Selective Decontamination of the Digestive Tract Works
Applying topical antibiotics to the upper digestive tract improved survival rates among patients on mechanical ventilation in a study conducted by Australian investigators and published by JAMA.
The researchers note the concept of selective decontamination of the digestive tract (SDD) has been around for decades, but this was the first study to use a high-quality commercially prepared product specifically designed to prevent ventilator-associated pneumonia (VAP).
In this case, non-absorbed antibiotics and antifungal agents were applied to the mouth and stomach, and patients also received a short course of intravenous antibiotics. The goal was to prevent VAP caused by harmful bacteria and the overgrowth of fungi that normally live in the upper part of the gut but enter the lungs when a patient goes on mechanical ventilation.
The trial involved 5,982 mechanically ventilated adults who were treated in 19 ICUs in Australia between April 2018 and May 2021. Each ICU delivered either SDD with usual care or usual care alone for 12 months and then crossed over to the other option for a second 12-month period.
While SDD with standard care compared to standard care alone did not result in a statistically significant reduction in in-hospital mortality (27.0% vs. 29.1% respectively), the range of values included a clinically important benefit. “In nearly 3,000 patients treated with SDD, we saw a reduction in death of around two percent, equivalent to one death prevented for every 50 patients treated,” said study author John Myburgh from the George Institute for Global Health.
Patients treated with SDD also had fewer hospital-acquired infections in general. No adverse events were noted.
The researchers went on to combine these results with those of other major randomized trials of SDD, and the meta-analysis was also published in JAMA. “This review provides a high degree of certainty for clinicians to administer SDD to critically ill, mechanically ventilated patients in their ICUs to reduce the incidence of ventilator-associated pneumonia and the potential increased risk of death,” said senior study author Anthony Delaney. Read More
Common Levels of Supplemental Oxygen Found Safe and Effective
According to researchers from Vanderbilt University, all three levels of supplemental oxygen commonly delivered to hospitalized patients appear to be safe and effective.
The investigators compared outcomes for patients receiving the three most common levels of supplemental oxygen recommended by international guidelines —
- A lower pulse oximetry target (SpO2 of 90%), which represented the least amount of supplemental oxygen needed to maintain a normal blood oxygen level.
- An intermediate level (SpO2 of 94%).
- A higher target (SpO2 of 98%).
“There was no evidence that any one of the three approaches was better than the others,” said study author Matthew Semler, MD, MSc. “As long as you’re avoiding extremely low targets and extremely high oxygen levels, anything in this normal range is reasonable to use in practice.”
The authors note, however, that more study is needed to determine whether the effects of these levels may differ for certain subsets of patients.
The three-year Pragmatic Investigation of optimaL Oxygen Targets trial — dubbed PILOT — was funded by the National Heart, Lung, and Blood Institute. It involved patients in Vanderbilt University Medical Center’s MICU, along with those in the emergency department who had a planned admission to the MICU. It was published by The New England Journal of Medicine. Read More
Researchers Make a Case for Adding Sleep to CVH Metrics
Should sleep be added to the American Heart Association’s Life’s Simple 7 metrics to predict cardiovascular health (CVH)? Researchers from Columbia University asked that question in a study involving about 2,000 middle-aged and older adults taking part in the Multi-Ethnic Study of Atherosclerosis study who had sleep study results available.
The study found —
- 63% of participants slept less than seven hours per night, and 30% slept less than six hours.
- 39% and 25% had high night-to-night variability in sleep duration and sleep timing, respectively.
- 14% percent and 36% reported having excessive daytime sleepiness and high insomnia symptoms, respectively.
- 47% had moderate-to-severe sleep apnea.
- Individuals with a short sleep duration had higher chances of having low sleep efficiency, irregular sleep patterns, excessive daytime sleepiness, and sleep apnea.
- Short sleepers also had a higher prevalence of overweight/obesity, type 2 diabetes, and hypertension.
The authors found that a sleep health score based solely on sleep duration, as well as a sleep health score based on multiple sleep dimensions, could enhance the definition of cardiovascular health.
“The formal integration of sleep health into CVH promotion guidance will provide benchmarks for surveillance and ensure that sleep becomes an equal counterpart in public health policy to the attention and resources given to other lifestyle behaviors,” said study author Nour Makarem, PhD.
The study was published by the Journal of the American Heart Association. Read More
Air Pollution Takes Heavy Toll on People with fILD
People with fibrotic interstitial lung disease (fILD) have worse outcomes if they live in areas with high amounts of air pollution from factories and motor vehicles, report researchers from the Pitt School of Public Health publishing in JAMA Internal Medicine.
The study was conducted among 6,683 fILD patients from across the country. The investigators linked their home addresses with satellite and ground-monitoring air pollution data to determine air pollutant composition to an accuracy of less than half a mile.
Results showed increasing levels of PM2.5, a tiny pollutant capable of infiltrating deep into the lungs and even crossing the bloodstream, were associated with more severe disease at diagnosis, faster disease progression, and a high likelihood of earlier mortality.
But where the PM2.5 came from made a difference. Pollution high in sulfate, typically produced by factories in the coal and steel industries, nitrate, mainly from fossil fuel combustion, and ammonium, usually produced by industry or agriculture, was associated with worse outcomes.
Chemical signatures from more naturally occurring particulate matter, such as sea salt or soil dust, didn’t carry as high of an association.
Calculations made by the authors suggested that if exposure to industrial pollutants hadn’t occurred, most premature deaths among participants living in areas of North America with a heavier burden of the industry could have been avoided. Read More
Newborn screening for CF May Miss Cases in the Non-white Population
Newborn screenings for cystic fibrosis may be shortchanging non-white populations, conclude the authors of a study published in Pediatric Pulmonology.
The investigators, from the University of California San Francisco and Ann & Robert H. Lurie Children’s Hospital of Chicago, analyzed the genetic mutations of 46,729 people in the 2020 Cystic Fibrosis Foundation Patient Registry, then calculated the rate of delayed diagnosis or false-negative tests by race and ethnicity. Data were compared across states as well.
The study found the detection rate of at least one CFTR variant in known CF patients was 56-77% in Asian patients, 73-86% in Black patients, 84-91% in American Indian and Alaska Native patients, and 81-94% in Hispanic patients. That compared to 95-97% in white patients.
When the tests aimed to detect two CTFR mutations instead of just one, the differences between races and ethnicities were even larger. States with greater racial and ethnic diversity had lower detection rates for each variant panel. Detection rates were higher overall with genetic panels that included more variants compared to fewer variants, though not for all races/ethnicities.
The authors note about 20% of CF cases are in racial and ethnic minority groups, and delays in treatment significantly worsen the prognosis for these patients.
“The bias in newborn screening testing is coupled with clinician bias against diagnosis of cystic fibrosis in Black, Hispanic, Asian, and American Indian/Native Alaskan babies that can have fatal consequences,” said study author Susanna McColley, MD, from Lurie Children’s. “We hope this work will lead to more equitable screening in all states.” Read More
Environment Matters When it Comes to Exercise and COPD
Where your COPD patients live may play a big role in their ability to exercise.
That’s the key finding from Spanish researchers who estimated the association between environmental factors, objective physical activity, functional exercise capacity, and the difficulty of physical activity in 405 patients with mild to very severe COPD.
Overall, the patients, who were 85% male and had a mean age of 69, took 7,524 steps per day. Living in higher population density areas was associated with taking fewer steps and having more sedentary time and worse exercise capacity while living in areas with longer pedestrian street lengths was associated with taking more steps and spending less time in sedentary activities.
Greater exercise capacity was seen in those living in places with hilly streets, and living in areas with higher long-term NO2 exposure was linked to more sedentary time and greater difficulty in engaging in physical activity.
The study was published by Environmental Research. Read More
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