Friday, October 24, 2014

Point-of-care ultrasonography in dyspnea


Is point-of-care (POC) lungultrasound (US) diagnostically useful in patients with suspected acute cardiogenic pulmonary edema (ACPE) ?


A systematic review was done. Studies of asymptomaticindividuals or in patients where there was no suspicion of ACPE wereexcluded. The outcome of interest was a diagnosis of ACPE using US
B-lines. A final diagnosis from clinical follow-up was accepted as the reference standard.


Seven articles (n = 1,075) were identified. The sensitivity of point-of-care US using B-lines to diagnosis ACPE is 94.1% (95% confidence interval [CI] = 81.3% to 98.3%) and the specificity is 92.4% (95% CI = 84.2% to 96.4%).


This study suggests that an US study showing B-lines can be used to strengthen an emergency physician's working diagnosis of ACPE.

Point-of-care ultrasonography for the diagnos... [Acad Emerg Med. 2014] - PubMed - NCBI

Saturday, October 18, 2014

Withdrawal of inhaled glucocorticoids and exacerbations of COPD.

Withdrawal of inhaled glucocorticoids and exacerbations of COPD.
BACKGROUND: Treatment with inhaled glucocorticoids in combination with long-acting bronchodilators is recommended in patients with frequent exacerbations of severe chronic obstructive pulmonary disease (COPD). However, the benefit of inhaled glucocorticoids in addition to two long-acting bronchodilators has not been fully explored.
METHODS: In this 12-month, double-blind, parallel-group study, 2485 patients with a history of exacerbation of COPD received triple therapy consisting of tiotropium (at a dose of 18 μg once daily), salmeterol (50 μg twice daily), and the inhaled glucocorticoid fluticasone propionate (500 μg twice daily) during a 6-week run-in period. Patients were then randomly assigned to continued triple therapy or withdrawal of fluticasone in three steps over a 12-week period. The primary end point was the time to the first moderate or severe COPD exacerbation. Spirometric findings, health status, and dyspnea were also monitored.
RESULTS: As compared with continued glucocorticoid use, glucocorticoid withdrawal met the prespecified noninferiority criterion of 1.20 for the upper limit of the 95% confidence interval (CI) with respect to the first moderate or severe COPD exacerbation (hazard ratio, 1.06; 95% CI, 0.94 to 1.19). At week 18, when glucocorticoid withdrawal was complete, the adjusted mean reduction from baseline in the trough forced expiratory volume in 1 second was 38 ml greater in the glucocorticoid-withdrawal group than in the glucocorticoid-continuation group (P<0.001); a similar between-group difference (43 ml) was seen at week 52 (P=0.001). No change in dyspnea and minor changes in health status occurred in the glucocorticoid-withdrawal group.

 CONCLUSIONS: In patients with severe COPD receiving tiotropium plus salmeterol, the risk of moderate or severe exacerbations was similar among those who discontinued inhaled glucocorticoids and those who continued glucocorticoid therapy. However, there was a greater decrease in lung function during the final step of glucocorticoid withdrawal.

N Engl J Med. 2014 Oct 2;371(14):1285-94