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- Diagnostic Implications of Soluble Triggering Receptor Expressed on Myeloid Cells-1 in BAL Fluid of Patients With Pulmonary Infiltrates in the ICU
ObjectivesProspective single center study to determine whether the presence of soluble triggering receptor expressed on myeloid cells (sTREM-1) has diagnostic utility in mechanically ventilated patients with pulmonary infiltrates undergoing BAL.
DesignProspective cohort study.
SettingBarnes-Jewish Hospital, a 1200-bed urban teaching hospital.
PatientsAdult patients with acute respiratory failure undergoing BAL for pulmonary infiltrates. Interventions: BAL fluid measurement of sTREM-1 using a Quantikine Human TREM-1 Immunoassay (R&D Systems, Minneapolis, MN, USA).
Measurements and Main Results.A total of 105 consecutive mechanically ventilated patients undergoing BAL were enrolled. Of those, 19 (18.1%) met definite microbiologic criteria for bacterial or fungal ventilator-associated pneumonia (VAP). Though the mean sTREM-1 concentration was greater in patients with definite VAP (n = 19, 171.9 ± 158.7 pg/mL) than in patients with definite absence of VAP (n = 21, 96.7 ± 76.2 pg/mL), this difference was not statistically significant (p = 0.06). A cutoff value for sTREM-1 > 200 pg/mL yielded a diagnostic sensitivity of 42.1% and a specificity of 75.6% for definite VAP. Patients with alveolar hemorrhage had the greatest values for sTREM-1 (n = 9, 555 ± 440 pg/mL). Receiver operating curve analysis and multivariate logistic regression analysis demonstrated that measurement of sTREM-1 was inferior to clinical parameters for the diagnosis of VAP.
ConclusionsMeasurement of sTREM-1 in BAL fluid appears to have minimal diagnostic value for VAP.
- Determinants of Right Ventricular Ejection Fraction in Pulmonary Arterial Hypertension
BackgroundRight ventricular function is a key determinant of exercise capacity and survival in pulmonary arterial hypertension. We aimed to study the predictors of right ventricular ejection fraction (RVEF) in newly-diagnosed patients with pulmonary arterial hypertension.
MethodsWe performed a cross-sectional analysis of a retrospective cohort of consecutive patients with idiopathic, familial, or anorexigen-associated pulmonary arterial hypertension who underwent equilibrium radionuclide angiography for measurement of RVEF at baseline.
ResultsOf the 84 patients in the cohort, 63 patients underwent equilibrium radionuclide angiography and right heart catheterization and were included. The mean age was 41 ± 13 years and 79% were female. The mean RVEF was 30 ± 8%. RVEF was directly associated with right ventricular stroke volume index and cardiac index and inversely associated with pulmonary vascular resistance index from right heart catheterization (all p ≤ 0.01). Older age and male sex were associated with lower RVEF (p < 0.05) after adjustment for pulmonary vascular resistance index and left ventricular ejection fraction. Higher plasma von Willebrand factor levels were also independently associated with lower RVEF (p < 0.01) (n = 55). Body size and type of pulmonary arterial hypertension were not associated with RVEF.
ConclusionsOlder patients and males with PAH had lower RVEF at baseline compared to younger patients and females even after controlling for left ventricular function and hemodynamics. Higher plasma von Willebrand factor levels, a marker of endothelial dysfunction, were also associated with lower RVEF.
- PHOX2B Mutation-Confirmed Congenital Central Hypoventilation Syndrome in a Chinese Family
BackgroundCongenital central hypoventilation syndrome (CCHS) is characterized by compromised chemo-reflexes resulting in sleep hypoventilation. We report a Chinese family with PHOX2B mutation-confirmed CCHS, with a clinical spectrum from newborn to adulthood, to increase awareness on its various manifestations.
MethodsAfter identifying central hypoventilation in an adult male (index case), clinical evaluation was performed on the complete family, which consisted of the parents, five siblings, and five offsprings. Pulmonary function tests, overnight polysomnography, arterial blood gases, hypercapnia ventilatory response, and PHOX2B gene mutation screening were performed on living family members. Brain MRI, 24-h Holter, and echocardiography were done on members with clinically diagnosed central hypoventilation.
ResultsThe index patient and four offsprings manifested with clinical features of central hypoventilation. The index patients had hypoxia and hypercapnia while awake, polycythemia, and hematocrit of 70%. The first and fourth children had frequent cyanotic spells and both died of respiratory failure. The second and third children remained asymptomatic until adulthood, when they experienced impaired hypercapnic ventilatory response. The third child had nocturnal hypoventilation with nadir SpO2 of 59%. Adult-onset CCHS with PHOX2B gene mutation of the + 5 alanine expansions were confirmed in the index patient and the second and third children. The index patient and the third child received BiPAP treatment, which improved the hypoxemia, hypercapnia, and polycythemia without altering their chemo-sensitivity.
ConclusionsTransmission of late-onset CCHS is autosomal-dominant. Genetic screening of family members of CCHS probands allows for early diagnosis and treatment.
- Children With Asthma Miss More School: Fact or Fiction?
RATIONALEIt is widely believed that children with asthma miss considerably more school than children without asthma. Previous surveys have indicated that 49% of children with asthma miss school (Asthma in America, 1998), but only a few studies have attempted to quantify the amount of school missed. Understanding the role of asthma in school attendance will help direct limited health care resources to the children who need them most.
MethodsFunded by the Dallas Asthma Consortium and the Summerfield Roberts Foundation, we investigated school absence rates in fourth-sixth grade students in 19 inner city schools. The sample consisted of 353 students who were identified as possibly asthmatic based on responses to a modified Brief Pediatric Screen instrument and who underwent spirometry and/or exercise testing to confirm the diagnosis of asthma: 25 were excluded for FEV1 \h 70% and without bronchodilator response, while 157 were exercise (+) (EC+), and 171 exercise (-)(EC-). We compared yearly absences for these students with each other, with all 4-sixth graders in the 19 study schools, and with all 4-sixth graders in the district, in addition to tabulating data for school RN identified asthmatics from a separate database. Absence data by school and by grade level was provided by the school district at the end of the from 2002 to 2003 school year.
ResultsAbsence rates were 2.54% (EC+), 2.12%(EC-), 2.59% (abnormal FEV1), 2.86% (RN identified), 2.85% (all 4-sixth graders in study schools), and 2.95% (all 4-sixth graders in DISD). Conclusion: asthmatic students in the DISD miss no more school than nonasthmatic classmates.
- Pulmonary Rehabilitation in Interstitial Lung Disease: Benefits and Predictors of Response
BackgroundData examining the role of pulmonary rehabilitation in interstitial lung disease are limited. We tested the hypothesis that pulmonary rehabilitation would improve functional status and dyspnea in a large group of patients with interstitial lung disease, and that certain baseline patient variables could predict this improvement.
MethodsData from patients referred to pulmonary rehabilitation with a diagnosis of interstitial lung disease were included. Baseline and post-pulmonary rehabilitation variables were recorded and changes in 6 min walk distance and dyspnea were evaluated. The impact of baseline variables on change in 6 min walk distance and dyspnea were analyzed.
ResultsA statistically significant difference was seen in both the change in Borg score and 6 min walk distance after pulmonary rehabilitation (p < 0.0001). These changes were consistent with previously established clinically significant differences. Baseline 6 min walk distance was a significant predictor of change in 6 min walk distance (p < 0.0001), with increasing baseline 6 min walk distance predicting a smaller improvement after pulmonary rehabilitation.
ConclusionsThese results suggest that pulmonary rehabilitation should be considered as standard of care for patients with interstitial lung disease.