Free and paid medical assistance in the United States News : Part 6

Pulmonary Abnormalities on High-Resolution CT Demonstrate More Rapid Decline Than FEV1 in Adults With Cystic Fibrosis: Patient Population

The CF radiology database was retrospectively searched from January 1997 to January 2005 by a single investigator (E.J.) for 39 consecutive patients with two HRCT scans (HRCT-1 and HRCT-2) > 18 months apart (19 males and 20 females; mean age, 22 years; range, 16 to 48 years). All patients had documented clinical, radiologic, or genotypic features of CF as well as abnormal sweat test results (sweat sodium and chloride > 60 mmol/L).
Clinical charts were reviewed and age, body mass index (BMI), spirometry, and sputum cultures were recorded at the time of the two HRCT scans. Only clinically stable patients at the time of a HRCT scan were included. Patients were excluded if they had the following: (1) only one HRCT (or two HRCTs < 18 months apart); (2) symptoms or signs of acute respiratory exacerbation at the time of HRCT or spirometry; (3) unstable spirometry results at the time of either HRCT (> 10% decrease in FEV1 compared with baseline values in the preceding 2 months); (4) required hospitalization for IV antibiotics in the 2 weeks prior to either HRCT for a respiratory tract infection; and (5) died before undergoing sequential HRCT. This resulted in approximately 210 patients being excluded from the study, leaving 39 in the final study group. The hospital ethics committee of out institution approved the study.
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Pulmonary Abnormalities on High-Resolution CT Demonstrate More Rapid Decline Than FEV1 in Adults With Cystic Fibrosis

Pulmonary Abnormalities on High-Resolution CT Demonstrate More Rapid Decline Than FEV1 in Adults With Cystic FibrosisCystic fibrosis (CF) is the most common autosomal recessive inherited disorder in whites, with a prevalence of 1 in 1,461 births in the Irish population. By the later teenage years, significant irreversible lung damage has occurred in many patients. The majority die of recurrent respiratory sepsis and respiratory failure in adulthood.
Spirometry, particularly FEV1, is used as a marker of lung disease because of its reproducibility and accuracy as an outcome surrogate. It is well known that spirometry results decline as lung disease progresses. In a thought-provoking article, de Jong et al showed that the rate of decline in high-resolution CT (HRCT) appearances was more significant than the rate of decline in spirometry results in children, and this has been confirmed by others. More recently, further novel work has shown that several HRCT abnormalities decline at a faster rate than FEV1 in adults. As a result, proposals for the use of HRCT as an outcome surrogate have been suggested.” In this regard, a combined HRCT/ spirometric score has been shown to be a sensitive marker in detecting treatment effects. More recently, HRCT has been shown to correlate with the number of respiratory exacerbations in children over time.
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Inhaled Corticosteroids and Mortality in COPD: Recommendation

The reduction in all-cause mortality that we found was of similar magnitude to that observed in other cohort studies and was present in time-dependent analyses that were comparable to those that produced negative results. Randomized trials of ICSs in COPD patients have not shown significant mortality effects, but pooled data from these trials have shown a mortality benefit of similar magnitude to ours. We believe that it is likely that ICSs do indeed reduce mortality in COPD patients, but further evidence from randomized trials would be helpful in resolving the controversy.
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Inhaled Corticosteroids and Mortality in COPD: Conclusion

Inhaled Corticosteroids and Mortality in COPD: ConclusionOur study has a number of strengths. It examined a large unselected population of patients, including those < 65 years of age, using a comprehensive database. We attempted to assess and adjust for comorbidities and disease severity by examining the use of other respiratory drugs and physician exposure. Excluding patients with a previous diagnosis of asthma, or those who had previously used ICSs did not affect our results. We avoided immortal time bias” by excluding deaths within the first 90 days of hospital discharge. We were further able to examine mortality in relation to the timing of the receipt of ICSs. starlix 60 mg
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Inhaled Corticosteroids and Mortality in COPD: Discussion

To ascertain the relationship between the length of time ICSs were used and mortality, we carried out nested case-control analyses examining a series of time frames. Subjects (n = 503) > 65 years of age who died within 90 to 365 days of hospital discharge were compared to age-matched and gender-matched control subjects who survived to the index date with respect to the timing of exposure to ICSs before the death of the case patient. Those who died (data not shown) had more comorbidities and physician visits, and received more prescriptions for respiratory medications other than ICSs than did control subjects.
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Inhaled Corticosteroids and Mortality in COPD: Research

Inhaled Corticosteroids and Mortality in COPD: ResearchIn the cohort analysis, subjects were classified into ICS users and nonusers on the basis of drug dispensation in the 90 days following discharge from the hospital. Subsequently, the two groups differed substantially in terms of the receipt of ICSs; 79.5% of those classified as users at 90 days had filled a prescription for ICSs between 90 and 365 days after hospital discharge compared with 12.0% of nonusers. Each month, between 90 days and the 12th month, approximately 40 to 45% of ICS users received additional ICSs compared to 5 to 10% of initial nonusers.
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Inhaled Corticosteroids and Mortality in COPD: Results

Among 1,007 subjects between 35 and 64 years of age, 42 (4.1%) died within the first 90 days and were excluded from the analysis. The remaining 965 subjects were divided into the following two groups: 369 subjects (38.2%) who received ICSs within 90 days of discharge from the hospital; and 596 subjects (61.8%) who did not (Table 1).
The characteristics of subjects who were treated and not treated with ICSs are compared in Table 1, In both age groups, those subjects who received ICSs were more likely to receive other medications within 90 days following hospital discharge. During the year prior to the hospitalization, they visited physicians more frequently for COPD and asthma, and were more likely to be treated with respiratory drugs. Among subjects in the older group, treatment with ICSs was significantly associated with less comorbidity. natural breast enhancement
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Inhaled Corticosteroids and Mortality in COPD: Statistical Analysis

Inhaled Corticosteroids and Mortality in COPD: Statistical AnalysisIn a nested case-control analysis, subjects who died within 90 to 365 days of hospital discharge were compared with respect to ICS exposure before death (ie, the index date) to age-matched and gender-matched control subjects who had survived to the same point in time. It was thus possible for the same individual to be both a case patient and a control subject. We compared case patients and control subjects regarding the most recent receipt of ICS between hospital discharge and the index date. Exposure to ICSs was divided into the following five mutually exclusive groups: ICSs within 30 days; ICSs in 30 to 60 days; ICSs in 60 to 90 days; and ICSs in > 90 days prior to death or not at all. We repeated this analysis for deaths ascribed to COPD and to cardiovascular causes.
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Inhaled Corticosteroids and Mortality in COPD: Subjects

We identified all people who had been admitted to the hospital between April 1, 1996, and March 31, 2000, and had been discharged from the hospital with a primary diagnosis of COPD (ie, International Classification of Diseases, ninth revision [ICD-9], codes 490 [not otherwise specified bronchitis], 491 [chronic bronchitis], 492 [emphysema], and 496 [chronic airflow obstruction]). Subjects had to be > 35 years of age on hospital admission as well as permanent residents of the province for at least 1 year prior to hospital admission and 1 year after discharge from the hospital or until death. eye drops for red eye
The outcome variable was death from any cause in the 365 days following discharge from the hospital. We extracted the date and cause of death. The causes of death were derived from death certificates and were divided into the following three groups: COPD and asthma (ICD-9 code 493); cardiovascular (ICD-9 codes 390-459 and 798); and all other causes.
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Inhaled Corticosteroids and Mortality in COPD

Inhaled Corticosteroids and Mortality in COPDSeveral studies have examined the course of COPD patients to whom inhaled corticosteroids (ICSs) were prescribed. In four studies, ICSs were prescribed within 90 days after discharge from the hospital for a COPD exacerbation, which is a time of relative instability when the risk for hospital readmission or death is high and therapy with ICSs might be expected to be administered to high-risk patients. In such patients > 65 years of age who are treated with ICSs, the risk of death was reduced by 21% over 1 year of follow-up in Ontario’ and 25% over 3 years of follow-up in Alberta. In the United Kingdom, the unadjusted risk of death was reduced by 30% in COPD patients > 50 years of age. On the other hand, there was no reduction in the 1-year mortality rate observed in patients > 55 years of age in Saskatchewan. All-cause mortality over 3 years was also reduced in patients > 50 years of age in the United Kingdom who had received at least three prescriptions of fluticasone over the initial 6-month period. Such a benefit was not found in the US study and the Saskatchewan study using either intent-to-treat or time-dependent analysis. Our objective was to determine the effect of ICSs on total and cause-specific mortality in a cohort of COPD patients using the Province of Manitoba health research database. buy glucophage
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