Prevention of Ventilator-Associated Pneumonia: The Multimodal Approach of the Spanish ICU “Pneumonia Zero” Program

Álvarez-Lerma F, Palomar-Martínez M, Sánchez-García M, et al. Crit Care Med 2018;46:181-8. [CrossRef] [PubMed]

The Spanish “Pneumonia Zero” project is a prospective, interventional, multimodal intervention to prevent ventilator-associated pneumonia (VAP). Ten VAP prevention measures were implemented in 181 ICUs throughout Spain. In a total of 171,237 ICU admissions a total of 3,474 VAP episodes were diagnosed in 3,186 patients. The adjusted VAP incidence density rate decreased from 9.83 (95% CI, 8.42–11.48) per 1,000 ventilator days in the baseline period to 4.34 (95% CI, 3.22–5.84) after 19–21 months of participation. Outcomes data (contained in the on-line supplement to table 3) reported that mortality did not change (38.5% baseline vs. 40.9% intervention, p=0.0320). The ICU length of stay increased with the intervention (27.9 + 20.7 vs. 32.5 + 24.5 days, p<0.001). The reduction in VAP was sustained 21 months after implementation. 

Prevention of Ventilator-Associated Pneumonia: The Multimodal Approach of the Spanish ICU “Pneumonia Zero” Program

Álvarez-Lerma F, Palomar-Martínez M, Sánchez-García M, et al. Crit Care Med 2018;46:181-8. [CrossRef] [PubMed]

The Spanish “Pneumonia Zero” project is a prospective, interventional, multimodal intervention to prevent ventilator-associated pneumonia (VAP). Ten VAP prevention measures were implemented in 181 ICUs throughout Spain. In a total of 171,237 ICU admissions a total of 3,474 VAP episodes were diagnosed in 3,186 patients. The adjusted VAP incidence density rate decreased from 9.83 (95% CI, 8.42–11.48) per 1,000 ventilator days in the baseline period to 4.34 (95% CI, 3.22–5.84) after 19–21 months of participation. Outcomes data (contained in the on-line supplement http://links.lww.com/CCM/C886ICU) reported that mortality did not change (38.5% baseline vs. 40.9% intervention, p=0.0320). The ICU length of stay increased after the intervention (27.9 + 20.7 vs. 32.5 + 24.5 days, p<0.001). The reduction in VAP was sustained 21 months after implementation. 

Progressive Massive Fibrosis in Coal Miners From 3 Clinics in Virginia

Blackley DJ, Reynolds LE, Short C, Carson R, Storey,E, Halldin,CN, Laney AS. JAMA 2018;319(5):50-1. doi and PubMed citations unavailable at the time of this writing.

The authors are reporting a clustering of 416 cases of progressive massive fibrosis (PMF) among 11,200 observed coal miners in Appalachia. PMF was rarely observed in the 1990’s but a 2014 report documented an apparent increase in PMF. A high proportion of these cases had r-type opacities, category B and C large opacities, and coal mining tenure of less than 20 years, which are indications of exceptionally severe and rapidly progressive disease. PMF has no treatment other than supportive care and lung transplantation. Smoking seems to hasten the disease. The reason for the sudden increase in reported cases is not clear but may be partly explained by workers seeking compensation after economic hardship brought on by a decline in the coal industry. A 2014 federal rule improved protection for miners, including decreased allowable dust concentrations, changes in dust monitoring, and expansion of the health surveillance. Whether these added protections will decrease the apparent increase in PMF requires continued observation.

Low cigarette consumption and risk of coronary heart disease and stroke: meta-analysis of 141 cohort studies in 55 study reports.

Hackshaw A,  Morris JK, Boniface S, Tang JL, Milenković D. BMJ. 2018;360:j5855. [CrossRef] [PubMed]

It is well known that the more cigarettes smoked per day, the greater the health risk. Based on this principle, many have assumed that smoking one or two cigarettes a day carried little risk, i.e., only about 5-10% of the risk of smoking 20 cigarettes (1 pack) per day. However, investigators from the UK challenged that assumption. The authors performed a meta-analysis and found that among men, the pooled relative risk for coronary heart disease was 1.48 for smoking one cigarette per day and 2.04 for 20 cigarettes per day. Among women, the pooled relative risks were 1.57 and 2.84 for one and 20 cigarettes per day. For stroke, the pooled relative risks were 1.25 and 1.64 for smoking one or 20 cigarettes for men per and 1.31 and 2.16 for women. The study is strongly suggestive that the only way to eliminate the risk from smoking is to quit.

Comparison of observed harms and expected mortality benefit for persons in the veterans health affairs lung cancer screening demonstration project

Caverly TJ, Fagerlin A, Wiener RS, Slatore CG, Tanner NT, Yun S, Hayward R. JAMA Intern Med. 2018 Jan 22. [Epub ahead of print] [CrossRef] [PubMed]

In a follow-up research letter to a study published last March, VA researchers are reporting a very high false-positive screening rate with low-dose computed tomographic screening compared to the National Lung Screening Trial (58.2% vs 26.3%) (1-2). In the present study 2084 patients agreed to screening. The subjects were divided into quintiles of about 400 subjects using the Bach risk assessment tool (age, gender, pack-years, smoking status, asbestos exposure) for assessing lung cancer risk (3). Patients in the highest quintiles of lung cancer risk had significantly more lung cancers diagnosed (29.7 lung cancers per 1000 screened in quintile 5 vs. 4.8 in quintile 1) supporting the model's risk stratification. The initial screen was least efficient for patients in quintile 1 (2749 false-positive results and 68 nonbeneficial diagnostic procedures per lung cancer death prevented) and most efficient for those in quintile 5 (363 false-positive results and 22 nonbeneficial diagnostic procedures per death prevented). Quintiles 2-4 had intermediate results between the lowest and highest risk quintiles. The authors state, “These real-world findings reinforce the need to risk stratify patients for lung cancer screening and provide support for personalized, risk-based harm-benefit estimates for all eligible persons during lung cancer screening decision-making”.

References

1. Kinsinger LS, Anderson C, Kim J, et al. Implementation of lung cancer screening in the Veterans Health Administration. JAMA Intern Med. 2017;177(3):399-406. [CrossRef] [PubMed]
2. Aberle DR, Adams AM, Berg CD, et al; National Lung Screening Trial Research Team. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med. 2011;365(5):395-409. [CrossRef] [PubMed]
3. Memorial Sloan Kettering Cancer Center. Lung cancer screening decision tool. Available at: https://www.mskcc.org/cancer-care/types/lung/screening/lung-screening-decision-tool (accessed 1/23/18).

Risk of thromboembolism in cisplatin versus carboplatin-treated patients with lung cancer

Kim ES, Baran AM, Mondo EL, et al. PLoS One. 2017 Dec 11;12(12):e0189410. [CrossRef] [PubMed]

Several studies have demonstrated that cisplatin-based regimen is associated with a high frequency of thromboembolic complications. All lung cancer patients treated with cisplatin or carboplatin at Wilmot Cancer Center, University of Rochester between 2011 and 2014 were included. Among 415 subjects, 317 patients (76.4%) received carboplatin and 98 (23.6%) patients received cisplatin. In the carboplatin group, 10.9% (33/302) of evaluable patients developed treatment-related TEEs vs. 14.7% (14/95) in the cisplatin group. There was no significant difference in the risk of developing TEEs between the two groups (P = 0.32). However, 15.2% of carboplatin-related TEEs were arterial thromboses compared to none in the cisplatin group. The incidence of carboplatin-related TEEs was high in lung cancer patients without significant difference in the risk of developing TEEs between cisplatin and carboplatin groups. The authors suggest that the potential use of prophylactic anticoagulation in all platinum-treated patients should be further investigated.

Association of cardiovascular risk with inhaled long-acting bronchodilators in patients with chronic obstructive pulmonary disease: A nested case-control study.

Wang MT, Liou JT, Lin CW, Tsai CL, Wang YH, Hsu YJ, Lai JH. JAMA Intern Med. 2018 Jan 2. [Epub ahead of print] [CrossRef] [PubMed] 

An article from Taiwan reports that new use of long-acting bronchodilators is associated with an early increase in the risk for cardiovascular disease (CVD). Cases with inpatient or emergency care visits for coronary artery disease, heart failure, ischemic stroke, or arrhythmia were identified and individually matched to 4 randomly selected controls. New long-acting beta agonist (LABA) and long-acting muscarinic antagonist (LAMA) use in COPD was associated with a 1.50-fold (95% CI, 1.35-1.67; P < .001) increased cardiovascular risk within 30 days of initiation. The risk was absent, or even reduced with prevalent use. Individual LABA agents, LAMA dosage forms, and concomitant COPD regimens did not differ in the CVD risks. The findings suggest that clinicians should "be very vigilant with regard to any cardiovascular symptoms within 30 days of initiating LABA or LAMA treatment for COPD”. After those initial 30 days, however, the risk for CVD associated with the use of long-acting bronchodilators appears to wane.