Unintended Consequences of Code Status in the Intensive Care Unit: What Happens After a Do-Not-Resuscitate Order Is Placed? A Retrospective Cohort Study.

Background: Some clinicians suspect that patients with do-not-resuscitate (DNR) orders receive less aggressive care. Extrapolation from code status to goals of care could cause significant harm. This study asked the question: Do DNR orders in the intensive care unit (ICU) lead to a decrease in invasive interventions? Methods: This was a retrospective cohort study of ICU patients from three teaching hospitals. All ICU patients were assessed for inclusion. Exclusion criteria were medical futility and death, comfort care, or ICU discharge <48 hours after DNR initiation. Five hundred thirty-six patients met inclusion criteria. One hundred forty-five were included in the final analysis. Primary outcomes were occurrence of invasive interventions after DNR initiation-surgical operation, central line, ventilation, dialysis, or other procedure. Secondary outcomes were antibiotic administration, blood transfusion, mortality, and discharge location. Results: Patients with DNR orders underwent fewer surgical operations (14.5% vs. 31.1%, p = 0.002), but more central lines (42.1% vs. 23.0%, p = 0.009), ventilator use (49.0% vs. 18.9%, p < 0.001), and dialysis (20.0% vs. 4.1%, p = 0.002), compared with patients without DNR orders. Transfusions and antibiotic use decreased similarly over admission for both groups (transfusions: ß = 1.25; p = 0.59; and antibiotics: ß = 1.44; p = 0.27). Mortality and hospice discharges were higher for DNR patients (p < 0.001.). Conclusions: DNR status did not decrease the number of nonoperative interventions patients received as compared with full code counterparts. Although differences in populations existed, patients with DNR orders were likely to receive a similar number of invasive interventions. This finding suggests that providers do not wholesale limit these options for patients with code status limitations.

Age matters: association between age and depression severity at the time of OSA diagnosis and PAP adherence in adult patients.

STUDY OBJECTIVES: Numerous studies have shown an association and symptom overlaps between obstructive sleep apnea (OSA) and depression. However, data are limited on the association between age, sex, the severity of depression at the time of OSA diagnosis, and its impact on positive airway pressure (PAP) adherence. The Patient Health Questionnaire (PHQ-9) is a validated depression screening and severity scoring tool recommended by the Diagnostic and Statistical Manual of Mental Disorders (fifth edition). In this retrospective observational study, we evaluate the interrelationship between age at OSA diagnosis, depression severity, and PAP adherence. METHODS: Patients with new OSA diagnosis, seen at the University of California San Francisco-Fresno Sleep Center between February and October of 2022, were evaluated. PHQ-9 scores for depression severity uses a 1 to 5 scale (1 = none, 2 = mild, 3 = moderate, 4 moderately severe, 5 = severe). The PHQ-9 was administered at the time of OSA diagnosis and follow-up. Average daily PAP usage hours were obtained from PAP devices between 1 to 3 months after therapy initiation. IBM SPSS version 29.0.0 was used to calculate descriptive statistics, Pearson correlation, and Mann-Whitney test. RESULTS: Seventy-seven patients fit the inclusion criteria, of which 28 were women (36.4%). The average baseline apnea-hypopnea index was 34.5 (standard deviation 31.8), with a PHQ-9 mean of 8.3 with standard deviation ± 5.9. A Mann-Whitney comparison between the group with normal PHQ-9 scores and the group with PHQ-9 scores consistent with depression (score of 5 or greater) showed no statistically significant differences in apnea-hypopnea index (P = .470) or average night hour use (P = .195). There was a statistically significant difference in age between both groups (P = .031). Spearman correlation confirmed a negative, statistically significant correlation between PHQ-9 scores and age in patients with OSA. CONCLUSIONS: This study showed that PHQ-9 scores at the time of OSA diagnosis are moderately correlated with younger age, with those patients younger than 50 years old having more moderate to severe depression scores than older patients. We did not find a correlation between age and PAP adherence or between PHQ-9 scores and PAP adherence. Our findings can help identify high-risk depression patients early in the diagnosis of OSA and bring awareness that the young adult population can be particularly vulnerable. CITATION: Niraula R, Singh A, DelRosso LM, Meghpara S, Keenan L. Age matters: association between age and depression severity at the time of OSA diagnosis and PAP adherence in adult patients. J Clin Sleep Med. 2024;20(6):859-862.

The Shunt of It.

Pulmonary arteriovenous malformations (PAVMs) are rare and most often identified in patients with hereditary hemorrhagic telangiectasia (HHT). We describe a patient with severe hypoxemia and orthodeoxia with imaging findings consistent with PAVMs. Resected lung pathologic findings confirmed the presence of numerous microscopic vascular abnormalities within the right lower lobe that was consistent with diffuse pulmonary arteriovenous shunts. Family history was negative for HHT but was positive for pulmonary arterial hypertension (PAH) in two second-degree relatives. A vascular malformation gene panel was negative for genes that commonly are associated with HHT but identified a pathogenic variant in the gene encoding bone morphogenetic protein receptor-2 (BMPR2 p.Cys123∗). Pathogenic variants in BMPR2 are a well-known cause of hereditary PAH; there have been several reports to date of patients with PAVMs and PAH. However, this is the first patient to be reported with a pathogenic variant in BMPR2 to have PAVMs in isolation.

Clinical, Bronchoscopic, and Imaging Findings of e-Cigarette, or Vaping, Product Use-Associated Lung Injury Among Patients Treated at an Academic Medical Center.

Importance: e-Cigarette, or vaping, product use-associated lung injury (EVALI) has caused more than 2800 illnesses and 68 deaths in the United States. Better characterization of this novel illness is needed to inform diagnosis and management. Objective: To describe the clinical features, bronchoscopic findings, imaging patterns, and outcomes of EVALI. Design, Setting, and Participants: This case series of 31 adult patients diagnosed with EVALI between June 24 and December 10, 2019, took place at an academic medical center in Salt Lake City, Utah. Exposures: e-Cigarette use, also known as vaping. Main Outcomes and Measures: Symptoms, laboratory findings, bronchoscopic results, imaging patterns, and clinical outcomes. Results: Data from 31 patients (median [interquartile range] age, 24 [21-31] years) were included in the study. Patients were primarily men (24 [77%]) and White individuals (27 [87%]) who used e-cigarette products containing tetrahydrocannabinol (THC) (29 [94%]). Patients presented with respiratory (30 [97%]), constitutional (28 [90%]), and gastrointestinal (28 [90%]) symptoms. Serum inflammatory markers were elevated in all patients. Bronchoscopy was performed in 23 of 28 inpatients (82%) and bronchoalveolar lavage (BAL) revealed the presence of lipid-laden macrophages (LLMs) in 22 of 24 cases (91%). BAL samples tested positive for Pneumocystis jirovecii (3 patients [13%]), rhinovirus (2 patients [8%]), human metapneumovirus and Aspergillus (1 patient each [4%]); all except human metapneumovirus were determined to be false-positives or clinically inconsequential. The exclusive or dominant computed tomography (CT) pattern was organizing pneumonia in 23 of 26 cases (89%). Patients received antibiotics (26 [84%]) and corticosteroids (24 [77%]), and all survived; 20 patients (65%) seen in follow-up showed marked improvement, but residual symptoms (13 [65%]), radiographic opacities (8 [40%]), and abnormal pulmonary function tests (8 of 18 [44%]) were common. Conclusions and Relevance: In this case series, patients with EVALI characteristically presented with a flu-like illness with elevated inflammatory markers, LLMs on BAL samples, and an organizing pneumonia pattern on CT imaging. Bronchoscopic testing for infection had a high incidence of false-positive results. Patients had substantial residual abnormal results at early follow-up. These data suggest a limited role for bronchoscopy in typical presentations of EVALI without risk factors for alternative diagnoses and the need for careful longitudinal follow-up.

Refractory Status Asthmaticus: Treatment With Sevoflurane.

A patient with life-threatening asthma and status asthmaticus was treated with sevoflurane general anesthesia.

Systematic Review of Hormonal Contraception and Risk of Venous Thrombosis.

BACKGROUND: Hormonal contraception (HC) is widely used throughout the world and has been associated with venous thrombosis (VT) such as deep vein thrombosis, pulmonary emboli, and cerebral VT. OBJECTIVES: To provide a current comprehensive overview of the risk of objectively confirmed VT with HC in healthy women compared to nonusers. SEARCH METHODS: PubMed was searched from inception to April 2018 for eligible studies in the English language, with hand searching from past systematic reviews. SELECTION CRITERIA: We selected original research evaluating risk of objectively confirmed VT in healthy women taking oral or nonoral HC compared with nonusers. DATA COLLECTION: The primary outcome of interest was a fatal or nonfatal VT in users of HC compared to nonusers or past users. Studies with at least twenty events were eligible. Adjusted relative risks with 95 percent confidence intervals were reported. Three independent reviewers extracted data from selected studies. RESULTS: 1,962 publications were retrieved through the search strategy, with 15 publications included. Users of oral contraception with levonorgesterol had increased risk of VT by a range of 2.79-4.07, while other oral hormonal preparations increased risk by 4.0-48.6. Levonorgestrel intrauterine devices did not increase risk. Etonogestrel/ethinyl estradiol vaginal rings increased the risk of VT by 6.5. Norelgestromin/ethinyl estradiol patches increased risk of VT by 7.9. Etonogestrel subcutaneous implants by 1.4 and depot-medroxyprogesterone by 3.6. The risk of fatal VT was increased in women aged fifteen to twenty-four by 18.8-fold. CONCLUSION: Users of HC have a significant increased risk of VT compared to nonusers. Current risks would project at least 300-400 healthy young women dying yearly in the United States due to HC. Women should be informed of these risks and offered education in fertility-awareness-based methods with comparable efficacy for family planning. SUMMARY: HC is widely used throughout the world and has been associated with blood clots in the legs and lungs. We searched the literature and found the risks of currently used forms of birth control increased between three- and ninefold for blood clots for healthy women. The risks found would project 300-400 women dying from using HC each year in the United States.

Statin prescribing in Northern Ireland and England pre and post introduction of the quality and outcomes framework.

OBJECTIVE: The objective of this research was to examine differences in patterns of statin prescribing between Northern Ireland and England both before and after the introduction of the Quality and Outcomes Framework (QOF). SETTING: Primary care practices in Northern Ireland and England. Method Northern Ireland practices were matched with practices in England, statin prescribing data and QOF achievement scores (for the first year post-QOF) were obtained. Crude prescribing data from matched practices were manipulated to provide a data set of Defined Daily Doses (DDDs)/1,000 patients and cost/DDD/1,000 patients for each statin drug entity covering 1 year before and after the introduction of QOF. QOF achievements were converted into percentage scores for matched practices. MAIN OUTCOME MEASURE: Cost per defined daily dose (DDD) per 1,000 patients. RESULTS: Significantly less statins (DDD/1,000 patients) were dispensed in Northern Ireland compared with the matched region in England both before and after the introduction of QOF (P < 0.001). However, significantly more statins were dispensed in both regions after the introduction of QOF. As a result of the introduction of QOF, the cost/DDD/1,000 patients rose by pound13.17 in NI, but fell by pound3.76 in the matched region in England. CONCLUSION: Strategies should be considered to educate prescribers on cost-effectiveness by increasing their awareness of the negative budgetary impact resulting from early adoption of new and expensive statins and by encouraging generic prescribing.