofilm barrier that inhibited the effect of the IV antibiotics and the body’s natural defenses and precipitated the embolic injury.

THE DEFENSE The patient was responsible for the delay in diagnosis, especially in light of the fact that she had a nursing background. Any negligence on the part of the nurse practitioner had no effect on the outcome.

VERDICT $1 million Washington settlement.

COMMENT Subacute bacterial endocarditis remains a challenging diagnosis with potentially devastating consequences. Be on the alert for this subtle masquerader.

Delayed diagnosis renders dominant hand and wrist useless

A WOMAN HOSPITALIZED WITH RESPIRATORY SYMPTOMS was treated and released 4 days later. She returned by ambulance the next day and was readmitted for chronic obstructive pulmonary disease and respiratory failure. She had a history of tobacco use. It turned out she had suffered a myocardial infarction. After a cardiac consultation, she was started on 3 anticoagulants, including enoxaparin.

When her condition failed to improve after 4 days, she was transferred to another hospital. Before the transfer, bruising and slight swelling were observed on the patient’s left side and chest, and a physician reportedly ordered that the enoxaparin be discontinued. The plaintiff received another dose of enoxaparin just after she arrived at the second hospital and 3 more doses before the drug was discontinued 2 days later. On the day after admission, the patient’s right forearm, her dominant arm, was noted to be swollen, firm, and painful; her torso was bruised. No immediate evaluation was performed.

An orthopedic consultation the following day led to a diagnosis of compartment syndrome. Emergency surgery resulted in loss of muscle and nerves in the arm and chronic pain. The patient also developed anemia, hypovolemic shock, and retroperitoneal hemorrhage requiring a number of blood transfusions. The patient lost almost all function in her right wrist and hand.

PLAINTIFF’S CLAIM The defendants were negligent in failing to promptly diagnose compartment syndrome and subsequent hemorrhaging.

THE DEFENSE No negligence occurred.

VERDICT $1.525 million Ohio verdict.

COMMENT Subtle and nonspecific findings make compartment syndrome a challenging diagnosis. The combination of extremity pain, swelling, and bruising in the context of anticoagulation should trigger consideration of this condition.

Failure to suspect endocarditis ends in heart surgery and memory deficit

GENERAL ACHES, FATIGUE, AND OCCASIONAL FEVER of 102.5°F led a 43-year-old woman to seek treatment at a local clinic. The nurse practitioner who examined her suspected influenza. Six days later the patient returned, complaining that her symptoms were making it difficult to care for her 4 children. She didn’t have a fever at the time. The nurse practitioner suggested that the woman might want to go to the local hospital for an examination; she also said she could prescribe oral antibiotics to see if they helped. The patient chose the antibiotics.

Her symptoms improved over the next week but then reappeared, prompting her to return to the clinic with complaints of headache, muscle aches, fatigue, chest tightening, an unproductive cough, and night sweats so severe she had to wrap herself in a towel to avoid soaking her bed. Although she was still having regular periods, a physician told her she was probably premenopausal. He also told her that overweight people often sweat at night and attributed her fatigue to her 4 children. He prescribed rizatriptan on the theory that the headaches might be migraines. Because the woman didn’t have a fever at the time of the visit and had just finished a course of antibiotics, the physician said he was sure that she didn’t have an infection.

After 6 days with no improvement, the patient went to a hospital emergency department (ED) for a complete checkup because she was planning to drive to Arizona with her family and wanted to make sure she was all right before leaving. The ED physician ordered scans, a spinal tap, and blood tests; he diagnosed a viral infection.

Three days later, the patient went to the clinic, accompanied by her entire family, to find out the results of the blood tests. She still had symptoms and had developed a swollen, tender sternum. The nurse practitioner noted a positive culture result for Streptococcus veridans on the test report; she allegedly told the patient, in the presence of her 10-year-old son, that it must be a skin contaminant. She advised the patient to go on vacation and have additional blood work if she didn’t feel better.

The nurse practitioner gave the patient another pack of oral antibiotics in case she had a lingering low-grade infection. The patient also received another prescription for rizatriptan and an acetaminophen and oxycodone prescription for pain.

The nurse practitioner claimed that she suggested that the patient could stop by the hospital for a blood test before leaving on vacation, but the patient denied that the nurse made the suggestion, and no notes supported the claim. The oral antibiotics relieved the patient’s symptoms only temporarily. The family cut short their vacation so the patient could return to the clinic, where she received another ineffectual antibiotic. When her condition continued to deteriorate, her husband took her to the ED of a larger hospital in the area.

The ED physician diagnosed subacute endocarditis, which was confirmed by subsequent tests. Testing also identified a bicuspid aortic valve, which increased the patient’s susceptibility to endocarditis. She was started on appropriate intravenous antibiotics and improved initially.

The patient subsequently noticed red patches on her hand and forearm. She also experienced problems with mental processing. She returned to the hospital, where a scan showed increased vegetative growth on her aortic valve. Pieces of the growth were breaking off, causing embolic injury to the patient’s brain, hand, and other areas of her body. The patient underwent open heart surgery to replace the aortic valve and prevent further embolic injury. She continues to suffer from significant short-term memory loss and will require warfarin for the rest of her life to prevent blood clotting.

PLAINTIFF’S CLAIM The patient should have been referred earlier for a complete workup, and the nurse practitioner should have taken seriously the culture showing S veridans. The nurse practitioner was mistaken in thinking that S veridans was found on the skin. Had she looked it up, which she should have done, she would have discovered that the organism is the most common bacterial cause of subacute endocarditis.

The patient had the classic symptoms of subacute endocarditis. The delay in diagnosis allowed bacteria to build up on her aortic valve, forming a biofilm barrier that inhibited the effect of the IV antibiotics and the body’s natural defenses and precipitated the embolic injury.

THE DEFENSE The patient was responsible for the delay in diagnosis, especially in light of the fact that she had a nursing background. Any negligence on the part of the nurse practitioner had no effect on the outcome.

VERDICT $1 million Washington settlement.

COMMENT Subacute bacterial endocarditis remains a challenging diagnosis with potentially devastating consequences. Be on the alert for this subtle masquerader.

Delayed diagnosis renders dominant hand and wrist useless

A WOMAN HOSPITALIZED WITH RESPIRATORY SYMPTOMS was treated and released 4 days later. She returned by ambulance the next day and was readmitted for chronic obstructive pulmonary disease and respiratory failure. She had a history of tobacco use. It turned out she had suffered a myocardial infarction. After a cardiac consultation, she was started on 3 anticoagulants, including enoxaparin.

When her condition failed to improve after 4 days, she was transferred to another hospital. Before the transfer, bruising and slight swelling were observed on the patient’s left side and chest, and a physician reportedly ordered that the enoxaparin be discontinued. The plaintiff received another dose of enoxaparin just after she arrived at the second hospital and 3 more doses before the drug was discontinued 2 days later. On the day after admission, the patient’s right forearm, her dominant arm, was noted to be swollen, firm, and painful; her torso was bruised. No immediate evaluation was performed.

An orthopedic consultation the following day led to a diagnosis of compartment syndrome. Emergency surgery resulted in loss of muscle and nerves in the arm and chronic pain. The patient also developed anemia, hypovolemic shock, and retroperitoneal hemorrhage requiring a number of blood transfusions. The patient lost almost all function in her right wrist and hand.

PLAINTIFF’S CLAIM The defendants were negligent in failing to promptly diagnose compartment syndrome and subsequent hemorrhaging.

THE DEFENSE No negligence occurred.

VERDICT $1.525 million Ohio verdict.

COMMENT Subtle and nonspecific findings make compartment syndrome a challenging diagnosis. The combination of extremity pain, swelling, and bruising in the context of anticoagulation should trigger consideration of this condition.

Failure to suspect endocarditis ends in heart surgery and memory deficit

GENERAL ACHES, FATIGUE, AND OCCASIONAL FEVER of 102.5°F led a 43-year-old woman to seek treatment at a local clinic. The nurse practitioner who examined her suspected influenza. Six days later the patient returned, complaining that her symptoms were making it difficult to care for her 4 children. She didn’t have a fever at the time. The nurse practitioner suggested that the woman might want to go to the local hospital for an examination; she also said she could prescribe oral antibiotics to see if they helped. The patient chose the antibiotics.

Her symptoms improved over the next week but then reappeared, prompting her to return to the clinic with complaints of headache, muscle aches, fatigue, chest tightening, an unproductive cough, and night sweats so severe she had to wrap herself in a towel to avoid soaking her bed. Although she was still having regular periods, a physician told her she was probably premenopausal. He also told her that overweight people often sweat at night and attributed her fatigue to her 4 children. He prescribed rizatriptan on the theory that the headaches might be migraines. Because the woman didn’t have a fever at the time of the visit and had just finished a course of antibiotics, the physician said he was sure that she didn’t have an infection.

After 6 days with no improvement, the patient went to a hospital emergency department (ED) for a complete checkup because she was planning to drive to Arizona with her family and wanted to make sure she was all right before leaving. The ED physician ordered scans, a spinal tap, and blood tests; he diagnosed a viral infection.

Three days later, the patient went to the clinic, accompanied by her entire family, to find out the results of the blood tests. She still had symptoms and had developed a swollen, tender sternum. The nurse practitioner noted a positive culture result for Streptococcus veridans on the test report; she allegedly told the patient, in the presence of her 10-year-old son, that it must be a skin contaminant. She advised the patient to go on vacation and have additional blood work if she didn’t feel better.

The nurse practitioner gave the patient another pack of oral antibiotics in case she had a lingering low-grade infection. The patient also received another prescription for rizatriptan and an acetaminophen and oxycodone prescription for pain.

The nurse practitioner claimed that she suggested that the patient could stop by the hospital for a blood test before leaving on vacation, but the patient denied that the nurse made the suggestion, and no notes supported the claim. The oral antibiotics relieved the patient’s symptoms only temporarily. The family cut short their vacation so the patient could return to the clinic, where she received another ineffectual antibiotic. When her condition continued to deteriorate, her husband took her to the ED of a larger hospital in the area.

The ED physician diagnosed subacute endocarditis, which was confirmed by subsequent tests. Testing also identified a bicuspid aortic valve, which increased the patient’s susceptibility to endocarditis. She was started on appropriate intravenous antibiotics and improved initially.

The patient subsequently noticed red patches on her hand and forearm. She also experienced problems with mental processing. She returned to the hospital, where a scan showed increased vegetative growth on her aortic valve. Pieces of the growth were breaking off, causing embolic injury to the patient’s brain, hand, and other areas of her body. The patient underwent open heart surgery to replace the aortic valve and prevent further embolic injury. She continues to suffer from significant short-term memory loss and will require warfarin for the rest of her life to prevent blood clotting.

PLAINTIFF’S CLAIM The patient should have been referred earlier for a complete workup, and the nurse practitioner should have taken seriously the culture showing S veridans. The nurse practitioner was mistaken in thinking that S veridans was found on the skin. Had she looked it up, which she should have done, she would have discovered that the organism is the most common bacterial cause of subacute endocarditis.

The patient had the classic symptoms of subacute endocarditis. The delay in diagnosis allowed bacteria to build up on her aortic valve, forming a biofilm barrier that inhibited the effect of the IV antibiotics and the body’s natural defenses and precipitated the embolic injury.

THE DEFENSE The patient was responsible for the delay in diagnosis, especially in light of the fact that she had a nursing background. Any negligence on the part of the nurse practitioner had no effect on the outcome.

VERDICT $1 million Washington settlement.

COMMENT Subacute bacterial endocarditis remains a challenging diagnosis with potentially devastating consequences. Be on the alert for this subtle masquerader.

MINNEAPOLIS – Sleep is in short supply, thanks to our "24-hour society" in which trading sleep for work or play is commonplace and sleep deprivation is worn as a badge of honor, according to Dr. Michel Cramer Bornemann, codirector of the Minnesota Regional Sleep Disorders Center at Hennepin County Medical Center in Minneapolis.

Not only have we become accustomed to trading sleep for work, Dr. Cramer Bornemann said at the annual meeting of the Associated Professional Sleep Societies, "lack of sleep is synonymous with hard work or achievement, when really it can impede both."

In fact, the effects of insufficient shut-eye extend across multiple domains, according to a collection of independent studies presented at this year’s meeting. For example, sleep loss was linked to the development or exacerbation of symptoms of ADHD in early childhood, an individual’s genetic risk of obesity, inhibitory response to images of high-calorie foods, and even marital discontent.

ADHD and Sleep Loss

In a study designed to tease out the complex relationship between sleep problems – particularly falling asleep and staying asleep – and the development or worsening of inattention and hyperactivity and impulsivity in children and adolescents diagnosed with ADHD, Erika Gaylor, Ph.D., of SRI International in Menlo Park, Calif., and her colleagues analyzed data from the preschool and kindergarten waves of the Early Childhood Longitudinal Study-Birth Cohort. The cohort comprises a representative sample of approximately 6,860 children and their families living the United States.

The investigators calculated total nighttime sleep duration based on parent-reported bedtime and wake time, and assessed children’s behavior using brief measures of attention and task persistence, Dr. Gaylor reported.

"We performed two sets of regression analyses to identify whether sleep duration in preschool-age children predicts attention and hyperactivity at kindergarten entry and [whether] attention and hyperactivity symptoms at preschool predict sleep duration at kindergarten," she explained.

Controlling for the outcome of interest at the preschool time point, sex, ethnicity, and family income, researchers found that less sleep at preschool significantly predicted worse scores on parent-reported hyperactivity and attention at kindergarten, whereas parent-reported hyperactivity and attention at preschool did not predict sleep duration at kindergarten, Dr. Gaylor stated.

"These findings suggest that some children who are not getting adequate sleep may be at risk for developing behavioral problems manifested by hyperactivity, impulsivity, and problems sitting still and paying attention," she said. The results extend those of a previous study in which she and her colleagues determined that having a consistent bedtime was the most reliable predictor of positive developmental outcomes by age 4 years, she noted.

The Link Between Sleep and Obesity

In a twin study designed to look more closely at the previously reported link between short sleep duration and elevated body mass index, Dr. Nathaniel Watson of the University of Washington in Seattle and his colleagues determined that short sleep may potentiate an underlying genetic mechanism for obesity.

The investigators examined whether sleep duration modified genetic and environmental influences on BMI in 1,811 pairs of twins drawn from the population-based University of Washington Twin Registry. The mean age of the study participants was 36.6 years. The participants provided self-reported information on height and weight, which was used to calculate BMI, as well as on habitual sleep duration, Dr. Watson said. The mean BMI of the group was 25.4 kg/m², and the mean sleep duration was 7.18 hours, he said.

©Nozomi Stall/Fotolia.com

Using behavioral genetic interaction models, the investigators found significant relationships between habitual sleep duration and genetic and shared environmental influences on BMI. Specifically, longer sleep duration was associated with decreased BMI, Dr. Watson reported.

"When sleep duration was 7 hours, the heritability of BMI was more than double [70%] that observed when sleep duration was 9 hours [33%]," he said, noting that "there appears to be something about short sleep that creates a permissive environment for expression of obesity-related genes." Similarly, he added, longer sleep duration may suppress genetic influences on body weight.

The findings are an important addition to the existing body of research on the relationship between sleep duration and BMI, Dr. Watson said. "Studies attempting to identify specific genotypes for BMI may benefit from considering the moderating role of sleep duration."

A connection between sleepiness and lack of self-control with respect to dietary choices may also contribute to the sleep loss/obesity equation, according to a study presented by William Killgore, Ph.D., of Harvard Medical School in Boston.

To test their hypothesis that greater daytime sleepiness correlates with reduced prefrontal cortex response during passive viewing of images of high-calorie foods, Dr. Killgore and his colleagues analyzed the functional magnetic resonance imaging (fMRI) scans of 12 healthy adults obtained while they were shown pictures of high-calorie foods, low-calorie foods, and control images of plants and rocks. Using a second-level regression model, the researchers correlated the fMRI findings with subjects’ self-reported daytime sleepiness, assessed via the Epworth Sleepiness Scale (ESS).

"Greater ESS scores correlated with reduced activation in the dorsolateral prefrontal cortex when high-calorie vs. low-calorie food images were perceived," Dr. Killgore reported, noting that this region is typically implicated in attention and inhibitory processing. Similarly, greater daytime sleepiness was also associated with increased activation in the right parietal and inferior temporal cortex, he said.

The findings suggest the possibility that sleepiness may affect an individual’s inhibitory control when he or she is exposed to highly appetizing, high-calorie foods, according to Dr. Killgore, although it’s uncertain as of yet whether the observed patterns relate to actual food consumption, he said.

Marital Discord

Although most sleep research focuses on the individual, the fact that sleep problems and relationship trouble often co-occur led Wendy M. Troxel, Ph.D., of the University of Pittsburgh, and her colleagues to consider the dyadic nature of sleep in a recent study. The investigators examined the bidirectional links between nightly sleep and daily marital interactions among 35 healthy married couples (mean age, 32 years) by correlating the actigraph results for sleep latency, wakefulness after sleep onset, and total sleep time of each partner over 10 nights, with daily self-reported positive and negative marital interactions assessed via electronic diaries during the same period.

"We found stronger evidence linking sleep to the next day’s marital interactions, rather than the reverse direction," Dr. Troxel reported.

Specifically, wives’ prolonged sleep latency significantly predicted their own and their husbands’ reports of more negative and less positive interactions the next day, even after adjustment for depressive symptoms, whereas the quality of marital interactions did not appear to predict sleep measures in women, she said. The sleep quality of husbands did not appear to affect their own or their wives’ reports of next-day marital interactions; however, for men, a higher level of positive marital interactions predicted shorter total sleep duration the next night.

The findings suggest, perhaps, that "men are more likely to repress their feelings or not be as aware" of mood changes, whereas women are more likely to express their emotional concerns and to "drive the emotional climate of the relationship," Dr. Troxel said. The results highlight the potential interpersonal consequences of sleep disorders, and as such may have important clinical implications, she said.

In March of this year, the Centers for Disease Control and Prevention reported that nearly a third of the country’s adults get fewer than the minimum recommended 7 hours of sleep per night, and it’s not because they’re not tired: Nearly 40% of the survey population reported unintentionally falling asleep during the day, and nearly 5% reported nodding off while driving in the preceding 30 days (MMWR 2011;60:233-8).

In addition to the negative consequences of sleep deprivation noted above, previous studies have linked sleep insufficiency to a range of adverse health outcomes, including cardiovascular disease, asthma, diabetes, and stroke, according to the report.

The presenters reported no financial conflicts of interest relevant to their respective presentations.

MINNEAPOLIS – Sleep is in short supply, thanks to our "24-hour society" in which trading sleep for work or play is commonplace and sleep deprivation is worn as a badge of honor, according to Dr. Michel Cramer Bornemann, codirector of the Minnesota Regional Sleep Disorders Center at Hennepin County Medical Center in Minneapolis.

Not only have we become accustomed to trading sleep for work, Dr. Cramer Bornemann said at the annual meeting of the Associated Professional Sleep Societies, "lack of sleep is synonymous with hard work or achievement, when really it can impede both."

In fact, the effects of insufficient shut-eye extend across multiple domains, according to a collection of independent studies presented at this year’s meeting. For example, sleep loss was linked to the development or exacerbation of symptoms of ADHD in early childhood, an individual’s genetic risk of obesity, inhibitory response to images of high-calorie foods, and even marital discontent.

ADHD and Sleep Loss

In a study designed to tease out the complex relationship between sleep problems – particularly falling asleep and staying asleep – and the development or worsening of inattention and hyperactivity and impulsivity in children and adolescents diagnosed with ADHD, Erika Gaylor, Ph.D., of SRI International in Menlo Park, Calif., and her colleagues analyzed data from the preschool and kindergarten waves of the Early Childhood Longitudinal Study-Birth Cohort. The cohort comprises a representative sample of approximately 6,860 children and their families living the United States.

The investigators calculated total nighttime sleep duration based on parent-reported bedtime and wake time, and assessed children’s behavior using brief measures of attention and task persistence, Dr. Gaylor reported.

"We performed two sets of regression analyses to identify whether sleep duration in preschool-age children predicts attention and hyperactivity at kindergarten entry and [whether] attention and hyperactivity symptoms at preschool predict sleep duration at kindergarten," she explained.

Controlling for the outcome of interest at the preschool time point, sex, ethnicity, and family income, researchers found that less sleep at preschool significantly predicted worse scores on parent-reported hyperactivity and attention at kindergarten, whereas parent-reported hyperactivity and attention at preschool did not predict sleep duration at kindergarten, Dr. Gaylor stated.

"These findings suggest that some children who are not getting adequate sleep may be at risk for developing behavioral problems manifested by hyperactivity, impulsivity, and problems sitting still and paying attention," she said. The results extend those of a previous study in which she and her colleagues determined that having a consistent bedtime was the most reliable predictor of positive developmental outcomes by age 4 years, she noted.

The Link Between Sleep and Obesity

In a twin study designed to look more closely at the previously reported link between short sleep duration and elevated body mass index, Dr. Nathaniel Watson of the University of Washington in Seattle and his colleagues determined that short sleep may potentiate an underlying genetic mechanism for obesity.

The investigators examined whether sleep duration modified genetic and environmental influences on BMI in 1,811 pairs of twins drawn from the population-based University of Washington Twin Registry. The mean age of the study participants was 36.6 years. The participants provided self-reported information on height and weight, which was used to calculate BMI, as well as on habitual sleep duration, Dr. Watson said. The mean BMI of the group was 25.4 kg/m², and the mean sleep duration was 7.18 hours, he said.

©Nozomi Stall/Fotolia.com

Using behavioral genetic interaction models, the investigators found significant relationships between habitual sleep duration and genetic and shared environmental influences on BMI. Specifically, longer sleep duration was associated with decreased BMI, Dr. Watson reported.

"When sleep duration was 7 hours, the heritability of BMI was more than double [70%] that observed when sleep duration was 9 hours [33%]," he said, noting that "there appears to be something about short sleep that creates a permissive environment for expression of obesity-related genes." Similarly, he added, longer sleep duration may suppress genetic influences on body weight.

The findings are an important addition to the existing body of research on the relationship between sleep duration and BMI, Dr. Watson said. "Studies attempting to identify specific genotypes for BMI may benefit from considering the moderating role of sleep duration."

A connection between sleepiness and lack of self-control with respect to dietary choices may also contribute to the sleep loss/obesity equation, according to a study presented by William Killgore, Ph.D., of Harvard Medical School in Boston.

To test their hypothesis that greater daytime sleepiness correlates with reduced prefrontal cortex response during passive viewing of images of high-calorie foods, Dr. Killgore and his colleagues analyzed the functional magnetic resonance imaging (fMRI) scans of 12 healthy adults obtained while they were shown pictures of high-calorie foods, low-calorie foods, and control images of plants and rocks. Using a second-level regression model, the researchers correlated the fMRI findings with subjects’ self-reported daytime sleepiness, assessed via the Epworth Sleepiness Scale (ESS).

"Greater ESS scores correlated with reduced activation in the dorsolateral prefrontal cortex when high-calorie vs. low-calorie food images were perceived," Dr. Killgore reported, noting that this region is typically implicated in attention and inhibitory processing. Similarly, greater daytime sleepiness was also associated with increased activation in the right parietal and inferior temporal cortex, he said.

The findings suggest the possibility that sleepiness may affect an individual’s inhibitory control when he or she is exposed to highly appetizing, high-calorie foods, according to Dr. Killgore, although it’s uncertain as of yet whether the observed patterns relate to actual food consumption, he said.

Marital Discord

Although most sleep research focuses on the individual, the fact that sleep problems and relationship trouble often co-occur led Wendy M. Troxel, Ph.D., of the University of Pittsburgh, and her colleagues to consider the dyadic nature of sleep in a recent study. The investigators examined the bidirectional links between nightly sleep and daily marital interactions among 35 healthy married couples (mean age, 32 years) by correlating the actigraph results for sleep latency, wakefulness after sleep onset, and total sleep time of each partner over 10 nights, with daily self-reported positive and negative marital interactions assessed via electronic diaries during the same period.

"We found stronger evidence linking sleep to the next day’s marital interactions, rather than the reverse direction," Dr. Troxel reported.

Specifically, wives’ prolonged sleep latency significantly predicted their own and their husbands’ reports of more negative and less positive interactions the next day, even after adjustment for depressive symptoms, whereas the quality of marital interactions did not appear to predict sleep measures in women, she said. The sleep quality of husbands did not appear to affect their own or their wives’ reports of next-day marital interactions; however, for men, a higher level of positive marital interactions predicted shorter total sleep duration the next night.

The findings suggest, perhaps, that "men are more likely to repress their feelings or not be as aware" of mood changes, whereas women are more likely to express their emotional concerns and to "drive the emotional climate of the relationship," Dr. Troxel said. The results highlight the potential interpersonal consequences of sleep disorders, and as such may have important clinical implications, she said.

In March of this year, the Centers for Disease Control and Prevention reported that nearly a third of the country’s adults get fewer than the minimum recommended 7 hours of sleep per night, and it’s not because they’re not tired: Nearly 40% of the survey population reported unintentionally falling asleep during the day, and nearly 5% reported nodding off while driving in the preceding 30 days (MMWR 2011;60:233-8).

In addition to the negative consequences of sleep deprivation noted above, previous studies have linked sleep insufficiency to a range of adverse health outcomes, including cardiovascular disease, asthma, diabetes, and stroke, according to the report.

The presenters reported no financial conflicts of interest relevant to their respective presentations.

MINNEAPOLIS – Sleep is in short supply, thanks to our "24-hour society" in which trading sleep for work or play is commonplace and sleep deprivation is worn as a badge of honor, according to Dr. Michel Cramer Bornemann, codirector of the Minnesota Regional Sleep Disorders Center at Hennepin County Medical Center in Minneapolis.

Not only have we become accustomed to trading sleep for work, Dr. Cramer Bornemann said at the annual meeting of the Associated Professional Sleep Societies, "lack of sleep is synonymous with hard work or achievement, when really it can impede both."

In fact, the effects of insufficient shut-eye extend across multiple domains, according to a collection of independent studies presented at this year’s meeting. For example, sleep loss was linked to the development or exacerbation of symptoms of ADHD in early childhood, an individual’s genetic risk of obesity, inhibitory response to images of high-calorie foods, and even marital discontent.

ADHD and Sleep Loss

In a study designed to tease out the complex relationship between sleep problems – particularly falling asleep and staying asleep – and the development or worsening of inattention and hyperactivity and impulsivity in children and adolescents diagnosed with ADHD, Erika Gaylor, Ph.D., of SRI International in Menlo Park, Calif., and her colleagues analyzed data from the preschool and kindergarten waves of the Early Childhood Longitudinal Study-Birth Cohort. The cohort comprises a representative sample of approximately 6,860 children and their families living the United States.

The investigators calculated total nighttime sleep duration based on parent-reported bedtime and wake time, and assessed children’s behavior using brief measures of attention and task persistence, Dr. Gaylor reported.

"We performed two sets of regression analyses to identify whether sleep duration in preschool-age children predicts attention and hyperactivity at kindergarten entry and [whether] attention and hyperactivity symptoms at preschool predict sleep duration at kindergarten," she explained.

Controlling for the outcome of interest at the preschool time point, sex, ethnicity, and family income, researchers found that less sleep at preschool significantly predicted worse scores on parent-reported hyperactivity and attention at kindergarten, whereas parent-reported hyperactivity and attention at preschool did not predict sleep duration at kindergarten, Dr. Gaylor stated.

"These findings suggest that some children who are not getting adequate sleep may be at risk for developing behavioral problems manifested by hyperactivity, impulsivity, and problems sitting still and paying attention," she said. The results extend those of a previous study in which she and her colleagues determined that having a consistent bedtime was the most reliable predictor of positive developmental outcomes by age 4 years, she noted.

The Link Between Sleep and Obesity

In a twin study designed to look more closely at the previously reported link between short sleep duration and elevated body mass index, Dr. Nathaniel Watson of the University of Washington in Seattle and his colleagues determined that short sleep may potentiate an underlying genetic mechanism for obesity.

The investigators examined whether sleep duration modified genetic and environmental influences on BMI in 1,811 pairs of twins drawn from the population-based University of Washington Twin Registry. The mean age of the study participants was 36.6 years. The participants provided self-reported information on height and weight, which was used to calculate BMI, as well as on habitual sleep duration, Dr. Watson said. The mean BMI of the group was 25.4 kg/m², and the mean sleep duration was 7.18 hours, he said.

©Nozomi Stall/Fotolia.com

Using behavioral genetic interaction models, the investigators found significant relationships between habitual sleep duration and genetic and shared environmental influences on BMI. Specifically, longer sleep duration was associated with decreased BMI, Dr. Watson reported.

"When sleep duration was 7 hours, the heritability of BMI was more than double [70%] that observed when sleep duration was 9 hours [33%]," he said, noting that "there appears to be something about short sleep that creates a permissive environment for expression of obesity-related genes." Similarly, he added, longer sleep duration may suppress genetic influences on body weight.

The findings are an important addition to the existing body of research on the relationship between sleep duration and BMI, Dr. Watson said. "Studies attempting to identify specific genotypes for BMI may benefit from considering the moderating role of sleep duration."

A connection between sleepiness and lack of self-control with respect to dietary choices may also contribute to the sleep loss/obesity equation, according to a study presented by William Killgore, Ph.D., of Harvard Medical School in Boston.

To test their hypothesis that greater daytime sleepiness correlates with reduced prefrontal cortex response during passive viewing of images of high-calorie foods, Dr. Killgore and his colleagues analyzed the functional magnetic resonance imaging (fMRI) scans of 12 healthy adults obtained while they were shown pictures of high-calorie foods, low-calorie foods, and control images of plants and rocks. Using a second-level regression model, the researchers correlated the fMRI findings with subjects’ self-reported daytime sleepiness, assessed via the Epworth Sleepiness Scale (ESS).

"Greater ESS scores correlated with reduced activation in the dorsolateral prefrontal cortex when high-calorie vs. low-calorie food images were perceived," Dr. Killgore reported, noting that this region is typically implicated in attention and inhibitory processing. Similarly, greater daytime sleepiness was also associated with increased activation in the right parietal and inferior temporal cortex, he said.

The findings suggest the possibility that sleepiness may affect an individual’s inhibitory control when he or she is exposed to highly appetizing, high-calorie foods, according to Dr. Killgore, although it’s uncertain as of yet whether the observed patterns relate to actual food consumption, he said.

Marital Discord

Although most sleep research focuses on the individual, the fact that sleep problems and relationship trouble often co-occur led Wendy M. Troxel, Ph.D., of the University of Pittsburgh, and her colleagues to consider the dyadic nature of sleep in a recent study. The investigators examined the bidirectional links between nightly sleep and daily marital interactions among 35 healthy married couples (mean age, 32 years) by correlating the actigraph results for sleep latency, wakefulness after sleep onset, and total sleep time of each partner over 10 nights, with daily self-reported positive and negative marital interactions assessed via electronic diaries during the same period.

"We found stronger evidence linking sleep to the next day’s marital interactions, rather than the reverse direction," Dr. Troxel reported.

Specifically, wives’ prolonged sleep latency significantly predicted their own and their husbands’ reports of more negative and less positive interactions the next day, even after adjustment for depressive symptoms, whereas the quality of marital interactions did not appear to predict sleep measures in women, she said. The sleep quality of husbands did not appear to affect their own or their wives’ reports of next-day marital interactions; however, for men, a higher level of positive marital interactions predicted shorter total sleep duration the next night.

The findings suggest, perhaps, that "men are more likely to repress their feelings or not be as aware" of mood changes, whereas women are more likely to express their emotional concerns and to "drive the emotional climate of the relationship," Dr. Troxel said. The results highlight the potential interpersonal consequences of sleep disorders, and as such may have important clinical implications, she said.

In March of this year, the Centers for Disease Control and Prevention reported that nearly a third of the country’s adults get fewer than the minimum recommended 7 hours of sleep per night, and it’s not because they’re not tired: Nearly 40% of the survey population reported unintentionally falling asleep during the day, and nearly 5% reported nodding off while driving in the preceding 30 days (MMWR 2011;60:233-8).

In addition to the negative consequences of sleep deprivation noted above, previous studies have linked sleep insufficiency to a range of adverse health outcomes, including cardiovascular disease, asthma, diabetes, and stroke, according to the report.

The presenters reported no financial conflicts of interest relevant to their respective presentations.

Constrictive bronchiolitis should be considered in all returning veterans who report exercise limitations due to dyspnea, according to the authors of a report in the July 21 issue of the New England Journal of Medicine.

Lung biopsies revealed diffuse constrictive bronchiolitis in 38 of 49 previously healthy soldiers who developed unexplained exertional dyspnea and diminished exercise tolerance after serving in Iraq or Afghanistan, said Dr. Matthew S. King of the division of pulmonary and critical care medicine, Meharry Medical College, Nashville, Tenn., and his associates (N. Engl. J. Med. 2011;365:222-30).

Although most of the 38 soldiers had been exposed to smoke from a sulfur-mine fire in northern Iraq, 10 reported no potentially toxic exposures – a "particular concern" given that the potential toxic exposures among those 10 may be similar to those of most troops who were deployed to Iraq and Afghanistan.

The rare disorder is a challenge to diagnose, especially in the absence of known predisposing conditions such as rheumatologic disorders, because patients often show low-normal pulmonary function and normal radiologic results.

During a recent 5-year period, the investigators evaluated 80 soldiers from one Kentucky military base who had persistent respiratory symptoms and exercise intolerance – an extensive assessment that included a detailed review of occupational and environmental exposures. A total of 49 were referred for video-assisted thorascopic lung biopsy by their treating physicians.

Of those 49, 38 were found to have diffuse constrictive bronchiolitis. The 35 men and 3 women had a median age of 33 years (range, 23 years to 44 years), and had served in a variety of positions. All had met the requirements of U.S. Army readiness testing wearing full combat gear before being deployed, but now became breathless after climbing a single flight of stairs.

Chest radiography had yielded normal findings in 37 of the soldiers, and high-resolution CT had done so in 25 soldiers. "Only a few soldiers had high-resolution CT showing the centrilobular nodules or expiratory air trapping that can be associated with constrictive bronchiolitis," the researchers said.

Spirometry results, lung volumes, and measures of carbon monoxide diffusing capacity had been normal in 13 of the soldiers, while another 19 had shown only isolated low carbon monoxide diffusing capacity.

All of the 30 soldiers who had undergone cardiopulmonary exercise testing showed mean levels of maximal oxygen consumption and an anaerobic threshold that were in the low-normal range. However, when compared with results for military control subjects rather than controls from the general population, their mean maximal oxygen consumption was significantly lower, and their anaerobic threshold was significantly reduced.

During biopsy, 37 of the 38 soldiers were found to have lacy black pigment on the visceral pleural surface, and specimens demonstrated polarizable material within the pigment. That is consistent with inhalation of particulate matter.

The biopsy specimens also showed mixed airway-wall inflammation and membranous bronchioles containing hypertrophic mural smooth muscle or fibrous thickening that narrowed the lumen in the small airways. That finding, too, is consistent with toxic inhalation.

Culturing the biopsy samples yielded negative results on all attempts to identify bacteria, fungus, or acid-fast bacilli, Dr. King and his colleagues said.

Of the 38 soldiers, 28 had been exposed to smoke from a sulfur-mine fire in northern Iraq, 33 had been exposed to dust storms, 24 to incinerated solid waste in large burn pits, and 18 to incinerated human waste. However, 10 solders reported no potentially toxic exposures at all.

"We expected that the finding of constrictive bronchiolitis would be limited to" the soldiers with prolonged exposure to toxic levels of sulfur dioxide from the sulfur-mine fire, the researchers explained. But soldiers without such exposure also developed the disorder.

"This group causes particular concern, since their potential toxic exposures are shared by most personnel who were deployed to Iraq and Afghanistan," the investigators noted. "These common exposures include open-air burn pits, in which solid waste was routinely incinerated in close proximity to living quarters, and desert dust storms of such severity that they obscured visibility.

"The presenting symptoms, smoking histories, evaluations, and biopsy samples of the 10 soldiers who did not report exposure to the sulfur-mine fire were indistinguishable from those of the 28 soldiers who did report such exposure," the researchers added.

Twenty-seven of the 38 soldiers responded to a follow-up survey in 2010. Nineteen had left the military with a "disabled" rating, while 8 were still serving "despite their inability to complete a 2-mile run within the regulation time." Twenty-two reported that their respiratory problems limited their job opportunities.

Since the case series was completed, nine more soldiers who presented to Dr. King and his associates have been diagnosed as having constrictive bronchiolitis, they noted.

The study was supported in part by the National Center for Research Resources. One of Dr. King’s associates reported ties to Actelion Pharmaceuticals.

Constrictive bronchiolitis should be considered in all returning veterans who report exercise limitations due to dyspnea, according to the authors of a report in the July 21 issue of the New England Journal of Medicine.

Lung biopsies revealed diffuse constrictive bronchiolitis in 38 of 49 previously healthy soldiers who developed unexplained exertional dyspnea and diminished exercise tolerance after serving in Iraq or Afghanistan, said Dr. Matthew S. King of the division of pulmonary and critical care medicine, Meharry Medical College, Nashville, Tenn., and his associates (N. Engl. J. Med. 2011;365:222-30).

Although most of the 38 soldiers had been exposed to smoke from a sulfur-mine fire in northern Iraq, 10 reported no potentially toxic exposures – a "particular concern" given that the potential toxic exposures among those 10 may be similar to those of most troops who were deployed to Iraq and Afghanistan.

The rare disorder is a challenge to diagnose, especially in the absence of known predisposing conditions such as rheumatologic disorders, because patients often show low-normal pulmonary function and normal radiologic results.

During a recent 5-year period, the investigators evaluated 80 soldiers from one Kentucky military base who had persistent respiratory symptoms and exercise intolerance – an extensive assessment that included a detailed review of occupational and environmental exposures. A total of 49 were referred for video-assisted thorascopic lung biopsy by their treating physicians.

Of those 49, 38 were found to have diffuse constrictive bronchiolitis. The 35 men and 3 women had a median age of 33 years (range, 23 years to 44 years), and had served in a variety of positions. All had met the requirements of U.S. Army readiness testing wearing full combat gear before being deployed, but now became breathless after climbing a single flight of stairs.

Chest radiography had yielded normal findings in 37 of the soldiers, and high-resolution CT had done so in 25 soldiers. "Only a few soldiers had high-resolution CT showing the centrilobular nodules or expiratory air trapping that can be associated with constrictive bronchiolitis," the researchers said.

Spirometry results, lung volumes, and measures of carbon monoxide diffusing capacity had been normal in 13 of the soldiers, while another 19 had shown only isolated low carbon monoxide diffusing capacity.

All of the 30 soldiers who had undergone cardiopulmonary exercise testing showed mean levels of maximal oxygen consumption and an anaerobic threshold that were in the low-normal range. However, when compared with results for military control subjects rather than controls from the general population, their mean maximal oxygen consumption was significantly lower, and their anaerobic threshold was significantly reduced.

During biopsy, 37 of the 38 soldiers were found to have lacy black pigment on the visceral pleural surface, and specimens demonstrated polarizable material within the pigment. That is consistent with inhalation of particulate matter.

The biopsy specimens also showed mixed airway-wall inflammation and membranous bronchioles containing hypertrophic mural smooth muscle or fibrous thickening that narrowed the lumen in the small airways. That finding, too, is consistent with toxic inhalation.

Culturing the biopsy samples yielded negative results on all attempts to identify bacteria, fungus, or acid-fast bacilli, Dr. King and his colleagues said.

Of the 38 soldiers, 28 had been exposed to smoke from a sulfur-mine fire in northern Iraq, 33 had been exposed to dust storms, 24 to incinerated solid waste in large burn pits, and 18 to incinerated human waste. However, 10 solders reported no potentially toxic exposures at all.

"We expected that the finding of constrictive bronchiolitis would be limited to" the soldiers with prolonged exposure to toxic levels of sulfur dioxide from the sulfur-mine fire, the researchers explained. But soldiers without such exposure also developed the disorder.

"This group causes particular concern, since their potential toxic exposures are shared by most personnel who were deployed to Iraq and Afghanistan," the investigators noted. "These common exposures include open-air burn pits, in which solid waste was routinely incinerated in close proximity to living quarters, and desert dust storms of such severity that they obscured visibility.

"The presenting symptoms, smoking histories, evaluations, and biopsy samples of the 10 soldiers who did not report exposure to the sulfur-mine fire were indistinguishable from those of the 28 soldiers who did report such exposure," the researchers added.

Twenty-seven of the 38 soldiers responded to a follow-up survey in 2010. Nineteen had left the military with a "disabled" rating, while 8 were still serving "despite their inability to complete a 2-mile run within the regulation time." Twenty-two reported that their respiratory problems limited their job opportunities.

Since the case series was completed, nine more soldiers who presented to Dr. King and his associates have been diagnosed as having constrictive bronchiolitis, they noted.

The study was supported in part by the National Center for Research Resources. One of Dr. King’s associates reported ties to Actelion Pharmaceuticals.

Constrictive bronchiolitis should be considered in all returning veterans who report exercise limitations due to dyspnea, according to the authors of a report in the July 21 issue of the New England Journal of Medicine.

Lung biopsies revealed diffuse constrictive bronchiolitis in 38 of 49 previously healthy soldiers who developed unexplained exertional dyspnea and diminished exercise tolerance after serving in Iraq or Afghanistan, said Dr. Matthew S. King of the division of pulmonary and critical care medicine, Meharry Medical College, Nashville, Tenn., and his associates (N. Engl. J. Med. 2011;365:222-30).

Although most of the 38 soldiers had been exposed to smoke from a sulfur-mine fire in northern Iraq, 10 reported no potentially toxic exposures – a "particular concern" given that the potential toxic exposures among those 10 may be similar to those of most troops who were deployed to Iraq and Afghanistan.

The rare disorder is a challenge to diagnose, especially in the absence of known predisposing conditions such as rheumatologic disorders, because patients often show low-normal pulmonary function and normal radiologic results.

During a recent 5-year period, the investigators evaluated 80 soldiers from one Kentucky military base who had persistent respiratory symptoms and exercise intolerance – an extensive assessment that included a detailed review of occupational and environmental exposures. A total of 49 were referred for video-assisted thorascopic lung biopsy by their treating physicians.

Of those 49, 38 were found to have diffuse constrictive bronchiolitis. The 35 men and 3 women had a median age of 33 years (range, 23 years to 44 years), and had served in a variety of positions. All had met the requirements of U.S. Army readiness testing wearing full combat gear before being deployed, but now became breathless after climbing a single flight of stairs.

Chest radiography had yielded normal findings in 37 of the soldiers, and high-resolution CT had done so in 25 soldiers. "Only a few soldiers had high-resolution CT showing the centrilobular nodules or expiratory air trapping that can be associated with constrictive bronchiolitis," the researchers said.

Spirometry results, lung volumes, and measures of carbon monoxide diffusing capacity had been normal in 13 of the soldiers, while another 19 had shown only isolated low carbon monoxide diffusing capacity.

All of the 30 soldiers who had undergone cardiopulmonary exercise testing showed mean levels of maximal oxygen consumption and an anaerobic threshold that were in the low-normal range. However, when compared with results for military control subjects rather than controls from the general population, their mean maximal oxygen consumption was significantly lower, and their anaerobic threshold was significantly reduced.

During biopsy, 37 of the 38 soldiers were found to have lacy black pigment on the visceral pleural surface, and specimens demonstrated polarizable material within the pigment. That is consistent with inhalation of particulate matter.

The biopsy specimens also showed mixed airway-wall inflammation and membranous bronchioles containing hypertrophic mural smooth muscle or fibrous thickening that narrowed the lumen in the small airways. That finding, too, is consistent with toxic inhalation.

Culturing the biopsy samples yielded negative results on all attempts to identify bacteria, fungus, or acid-fast bacilli, Dr. King and his colleagues said.

Of the 38 soldiers, 28 had been exposed to smoke from a sulfur-mine fire in northern Iraq, 33 had been exposed to dust storms, 24 to incinerated solid waste in large burn pits, and 18 to incinerated human waste. However, 10 solders reported no potentially toxic exposures at all.

"We expected that the finding of constrictive bronchiolitis would be limited to" the soldiers with prolonged exposure to toxic levels of sulfur dioxide from the sulfur-mine fire, the researchers explained. But soldiers without such exposure also developed the disorder.

"This group causes particular concern, since their potential toxic exposures are shared by most personnel who were deployed to Iraq and Afghanistan," the investigators noted. "These common exposures include open-air burn pits, in which solid waste was routinely incinerated in close proximity to living quarters, and desert dust storms of such severity that they obscured visibility.

"The presenting symptoms, smoking histories, evaluations, and biopsy samples of the 10 soldiers who did not report exposure to the sulfur-mine fire were indistinguishable from those of the 28 soldiers who did report such exposure," the researchers added.

Twenty-seven of the 38 soldiers responded to a follow-up survey in 2010. Nineteen had left the military with a "disabled" rating, while 8 were still serving "despite their inability to complete a 2-mile run within the regulation time." Twenty-two reported that their respiratory problems limited their job opportunities.

Since the case series was completed, nine more soldiers who presented to Dr. King and his associates have been diagnosed as having constrictive bronchiolitis, they noted.

The study was supported in part by the National Center for Research Resources. One of Dr. King’s associates reported ties to Actelion Pharmaceuticals.

BOSTON – Coinfections with both respiratory syncytial virus and rhinovirus were common and associated with increased length of stay in a prospective multicenter study of over 2,000 children under 2 years of age who were hospitalized with bronchiolitis.

The clinical value of testing for an infectious etiology in a child with bronchiolitis is unclear. Indeed, the recommendation is not to test (Pediatrics 2006;118:1774-93). Some argue however, that testing may be useful for the influenza treatment or to identify the beginning of the viral "seasons" and which viruses are circulating, Dr. Jonathan M. Mansbach, a hospitalist physician at Children’s Hospital Boston, said at the annual meeting of the Society for Academic Emergency Medicine.

Photo credit: © Dr. Craig Lyerla / CDC

Additionally, Dr. Mansbach said that the 70% frequency of coinfection seen in this study raises questions about the effectiveness of inpatient cohorting by viral etiology, which some researchers contend is of use. Moreover, the findings suggest that hospitals consider adding RV to respiratory viral panels, he said.

The 16-center study enrolled consecutive children between November and March during 2007-2010. Of the total 2,207 children enrolled, 83% were located on the ward while 17% were admitted to the intensive care unit. Of those 377, 42% were intubated or given continuous positive airway pressure. Overall mean length of stay was 2 days. The patients had a median age of 4 months; 59% were male, 61% were white, 24% black, and 15% other races. A third (36%) were of Hispanic ethnicity.

The three most common viral etiologies identified by polymerase chain reaction were RSV-A (43%) RSV-B (30%) and RV (26%). Adenovirus, human metapneumovirus, and the coronaviruses were all 7%-8%, and only 6% of the children had no virus detected. (These figures add up to more than 100 because of a 30% rate of coinfections.) The low-frequency infections did not affect results, so subsequent analysis focused on RSV (subtypes A and B) and RV, Dr. Mansbach said.

Of the 940 children in whom RSV-A was identified, it was the only virus in 66%, while one or more additional viruses were identified in the other 34%. Similarly, 68% of the 664 RSV-B infected patients had only one virus identified, while 32% were coinfected.

Rhinovirus was somewhat different, however, in that just 30% of 564 had only that and 70% had coinfections.

For children with both RSV-A and RSV-B, the likelihood of having a length of stay of 3 or more days did not differ between those who had the single virus infection and those who were coinfected (48% vs. 49%, respectively, for RSV-A, and 47% and 54% for RSV-B). There was a significant difference with rhinovirus, however, with 28% of those with the single infection and 46% with coinfections hospitalized 3 or more days.

After adjustment for age, gender, race, eczema history, intubation history, apnea, retractions, oxygen saturation, oral intake, comorbid medical condition, and site, rhinovirus alone was associated with a lower chance of being hospitalized 3 or more days compared with RSV-A or RSV-B alone (odds ratio 0.4), while RSV-RV co-infections were associated with a significantly greater chance of being hospitalized for that duration compared with RSV-A or RSV-B alone (OR 1.3).

Clustering by site did not affect the results, and in a preliminary analysis, controlling for acute severity as defined by ICU, CPAP, or intubation also did not materially change the results, Dr. Mansbach said.

This study was conducted as part of the Multicenter Airway Research Collaboration (MARC), a program of the Emergency Medicine Network. Pediatric Research in Inpatient Settings sites collaborated with EMNet, Dr. Mansbach said.

Dr. Mansbach stated that he had no relevant financial disclosures.

BOSTON – Coinfections with both respiratory syncytial virus and rhinovirus were common and associated with increased length of stay in a prospective multicenter study of over 2,000 children under 2 years of age who were hospitalized with bronchiolitis.

The clinical value of testing for an infectious etiology in a child with bronchiolitis is unclear. Indeed, the recommendation is not to test (Pediatrics 2006;118:1774-93). Some argue however, that testing may be useful for the influenza treatment or to identify the beginning of the viral "seasons" and which viruses are circulating, Dr. Jonathan M. Mansbach, a hospitalist physician at Children’s Hospital Boston, said at the annual meeting of the Society for Academic Emergency Medicine.

Photo credit: © Dr. Craig Lyerla / CDC

Additionally, Dr. Mansbach said that the 70% frequency of coinfection seen in this study raises questions about the effectiveness of inpatient cohorting by viral etiology, which some researchers contend is of use. Moreover, the findings suggest that hospitals consider adding RV to respiratory viral panels, he said.

The 16-center study enrolled consecutive children between November and March during 2007-2010. Of the total 2,207 children enrolled, 83% were located on the ward while 17% were admitted to the intensive care unit. Of those 377, 42% were intubated or given continuous positive airway pressure. Overall mean length of stay was 2 days. The patients had a median age of 4 months; 59% were male, 61% were white, 24% black, and 15% other races. A third (36%) were of Hispanic ethnicity.

The three most common viral etiologies identified by polymerase chain reaction were RSV-A (43%) RSV-B (30%) and RV (26%). Adenovirus, human metapneumovirus, and the coronaviruses were all 7%-8%, and only 6% of the children had no virus detected. (These figures add up to more than 100 because of a 30% rate of coinfections.) The low-frequency infections did not affect results, so subsequent analysis focused on RSV (subtypes A and B) and RV, Dr. Mansbach said.

Of the 940 children in whom RSV-A was identified, it was the only virus in 66%, while one or more additional viruses were identified in the other 34%. Similarly, 68% of the 664 RSV-B infected patients had only one virus identified, while 32% were coinfected.

Rhinovirus was somewhat different, however, in that just 30% of 564 had only that and 70% had coinfections.

For children with both RSV-A and RSV-B, the likelihood of having a length of stay of 3 or more days did not differ between those who had the single virus infection and those who were coinfected (48% vs. 49%, respectively, for RSV-A, and 47% and 54% for RSV-B). There was a significant difference with rhinovirus, however, with 28% of those with the single infection and 46% with coinfections hospitalized 3 or more days.

After adjustment for age, gender, race, eczema history, intubation history, apnea, retractions, oxygen saturation, oral intake, comorbid medical condition, and site, rhinovirus alone was associated with a lower chance of being hospitalized 3 or more days compared with RSV-A or RSV-B alone (odds ratio 0.4), while RSV-RV co-infections were associated with a significantly greater chance of being hospitalized for that duration compared with RSV-A or RSV-B alone (OR 1.3).

Clustering by site did not affect the results, and in a preliminary analysis, controlling for acute severity as defined by ICU, CPAP, or intubation also did not materially change the results, Dr. Mansbach said.

This study was conducted as part of the Multicenter Airway Research Collaboration (MARC), a program of the Emergency Medicine Network. Pediatric Research in Inpatient Settings sites collaborated with EMNet, Dr. Mansbach said.

Dr. Mansbach stated that he had no relevant financial disclosures.

BOSTON – Coinfections with both respiratory syncytial virus and rhinovirus were common and associated with increased length of stay in a prospective multicenter study of over 2,000 children under 2 years of age who were hospitalized with bronchiolitis.

The clinical value of testing for an infectious etiology in a child with bronchiolitis is unclear. Indeed, the recommendation is not to test (Pediatrics 2006;118:1774-93). Some argue however, that testing may be useful for the influenza treatment or to identify the beginning of the viral "seasons" and which viruses are circulating, Dr. Jonathan M. Mansbach, a hospitalist physician at Children’s Hospital Boston, said at the annual meeting of the Society for Academic Emergency Medicine.

Photo credit: © Dr. Craig Lyerla / CDC

Additionally, Dr. Mansbach said that the 70% frequency of coinfection seen in this study raises questions about the effectiveness of inpatient cohorting by viral etiology, which some researchers contend is of use. Moreover, the findings suggest that hospitals consider adding RV to respiratory viral panels, he said.

The 16-center study enrolled consecutive children between November and March during 2007-2010. Of the total 2,207 children enrolled, 83% were located on the ward while 17% were admitted to the intensive care unit. Of those 377, 42% were intubated or given continuous positive airway pressure. Overall mean length of stay was 2 days. The patients had a median age of 4 months; 59% were male, 61% were white, 24% black, and 15% other races. A third (36%) were of Hispanic ethnicity.

The three most common viral etiologies identified by polymerase chain reaction were RSV-A (43%) RSV-B (30%) and RV (26%). Adenovirus, human metapneumovirus, and the coronaviruses were all 7%-8%, and only 6% of the children had no virus detected. (These figures add up to more than 100 because of a 30% rate of coinfections.) The low-frequency infections did not affect results, so subsequent analysis focused on RSV (subtypes A and B) and RV, Dr. Mansbach said.

Of the 940 children in whom RSV-A was identified, it was the only virus in 66%, while one or more additional viruses were identified in the other 34%. Similarly, 68% of the 664 RSV-B infected patients had only one virus identified, while 32% were coinfected.

Rhinovirus was somewhat different, however, in that just 30% of 564 had only that and 70% had coinfections.

For children with both RSV-A and RSV-B, the likelihood of having a length of stay of 3 or more days did not differ between those who had the single virus infection and those who were coinfected (48% vs. 49%, respectively, for RSV-A, and 47% and 54% for RSV-B). There was a significant difference with rhinovirus, however, with 28% of those with the single infection and 46% with coinfections hospitalized 3 or more days.

After adjustment for age, gender, race, eczema history, intubation history, apnea, retractions, oxygen saturation, oral intake, comorbid medical condition, and site, rhinovirus alone was associated with a lower chance of being hospitalized 3 or more days compared with RSV-A or RSV-B alone (odds ratio 0.4), while RSV-RV co-infections were associated with a significantly greater chance of being hospitalized for that duration compared with RSV-A or RSV-B alone (OR 1.3).

Clustering by site did not affect the results, and in a preliminary analysis, controlling for acute severity as defined by ICU, CPAP, or intubation also did not materially change the results, Dr. Mansbach said.

This study was conducted as part of the Multicenter Airway Research Collaboration (MARC), a program of the Emergency Medicine Network. Pediatric Research in Inpatient Settings sites collaborated with EMNet, Dr. Mansbach said.

Dr. Mansbach stated that he had no relevant financial disclosures.

LONDON – Patients with rheumatoid arthritis have a high risk of concomitant chronic obstructive pulmonary disease, according to data from two studies.

In one of the studies – which involved more than 15,000 patients with rheumatoid arthritis (RA) and 15,000 healthy individuals as case-matched controls – the risk of the long-term lung condition was 8.9% vs. 4.4%, respectively (P less than .001).

Other data, from the Norfolk Arthritis Register (NOAR) showed that the prevalence of chronic obstructive pulmonary disease (COPD) in patients with inflammatory polyarthritis (IP) or RA was 7.3% (n = 425) at 15 years’ follow-up. Prevalence of the respiratory disease was again doubled when compared to the general population.

"Lung involvement is a common extra-articular manifestation in rheumatoid arthritis," said Dr. Suzanne Verstappen, who presented the findings from the NOAR at the annual European Congress of Rheumatology.

"As could be expected, age and gender were associated with obstructive and restrictive lung disease," said Dr. Verstappen, a research fellow at the Arthritis Research UK Epidemiology Unit at the University of Manchester, England, where the NOAR is coordinated.

Validated spirometry parameters and the Medical Research Council respiratory symptoms questionnaire were used to identify patients with IP or RA who also had COPD. The latter was distinguished from restrictive lung disease whereby the lungs are restricted by the extent that they can inflate. The prevalence of restrictive lung disease was 9.7%.

COPD was observed in 7.3% of the population at 15 years, with higher prevalence rates found in men versus women over the age of 45 years (12.7% vs. 6%, respectively) in a crude comparison. Published rates for the U.K. general population without IP or RA are 6.8% and 3.9% (Popul. Health Metr. 2007;5:8).

Like RA, COPD is a chronic and often debilitating disease. The disease manifests later in life and treatment is symptomatic rather than curative, as the obstruction in the airways is permanent and not usually reversible with bronchodilator therapy. Unlike RA, however, which has multiple etiologic factors and autoimmunity at its root, COPD is almost always caused by smoking. In the NOAR analysis, 53% of the 425 patients were ex-smokers and 13% were current smokers; 34% had never smoked.

Data from the first study, presented during a poster session by Dr. Howard Amital of Sheba Medical Centre in Tel Hashomer, Israel, showed, however, that even with smoking out of the equation, the risk of COPD in patients with RA was higher than in the general population.

Indeed, multivariate analysis showed that RA was associated with COPD after the researchers controlled for confounding factors such as age, gender, smoking, obesity and socioeconomic status.

"The strength of the association increased," Dr. Amital and colleagues reported, with an adjusted odds ratio (OR) of 2.015 (95% confidence interval 1.83-2.22; P less than .001) and an unadjusted OR of 1.89 (95% CI 1.74-2.05, P less than .0001).

The case-control study involved 15,766 patients with RA and 15,240 age- and sex-matched healthy individuals without RA. The study also found higher rates of other chronic disease in patients versus controls, including diabetes (23.9% vs. 19.8%, P less than .0001), ischemic heart disease (19.5% vs. 15.4%, P less than .0001), and heart failure (6.3% vs. 4.3%, P less than .0001).

"This study corroborates the hypothesis that COPD and RA are closely interrelated," Dr. Amital and his team concluded.

NOAR is funded by Arthritis Research UK. Dr. Verstappen and Dr. Amital and colleagues had no conflicts of interest to declare.

LONDON – Patients with rheumatoid arthritis have a high risk of concomitant chronic obstructive pulmonary disease, according to data from two studies.

In one of the studies – which involved more than 15,000 patients with rheumatoid arthritis (RA) and 15,000 healthy individuals as case-matched controls – the risk of the long-term lung condition was 8.9% vs. 4.4%, respectively (P less than .001).

Other data, from the Norfolk Arthritis Register (NOAR) showed that the prevalence of chronic obstructive pulmonary disease (COPD) in patients with inflammatory polyarthritis (IP) or RA was 7.3% (n = 425) at 15 years’ follow-up. Prevalence of the respiratory disease was again doubled when compared to the general population.

"Lung involvement is a common extra-articular manifestation in rheumatoid arthritis," said Dr. Suzanne Verstappen, who presented the findings from the NOAR at the annual European Congress of Rheumatology.

"As could be expected, age and gender were associated with obstructive and restrictive lung disease," said Dr. Verstappen, a research fellow at the Arthritis Research UK Epidemiology Unit at the University of Manchester, England, where the NOAR is coordinated.

Validated spirometry parameters and the Medical Research Council respiratory symptoms questionnaire were used to identify patients with IP or RA who also had COPD. The latter was distinguished from restrictive lung disease whereby the lungs are restricted by the extent that they can inflate. The prevalence of restrictive lung disease was 9.7%.

COPD was observed in 7.3% of the population at 15 years, with higher prevalence rates found in men versus women over the age of 45 years (12.7% vs. 6%, respectively) in a crude comparison. Published rates for the U.K. general population without IP or RA are 6.8% and 3.9% (Popul. Health Metr. 2007;5:8).

Like RA, COPD is a chronic and often debilitating disease. The disease manifests later in life and treatment is symptomatic rather than curative, as the obstruction in the airways is permanent and not usually reversible with bronchodilator therapy. Unlike RA, however, which has multiple etiologic factors and autoimmunity at its root, COPD is almost always caused by smoking. In the NOAR analysis, 53% of the 425 patients were ex-smokers and 13% were current smokers; 34% had never smoked.

Data from the first study, presented during a poster session by Dr. Howard Amital of Sheba Medical Centre in Tel Hashomer, Israel, showed, however, that even with smoking out of the equation, the risk of COPD in patients with RA was higher than in the general population.

Indeed, multivariate analysis showed that RA was associated with COPD after the researchers controlled for confounding factors such as age, gender, smoking, obesity and socioeconomic status.

"The strength of the association increased," Dr. Amital and colleagues reported, with an adjusted odds ratio (OR) of 2.015 (95% confidence interval 1.83-2.22; P less than .001) and an unadjusted OR of 1.89 (95% CI 1.74-2.05, P less than .0001).

The case-control study involved 15,766 patients with RA and 15,240 age- and sex-matched healthy individuals without RA. The study also found higher rates of other chronic disease in patients versus controls, including diabetes (23.9% vs. 19.8%, P less than .0001), ischemic heart disease (19.5% vs. 15.4%, P less than .0001), and heart failure (6.3% vs. 4.3%, P less than .0001).

"This study corroborates the hypothesis that COPD and RA are closely interrelated," Dr. Amital and his team concluded.

NOAR is funded by Arthritis Research UK. Dr. Verstappen and Dr. Amital and colleagues had no conflicts of interest to declare.

LONDON – Patients with rheumatoid arthritis have a high risk of concomitant chronic obstructive pulmonary disease, according to data from two studies.

In one of the studies – which involved more than 15,000 patients with rheumatoid arthritis (RA) and 15,000 healthy individuals as case-matched controls – the risk of the long-term lung condition was 8.9% vs. 4.4%, respectively (P less than .001).

Other data, from the Norfolk Arthritis Register (NOAR) showed that the prevalence of chronic obstructive pulmonary disease (COPD) in patients with inflammatory polyarthritis (IP) or RA was 7.3% (n = 425) at 15 years’ follow-up. Prevalence of the respiratory disease was again doubled when compared to the general population.

"Lung involvement is a common extra-articular manifestation in rheumatoid arthritis," said Dr. Suzanne Verstappen, who presented the findings from the NOAR at the annual European Congress of Rheumatology.

"As could be expected, age and gender were associated with obstructive and restrictive lung disease," said Dr. Verstappen, a research fellow at the Arthritis Research UK Epidemiology Unit at the University of Manchester, England, where the NOAR is coordinated.

Validated spirometry parameters and the Medical Research Council respiratory symptoms questionnaire were used to identify patients with IP or RA who also had COPD. The latter was distinguished from restrictive lung disease whereby the lungs are restricted by the extent that they can inflate. The prevalence of restrictive lung disease was 9.7%.

COPD was observed in 7.3% of the population at 15 years, with higher prevalence rates found in men versus women over the age of 45 years (12.7% vs. 6%, respectively) in a crude comparison. Published rates for the U.K. general population without IP or RA are 6.8% and 3.9% (Popul. Health Metr. 2007;5:8).

Like RA, COPD is a chronic and often debilitating disease. The disease manifests later in life and treatment is symptomatic rather than curative, as the obstruction in the airways is permanent and not usually reversible with bronchodilator therapy. Unlike RA, however, which has multiple etiologic factors and autoimmunity at its root, COPD is almost always caused by smoking. In the NOAR analysis, 53% of the 425 patients were ex-smokers and 13% were current smokers; 34% had never smoked.

Data from the first study, presented during a poster session by Dr. Howard Amital of Sheba Medical Centre in Tel Hashomer, Israel, showed, however, that even with smoking out of the equation, the risk of COPD in patients with RA was higher than in the general population.

Indeed, multivariate analysis showed that RA was associated with COPD after the researchers controlled for confounding factors such as age, gender, smoking, obesity and socioeconomic status.

"The strength of the association increased," Dr. Amital and colleagues reported, with an adjusted odds ratio (OR) of 2.015 (95% confidence interval 1.83-2.22; P less than .001) and an unadjusted OR of 1.89 (95% CI 1.74-2.05, P less than .0001).

The case-control study involved 15,766 patients with RA and 15,240 age- and sex-matched healthy individuals without RA. The study also found higher rates of other chronic disease in patients versus controls, including diabetes (23.9% vs. 19.8%, P less than .0001), ischemic heart disease (19.5% vs. 15.4%, P less than .0001), and heart failure (6.3% vs. 4.3%, P less than .0001).

"This study corroborates the hypothesis that COPD and RA are closely interrelated," Dr. Amital and his team concluded.

NOAR is funded by Arthritis Research UK. Dr. Verstappen and Dr. Amital and colleagues had no conflicts of interest to declare.

In a pilot study designed to tease out placebo effects from genuine clinical responses, asthma patients rated albuterol and two placebo interventions as effective, yet only the albuterol objectively improved forced expiratory volume in 1 second, according to a report in the July 14 issue of the New England Journal of Medicine.

The 46 study subjects also rated both placebo interventions as superior to a no-intervention control situation, even though the objective forced expiratory volume in 1 second (FEV₁) response was nearly identical in all three, said Dr. Michael E. Wechsler of the division of pulmonary and critical care medicine, Brigham and Women’s Hospital and Harvard Medical School, both in Boston, and his associates.

(c) Monkey Business/Fotolia.com

"Even though there was a large, objective drug effect (mean percent improvement in FEV₁, 20%) that was nearly three times the effect of the two placebos and the no-intervention control (mean percent improvement in FEV₁, approximately 7% for all three), patients could not reliably detect the difference between this robust effect of the active drug and the effects of inhaled placebo and sham acupuncture (mean subjective improvement reported by all patients, regardless of intervention, ranged between 45% and 50%)," they wrote.

These findings suggest that asthma patients poorly perceive changes in FEV₁ and that subjective assessments in clinical studies of asthma are severely limited. "Furthermore, it can justly be asserted that for self-appraised symptoms, placebos can have a powerful effect," Dr. Wechsler and his colleagues said.

Their results may also have important implications for placebo effects in general, not just in asthma patients. "Although effective medications target and modulate objective biologic features, the mere ritual of treatment may affect patients’ self-monitoring and subjective experience of their disease," the investigators said.

They chose asthma patients as ideal subjects for this pilot study of placebo effects because repeated objective lung-function assessments can be performed over a short period of time. "We compared acute changes in lung function that occurred after repeated administration of four interventions: a masked bronchodilator (inhaled albuterol), two different types of placebo (an inert inhaler and a validated sham acupuncture needle), and a [waiting] period of no intervention."

A total of 46 adults with stable, mild to moderate asthma who had experience using inhalers were enrolled. They were assigned to each of the four interventions in random order on four separate occasions, 3-7 days apart. On each occasion, they underwent spirometry at baseline and at 20-minute intervals for 2 hours following the intervention. The study subjects documented their subjective treatment responses using a 10-point visual analog scale.

The mean percent improvement in FEV₁ was 20.1% for inhaled albuterol, compared with 7.5% for inhaled placebo, 7.3% for sham acupuncture, and 7.1% for the no-intervention control situation of sitting in a waiting room. This constitutes a "significant" and "large" difference between active and nonactive interventions.

Moreover, using a standard definition of treatment response (12% or greater improvement in FEV₁), patients using the albuterol inhaler responded 77% of the time, while those using the placebo inhaler responded 24% of the time, those using sham acupuncture responded 20% of the time, and those using no intervention responded 18% of the time, Dr. Wechsler and his associates said (N. Engl. J. Med. 2011;365:119-26).

However, the subjects’ assessments did not reflect these results. They reported a 50% improvement in asthma symptoms with inhaled albuterol, a 45% improvement with inhaled placebo, and a 46% improvement with sham acupuncture, compared with a significantly lower 21% improvement with no intervention.

Patients were asked whether they thought they had received active or placebo interventions. Most believed all the interventions except sitting in a waiting room were active. A total of 73% believed the albuterol was active, 66% believed the placebo inhaler was active, and "a remarkable" 85% believed the sham acupuncture was active.

The study findings complement those of a recent trial in which placebo given with "enhanced expectations" – such as deceptive remarks that subjects were receiving a powerful medication – had no effect on objective outcomes but did increase subjective response.

Dr. Wechsler and his colleagues said their results suggest that "subjective improvement in asthma should be interpreted with caution and that objective outcomes should be more heavily relied on for optimal asthma care."

But this interpretation can be questioned. Dr. Wechsler and his colleagues concluded that asthma patients’ reports were "unreliable" because "they reported improvement when there was none – that is, the subjective experiences were simply wrong because they ignored objective facts as measured by FEV₁," Daniel E. Moerman, Ph.D., wrote in an editorial accompanying Dr. Wechsler’s report (N. Engl. J. Med. 2011;365:171-2).

"It is the subjective symptoms that brought these patients to medical care in the first place. They came because they were wheezing and felt suffocated, not because they had a reduced FEV₁," noted Dr. Moerman of the University of Michigan, Dearborn.

For subjective and functional conditions, including migraine, back pain, depression, asthma, inflammatory bowel disease, many autoimmune disorders, and any condition defined by its symptoms, "a patient-centered approach requires that patient-preferred outcomes trump the judgment of the physician.

"Under these conditions, inert pills can be as useful as ‘real’ ones; two inert pills can work better than one; colorful inert pills can work better than plain ones; and injections can work better than pills," wrote Dr. Moerman.

Dr. Wechsler’s study was supported by the National Center for Complementary and Alternative Medicine. Dr. Wechsler and his associates reported ties to numerous industry sources. Dr. Moerman reported no financial conflicts.

In a pilot study designed to tease out placebo effects from genuine clinical responses, asthma patients rated albuterol and two placebo interventions as effective, yet only the albuterol objectively improved forced expiratory volume in 1 second, according to a report in the July 14 issue of the New England Journal of Medicine.

The 46 study subjects also rated both placebo interventions as superior to a no-intervention control situation, even though the objective forced expiratory volume in 1 second (FEV₁) response was nearly identical in all three, said Dr. Michael E. Wechsler of the division of pulmonary and critical care medicine, Brigham and Women’s Hospital and Harvard Medical School, both in Boston, and his associates.

(c) Monkey Business/Fotolia.com

"Even though there was a large, objective drug effect (mean percent improvement in FEV₁, 20%) that was nearly three times the effect of the two placebos and the no-intervention control (mean percent improvement in FEV₁, approximately 7% for all three), patients could not reliably detect the difference between this robust effect of the active drug and the effects of inhaled placebo and sham acupuncture (mean subjective improvement reported by all patients, regardless of intervention, ranged between 45% and 50%)," they wrote.

These findings suggest that asthma patients poorly perceive changes in FEV₁ and that subjective assessments in clinical studies of asthma are severely limited. "Furthermore, it can justly be asserted that for self-appraised symptoms, placebos can have a powerful effect," Dr. Wechsler and his colleagues said.

Their results may also have important implications for placebo effects in general, not just in asthma patients. "Although effective medications target and modulate objective biologic features, the mere ritual of treatment may affect patients’ self-monitoring and subjective experience of their disease," the investigators said.

They chose asthma patients as ideal subjects for this pilot study of placebo effects because repeated objective lung-function assessments can be performed over a short period of time. "We compared acute changes in lung function that occurred after repeated administration of four interventions: a masked bronchodilator (inhaled albuterol), two different types of placebo (an inert inhaler and a validated sham acupuncture needle), and a [waiting] period of no intervention."

A total of 46 adults with stable, mild to moderate asthma who had experience using inhalers were enrolled. They were assigned to each of the four interventions in random order on four separate occasions, 3-7 days apart. On each occasion, they underwent spirometry at baseline and at 20-minute intervals for 2 hours following the intervention. The study subjects documented their subjective treatment responses using a 10-point visual analog scale.

The mean percent improvement in FEV₁ was 20.1% for inhaled albuterol, compared with 7.5% for inhaled placebo, 7.3% for sham acupuncture, and 7.1% for the no-intervention control situation of sitting in a waiting room. This constitutes a "significant" and "large" difference between active and nonactive interventions.

Moreover, using a standard definition of treatment response (12% or greater improvement in FEV₁), patients using the albuterol inhaler responded 77% of the time, while those using the placebo inhaler responded 24% of the time, those using sham acupuncture responded 20% of the time, and those using no intervention responded 18% of the time, Dr. Wechsler and his associates said (N. Engl. J. Med. 2011;365:119-26).

However, the subjects’ assessments did not reflect these results. They reported a 50% improvement in asthma symptoms with inhaled albuterol, a 45% improvement with inhaled placebo, and a 46% improvement with sham acupuncture, compared with a significantly lower 21% improvement with no intervention.

Patients were asked whether they thought they had received active or placebo interventions. Most believed all the interventions except sitting in a waiting room were active. A total of 73% believed the albuterol was active, 66% believed the placebo inhaler was active, and "a remarkable" 85% believed the sham acupuncture was active.

The study findings complement those of a recent trial in which placebo given with "enhanced expectations" – such as deceptive remarks that subjects were receiving a powerful medication – had no effect on objective outcomes but did increase subjective response.

Dr. Wechsler and his colleagues said their results suggest that "subjective improvement in asthma should be interpreted with caution and that objective outcomes should be more heavily relied on for optimal asthma care."

But this interpretation can be questioned. Dr. Wechsler and his colleagues concluded that asthma patients’ reports were "unreliable" because "they reported improvement when there was none – that is, the subjective experiences were simply wrong because they ignored objective facts as measured by FEV₁," Daniel E. Moerman, Ph.D., wrote in an editorial accompanying Dr. Wechsler’s report (N. Engl. J. Med. 2011;365:171-2).

"It is the subjective symptoms that brought these patients to medical care in the first place. They came because they were wheezing and felt suffocated, not because they had a reduced FEV₁," noted Dr. Moerman of the University of Michigan, Dearborn.

For subjective and functional conditions, including migraine, back pain, depression, asthma, inflammatory bowel disease, many autoimmune disorders, and any condition defined by its symptoms, "a patient-centered approach requires that patient-preferred outcomes trump the judgment of the physician.

"Under these conditions, inert pills can be as useful as ‘real’ ones; two inert pills can work better than one; colorful inert pills can work better than plain ones; and injections can work better than pills," wrote Dr. Moerman.

Dr. Wechsler’s study was supported by the National Center for Complementary and Alternative Medicine. Dr. Wechsler and his associates reported ties to numerous industry sources. Dr. Moerman reported no financial conflicts.

In a pilot study designed to tease out placebo effects from genuine clinical responses, asthma patients rated albuterol and two placebo interventions as effective, yet only the albuterol objectively improved forced expiratory volume in 1 second, according to a report in the July 14 issue of the New England Journal of Medicine.

The 46 study subjects also rated both placebo interventions as superior to a no-intervention control situation, even though the objective forced expiratory volume in 1 second (FEV₁) response was nearly identical in all three, said Dr. Michael E. Wechsler of the division of pulmonary and critical care medicine, Brigham and Women’s Hospital and Harvard Medical School, both in Boston, and his associates.

(c) Monkey Business/Fotolia.com

"Even though there was a large, objective drug effect (mean percent improvement in FEV₁, 20%) that was nearly three times the effect of the two placebos and the no-intervention control (mean percent improvement in FEV₁, approximately 7% for all three), patients could not reliably detect the difference between this robust effect of the active drug and the effects of inhaled placebo and sham acupuncture (mean subjective improvement reported by all patients, regardless of intervention, ranged between 45% and 50%)," they wrote.

These findings suggest that asthma patients poorly perceive changes in FEV₁ and that subjective assessments in clinical studies of asthma are severely limited. "Furthermore, it can justly be asserted that for self-appraised symptoms, placebos can have a powerful effect," Dr. Wechsler and his colleagues said.

Their results may also have important implications for placebo effects in general, not just in asthma patients. "Although effective medications target and modulate objective biologic features, the mere ritual of treatment may affect patients’ self-monitoring and subjective experience of their disease," the investigators said.

They chose asthma patients as ideal subjects for this pilot study of placebo effects because repeated objective lung-function assessments can be performed over a short period of time. "We compared acute changes in lung function that occurred after repeated administration of four interventions: a masked bronchodilator (inhaled albuterol), two different types of placebo (an inert inhaler and a validated sham acupuncture needle), and a [waiting] period of no intervention."

A total of 46 adults with stable, mild to moderate asthma who had experience using inhalers were enrolled. They were assigned to each of the four interventions in random order on four separate occasions, 3-7 days apart. On each occasion, they underwent spirometry at baseline and at 20-minute intervals for 2 hours following the intervention. The study subjects documented their subjective treatment responses using a 10-point visual analog scale.

The mean percent improvement in FEV₁ was 20.1% for inhaled albuterol, compared with 7.5% for inhaled placebo, 7.3% for sham acupuncture, and 7.1% for the no-intervention control situation of sitting in a waiting room. This constitutes a "significant" and "large" difference between active and nonactive interventions.

Moreover, using a standard definition of treatment response (12% or greater improvement in FEV₁), patients using the albuterol inhaler responded 77% of the time, while those using the placebo inhaler responded 24% of the time, those using sham acupuncture responded 20% of the time, and those using no intervention responded 18% of the time, Dr. Wechsler and his associates said (N. Engl. J. Med. 2011;365:119-26).

However, the subjects’ assessments did not reflect these results. They reported a 50% improvement in asthma symptoms with inhaled albuterol, a 45% improvement with inhaled placebo, and a 46% improvement with sham acupuncture, compared with a significantly lower 21% improvement with no intervention.

Patients were asked whether they thought they had received active or placebo interventions. Most believed all the interventions except sitting in a waiting room were active. A total of 73% believed the albuterol was active, 66% believed the placebo inhaler was active, and "a remarkable" 85% believed the sham acupuncture was active.

The study findings complement those of a recent trial in which placebo given with "enhanced expectations" – such as deceptive remarks that subjects were receiving a powerful medication – had no effect on objective outcomes but did increase subjective response.

Dr. Wechsler and his colleagues said their results suggest that "subjective improvement in asthma should be interpreted with caution and that objective outcomes should be more heavily relied on for optimal asthma care."

But this interpretation can be questioned. Dr. Wechsler and his colleagues concluded that asthma patients’ reports were "unreliable" because "they reported improvement when there was none – that is, the subjective experiences were simply wrong because they ignored objective facts as measured by FEV₁," Daniel E. Moerman, Ph.D., wrote in an editorial accompanying Dr. Wechsler’s report (N. Engl. J. Med. 2011;365:171-2).

"It is the subjective symptoms that brought these patients to medical care in the first place. They came because they were wheezing and felt suffocated, not because they had a reduced FEV₁," noted Dr. Moerman of the University of Michigan, Dearborn.

For subjective and functional conditions, including migraine, back pain, depression, asthma, inflammatory bowel disease, many autoimmune disorders, and any condition defined by its symptoms, "a patient-centered approach requires that patient-preferred outcomes trump the judgment of the physician.

"Under these conditions, inert pills can be as useful as ‘real’ ones; two inert pills can work better than one; colorful inert pills can work better than plain ones; and injections can work better than pills," wrote Dr. Moerman.

Dr. Wechsler’s study was supported by the National Center for Complementary and Alternative Medicine. Dr. Wechsler and his associates reported ties to numerous industry sources. Dr. Moerman reported no financial conflicts.

MINNEAPOLIS – Maxillomandibular advancement may be a reasonable option for patients who have severe sleep apnea and are unable to tolerate continuous positive airway pressure therapy, according to a study by the Department of Veterans Affairs.

In maxillomandibular advancement (MMA), the upper and lower jaws are moved forward to optimize the airway and minimize soft-tissue blockages. Dr. Vincent Mysliwiec and his colleagues in the Critical Care Medicine and Sleep Medicine Service at Madigan Healthcare System, Joint Base Lewis-McChord in Tacoma, Wash., evaluated the outcomes of the surgery in an active-duty population.

"Obstructive sleep apnea is an increasingly common diagnosis in soldiers, and those soldiers with more severe cases are not deployable without going through an extensive waiver process," Dr. Mysliwiec said at the annual meeting of the Associated Professional Sleep Societies. "We wanted to assess whether [MMA] represents a surgical cure that can potentially remove the requirement for CPAP in these individuals and, in so doing, increase the number of soldiers who are fully deployable."

The researchers reviewed all of the MMA procedures performed for obstructive sleep apnea at their institution in 2006-2009 and identified 37 soldiers who had severe disease – defined as an apnea-hypopnea index (AHI) of more than 30 events/hr – and underwent the surgery as well as pre- and postoperative polysomnography. The primary study outcomes were comparisons of the pre- and postoperative AHI and minimum nocturnal oxyhemoglobin saturation. Surgical cure was defined as an AHI reduction of at least 50%, compared with preoperative AHI, and a postoperative AHI of less than 15.

The mean body mass index of the study cohort was 29 kg/m², and the mean preoperative AHI was 50.5, Dr. Mysliwiec reported. Following the procedure, "the mean postoperative [AHI] dropped significantly to 13.8," he said. "Twenty-two of the soldiers – nearly 60% of the group – reduced their [AHI] by at least half, which met the criteria for surgical cure." Further, he said, 16 of the soldiers had a postoperative AHI of less than 5, "meaning they had no residual disease at all following the procedure." One study patient did not experience a clinically significant reduction in AHI following the surgery. The mean minimum nocturnal oxyhemoglobin saturation increased postoperatively from 85% to 86%, a nonsignificant change (P = .21; standard deviation for both measures, 7%).

"Maxillomandibular advancement significantly reduced the severity of sleep apnea for our patients and improved the quality of their sleep," Dr. Mysliwiec said. "These findings could improve the standard of care for civilians and active-duty service members with severe obstructive sleep apnea who can’t tolerate CPAP or have failed other soft-tissue procedures."

Dr. Mysliwiec reported having no financial conflicts of interest.

MINNEAPOLIS – Maxillomandibular advancement may be a reasonable option for patients who have severe sleep apnea and are unable to tolerate continuous positive airway pressure therapy, according to a study by the Department of Veterans Affairs.

In maxillomandibular advancement (MMA), the upper and lower jaws are moved forward to optimize the airway and minimize soft-tissue blockages. Dr. Vincent Mysliwiec and his colleagues in the Critical Care Medicine and Sleep Medicine Service at Madigan Healthcare System, Joint Base Lewis-McChord in Tacoma, Wash., evaluated the outcomes of the surgery in an active-duty population.

"Obstructive sleep apnea is an increasingly common diagnosis in soldiers, and those soldiers with more severe cases are not deployable without going through an extensive waiver process," Dr. Mysliwiec said at the annual meeting of the Associated Professional Sleep Societies. "We wanted to assess whether [MMA] represents a surgical cure that can potentially remove the requirement for CPAP in these individuals and, in so doing, increase the number of soldiers who are fully deployable."

The researchers reviewed all of the MMA procedures performed for obstructive sleep apnea at their institution in 2006-2009 and identified 37 soldiers who had severe disease – defined as an apnea-hypopnea index (AHI) of more than 30 events/hr – and underwent the surgery as well as pre- and postoperative polysomnography. The primary study outcomes were comparisons of the pre- and postoperative AHI and minimum nocturnal oxyhemoglobin saturation. Surgical cure was defined as an AHI reduction of at least 50%, compared with preoperative AHI, and a postoperative AHI of less than 15.

The mean body mass index of the study cohort was 29 kg/m², and the mean preoperative AHI was 50.5, Dr. Mysliwiec reported. Following the procedure, "the mean postoperative [AHI] dropped significantly to 13.8," he said. "Twenty-two of the soldiers – nearly 60% of the group – reduced their [AHI] by at least half, which met the criteria for surgical cure." Further, he said, 16 of the soldiers had a postoperative AHI of less than 5, "meaning they had no residual disease at all following the procedure." One study patient did not experience a clinically significant reduction in AHI following the surgery. The mean minimum nocturnal oxyhemoglobin saturation increased postoperatively from 85% to 86%, a nonsignificant change (P = .21; standard deviation for both measures, 7%).

"Maxillomandibular advancement significantly reduced the severity of sleep apnea for our patients and improved the quality of their sleep," Dr. Mysliwiec said. "These findings could improve the standard of care for civilians and active-duty service members with severe obstructive sleep apnea who can’t tolerate CPAP or have failed other soft-tissue procedures."

Dr. Mysliwiec reported having no financial conflicts of interest.

MINNEAPOLIS – Maxillomandibular advancement may be a reasonable option for patients who have severe sleep apnea and are unable to tolerate continuous positive airway pressure therapy, according to a study by the Department of Veterans Affairs.

In maxillomandibular advancement (MMA), the upper and lower jaws are moved forward to optimize the airway and minimize soft-tissue blockages. Dr. Vincent Mysliwiec and his colleagues in the Critical Care Medicine and Sleep Medicine Service at Madigan Healthcare System, Joint Base Lewis-McChord in Tacoma, Wash., evaluated the outcomes of the surgery in an active-duty population.

"Obstructive sleep apnea is an increasingly common diagnosis in soldiers, and those soldiers with more severe cases are not deployable without going through an extensive waiver process," Dr. Mysliwiec said at the annual meeting of the Associated Professional Sleep Societies. "We wanted to assess whether [MMA] represents a surgical cure that can potentially remove the requirement for CPAP in these individuals and, in so doing, increase the number of soldiers who are fully deployable."

The researchers reviewed all of the MMA procedures performed for obstructive sleep apnea at their institution in 2006-2009 and identified 37 soldiers who had severe disease – defined as an apnea-hypopnea index (AHI) of more than 30 events/hr – and underwent the surgery as well as pre- and postoperative polysomnography. The primary study outcomes were comparisons of the pre- and postoperative AHI and minimum nocturnal oxyhemoglobin saturation. Surgical cure was defined as an AHI reduction of at least 50%, compared with preoperative AHI, and a postoperative AHI of less than 15.

The mean body mass index of the study cohort was 29 kg/m², and the mean preoperative AHI was 50.5, Dr. Mysliwiec reported. Following the procedure, "the mean postoperative [AHI] dropped significantly to 13.8," he said. "Twenty-two of the soldiers – nearly 60% of the group – reduced their [AHI] by at least half, which met the criteria for surgical cure." Further, he said, 16 of the soldiers had a postoperative AHI of less than 5, "meaning they had no residual disease at all following the procedure." One study patient did not experience a clinically significant reduction in AHI following the surgery. The mean minimum nocturnal oxyhemoglobin saturation increased postoperatively from 85% to 86%, a nonsignificant change (P = .21; standard deviation for both measures, 7%).

"Maxillomandibular advancement significantly reduced the severity of sleep apnea for our patients and improved the quality of their sleep," Dr. Mysliwiec said. "These findings could improve the standard of care for civilians and active-duty service members with severe obstructive sleep apnea who can’t tolerate CPAP or have failed other soft-tissue procedures."

Dr. Mysliwiec reported having no financial conflicts of interest.