American Thoracic Society (ATS): International Conference 2012

SAN FRANCISCO – Conservative treatment may be best for pneumonia-related pleural effusions in children, according to a retrospective review from Washington University in St. Louis.

Median hospital costs were significantly lower ($11,149 vs. $28,552; P less than .001) and there was a nonsignificant trend toward shorter median hospital stays (6 vs. 8 days) for 17 children with moderate-large pleural effusions treated at St. Louis Children’s Hospital with intravenous antibiotics or tube drainage from 2007 to 2010 compared with 81 treated more aggressively with thoracotomy and decortication or video-assisted thoracoscopic surgery (VATS), which has become first-line treatment at the hospital and many other medical centers.

It’s not that the children treated aggressively were sicker, said lead investigator Dr. Piyaporn Chuen-Im, a third-year fellow in pediatric pulmonology.

"In terms of fever, white count, acuity" and other measures, "there were really no [statistically significant] differences between the two groups." That some children were managed medically and others surgically illustrates the "inconsistencies in how plural effusions are treated" in children in St. Louis and elsewhere, she said.

Overall, "the trend is to treat more aggressively" but it might not be necessary, at least in some cases, she said. Surgery "did not offer significant benefits" in the study; children "might have better outcomes and maybe lower hospital charges" with a gentler approach, Dr. Chuen-Im said.

The investigators also looked at records for children treated from 2000 to 2006, although in less depth than for children treated later; the review involved 338 children ranging in age from 1 month to 20 years.

VATS was used for less than 10% of moderate-large pediatric pleural effusions in the early part of the decade, but about 75% in 2009.

Some studies have found better effusion outcomes with VATS in children, leading to its adoption as first-line treatment. Other studies suggest it should be kept in reserve for failed medical treatment (Thorax 2005;60:94-6).

What’s needed is "a big, prospective, randomized, controlled trial to determine the benefits of surgical intervention as first-line therapy," Dr. Chuen-Im said.

Assessment and treatment need to be standardized as well, perhaps according to radiologic parameters, presence of loculation on ultrasound, fluid make-up, or other factors, she said.

Effusion size alone is not enough to guide treatment. Children managed aggressively in the study did tend to have larger effusions, but "we did not find that the size predicted whether the fluid is complicated," indicating more severe disease. "That’s why I’m not sure [basing intervention] on size is a good idea," Dr. Chuen-Im said.

Also, radiologists who reviewed imaging for the study "had considerable disagreement in terms of the assessment of size," a problem because "many people tend to rely on [radiologist] assessment for management." If nothing else, "standardized radiographic measures to consistently define the size of pleural effusions are needed" for children, she said.

Treatment inconstancies are a problem "across the board, not just at this hospital, and even across single institutions. We all deal with this," said Dr. Cori Daines, a pediatric pulmonologist the University of Arizona in Tucson, commenting on the study.

"As a clinician, I rely on my radiologist to give me information to decide [if] I need to call my surgeon. [When] I am getting different opinions from radiologists based on their own tests, that’s concerning." Meanwhile, "we are [also] seeing way more of our pleural effusions going to VATS and surgical intervention," she said.

Dr. Daines, Dr. Chuen-Im, and coinvestigators said they have no relevant disclosures.

SAN FRANCISCO – Conservative treatment may be best for pneumonia-related pleural effusions in children, according to a retrospective review from Washington University in St. Louis.

Median hospital costs were significantly lower ($11,149 vs. $28,552; P less than .001) and there was a nonsignificant trend toward shorter median hospital stays (6 vs. 8 days) for 17 children with moderate-large pleural effusions treated at St. Louis Children’s Hospital with intravenous antibiotics or tube drainage from 2007 to 2010 compared with 81 treated more aggressively with thoracotomy and decortication or video-assisted thoracoscopic surgery (VATS), which has become first-line treatment at the hospital and many other medical centers.

It’s not that the children treated aggressively were sicker, said lead investigator Dr. Piyaporn Chuen-Im, a third-year fellow in pediatric pulmonology.

"In terms of fever, white count, acuity" and other measures, "there were really no [statistically significant] differences between the two groups." That some children were managed medically and others surgically illustrates the "inconsistencies in how plural effusions are treated" in children in St. Louis and elsewhere, she said.

Overall, "the trend is to treat more aggressively" but it might not be necessary, at least in some cases, she said. Surgery "did not offer significant benefits" in the study; children "might have better outcomes and maybe lower hospital charges" with a gentler approach, Dr. Chuen-Im said.

The investigators also looked at records for children treated from 2000 to 2006, although in less depth than for children treated later; the review involved 338 children ranging in age from 1 month to 20 years.

VATS was used for less than 10% of moderate-large pediatric pleural effusions in the early part of the decade, but about 75% in 2009.

Some studies have found better effusion outcomes with VATS in children, leading to its adoption as first-line treatment. Other studies suggest it should be kept in reserve for failed medical treatment (Thorax 2005;60:94-6).

What’s needed is "a big, prospective, randomized, controlled trial to determine the benefits of surgical intervention as first-line therapy," Dr. Chuen-Im said.

Assessment and treatment need to be standardized as well, perhaps according to radiologic parameters, presence of loculation on ultrasound, fluid make-up, or other factors, she said.

Effusion size alone is not enough to guide treatment. Children managed aggressively in the study did tend to have larger effusions, but "we did not find that the size predicted whether the fluid is complicated," indicating more severe disease. "That’s why I’m not sure [basing intervention] on size is a good idea," Dr. Chuen-Im said.

Also, radiologists who reviewed imaging for the study "had considerable disagreement in terms of the assessment of size," a problem because "many people tend to rely on [radiologist] assessment for management." If nothing else, "standardized radiographic measures to consistently define the size of pleural effusions are needed" for children, she said.

Treatment inconstancies are a problem "across the board, not just at this hospital, and even across single institutions. We all deal with this," said Dr. Cori Daines, a pediatric pulmonologist the University of Arizona in Tucson, commenting on the study.

"As a clinician, I rely on my radiologist to give me information to decide [if] I need to call my surgeon. [When] I am getting different opinions from radiologists based on their own tests, that’s concerning." Meanwhile, "we are [also] seeing way more of our pleural effusions going to VATS and surgical intervention," she said.

Dr. Daines, Dr. Chuen-Im, and coinvestigators said they have no relevant disclosures.

SAN FRANCISCO – Conservative treatment may be best for pneumonia-related pleural effusions in children, according to a retrospective review from Washington University in St. Louis.

Median hospital costs were significantly lower ($11,149 vs. $28,552; P less than .001) and there was a nonsignificant trend toward shorter median hospital stays (6 vs. 8 days) for 17 children with moderate-large pleural effusions treated at St. Louis Children’s Hospital with intravenous antibiotics or tube drainage from 2007 to 2010 compared with 81 treated more aggressively with thoracotomy and decortication or video-assisted thoracoscopic surgery (VATS), which has become first-line treatment at the hospital and many other medical centers.

It’s not that the children treated aggressively were sicker, said lead investigator Dr. Piyaporn Chuen-Im, a third-year fellow in pediatric pulmonology.

"In terms of fever, white count, acuity" and other measures, "there were really no [statistically significant] differences between the two groups." That some children were managed medically and others surgically illustrates the "inconsistencies in how plural effusions are treated" in children in St. Louis and elsewhere, she said.

Overall, "the trend is to treat more aggressively" but it might not be necessary, at least in some cases, she said. Surgery "did not offer significant benefits" in the study; children "might have better outcomes and maybe lower hospital charges" with a gentler approach, Dr. Chuen-Im said.

The investigators also looked at records for children treated from 2000 to 2006, although in less depth than for children treated later; the review involved 338 children ranging in age from 1 month to 20 years.

VATS was used for less than 10% of moderate-large pediatric pleural effusions in the early part of the decade, but about 75% in 2009.

Some studies have found better effusion outcomes with VATS in children, leading to its adoption as first-line treatment. Other studies suggest it should be kept in reserve for failed medical treatment (Thorax 2005;60:94-6).

What’s needed is "a big, prospective, randomized, controlled trial to determine the benefits of surgical intervention as first-line therapy," Dr. Chuen-Im said.

Assessment and treatment need to be standardized as well, perhaps according to radiologic parameters, presence of loculation on ultrasound, fluid make-up, or other factors, she said.

Effusion size alone is not enough to guide treatment. Children managed aggressively in the study did tend to have larger effusions, but "we did not find that the size predicted whether the fluid is complicated," indicating more severe disease. "That’s why I’m not sure [basing intervention] on size is a good idea," Dr. Chuen-Im said.

Also, radiologists who reviewed imaging for the study "had considerable disagreement in terms of the assessment of size," a problem because "many people tend to rely on [radiologist] assessment for management." If nothing else, "standardized radiographic measures to consistently define the size of pleural effusions are needed" for children, she said.

Treatment inconstancies are a problem "across the board, not just at this hospital, and even across single institutions. We all deal with this," said Dr. Cori Daines, a pediatric pulmonologist the University of Arizona in Tucson, commenting on the study.

"As a clinician, I rely on my radiologist to give me information to decide [if] I need to call my surgeon. [When] I am getting different opinions from radiologists based on their own tests, that’s concerning." Meanwhile, "we are [also] seeing way more of our pleural effusions going to VATS and surgical intervention," she said.

Dr. Daines, Dr. Chuen-Im, and coinvestigators said they have no relevant disclosures.

SAN FRANCISCO – Children aged 12 years and older may be less likely to have asthma exacerbations than are younger children, according a 44-week trial in 288 children with mild, persistent asthma.

Girls also may be less likely to have asthma exacerbations than are boys. The lower risk in girls and older children means that these patients probably don’t need inhaled corticosteroids (ICS) daily, but only for symptoms or rescue, said Dr. Joseph Gerald of the University of Arizona, Tucson.

"It’s a reasonable" approach that limits impaired growth and other potential ICS side effects when "the benefit to be gained from daily inhaled steroids is not that great," he said at an international conference of the American Thoracic Society.

The researchers randomized 72 children to daily ICS, 71 to rescue ICS only, 71 to combined treatment with ICS and inhaled albuterol, and 74 to placebo. The daily ICS regimen consisted of one 40-mcg puff of beclomethasone twice daily; combined treatment consisted of one 40-mcg puff of beclomethasone with each albuterol puff used for symptom relief. Dummy inhalers were used as needed to maintain blinding. The participants were 6-18 years old.

Compared with placebo, all three ICS regimens reduced treatment failures (defined as more than two exacerbations requiring oral corticosteroids) in boys, in children 6-11 years old, and in children with allergic forms of the disease as indicated by eczema, positive skin tests, methacholine PC₂₀ (a provocative concentration of methacholine causing a 20% fall in forced expiratory volume in 1 second) at or below 12.5 mg/dL, and IgE levels at or above 185 kU/L. For instance, 29.3% of boys (12 of 41) in the placebo group failed treatment, but only 2.4% of boys (1 of 42) in the daily ICS group did so.

The investigators were unable to show a statistically significant benefit for any ICS strategy in girls, in children 12-18 years old, and in those with higher methacholine PC₂₀ levels, lower IgE levels, negative skin tests, and no eczema.

That’s probably not because inhaled steroids work better in boys and other responders, but rather because nonresponders had lower exacerbation rates in general, making it harder to detect a benefit, Dr. Gerald said.

For example, although almost 30% of boys in the placebo group failed treatment, only 15.2% of girls (5 of 33) in the placebo group failed. Similarly, 26% of children aged 6-11 years (13 of 50) failed treatment in the placebo arm, but only 16.7% of children aged 12-18 years (4 of 24) did so.

"We think the baseline [exacerbation] risk is what we are detecting here. [Nonresponders] started from a lower risk and just didn’t benefit as much," Dr. Gerald said. The study did not determine the best ICS regimen among responders.

Dr. Gerald and his coinvestigators said they have no relevant disclosures.

SAN FRANCISCO – Children aged 12 years and older may be less likely to have asthma exacerbations than are younger children, according a 44-week trial in 288 children with mild, persistent asthma.

Girls also may be less likely to have asthma exacerbations than are boys. The lower risk in girls and older children means that these patients probably don’t need inhaled corticosteroids (ICS) daily, but only for symptoms or rescue, said Dr. Joseph Gerald of the University of Arizona, Tucson.

"It’s a reasonable" approach that limits impaired growth and other potential ICS side effects when "the benefit to be gained from daily inhaled steroids is not that great," he said at an international conference of the American Thoracic Society.

The researchers randomized 72 children to daily ICS, 71 to rescue ICS only, 71 to combined treatment with ICS and inhaled albuterol, and 74 to placebo. The daily ICS regimen consisted of one 40-mcg puff of beclomethasone twice daily; combined treatment consisted of one 40-mcg puff of beclomethasone with each albuterol puff used for symptom relief. Dummy inhalers were used as needed to maintain blinding. The participants were 6-18 years old.

Compared with placebo, all three ICS regimens reduced treatment failures (defined as more than two exacerbations requiring oral corticosteroids) in boys, in children 6-11 years old, and in children with allergic forms of the disease as indicated by eczema, positive skin tests, methacholine PC₂₀ (a provocative concentration of methacholine causing a 20% fall in forced expiratory volume in 1 second) at or below 12.5 mg/dL, and IgE levels at or above 185 kU/L. For instance, 29.3% of boys (12 of 41) in the placebo group failed treatment, but only 2.4% of boys (1 of 42) in the daily ICS group did so.

The investigators were unable to show a statistically significant benefit for any ICS strategy in girls, in children 12-18 years old, and in those with higher methacholine PC₂₀ levels, lower IgE levels, negative skin tests, and no eczema.

That’s probably not because inhaled steroids work better in boys and other responders, but rather because nonresponders had lower exacerbation rates in general, making it harder to detect a benefit, Dr. Gerald said.

For example, although almost 30% of boys in the placebo group failed treatment, only 15.2% of girls (5 of 33) in the placebo group failed. Similarly, 26% of children aged 6-11 years (13 of 50) failed treatment in the placebo arm, but only 16.7% of children aged 12-18 years (4 of 24) did so.

"We think the baseline [exacerbation] risk is what we are detecting here. [Nonresponders] started from a lower risk and just didn’t benefit as much," Dr. Gerald said. The study did not determine the best ICS regimen among responders.

Dr. Gerald and his coinvestigators said they have no relevant disclosures.

SAN FRANCISCO – Children aged 12 years and older may be less likely to have asthma exacerbations than are younger children, according a 44-week trial in 288 children with mild, persistent asthma.

Girls also may be less likely to have asthma exacerbations than are boys. The lower risk in girls and older children means that these patients probably don’t need inhaled corticosteroids (ICS) daily, but only for symptoms or rescue, said Dr. Joseph Gerald of the University of Arizona, Tucson.

"It’s a reasonable" approach that limits impaired growth and other potential ICS side effects when "the benefit to be gained from daily inhaled steroids is not that great," he said at an international conference of the American Thoracic Society.

The researchers randomized 72 children to daily ICS, 71 to rescue ICS only, 71 to combined treatment with ICS and inhaled albuterol, and 74 to placebo. The daily ICS regimen consisted of one 40-mcg puff of beclomethasone twice daily; combined treatment consisted of one 40-mcg puff of beclomethasone with each albuterol puff used for symptom relief. Dummy inhalers were used as needed to maintain blinding. The participants were 6-18 years old.

Compared with placebo, all three ICS regimens reduced treatment failures (defined as more than two exacerbations requiring oral corticosteroids) in boys, in children 6-11 years old, and in children with allergic forms of the disease as indicated by eczema, positive skin tests, methacholine PC₂₀ (a provocative concentration of methacholine causing a 20% fall in forced expiratory volume in 1 second) at or below 12.5 mg/dL, and IgE levels at or above 185 kU/L. For instance, 29.3% of boys (12 of 41) in the placebo group failed treatment, but only 2.4% of boys (1 of 42) in the daily ICS group did so.

The investigators were unable to show a statistically significant benefit for any ICS strategy in girls, in children 12-18 years old, and in those with higher methacholine PC₂₀ levels, lower IgE levels, negative skin tests, and no eczema.

That’s probably not because inhaled steroids work better in boys and other responders, but rather because nonresponders had lower exacerbation rates in general, making it harder to detect a benefit, Dr. Gerald said.

For example, although almost 30% of boys in the placebo group failed treatment, only 15.2% of girls (5 of 33) in the placebo group failed. Similarly, 26% of children aged 6-11 years (13 of 50) failed treatment in the placebo arm, but only 16.7% of children aged 12-18 years (4 of 24) did so.

"We think the baseline [exacerbation] risk is what we are detecting here. [Nonresponders] started from a lower risk and just didn’t benefit as much," Dr. Gerald said. The study did not determine the best ICS regimen among responders.

Dr. Gerald and his coinvestigators said they have no relevant disclosures.

SAN FRANCISCO – Long-term, low-dose erythromycin reduces pulmonary exacerbations, sputum production, and breathing problems in patients with non–cystic fibrosis bronchiectasis, according to a randomized, placebo-controlled Australian study.

Low-dose erythromycin also may be less likely than azithromycin to induce antibiotic resistance, the usual choice for antibiotic prophylaxis. For these reasons, erythromycin "should be considered for the management of subjects with" non-CF bronchiectasis, said lead investigator Dr. David Serisier at an international conference of the American Thoracic Society.

A total of 59 nonsmoking adults with the disease were randomized to erythromycin ethylsuccinate 400 mg twice daily and 58 to placebo, for 48 weeks. (The dosage of the better-tolerated salt is the equivalent of 250 mg of erythromycin b.i.d.) All patients had at least two infective exacerbations in the preceding year, said Dr. Serisier, a chest physician and associate professor of medicine at the University of Queensland in Brisbane.

The erythromycin group had almost 40% fewer exacerbations (odds ratio, 0.64; 95% confidence interval [CI], 0.48-0.86; P = .02), corresponding to a mean reduction of 0.7 exacerbations per patient per year. About a third of the erythromycin patients (19) and more than half (30) of the placebo patients had two or more exacerbations during the trial (P = .039). Only one erythromycin patient was withdrawn for possible QTc prolongation at 6 months.

Forced expiratory volume in 1 second (FEV₁) declined slightly in both groups, but more so in the placebo arm, with a treatment effect of 2.02% (95% CI, 0.04-4.2; P = .046) in favor of erythromycin. Erythromycin patients also produced about 6 g less of sputum per day.

By study’s end, about 36% of oropharyngeal streptococci isolates in the erythromycin group were resistant, versus about 5% in the placebo group (P less than .0001). "Erythromycin resulted in a very substantial increase in the proportion of macrolide-resistant streptococci," Dr. Serisier said.

Azithromycin, however, appears to be a more potent inducer of resistance, according to a randomized Belgian trial that found a 53.4% increase (P less than .0001) in macrolide-resistant oral streptococci after just 3 days of treatment (Lancet 2007;369:482-90).

"We are not exactly comparing apples with apples, but there’s a suggestion that this effect is less with erythromycin," even after an entire year of therapy, he said.

Even so, "I think [erythromycin] should be reserved for subjects who have evidence of more severe airway infection. I don’t think it’s something we should be throwing at all non-CF bronchiectasis patients, and [certainly] not those who just have a mild, troublesome cough. I want this drug to be used in patients who really need it," Dr. Serisier said.

Dr. Serisier said he had no relevant disclosures.

SAN FRANCISCO – Long-term, low-dose erythromycin reduces pulmonary exacerbations, sputum production, and breathing problems in patients with non–cystic fibrosis bronchiectasis, according to a randomized, placebo-controlled Australian study.

Low-dose erythromycin also may be less likely than azithromycin to induce antibiotic resistance, the usual choice for antibiotic prophylaxis. For these reasons, erythromycin "should be considered for the management of subjects with" non-CF bronchiectasis, said lead investigator Dr. David Serisier at an international conference of the American Thoracic Society.

A total of 59 nonsmoking adults with the disease were randomized to erythromycin ethylsuccinate 400 mg twice daily and 58 to placebo, for 48 weeks. (The dosage of the better-tolerated salt is the equivalent of 250 mg of erythromycin b.i.d.) All patients had at least two infective exacerbations in the preceding year, said Dr. Serisier, a chest physician and associate professor of medicine at the University of Queensland in Brisbane.

The erythromycin group had almost 40% fewer exacerbations (odds ratio, 0.64; 95% confidence interval [CI], 0.48-0.86; P = .02), corresponding to a mean reduction of 0.7 exacerbations per patient per year. About a third of the erythromycin patients (19) and more than half (30) of the placebo patients had two or more exacerbations during the trial (P = .039). Only one erythromycin patient was withdrawn for possible QTc prolongation at 6 months.

Forced expiratory volume in 1 second (FEV₁) declined slightly in both groups, but more so in the placebo arm, with a treatment effect of 2.02% (95% CI, 0.04-4.2; P = .046) in favor of erythromycin. Erythromycin patients also produced about 6 g less of sputum per day.

By study’s end, about 36% of oropharyngeal streptococci isolates in the erythromycin group were resistant, versus about 5% in the placebo group (P less than .0001). "Erythromycin resulted in a very substantial increase in the proportion of macrolide-resistant streptococci," Dr. Serisier said.

Azithromycin, however, appears to be a more potent inducer of resistance, according to a randomized Belgian trial that found a 53.4% increase (P less than .0001) in macrolide-resistant oral streptococci after just 3 days of treatment (Lancet 2007;369:482-90).

"We are not exactly comparing apples with apples, but there’s a suggestion that this effect is less with erythromycin," even after an entire year of therapy, he said.

Even so, "I think [erythromycin] should be reserved for subjects who have evidence of more severe airway infection. I don’t think it’s something we should be throwing at all non-CF bronchiectasis patients, and [certainly] not those who just have a mild, troublesome cough. I want this drug to be used in patients who really need it," Dr. Serisier said.

Dr. Serisier said he had no relevant disclosures.

SAN FRANCISCO – Long-term, low-dose erythromycin reduces pulmonary exacerbations, sputum production, and breathing problems in patients with non–cystic fibrosis bronchiectasis, according to a randomized, placebo-controlled Australian study.

Low-dose erythromycin also may be less likely than azithromycin to induce antibiotic resistance, the usual choice for antibiotic prophylaxis. For these reasons, erythromycin "should be considered for the management of subjects with" non-CF bronchiectasis, said lead investigator Dr. David Serisier at an international conference of the American Thoracic Society.

A total of 59 nonsmoking adults with the disease were randomized to erythromycin ethylsuccinate 400 mg twice daily and 58 to placebo, for 48 weeks. (The dosage of the better-tolerated salt is the equivalent of 250 mg of erythromycin b.i.d.) All patients had at least two infective exacerbations in the preceding year, said Dr. Serisier, a chest physician and associate professor of medicine at the University of Queensland in Brisbane.

The erythromycin group had almost 40% fewer exacerbations (odds ratio, 0.64; 95% confidence interval [CI], 0.48-0.86; P = .02), corresponding to a mean reduction of 0.7 exacerbations per patient per year. About a third of the erythromycin patients (19) and more than half (30) of the placebo patients had two or more exacerbations during the trial (P = .039). Only one erythromycin patient was withdrawn for possible QTc prolongation at 6 months.

Forced expiratory volume in 1 second (FEV₁) declined slightly in both groups, but more so in the placebo arm, with a treatment effect of 2.02% (95% CI, 0.04-4.2; P = .046) in favor of erythromycin. Erythromycin patients also produced about 6 g less of sputum per day.

By study’s end, about 36% of oropharyngeal streptococci isolates in the erythromycin group were resistant, versus about 5% in the placebo group (P less than .0001). "Erythromycin resulted in a very substantial increase in the proportion of macrolide-resistant streptococci," Dr. Serisier said.

Azithromycin, however, appears to be a more potent inducer of resistance, according to a randomized Belgian trial that found a 53.4% increase (P less than .0001) in macrolide-resistant oral streptococci after just 3 days of treatment (Lancet 2007;369:482-90).

"We are not exactly comparing apples with apples, but there’s a suggestion that this effect is less with erythromycin," even after an entire year of therapy, he said.

Even so, "I think [erythromycin] should be reserved for subjects who have evidence of more severe airway infection. I don’t think it’s something we should be throwing at all non-CF bronchiectasis patients, and [certainly] not those who just have a mild, troublesome cough. I want this drug to be used in patients who really need it," Dr. Serisier said.

Dr. Serisier said he had no relevant disclosures.

SAN FRANCISCO – Almost a third of 196 patients (61) were smoke free a year after starting 12 weeks of varenicline therapy and having smoking-cessation counseling in a randomized Australian trial. Only 21% (42) of 196 patients given counseling alone stopped smoking.

The varenicline-plus-counseling results are impressive because the study included people who were on antidepressants and those with depression histories, both of whom had been excluded from several earlier studies of varenicline (Chantix), said lead investigator Dr. Brian Smith of the respiratory medicine unit at the Queen Elizabeth Hospital in Woodville, Australia.

But the most important take-home message of the study was its setup, he said at an international conference of the American Thoracic Society.

The participants had all been hospitalized for at least 1 day for cardiac, respiratory, neurologic, or vascular smoking-related complications. Instead of handing them a quit-smoking hotline card as they walked out the door – the general practice in many hospitals – the investigators had them make their initial counseling service call from the bedside table while they were still in the hospital, Dr. Smith said.

"Only about 6% of patients will make that call" from home. "[We took] the opportunity while they were still inpatients – a captive audience, if you like – to use the bedside phone to make the call. Instead of a 6% success rate, [we had a] 100% success rate," he said.

Patients found a friendly counselor on the other end of the line who emphasized the benefits of quitting instead of the dangers of continuing to smoke. Patients could arrange calls for days when they knew they would be particularly stressed. Counselors would call then to "pull them through," Dr. Smith said.

Both groups got the same standard 5A counseling (ask, advise, assess, assist, and arrange). Patients had the option, if they desired, of several calls a week, but that option wasn’t popular. The mean number of phone calls in the varenicline-plus-counseling arm was 3.8, and in the counseling-only arm it was 4.1.

Varenicline was titrated from 0.5 mg daily to 1 mg twice daily, based largely on nausea. Overall, varenicline patients reported more problems with insomnia (5.1% vs. 2.0% in the counseling-alone group), headache (6.1% vs. 1.5%), vomiting (4.1% vs. 0.5%), and abnormal dreams (6.1% vs. 1.0%).

Despite concerns about the drug, the investigators found no evidence of increased cardiovascular or psychiatric problems in the varenicline group.

"The novel thing of our study is [that we] grabbed the opportunity while these patients were in hospital to get them to make the phone call that otherwise [they] would have been reluctant to make. [We got] them over that hump, got the medication going, [and made] sure they were tolerating it well," Dr. Smith said.

Dr. Smith said he had no disclosures. Pfizer, the maker of Chantix, did not fund and was not involved in the trial, he said. Patients covered at least part of the cost of the drug themselves.

SAN FRANCISCO – Almost a third of 196 patients (61) were smoke free a year after starting 12 weeks of varenicline therapy and having smoking-cessation counseling in a randomized Australian trial. Only 21% (42) of 196 patients given counseling alone stopped smoking.

The varenicline-plus-counseling results are impressive because the study included people who were on antidepressants and those with depression histories, both of whom had been excluded from several earlier studies of varenicline (Chantix), said lead investigator Dr. Brian Smith of the respiratory medicine unit at the Queen Elizabeth Hospital in Woodville, Australia.

But the most important take-home message of the study was its setup, he said at an international conference of the American Thoracic Society.

The participants had all been hospitalized for at least 1 day for cardiac, respiratory, neurologic, or vascular smoking-related complications. Instead of handing them a quit-smoking hotline card as they walked out the door – the general practice in many hospitals – the investigators had them make their initial counseling service call from the bedside table while they were still in the hospital, Dr. Smith said.

"Only about 6% of patients will make that call" from home. "[We took] the opportunity while they were still inpatients – a captive audience, if you like – to use the bedside phone to make the call. Instead of a 6% success rate, [we had a] 100% success rate," he said.

Patients found a friendly counselor on the other end of the line who emphasized the benefits of quitting instead of the dangers of continuing to smoke. Patients could arrange calls for days when they knew they would be particularly stressed. Counselors would call then to "pull them through," Dr. Smith said.

Both groups got the same standard 5A counseling (ask, advise, assess, assist, and arrange). Patients had the option, if they desired, of several calls a week, but that option wasn’t popular. The mean number of phone calls in the varenicline-plus-counseling arm was 3.8, and in the counseling-only arm it was 4.1.

Varenicline was titrated from 0.5 mg daily to 1 mg twice daily, based largely on nausea. Overall, varenicline patients reported more problems with insomnia (5.1% vs. 2.0% in the counseling-alone group), headache (6.1% vs. 1.5%), vomiting (4.1% vs. 0.5%), and abnormal dreams (6.1% vs. 1.0%).

Despite concerns about the drug, the investigators found no evidence of increased cardiovascular or psychiatric problems in the varenicline group.

"The novel thing of our study is [that we] grabbed the opportunity while these patients were in hospital to get them to make the phone call that otherwise [they] would have been reluctant to make. [We got] them over that hump, got the medication going, [and made] sure they were tolerating it well," Dr. Smith said.

Dr. Smith said he had no disclosures. Pfizer, the maker of Chantix, did not fund and was not involved in the trial, he said. Patients covered at least part of the cost of the drug themselves.

SAN FRANCISCO – Almost a third of 196 patients (61) were smoke free a year after starting 12 weeks of varenicline therapy and having smoking-cessation counseling in a randomized Australian trial. Only 21% (42) of 196 patients given counseling alone stopped smoking.

The varenicline-plus-counseling results are impressive because the study included people who were on antidepressants and those with depression histories, both of whom had been excluded from several earlier studies of varenicline (Chantix), said lead investigator Dr. Brian Smith of the respiratory medicine unit at the Queen Elizabeth Hospital in Woodville, Australia.

But the most important take-home message of the study was its setup, he said at an international conference of the American Thoracic Society.

The participants had all been hospitalized for at least 1 day for cardiac, respiratory, neurologic, or vascular smoking-related complications. Instead of handing them a quit-smoking hotline card as they walked out the door – the general practice in many hospitals – the investigators had them make their initial counseling service call from the bedside table while they were still in the hospital, Dr. Smith said.

"Only about 6% of patients will make that call" from home. "[We took] the opportunity while they were still inpatients – a captive audience, if you like – to use the bedside phone to make the call. Instead of a 6% success rate, [we had a] 100% success rate," he said.

Patients found a friendly counselor on the other end of the line who emphasized the benefits of quitting instead of the dangers of continuing to smoke. Patients could arrange calls for days when they knew they would be particularly stressed. Counselors would call then to "pull them through," Dr. Smith said.

Both groups got the same standard 5A counseling (ask, advise, assess, assist, and arrange). Patients had the option, if they desired, of several calls a week, but that option wasn’t popular. The mean number of phone calls in the varenicline-plus-counseling arm was 3.8, and in the counseling-only arm it was 4.1.

Varenicline was titrated from 0.5 mg daily to 1 mg twice daily, based largely on nausea. Overall, varenicline patients reported more problems with insomnia (5.1% vs. 2.0% in the counseling-alone group), headache (6.1% vs. 1.5%), vomiting (4.1% vs. 0.5%), and abnormal dreams (6.1% vs. 1.0%).

Despite concerns about the drug, the investigators found no evidence of increased cardiovascular or psychiatric problems in the varenicline group.

"The novel thing of our study is [that we] grabbed the opportunity while these patients were in hospital to get them to make the phone call that otherwise [they] would have been reluctant to make. [We got] them over that hump, got the medication going, [and made] sure they were tolerating it well," Dr. Smith said.

Dr. Smith said he had no disclosures. Pfizer, the maker of Chantix, did not fund and was not involved in the trial, he said. Patients covered at least part of the cost of the drug themselves.

SAN FRANCISCO – Underlying pulmonary fungal colonization or infection may be the reason that some children with severe asthma don’t respond fully to conventional treatments.

Severe asthma with fungal sensitization (SAFS) has been recognized only recently. In adults, SAFS has been found to respond to oral itraconazole (Am. J. Respir. Crit. Care Med. 2009;179:11-8).

CDC/Dr. Lucille K. Georg

SAFS also occurs in children, according to Dr. Alfin G. Vicencio, chief of pediatric pulmonology and cystic fibrosis at Cohen Children’s Medical Center in New Hyde Park, N.Y., and his colleagues.

The researchers looked at 41 children, teens, and young adults (aged 2-21 years) with severe asthma who were failing level 4 or greater combination asthma therapy, and found that 17 (41.5%) had serum fungal IgE levels above 100 IU/mL and evidence of fungal sensitization on radioallergosorbent or skin-prick tests, indicating SAFS.

Eleven (65%) of those patients were sensitive to more than one fungal species. Aspergillus was the most commonly implicated species, followed by Alternaria, Candida, Cladosporium, Setomelanomma, Mucor, and Penicillium, Dr. Vicencio said at an international conference of the American Thoracic Society.

Boys and girls were affected equally, but SAFS patients tended to be older and have worse results on pulmonary function tests (PFTs) than their peers did, with forced expiratory volume in 1 second (FEV₁) at 73.33% of predicted, for instance, compared with 91.60% in those without SAFS. Some of the children who didn’t meet the criteria for SAFS diagnosis had high IgE levels but no evidence of fungal sensitization, or evidence of fungal sensitivity but normal IgE levels.

"The contribution of fungi to poorly controlled asthma in children is likely to be underestimated, as is the number of patients who might benefit from antifungal therapy," Dr. Vicencio said.

So far, he’s treated about a dozen pediatric SAFS patients with itraconazole. "About half of them have done very well. Their asthma is better controlled. We have documented some PFT improvements. Their IgE levels are variable; some of them are dropping dramatically, and some are not," he said.

Overall, "what it looks like is that fungal sensitization is a risk factor for severe persistent disease. We do believe that there is going to be a role for antifungal agents in certain select populations," he said.

The ongoing series now includes about 60 children with severe, poorly controlled asthma. "Something on the order of 60% actually have fungal sensitization," Dr. Vicencio said.

Sputum testing or bronchoalveolar lavage is planned to see if young SAFS patients actually have fungus in their lungs.

Genotyping is also underway to see if these patients have a mutation in the CHIT1 gene, which encodes for chitotriosidase, a kind of natural antifungal found in mammals. Dr. Vicencio has published a case series in which the mutation was present in six pediatric SAFS patients tested for it. Of the three treated with itraconazole, two responded well and one responded "dramatically" (Pediatrics 2010;126:e982-5).

About a third of the general population has the mutation, and it doesn’t cause disease in most. However, in someone with asthma and fungal exposure, "we believe the mutation" might cause "a perfect storm for asthma," he said.

Dr. Vicencio said he has no relevant disclosures.

SAN FRANCISCO – Underlying pulmonary fungal colonization or infection may be the reason that some children with severe asthma don’t respond fully to conventional treatments.

Severe asthma with fungal sensitization (SAFS) has been recognized only recently. In adults, SAFS has been found to respond to oral itraconazole (Am. J. Respir. Crit. Care Med. 2009;179:11-8).

CDC/Dr. Lucille K. Georg

SAFS also occurs in children, according to Dr. Alfin G. Vicencio, chief of pediatric pulmonology and cystic fibrosis at Cohen Children’s Medical Center in New Hyde Park, N.Y., and his colleagues.

The researchers looked at 41 children, teens, and young adults (aged 2-21 years) with severe asthma who were failing level 4 or greater combination asthma therapy, and found that 17 (41.5%) had serum fungal IgE levels above 100 IU/mL and evidence of fungal sensitization on radioallergosorbent or skin-prick tests, indicating SAFS.

Eleven (65%) of those patients were sensitive to more than one fungal species. Aspergillus was the most commonly implicated species, followed by Alternaria, Candida, Cladosporium, Setomelanomma, Mucor, and Penicillium, Dr. Vicencio said at an international conference of the American Thoracic Society.

Boys and girls were affected equally, but SAFS patients tended to be older and have worse results on pulmonary function tests (PFTs) than their peers did, with forced expiratory volume in 1 second (FEV₁) at 73.33% of predicted, for instance, compared with 91.60% in those without SAFS. Some of the children who didn’t meet the criteria for SAFS diagnosis had high IgE levels but no evidence of fungal sensitization, or evidence of fungal sensitivity but normal IgE levels.

"The contribution of fungi to poorly controlled asthma in children is likely to be underestimated, as is the number of patients who might benefit from antifungal therapy," Dr. Vicencio said.

So far, he’s treated about a dozen pediatric SAFS patients with itraconazole. "About half of them have done very well. Their asthma is better controlled. We have documented some PFT improvements. Their IgE levels are variable; some of them are dropping dramatically, and some are not," he said.

Overall, "what it looks like is that fungal sensitization is a risk factor for severe persistent disease. We do believe that there is going to be a role for antifungal agents in certain select populations," he said.

The ongoing series now includes about 60 children with severe, poorly controlled asthma. "Something on the order of 60% actually have fungal sensitization," Dr. Vicencio said.

Sputum testing or bronchoalveolar lavage is planned to see if young SAFS patients actually have fungus in their lungs.

Genotyping is also underway to see if these patients have a mutation in the CHIT1 gene, which encodes for chitotriosidase, a kind of natural antifungal found in mammals. Dr. Vicencio has published a case series in which the mutation was present in six pediatric SAFS patients tested for it. Of the three treated with itraconazole, two responded well and one responded "dramatically" (Pediatrics 2010;126:e982-5).

About a third of the general population has the mutation, and it doesn’t cause disease in most. However, in someone with asthma and fungal exposure, "we believe the mutation" might cause "a perfect storm for asthma," he said.

Dr. Vicencio said he has no relevant disclosures.

SAN FRANCISCO – Underlying pulmonary fungal colonization or infection may be the reason that some children with severe asthma don’t respond fully to conventional treatments.

Severe asthma with fungal sensitization (SAFS) has been recognized only recently. In adults, SAFS has been found to respond to oral itraconazole (Am. J. Respir. Crit. Care Med. 2009;179:11-8).

CDC/Dr. Lucille K. Georg

SAFS also occurs in children, according to Dr. Alfin G. Vicencio, chief of pediatric pulmonology and cystic fibrosis at Cohen Children’s Medical Center in New Hyde Park, N.Y., and his colleagues.

The researchers looked at 41 children, teens, and young adults (aged 2-21 years) with severe asthma who were failing level 4 or greater combination asthma therapy, and found that 17 (41.5%) had serum fungal IgE levels above 100 IU/mL and evidence of fungal sensitization on radioallergosorbent or skin-prick tests, indicating SAFS.

Eleven (65%) of those patients were sensitive to more than one fungal species. Aspergillus was the most commonly implicated species, followed by Alternaria, Candida, Cladosporium, Setomelanomma, Mucor, and Penicillium, Dr. Vicencio said at an international conference of the American Thoracic Society.

Boys and girls were affected equally, but SAFS patients tended to be older and have worse results on pulmonary function tests (PFTs) than their peers did, with forced expiratory volume in 1 second (FEV₁) at 73.33% of predicted, for instance, compared with 91.60% in those without SAFS. Some of the children who didn’t meet the criteria for SAFS diagnosis had high IgE levels but no evidence of fungal sensitization, or evidence of fungal sensitivity but normal IgE levels.

"The contribution of fungi to poorly controlled asthma in children is likely to be underestimated, as is the number of patients who might benefit from antifungal therapy," Dr. Vicencio said.

So far, he’s treated about a dozen pediatric SAFS patients with itraconazole. "About half of them have done very well. Their asthma is better controlled. We have documented some PFT improvements. Their IgE levels are variable; some of them are dropping dramatically, and some are not," he said.

Overall, "what it looks like is that fungal sensitization is a risk factor for severe persistent disease. We do believe that there is going to be a role for antifungal agents in certain select populations," he said.

The ongoing series now includes about 60 children with severe, poorly controlled asthma. "Something on the order of 60% actually have fungal sensitization," Dr. Vicencio said.

Sputum testing or bronchoalveolar lavage is planned to see if young SAFS patients actually have fungus in their lungs.

Genotyping is also underway to see if these patients have a mutation in the CHIT1 gene, which encodes for chitotriosidase, a kind of natural antifungal found in mammals. Dr. Vicencio has published a case series in which the mutation was present in six pediatric SAFS patients tested for it. Of the three treated with itraconazole, two responded well and one responded "dramatically" (Pediatrics 2010;126:e982-5).

About a third of the general population has the mutation, and it doesn’t cause disease in most. However, in someone with asthma and fungal exposure, "we believe the mutation" might cause "a perfect storm for asthma," he said.

Dr. Vicencio said he has no relevant disclosures.

SAN FRANCISCO – Patients on selective serotonin reuptake inhibitors or serotonin norepinephrine reuptake inhibitors when they were admitted to an intensive care unit were 73% more likely to die in the hospital, compared with ICU patients who were not on these antidepressants, a retrospective study found.

Dr. Katherine M. Berg and her associates analyzed electronic records from admissions to four ICUs in 2001-2008 to compare outcomes for 1,876 patients who were on a selective serotonin reuptake inhibitor (SSRI) or serotonin norepinephrine reuptake inhibitor (SNRI) and 8,692 control patients who were not taking an SSRI or SNRI before admission.

Sherry Boschert/IMNG Medical Media

The mortality risk remained elevated at 1,000 days after ICU admission, she reported in a late-breaking poster presentation and discussion session at an international conference of the American Thoracic Society.

Certain subgroups were at even greater risk of dying in the hospital if they were on an SSRI or SNRI when admitted to the ICU. Patients who had acute coronary syndrome or had undergone cardiac surgery were more than twice as likely to die if they were on an SSRI/SNRI when entering the ICU, compared with controls, said Dr. Berg, a pulmonary/critical care fellow at Massachusetts General Hospital and Harvard University, Boston.

The increased mortality risk appeared to be associated mainly with medications that have higher degrees of serotonin reuptake inhibition. "Citalopram, which is a lower-potency drug, by itself did not incur a higher mortality risk, but sertraline, which is one of the more potent drugs, did. Even comparing the two drugs to each other, if you were on sertraline, your mortality risk was higher" than if you were on citalopram, Dr. Berg said in an interview.

Fluoxetine, paroxetine, and sertraline were associated with significantly higher mortality, but no significant mortality differences were seen between patients on citalopram or escitalopram and control patients.

Of the 8,692 control patients, 7% died in the hospital, compared with in-hospital death rates of 10% in 286 patients on fluoxetine, 13% in 320 patients on paroxetine, and 15% in 426 patients on sertraline at the time of ICU admission. The remaining 844 patients were on other antidepressants.

The study adjusted for the effects of each patient’s age, Simplified Acute Physiology Score, and combined Elixhauser comorbidity score on in-hospital mortality risk.

Slight but statistically significant differences in the characteristics of the two groups included a greater proportion of women in the SSRI/SNRI group, compared with controls (57% vs. 40%), and a higher prevalence of diabetes (21% vs. 17%) or chronic obstructive pulmonary disease (11% vs. 7%) in patients on an SSRI/SNRI, compared with controls. Patients in the SSRI/SNRI group were more likely to have an infection than were controls (11% vs. 8%), but less likely to have acute coronary syndrome (8% vs. 10%) or cardiovascular disease (67% vs. 70%).

Further studies are needed to ascertain if this is a causal relationship or just an association between SSRI/SNRI use and mortality in ICU patients, she said. The findings are limited by the retrospective nature of the study, which also was unable to control for the effects of potentially important confounders such as smoking status or the presence of depression.

The data came from the Multiparameter Intelligent Monitoring in Intensive Care II database, a public collection of data with patient identifiers removed.

Antidepressants were the most commonly prescribed medication class in the United States in 2011, and SSRIs were the most common type of antidepressant, she said. SSRI use has been associated with increased risk of bleeding, falls, bradycardia, and stroke in previous studies, which also suggest a possible protective effect of SSRIs in patients with coronary artery disease.

Dr. Berg reported having no financial disclosures.

SAN FRANCISCO – Patients on selective serotonin reuptake inhibitors or serotonin norepinephrine reuptake inhibitors when they were admitted to an intensive care unit were 73% more likely to die in the hospital, compared with ICU patients who were not on these antidepressants, a retrospective study found.

Dr. Katherine M. Berg and her associates analyzed electronic records from admissions to four ICUs in 2001-2008 to compare outcomes for 1,876 patients who were on a selective serotonin reuptake inhibitor (SSRI) or serotonin norepinephrine reuptake inhibitor (SNRI) and 8,692 control patients who were not taking an SSRI or SNRI before admission.

Sherry Boschert/IMNG Medical Media

The mortality risk remained elevated at 1,000 days after ICU admission, she reported in a late-breaking poster presentation and discussion session at an international conference of the American Thoracic Society.

Certain subgroups were at even greater risk of dying in the hospital if they were on an SSRI or SNRI when admitted to the ICU. Patients who had acute coronary syndrome or had undergone cardiac surgery were more than twice as likely to die if they were on an SSRI/SNRI when entering the ICU, compared with controls, said Dr. Berg, a pulmonary/critical care fellow at Massachusetts General Hospital and Harvard University, Boston.

The increased mortality risk appeared to be associated mainly with medications that have higher degrees of serotonin reuptake inhibition. "Citalopram, which is a lower-potency drug, by itself did not incur a higher mortality risk, but sertraline, which is one of the more potent drugs, did. Even comparing the two drugs to each other, if you were on sertraline, your mortality risk was higher" than if you were on citalopram, Dr. Berg said in an interview.

Fluoxetine, paroxetine, and sertraline were associated with significantly higher mortality, but no significant mortality differences were seen between patients on citalopram or escitalopram and control patients.

Of the 8,692 control patients, 7% died in the hospital, compared with in-hospital death rates of 10% in 286 patients on fluoxetine, 13% in 320 patients on paroxetine, and 15% in 426 patients on sertraline at the time of ICU admission. The remaining 844 patients were on other antidepressants.

The study adjusted for the effects of each patient’s age, Simplified Acute Physiology Score, and combined Elixhauser comorbidity score on in-hospital mortality risk.

Slight but statistically significant differences in the characteristics of the two groups included a greater proportion of women in the SSRI/SNRI group, compared with controls (57% vs. 40%), and a higher prevalence of diabetes (21% vs. 17%) or chronic obstructive pulmonary disease (11% vs. 7%) in patients on an SSRI/SNRI, compared with controls. Patients in the SSRI/SNRI group were more likely to have an infection than were controls (11% vs. 8%), but less likely to have acute coronary syndrome (8% vs. 10%) or cardiovascular disease (67% vs. 70%).

Further studies are needed to ascertain if this is a causal relationship or just an association between SSRI/SNRI use and mortality in ICU patients, she said. The findings are limited by the retrospective nature of the study, which also was unable to control for the effects of potentially important confounders such as smoking status or the presence of depression.

The data came from the Multiparameter Intelligent Monitoring in Intensive Care II database, a public collection of data with patient identifiers removed.

Antidepressants were the most commonly prescribed medication class in the United States in 2011, and SSRIs were the most common type of antidepressant, she said. SSRI use has been associated with increased risk of bleeding, falls, bradycardia, and stroke in previous studies, which also suggest a possible protective effect of SSRIs in patients with coronary artery disease.

Dr. Berg reported having no financial disclosures.

SAN FRANCISCO – Patients on selective serotonin reuptake inhibitors or serotonin norepinephrine reuptake inhibitors when they were admitted to an intensive care unit were 73% more likely to die in the hospital, compared with ICU patients who were not on these antidepressants, a retrospective study found.

Dr. Katherine M. Berg and her associates analyzed electronic records from admissions to four ICUs in 2001-2008 to compare outcomes for 1,876 patients who were on a selective serotonin reuptake inhibitor (SSRI) or serotonin norepinephrine reuptake inhibitor (SNRI) and 8,692 control patients who were not taking an SSRI or SNRI before admission.

Sherry Boschert/IMNG Medical Media

The mortality risk remained elevated at 1,000 days after ICU admission, she reported in a late-breaking poster presentation and discussion session at an international conference of the American Thoracic Society.

Certain subgroups were at even greater risk of dying in the hospital if they were on an SSRI or SNRI when admitted to the ICU. Patients who had acute coronary syndrome or had undergone cardiac surgery were more than twice as likely to die if they were on an SSRI/SNRI when entering the ICU, compared with controls, said Dr. Berg, a pulmonary/critical care fellow at Massachusetts General Hospital and Harvard University, Boston.

The increased mortality risk appeared to be associated mainly with medications that have higher degrees of serotonin reuptake inhibition. "Citalopram, which is a lower-potency drug, by itself did not incur a higher mortality risk, but sertraline, which is one of the more potent drugs, did. Even comparing the two drugs to each other, if you were on sertraline, your mortality risk was higher" than if you were on citalopram, Dr. Berg said in an interview.

Fluoxetine, paroxetine, and sertraline were associated with significantly higher mortality, but no significant mortality differences were seen between patients on citalopram or escitalopram and control patients.

Of the 8,692 control patients, 7% died in the hospital, compared with in-hospital death rates of 10% in 286 patients on fluoxetine, 13% in 320 patients on paroxetine, and 15% in 426 patients on sertraline at the time of ICU admission. The remaining 844 patients were on other antidepressants.

The study adjusted for the effects of each patient’s age, Simplified Acute Physiology Score, and combined Elixhauser comorbidity score on in-hospital mortality risk.

Slight but statistically significant differences in the characteristics of the two groups included a greater proportion of women in the SSRI/SNRI group, compared with controls (57% vs. 40%), and a higher prevalence of diabetes (21% vs. 17%) or chronic obstructive pulmonary disease (11% vs. 7%) in patients on an SSRI/SNRI, compared with controls. Patients in the SSRI/SNRI group were more likely to have an infection than were controls (11% vs. 8%), but less likely to have acute coronary syndrome (8% vs. 10%) or cardiovascular disease (67% vs. 70%).

Further studies are needed to ascertain if this is a causal relationship or just an association between SSRI/SNRI use and mortality in ICU patients, she said. The findings are limited by the retrospective nature of the study, which also was unable to control for the effects of potentially important confounders such as smoking status or the presence of depression.

The data came from the Multiparameter Intelligent Monitoring in Intensive Care II database, a public collection of data with patient identifiers removed.

Antidepressants were the most commonly prescribed medication class in the United States in 2011, and SSRIs were the most common type of antidepressant, she said. SSRI use has been associated with increased risk of bleeding, falls, bradycardia, and stroke in previous studies, which also suggest a possible protective effect of SSRIs in patients with coronary artery disease.

Dr. Berg reported having no financial disclosures.

SAN FRANCISCO – The recent findings of significantly increased risk for cancer incidence and mortality in people with sleep apnea echo previous in vitro and animal studies that found repeated episodes of hypoxia were associated with accelerated cancer progression.

In one of two new studies, people with obstructive sleep apnea were 10%-480% more likely to die of cancer, depending on apnea severity, compared with people without OSA, in a 20-year follow-up study of 1,522 participants in the Wisconsin Sleep Cohort.

Both the number of dips in oxygen level during sleep and the severity of hypoxia during those episodes were associated with increased risk of cancer mortality, but the association was stronger with hypoxia severity. Patients who spent much of their sleep time getting less than 90% oxyhemoglobin saturation were nearly nine times more likely to die of cancer during the study, compared with controls, said Dr. F. Javier Nieto and his associates reported in a press briefing at the annual meeting of the American Thoracic Society.

In a separate prospective 5-year study of 5,618 patients who were referred to seven sleep clinics in Spain, severe hypoxemia during sleep was associated with significantly increased incidence of cancer. Patients with OSA who spent more than 30% of their sleep time getting less than 90% oxyhemoglobin saturation had more than twice the risk for a new diagnosis of cancer during 5 years of follow-up, compared with patients without sleep apnea, Dr. Miguel A. Martinez-Garcia and his associates reported at the briefing.

"In both studies, when they looked at the amount of low oxygen that they were getting, that’s when the incidence and mortality from cancer went up," said Mary J. Morrell, Ph.D., who moderated the press briefing. "What it suggests is that there’s something associated with low oxygen that’s triggering the cancer, which would fit with the initial animal work that caused them to look into the two large cohorts" of people, added Dr. Morrell, professor of sleep and respiratory physiology at Imperial College, London.

The U.S. study analyzed mortality data for participants in the Wisconsin Sleep Cohort, a prospective, community-based study of the predictors and natural history of sleep disorders. All underwent polysomnography at the start of the study. Sleep-disordered breathing was defined as an apnea-hypopnea index (AHI) score of 5 or greater, representing the mean number of apnea and hypopnea events per hour of sleep.

The mortality risks were associated with the presence and severity of sleep apnea in a dose-response fashion, said Dr. Nieto, chair of the department of population health sciences at the University of Wisconsin, Madison.

Compared with participants who did not have sleep apnea, those with mild sleep apnea (defined as an AHI of 5-14.9) were 10% more likely to die of cancer during the follow-up years. People with moderate sleep apnea (an AHI of 15-29.9) were twice as likely and those with severe apnea (an AHI of 30 or greater) were nearly five times as likely to die of cancer, compared with the control group without sleep apnea. The results were adjusted for the confounding effects of age, sex, body mass index, and smoking, Dr. Nieto said.

"The key thing is that it’s the amount of low oxygen that the patients are getting, not essentially how many times it occurs, which is the apnea-hypopnea index. It’s the amount that they’re getting" that matters most, Dr. Morrell noted.

When the results of the Spanish study were analyzed according to scores on the AHI, which includes both hypopnea and hypoxemia, the increased incidence of cancer in patients with sleep apnea became statistically nonsignificant after adjusting for the confounding effects of age, gender, and body mass index, said Dr. Martinez-Garcia of Le Fe University and Polytechnic Hospital, Valencia, Spain. Subset analyses suggest that the association between the hypoxemia index and cancer incidence may be limited to males and younger patients, Dr. Martinez-Garcia said.

Dr. Nieto, Dr. Martinez-Garcia, and Dr. Morrell reported having no financial disclosures.

SAN FRANCISCO – The recent findings of significantly increased risk for cancer incidence and mortality in people with sleep apnea echo previous in vitro and animal studies that found repeated episodes of hypoxia were associated with accelerated cancer progression.

In one of two new studies, people with obstructive sleep apnea were 10%-480% more likely to die of cancer, depending on apnea severity, compared with people without OSA, in a 20-year follow-up study of 1,522 participants in the Wisconsin Sleep Cohort.

Both the number of dips in oxygen level during sleep and the severity of hypoxia during those episodes were associated with increased risk of cancer mortality, but the association was stronger with hypoxia severity. Patients who spent much of their sleep time getting less than 90% oxyhemoglobin saturation were nearly nine times more likely to die of cancer during the study, compared with controls, said Dr. F. Javier Nieto and his associates reported in a press briefing at the annual meeting of the American Thoracic Society.

In a separate prospective 5-year study of 5,618 patients who were referred to seven sleep clinics in Spain, severe hypoxemia during sleep was associated with significantly increased incidence of cancer. Patients with OSA who spent more than 30% of their sleep time getting less than 90% oxyhemoglobin saturation had more than twice the risk for a new diagnosis of cancer during 5 years of follow-up, compared with patients without sleep apnea, Dr. Miguel A. Martinez-Garcia and his associates reported at the briefing.

"In both studies, when they looked at the amount of low oxygen that they were getting, that’s when the incidence and mortality from cancer went up," said Mary J. Morrell, Ph.D., who moderated the press briefing. "What it suggests is that there’s something associated with low oxygen that’s triggering the cancer, which would fit with the initial animal work that caused them to look into the two large cohorts" of people, added Dr. Morrell, professor of sleep and respiratory physiology at Imperial College, London.

The U.S. study analyzed mortality data for participants in the Wisconsin Sleep Cohort, a prospective, community-based study of the predictors and natural history of sleep disorders. All underwent polysomnography at the start of the study. Sleep-disordered breathing was defined as an apnea-hypopnea index (AHI) score of 5 or greater, representing the mean number of apnea and hypopnea events per hour of sleep.

The mortality risks were associated with the presence and severity of sleep apnea in a dose-response fashion, said Dr. Nieto, chair of the department of population health sciences at the University of Wisconsin, Madison.

Compared with participants who did not have sleep apnea, those with mild sleep apnea (defined as an AHI of 5-14.9) were 10% more likely to die of cancer during the follow-up years. People with moderate sleep apnea (an AHI of 15-29.9) were twice as likely and those with severe apnea (an AHI of 30 or greater) were nearly five times as likely to die of cancer, compared with the control group without sleep apnea. The results were adjusted for the confounding effects of age, sex, body mass index, and smoking, Dr. Nieto said.

"The key thing is that it’s the amount of low oxygen that the patients are getting, not essentially how many times it occurs, which is the apnea-hypopnea index. It’s the amount that they’re getting" that matters most, Dr. Morrell noted.

When the results of the Spanish study were analyzed according to scores on the AHI, which includes both hypopnea and hypoxemia, the increased incidence of cancer in patients with sleep apnea became statistically nonsignificant after adjusting for the confounding effects of age, gender, and body mass index, said Dr. Martinez-Garcia of Le Fe University and Polytechnic Hospital, Valencia, Spain. Subset analyses suggest that the association between the hypoxemia index and cancer incidence may be limited to males and younger patients, Dr. Martinez-Garcia said.

Dr. Nieto, Dr. Martinez-Garcia, and Dr. Morrell reported having no financial disclosures.

SAN FRANCISCO – The recent findings of significantly increased risk for cancer incidence and mortality in people with sleep apnea echo previous in vitro and animal studies that found repeated episodes of hypoxia were associated with accelerated cancer progression.

In one of two new studies, people with obstructive sleep apnea were 10%-480% more likely to die of cancer, depending on apnea severity, compared with people without OSA, in a 20-year follow-up study of 1,522 participants in the Wisconsin Sleep Cohort.

Both the number of dips in oxygen level during sleep and the severity of hypoxia during those episodes were associated with increased risk of cancer mortality, but the association was stronger with hypoxia severity. Patients who spent much of their sleep time getting less than 90% oxyhemoglobin saturation were nearly nine times more likely to die of cancer during the study, compared with controls, said Dr. F. Javier Nieto and his associates reported in a press briefing at the annual meeting of the American Thoracic Society.

In a separate prospective 5-year study of 5,618 patients who were referred to seven sleep clinics in Spain, severe hypoxemia during sleep was associated with significantly increased incidence of cancer. Patients with OSA who spent more than 30% of their sleep time getting less than 90% oxyhemoglobin saturation had more than twice the risk for a new diagnosis of cancer during 5 years of follow-up, compared with patients without sleep apnea, Dr. Miguel A. Martinez-Garcia and his associates reported at the briefing.

"In both studies, when they looked at the amount of low oxygen that they were getting, that’s when the incidence and mortality from cancer went up," said Mary J. Morrell, Ph.D., who moderated the press briefing. "What it suggests is that there’s something associated with low oxygen that’s triggering the cancer, which would fit with the initial animal work that caused them to look into the two large cohorts" of people, added Dr. Morrell, professor of sleep and respiratory physiology at Imperial College, London.

The U.S. study analyzed mortality data for participants in the Wisconsin Sleep Cohort, a prospective, community-based study of the predictors and natural history of sleep disorders. All underwent polysomnography at the start of the study. Sleep-disordered breathing was defined as an apnea-hypopnea index (AHI) score of 5 or greater, representing the mean number of apnea and hypopnea events per hour of sleep.

The mortality risks were associated with the presence and severity of sleep apnea in a dose-response fashion, said Dr. Nieto, chair of the department of population health sciences at the University of Wisconsin, Madison.

Compared with participants who did not have sleep apnea, those with mild sleep apnea (defined as an AHI of 5-14.9) were 10% more likely to die of cancer during the follow-up years. People with moderate sleep apnea (an AHI of 15-29.9) were twice as likely and those with severe apnea (an AHI of 30 or greater) were nearly five times as likely to die of cancer, compared with the control group without sleep apnea. The results were adjusted for the confounding effects of age, sex, body mass index, and smoking, Dr. Nieto said.

"The key thing is that it’s the amount of low oxygen that the patients are getting, not essentially how many times it occurs, which is the apnea-hypopnea index. It’s the amount that they’re getting" that matters most, Dr. Morrell noted.

When the results of the Spanish study were analyzed according to scores on the AHI, which includes both hypopnea and hypoxemia, the increased incidence of cancer in patients with sleep apnea became statistically nonsignificant after adjusting for the confounding effects of age, gender, and body mass index, said Dr. Martinez-Garcia of Le Fe University and Polytechnic Hospital, Valencia, Spain. Subset analyses suggest that the association between the hypoxemia index and cancer incidence may be limited to males and younger patients, Dr. Martinez-Garcia said.

Dr. Nieto, Dr. Martinez-Garcia, and Dr. Morrell reported having no financial disclosures.

SAN FRANCISCO – Black women with a history of sarcoidosis have a mortality rate twice that of women without sarcoidosis, according to an analysis of data from approximately 59,000 women in the Black Women’s Health Study during 1995-2009.

The age-adjusted mortality rate was 17/10,000 person-years in black women with a history of sarcoidosis and 8/10,000 person-years in those without a history of sarcoidosis, Dr. Melissa H. Tukey reported.

A total of 686 women had a diagnosis of sarcoidosis at the start of the Black Women's Health Study in 1995, and 506 women developed sarcoidosis during follow-up; of these, 121 died. Among the remaining women without sarcoidosis, 2,813 died. Cumulative mortality rates were 10% in those with sarcoidosis and 5% in those without sarcoidosis, Dr. Tukey and her associates reported in a poster presentation and discussion at an international conference of the American Thoracic Society.

Sarcoidosis was the leading cause of death in women with the disease who died. Of deaths among women with a history of sarcoidosis, 24% were directly attributable to the disease, and 47% of these deaths were caused by respiratory failure, an analysis of National Death Index data showed. Another 6% died from pulmonary fibrosis or pulmonary hypertension.

The current analysis is the largest epidemiologic study specifically focused on mortality in black women with sarcoidosis, said Dr. Tukey of Boston University. Previous data suggesting that African American women are disproportionately affected by sarcoidosis and have a higher mortality from the disease come primarily from single-site studies, she added.

Other causes of death among black women with a history of sarcoidosis in the Black Women’s Health Study were listed as cancer in 23%, infection in 11%, coronary artery disease in 8%, other cardiac disease in 10%, chronic obstructive pulmonary disease in 2%, and other causes in 16%.

In each age category at the end of the follow-up period, the all-cause mortality rate among women with a history of sarcoidosis was higher than for women with no history of sarcoidosis.

For most black women with sarcoidosis, "it’s primarily a benign disease," Dr. Tukey said. "But there is this cohort of patients that just have a more progressive and severe course, and often end up dying of their disease. Now we’re finally able to really quantify what that actual risk is."

A clinician who has a female black patient with sarcoidosis who starts to develop pulmonary fibrosis or signs of severe disease should discuss the option of more aggressive treatment with the patient, she suggested.

The Black Women’s Health Study relied on self-report of a sarcoidosis diagnosis, but Dr. Tukey and her associates confirmed the diagnosis in 96% of patients for whom medical records or physician checklists were obtained. The Black Women’s Health Study is not a random sample of black women in the United States, so results may not be generalizable to the entire population of black women.

Dr. Tukey reported having no financial disclosures.

SAN FRANCISCO – Black women with a history of sarcoidosis have a mortality rate twice that of women without sarcoidosis, according to an analysis of data from approximately 59,000 women in the Black Women’s Health Study during 1995-2009.

The age-adjusted mortality rate was 17/10,000 person-years in black women with a history of sarcoidosis and 8/10,000 person-years in those without a history of sarcoidosis, Dr. Melissa H. Tukey reported.

A total of 686 women had a diagnosis of sarcoidosis at the start of the Black Women's Health Study in 1995, and 506 women developed sarcoidosis during follow-up; of these, 121 died. Among the remaining women without sarcoidosis, 2,813 died. Cumulative mortality rates were 10% in those with sarcoidosis and 5% in those without sarcoidosis, Dr. Tukey and her associates reported in a poster presentation and discussion at an international conference of the American Thoracic Society.

Sarcoidosis was the leading cause of death in women with the disease who died. Of deaths among women with a history of sarcoidosis, 24% were directly attributable to the disease, and 47% of these deaths were caused by respiratory failure, an analysis of National Death Index data showed. Another 6% died from pulmonary fibrosis or pulmonary hypertension.

The current analysis is the largest epidemiologic study specifically focused on mortality in black women with sarcoidosis, said Dr. Tukey of Boston University. Previous data suggesting that African American women are disproportionately affected by sarcoidosis and have a higher mortality from the disease come primarily from single-site studies, she added.

Other causes of death among black women with a history of sarcoidosis in the Black Women’s Health Study were listed as cancer in 23%, infection in 11%, coronary artery disease in 8%, other cardiac disease in 10%, chronic obstructive pulmonary disease in 2%, and other causes in 16%.

In each age category at the end of the follow-up period, the all-cause mortality rate among women with a history of sarcoidosis was higher than for women with no history of sarcoidosis.

For most black women with sarcoidosis, "it’s primarily a benign disease," Dr. Tukey said. "But there is this cohort of patients that just have a more progressive and severe course, and often end up dying of their disease. Now we’re finally able to really quantify what that actual risk is."

A clinician who has a female black patient with sarcoidosis who starts to develop pulmonary fibrosis or signs of severe disease should discuss the option of more aggressive treatment with the patient, she suggested.

The Black Women’s Health Study relied on self-report of a sarcoidosis diagnosis, but Dr. Tukey and her associates confirmed the diagnosis in 96% of patients for whom medical records or physician checklists were obtained. The Black Women’s Health Study is not a random sample of black women in the United States, so results may not be generalizable to the entire population of black women.

Dr. Tukey reported having no financial disclosures.

SAN FRANCISCO – Black women with a history of sarcoidosis have a mortality rate twice that of women without sarcoidosis, according to an analysis of data from approximately 59,000 women in the Black Women’s Health Study during 1995-2009.

The age-adjusted mortality rate was 17/10,000 person-years in black women with a history of sarcoidosis and 8/10,000 person-years in those without a history of sarcoidosis, Dr. Melissa H. Tukey reported.

A total of 686 women had a diagnosis of sarcoidosis at the start of the Black Women's Health Study in 1995, and 506 women developed sarcoidosis during follow-up; of these, 121 died. Among the remaining women without sarcoidosis, 2,813 died. Cumulative mortality rates were 10% in those with sarcoidosis and 5% in those without sarcoidosis, Dr. Tukey and her associates reported in a poster presentation and discussion at an international conference of the American Thoracic Society.

Sarcoidosis was the leading cause of death in women with the disease who died. Of deaths among women with a history of sarcoidosis, 24% were directly attributable to the disease, and 47% of these deaths were caused by respiratory failure, an analysis of National Death Index data showed. Another 6% died from pulmonary fibrosis or pulmonary hypertension.

The current analysis is the largest epidemiologic study specifically focused on mortality in black women with sarcoidosis, said Dr. Tukey of Boston University. Previous data suggesting that African American women are disproportionately affected by sarcoidosis and have a higher mortality from the disease come primarily from single-site studies, she added.

Other causes of death among black women with a history of sarcoidosis in the Black Women’s Health Study were listed as cancer in 23%, infection in 11%, coronary artery disease in 8%, other cardiac disease in 10%, chronic obstructive pulmonary disease in 2%, and other causes in 16%.

In each age category at the end of the follow-up period, the all-cause mortality rate among women with a history of sarcoidosis was higher than for women with no history of sarcoidosis.

For most black women with sarcoidosis, "it’s primarily a benign disease," Dr. Tukey said. "But there is this cohort of patients that just have a more progressive and severe course, and often end up dying of their disease. Now we’re finally able to really quantify what that actual risk is."

A clinician who has a female black patient with sarcoidosis who starts to develop pulmonary fibrosis or signs of severe disease should discuss the option of more aggressive treatment with the patient, she suggested.

The Black Women’s Health Study relied on self-report of a sarcoidosis diagnosis, but Dr. Tukey and her associates confirmed the diagnosis in 96% of patients for whom medical records or physician checklists were obtained. The Black Women’s Health Study is not a random sample of black women in the United States, so results may not be generalizable to the entire population of black women.

Dr. Tukey reported having no financial disclosures.

SAN FRANCISCO – Newborn lung function was significantly better in pregnant smokers who took vitamin C supplements, compared with smoking mothers on placebo, in a double-blind trial that randomized 179 women.

Among 159 infants who underwent pulmonary function tests at around 48 hours of age, results in the 76 newborns of smokers getting vitamin C were similar to results for 76 newborns of nonsmoking women in a nonrandomized comparison group. Both subgroups had better pulmonary function than did the 83 newborns of placebo-treated smokers, Dr. Cindy T. McEvoy and her associates reported at an international conference of the American Thoracic Society.

Photo Courtesy Dr. Cindy T. McEvoy

"We speculate that vitamin C supplementation in pregnant women who cannot quit smoking is helpful," said Dr. McEvoy of Oregon Health and Science University, Portland.

The current study randomized pregnant smokers aged 15 years and older, and prior to 22 weeks gestation of their singletons, to take 500 mg/day of vitamin C or placebo until delivery. The women were counseled throughout the trial to quit smoking but declined to do so.

Maternal plasma levels of ascorbic acid were significantly lower in the two smoking groups at randomization, compared with levels in nonsmokers. By mid-gestation, ascorbic acid levels in the vitamin C group were similar to levels in nonsmokers (59 and 58 micromol/L, respectively), but levels in the placebo group remained significantly lower (40 micromol/L).

Infant pulmonary flow volume, characterized as a ratio of the time to peak tidal expiratory flow to expiratory time, was significantly lower in the placebo group (0.345), compared with the vitamin C group (0.383) and the nonsmoking group (0.399), Dr. McEvoy said.

Investigators also measured the newborns’ passive respiratory mechanics, or compliance of the respiratory system (Crs/kg), and found significantly lower results in the placebo group (1.2 Crs/kg), compared with the vitamin C group (1.32 Crs/kg) or the nonsmoking group (1.36 Crs/kg).

Treatment did not significantly affect respiratory rate.

There were no significant differences between the randomized groups at the start of the study in characteristics including maternal age, insurance coverage, cotinine levels, medication adherence, history of asthma, or the proportion of women smoking 10 or more cigarettes per day.

Infant demographics were similar in the two groups of smokers and the reference group of nonsmokers, including birth weight, gestational age at delivery, sex, rate of delivery before 32 weeks’ gestation, and rate of vaginal delivery.

The investigators plan to perform infant pulmonary function tests again when the study babies are 1 year old and compare it with clinical outcomes such as episodes of wheezing. They have secured support from the National Heart, Lung, and Blood Institute to randomize a new cohort and measure newborn forced expiratory flows as the primary outcome, she said.

The investigators did not give vitamin C supplementation to infants, but that strategy may deserve study as well, Dr. McEvoy said.

The study excluded pregnancies with multiple gestation or fetal congenital anomalies and women who currently used illicit drugs or abused alcohol, had a history of kidney stones, had insulin-dependent diabetes, or who had been taking vitamin C daily since their last menstrual period. Before the treatment period began, participants were asked to take a daily placebo; those who complied with fewer than 75% of placebo doses were excluded from randomization.

Approximately 12% of U.S. women smoke during pregnancy and at least 500,000 newborns each year have been exposed to smoke in utero. Previous studies have shown that infants of smokers have worse lung function at birth and a higher risk of developing lung diseases, including asthma, bronchitis, and pneumonia, compared with infants of nonsmokers.

The current findings support evidence from nonhuman primates that daily vitamin C can block the in utero effects of nicotine on lung development and newborn pulmonary function (Am. J. Respir. Crit. Care Med. 2005;171:1032-9).

Dr. McEvoy reported having no financial disclosures. The National Heart, Lung, and Blood Institute funded the study.

SAN FRANCISCO – Newborn lung function was significantly better in pregnant smokers who took vitamin C supplements, compared with smoking mothers on placebo, in a double-blind trial that randomized 179 women.

Among 159 infants who underwent pulmonary function tests at around 48 hours of age, results in the 76 newborns of smokers getting vitamin C were similar to results for 76 newborns of nonsmoking women in a nonrandomized comparison group. Both subgroups had better pulmonary function than did the 83 newborns of placebo-treated smokers, Dr. Cindy T. McEvoy and her associates reported at an international conference of the American Thoracic Society.

Photo Courtesy Dr. Cindy T. McEvoy

"We speculate that vitamin C supplementation in pregnant women who cannot quit smoking is helpful," said Dr. McEvoy of Oregon Health and Science University, Portland.

The current study randomized pregnant smokers aged 15 years and older, and prior to 22 weeks gestation of their singletons, to take 500 mg/day of vitamin C or placebo until delivery. The women were counseled throughout the trial to quit smoking but declined to do so.

Maternal plasma levels of ascorbic acid were significantly lower in the two smoking groups at randomization, compared with levels in nonsmokers. By mid-gestation, ascorbic acid levels in the vitamin C group were similar to levels in nonsmokers (59 and 58 micromol/L, respectively), but levels in the placebo group remained significantly lower (40 micromol/L).

Infant pulmonary flow volume, characterized as a ratio of the time to peak tidal expiratory flow to expiratory time, was significantly lower in the placebo group (0.345), compared with the vitamin C group (0.383) and the nonsmoking group (0.399), Dr. McEvoy said.

Investigators also measured the newborns’ passive respiratory mechanics, or compliance of the respiratory system (Crs/kg), and found significantly lower results in the placebo group (1.2 Crs/kg), compared with the vitamin C group (1.32 Crs/kg) or the nonsmoking group (1.36 Crs/kg).

Treatment did not significantly affect respiratory rate.

There were no significant differences between the randomized groups at the start of the study in characteristics including maternal age, insurance coverage, cotinine levels, medication adherence, history of asthma, or the proportion of women smoking 10 or more cigarettes per day.

Infant demographics were similar in the two groups of smokers and the reference group of nonsmokers, including birth weight, gestational age at delivery, sex, rate of delivery before 32 weeks’ gestation, and rate of vaginal delivery.

The investigators plan to perform infant pulmonary function tests again when the study babies are 1 year old and compare it with clinical outcomes such as episodes of wheezing. They have secured support from the National Heart, Lung, and Blood Institute to randomize a new cohort and measure newborn forced expiratory flows as the primary outcome, she said.

The investigators did not give vitamin C supplementation to infants, but that strategy may deserve study as well, Dr. McEvoy said.

The study excluded pregnancies with multiple gestation or fetal congenital anomalies and women who currently used illicit drugs or abused alcohol, had a history of kidney stones, had insulin-dependent diabetes, or who had been taking vitamin C daily since their last menstrual period. Before the treatment period began, participants were asked to take a daily placebo; those who complied with fewer than 75% of placebo doses were excluded from randomization.

Approximately 12% of U.S. women smoke during pregnancy and at least 500,000 newborns each year have been exposed to smoke in utero. Previous studies have shown that infants of smokers have worse lung function at birth and a higher risk of developing lung diseases, including asthma, bronchitis, and pneumonia, compared with infants of nonsmokers.

The current findings support evidence from nonhuman primates that daily vitamin C can block the in utero effects of nicotine on lung development and newborn pulmonary function (Am. J. Respir. Crit. Care Med. 2005;171:1032-9).

Dr. McEvoy reported having no financial disclosures. The National Heart, Lung, and Blood Institute funded the study.

SAN FRANCISCO – Newborn lung function was significantly better in pregnant smokers who took vitamin C supplements, compared with smoking mothers on placebo, in a double-blind trial that randomized 179 women.

Among 159 infants who underwent pulmonary function tests at around 48 hours of age, results in the 76 newborns of smokers getting vitamin C were similar to results for 76 newborns of nonsmoking women in a nonrandomized comparison group. Both subgroups had better pulmonary function than did the 83 newborns of placebo-treated smokers, Dr. Cindy T. McEvoy and her associates reported at an international conference of the American Thoracic Society.

Photo Courtesy Dr. Cindy T. McEvoy

"We speculate that vitamin C supplementation in pregnant women who cannot quit smoking is helpful," said Dr. McEvoy of Oregon Health and Science University, Portland.

The current study randomized pregnant smokers aged 15 years and older, and prior to 22 weeks gestation of their singletons, to take 500 mg/day of vitamin C or placebo until delivery. The women were counseled throughout the trial to quit smoking but declined to do so.

Maternal plasma levels of ascorbic acid were significantly lower in the two smoking groups at randomization, compared with levels in nonsmokers. By mid-gestation, ascorbic acid levels in the vitamin C group were similar to levels in nonsmokers (59 and 58 micromol/L, respectively), but levels in the placebo group remained significantly lower (40 micromol/L).

Infant pulmonary flow volume, characterized as a ratio of the time to peak tidal expiratory flow to expiratory time, was significantly lower in the placebo group (0.345), compared with the vitamin C group (0.383) and the nonsmoking group (0.399), Dr. McEvoy said.

Investigators also measured the newborns’ passive respiratory mechanics, or compliance of the respiratory system (Crs/kg), and found significantly lower results in the placebo group (1.2 Crs/kg), compared with the vitamin C group (1.32 Crs/kg) or the nonsmoking group (1.36 Crs/kg).

Treatment did not significantly affect respiratory rate.

There were no significant differences between the randomized groups at the start of the study in characteristics including maternal age, insurance coverage, cotinine levels, medication adherence, history of asthma, or the proportion of women smoking 10 or more cigarettes per day.

Infant demographics were similar in the two groups of smokers and the reference group of nonsmokers, including birth weight, gestational age at delivery, sex, rate of delivery before 32 weeks’ gestation, and rate of vaginal delivery.

The investigators plan to perform infant pulmonary function tests again when the study babies are 1 year old and compare it with clinical outcomes such as episodes of wheezing. They have secured support from the National Heart, Lung, and Blood Institute to randomize a new cohort and measure newborn forced expiratory flows as the primary outcome, she said.

The investigators did not give vitamin C supplementation to infants, but that strategy may deserve study as well, Dr. McEvoy said.

The study excluded pregnancies with multiple gestation or fetal congenital anomalies and women who currently used illicit drugs or abused alcohol, had a history of kidney stones, had insulin-dependent diabetes, or who had been taking vitamin C daily since their last menstrual period. Before the treatment period began, participants were asked to take a daily placebo; those who complied with fewer than 75% of placebo doses were excluded from randomization.

Approximately 12% of U.S. women smoke during pregnancy and at least 500,000 newborns each year have been exposed to smoke in utero. Previous studies have shown that infants of smokers have worse lung function at birth and a higher risk of developing lung diseases, including asthma, bronchitis, and pneumonia, compared with infants of nonsmokers.

The current findings support evidence from nonhuman primates that daily vitamin C can block the in utero effects of nicotine on lung development and newborn pulmonary function (Am. J. Respir. Crit. Care Med. 2005;171:1032-9).

Dr. McEvoy reported having no financial disclosures. The National Heart, Lung, and Blood Institute funded the study.

SAN FRANCISCO – Clinicians may have become too enthusiastic about using noninvasive ventilation in lieu of intubation and mechanical ventilation, according to a nationwide database study from the Boston University Pulmonary Center.

Noninvasive ventilation (NIV) use tripled during 2000-2009 for acute respiratory failure (ARF) caused by chronic obstructive pulmonary disease, for which there is good evidence of a mortality benefit (Cochrane Database Syst. Rev. 2004;1:CD004104).

But in the same period, use increased 3.4-fold for ARF caused by conditions for which there is little evidence to support its use, including asthma, pneumonia, neurologic diseases, and nonpulmonary sepsis. Currently, about half of ARF patients receiving NIV have COPD, while half have other conditions.

The investigators found that patients are more likely to fail NIV – and subsequently receive mechanical ventilation – when it’s used for those conditions instead of COPD (odds ratio, 1.12; 95% confidence interval, 1.08-1.16). Overall, 12% of COPD patients failed NIV, compared with 18% of non-COPD patients (P less than .001).

Of the study patients who failed NIV, 37% died, compared with 35% who received mechanical ventilation alone (P = .002).

The researchers analyzed approximately 11 million hospital records from 2000-2009 coded for ARF in the Agency for Healthcare Research and Quality’s Nationwide Inpatient Sample (NIS) database, excluding patients with sleep apnea.

"People might have a little too much faith in noninvasive ventilation. They see it work really well in COPD, so they think it might work well in everyone," said lead investigator Dr. Allan J. Walkey, director of pulmonary and critical care education at Boston University.

He said the study’s take-home message is to "think twice if you are going to put a noninvasive ventilator on someone without COPD or acute cardiogenic pulmonary edema," for which there is also strong evidence of benefit (Cochrane Database Syst. Rev. 2008;3:CD005351). In other patients, "there’s generally not good evidence to support use of noninvasive ventilation, and [our study suggests] it may be associated with worse outcomes. [Those patients] need to be monitored closely, and if they are showing signs of failure, they need to be intubated," he said at an international conference of the American Thoracic Society.

It’s unclear why NIV might be problematic for some. Perhaps not being able to suction secretions out of an endotracheal tube leads to problems in pneumonia. Maybe fading sensorium in other conditions increases the likelihood of gastric aspiration if there’s no tube in place to protect the airway, Dr. Walkey said.

Although the NIS database does not include vital signs, lab reports, and other patient-level clinical data, the researchers used an algorithm to assess and control for disease severity. "There is growing evidence that the adjustment of disease severity using data you do have in large databases" – such as information on comorbidities, billing codes, and demographics – "is actually as accurate as those based on disease severity scores," Dr. Walkey said (Crit. Care Med. 2011;39:2425-30).

The researchers also found wide regional variations in NIV use, with the heaviest use in the Northeast and the lowest in the Midwest; use was roughly equal in teaching and nonteaching hospitals.

Insurance claims for acute respiratory failure increased from 818,781 in 2000 to 1,531,352 in 2009, with an associated 25% decrease in ARF mortality over that period.

Dr. Walkey said he had no financial disclosures.

SAN FRANCISCO – Clinicians may have become too enthusiastic about using noninvasive ventilation in lieu of intubation and mechanical ventilation, according to a nationwide database study from the Boston University Pulmonary Center.

Noninvasive ventilation (NIV) use tripled during 2000-2009 for acute respiratory failure (ARF) caused by chronic obstructive pulmonary disease, for which there is good evidence of a mortality benefit (Cochrane Database Syst. Rev. 2004;1:CD004104).

But in the same period, use increased 3.4-fold for ARF caused by conditions for which there is little evidence to support its use, including asthma, pneumonia, neurologic diseases, and nonpulmonary sepsis. Currently, about half of ARF patients receiving NIV have COPD, while half have other conditions.

The investigators found that patients are more likely to fail NIV – and subsequently receive mechanical ventilation – when it’s used for those conditions instead of COPD (odds ratio, 1.12; 95% confidence interval, 1.08-1.16). Overall, 12% of COPD patients failed NIV, compared with 18% of non-COPD patients (P less than .001).

Of the study patients who failed NIV, 37% died, compared with 35% who received mechanical ventilation alone (P = .002).

The researchers analyzed approximately 11 million hospital records from 2000-2009 coded for ARF in the Agency for Healthcare Research and Quality’s Nationwide Inpatient Sample (NIS) database, excluding patients with sleep apnea.

"People might have a little too much faith in noninvasive ventilation. They see it work really well in COPD, so they think it might work well in everyone," said lead investigator Dr. Allan J. Walkey, director of pulmonary and critical care education at Boston University.

He said the study’s take-home message is to "think twice if you are going to put a noninvasive ventilator on someone without COPD or acute cardiogenic pulmonary edema," for which there is also strong evidence of benefit (Cochrane Database Syst. Rev. 2008;3:CD005351). In other patients, "there’s generally not good evidence to support use of noninvasive ventilation, and [our study suggests] it may be associated with worse outcomes. [Those patients] need to be monitored closely, and if they are showing signs of failure, they need to be intubated," he said at an international conference of the American Thoracic Society.

It’s unclear why NIV might be problematic for some. Perhaps not being able to suction secretions out of an endotracheal tube leads to problems in pneumonia. Maybe fading sensorium in other conditions increases the likelihood of gastric aspiration if there’s no tube in place to protect the airway, Dr. Walkey said.

Although the NIS database does not include vital signs, lab reports, and other patient-level clinical data, the researchers used an algorithm to assess and control for disease severity. "There is growing evidence that the adjustment of disease severity using data you do have in large databases" – such as information on comorbidities, billing codes, and demographics – "is actually as accurate as those based on disease severity scores," Dr. Walkey said (Crit. Care Med. 2011;39:2425-30).

The researchers also found wide regional variations in NIV use, with the heaviest use in the Northeast and the lowest in the Midwest; use was roughly equal in teaching and nonteaching hospitals.

Insurance claims for acute respiratory failure increased from 818,781 in 2000 to 1,531,352 in 2009, with an associated 25% decrease in ARF mortality over that period.

Dr. Walkey said he had no financial disclosures.

SAN FRANCISCO – Clinicians may have become too enthusiastic about using noninvasive ventilation in lieu of intubation and mechanical ventilation, according to a nationwide database study from the Boston University Pulmonary Center.

Noninvasive ventilation (NIV) use tripled during 2000-2009 for acute respiratory failure (ARF) caused by chronic obstructive pulmonary disease, for which there is good evidence of a mortality benefit (Cochrane Database Syst. Rev. 2004;1:CD004104).

But in the same period, use increased 3.4-fold for ARF caused by conditions for which there is little evidence to support its use, including asthma, pneumonia, neurologic diseases, and nonpulmonary sepsis. Currently, about half of ARF patients receiving NIV have COPD, while half have other conditions.

The investigators found that patients are more likely to fail NIV – and subsequently receive mechanical ventilation – when it’s used for those conditions instead of COPD (odds ratio, 1.12; 95% confidence interval, 1.08-1.16). Overall, 12% of COPD patients failed NIV, compared with 18% of non-COPD patients (P less than .001).

Of the study patients who failed NIV, 37% died, compared with 35% who received mechanical ventilation alone (P = .002).

The researchers analyzed approximately 11 million hospital records from 2000-2009 coded for ARF in the Agency for Healthcare Research and Quality’s Nationwide Inpatient Sample (NIS) database, excluding patients with sleep apnea.

"People might have a little too much faith in noninvasive ventilation. They see it work really well in COPD, so they think it might work well in everyone," said lead investigator Dr. Allan J. Walkey, director of pulmonary and critical care education at Boston University.

He said the study’s take-home message is to "think twice if you are going to put a noninvasive ventilator on someone without COPD or acute cardiogenic pulmonary edema," for which there is also strong evidence of benefit (Cochrane Database Syst. Rev. 2008;3:CD005351). In other patients, "there’s generally not good evidence to support use of noninvasive ventilation, and [our study suggests] it may be associated with worse outcomes. [Those patients] need to be monitored closely, and if they are showing signs of failure, they need to be intubated," he said at an international conference of the American Thoracic Society.

It’s unclear why NIV might be problematic for some. Perhaps not being able to suction secretions out of an endotracheal tube leads to problems in pneumonia. Maybe fading sensorium in other conditions increases the likelihood of gastric aspiration if there’s no tube in place to protect the airway, Dr. Walkey said.

Although the NIS database does not include vital signs, lab reports, and other patient-level clinical data, the researchers used an algorithm to assess and control for disease severity. "There is growing evidence that the adjustment of disease severity using data you do have in large databases" – such as information on comorbidities, billing codes, and demographics – "is actually as accurate as those based on disease severity scores," Dr. Walkey said (Crit. Care Med. 2011;39:2425-30).

The researchers also found wide regional variations in NIV use, with the heaviest use in the Northeast and the lowest in the Midwest; use was roughly equal in teaching and nonteaching hospitals.

Insurance claims for acute respiratory failure increased from 818,781 in 2000 to 1,531,352 in 2009, with an associated 25% decrease in ARF mortality over that period.

Dr. Walkey said he had no financial disclosures.