The pandemic is not the great equalizer: front-line labor and rationing in COVID-19 critical care.

BACKGROUND: Framed as "the great-equalizer," the COVID-19 pandemic has intensified pressure to adapt critical care labor and resulted in rationing by healthcare workers across the world. OBJECTIVE: To critically investigate how hospital intensive care units are critical sites of care labor and examine how rationing highlights key features of healthcare labor and its inequalities. METHODS: A practice-oriented ethnographic study was conducted in a United States academic ICU by a medical anthropologist and medical intensivists with global health expertise. The analysis drew on 57 in-depth interviews and 25 months of participant observation between 2020 and 2021. RESULTS: Embodied labor constitutes sites and practices of shortage or rationing along three domains: equipment and technology, labor, and emotions and energy. The resulting workers' practices of adaptation and resilience point to a potentially more robust global health labor politics based on seeing rationing as work. CONCLUSION: Studies of pandemic rationing practices and critical care labor can disrupt too-simple comparative narratives of Global North/South divides. Further studies and efforts must address the toll of healthcare labor.

CONTEXTE: Présentée comme « le grand égalisateur ¼, la pandémie de COVID-19 a accentué la pression pour adapter le travail des soins intensifs et a entraîné le rationnement des travailleurs de la santé dans le monde entier. OBJECTIF: Étudier de manière critique comment les unités de soins intensifs des hôpitaux sont des sites critiques dans le système de santé et examiner comment le rationnement met en évidence les caractéristiques clés du travail de la santé et ses inégalités. MÉTHODES: Une étude ethnographique axée sur la pratique a été menée dans une unité de soins intensifs universitaire des États-Unis par un anthropologue médical et des médecins intensivistes spécialisés dans la santé mondiale. L'analyse s'est appuyée sur 57 entretiens approfondis et 25 mois d'observation participante entre 2020 et 2021. RÉSULTATS: Le travail incarné constitue des sites et des pratiques de pénurie ou de rationnement le long de trois domaines : équipement et technologie, travail, émotions et énergie. Les pratiques d'adaptation et de résilience des travailleurs qui en résultent indiquent une politique du travail potentiellement plus robuste dans le domaine de la santé mondiale, fondée sur une vision du rationnement en tant que travail. CONCLUSION: Les études sur les pratiques de rationnement en cas de pandémie et sur le travail dans le domaine des soins intensifs peuvent perturber les récits comparatifs trop simples des divisions Nord/Sud. D'autres études et efforts doivent porter sur le coût du travail dans le secteur des soins de santé.

Validation of spirometry prediction equations in western Kenya.

SETTING: Community of Eldoret, Kenya. OBJECTIVE: To test the performance of three commonly used spirometry prediction equations in a healthy Kenyan population. DESIGN: Cross-sectional assessment of healthy adults in Eldoret. RESULTS: Of the 331 subjects enrolled in the study, 282 subjects aged 18-85 years (45% males, 55% females) produced high-quality spirograms. Lung function predictions were made using the Global Lung Initiative 2012 (GLI 2012) prediction equations for African Americans, the National Health and Nutrition Examination Survey III (NHANES III) prediction equations for African Americans, and the Crapo prediction equation. Bland-Altman analyses were performed to measure the agreement between observed and predicted spirometry parameters. Overall, the GLI 2012 and NHANES equations for African Americans performed similarly for forced vital capacity (FVC) and forced expiratory volume in 1 s (FEV1), significantly overestimating FVC while accurately predicting observed FEV1 values. CONCLUSION: The study brings into question the utility of three major spirometry prediction equations in a Kenyan population. The significant overestimation of FVC by the best-performing equations despite accurate prediction of FEV1 suggests poor performance of these equations in our population.

Withholding versus withdrawing life-sustaining treatment: patient factors and documentation associated with dialysis decisions.

OBJECTIVE: We evaluated prospectively the use of acute hemodialysis among hospitalized patients to identify demographic and clinical predictors of and chart documentation concerning dialysis withheld and withdrawn. DESIGN: Prospective cohort study. SETTING: Five teaching hospitals. PATIENTS: Five hundred sixty-five seriously ill hospitalized patients who had not previously undergone dialysis who developed renal failure. MAIN OUTCOME MEASURES: Patient demographics, clinical characteristics, preferences, and prognostic estimates associated with having dialysis withheld rather than initiated and withdrawn rather than continued. Differences in chart documentation concerning decision-making for dialysis withheld, withdrawn, and continued. RESULTS: Older patient age, cancer diagnosis, and male gender were associated with dialysis withheld rather than withdrawn. Age and gender differences persisted after adjustment for patients' aggressiveness of care preference. Worse 2-month prognosis was associated with both withholding and withdrawing dialysis. Chart documentation of decision-making was lacking more often for patients with dialysis withheld than for dialysis withdrawn. CONCLUSIONS: Measuring the equity of life-sustaining treatment use will require evaluation of care withheld, not just care withdrawn. Older patients and men, after accounting for prognosis and function, are more likely to have dialysis withheld than withdrawn after a trial. Further exploration is needed into this disparity and the inadequate chart documentation for patients with dialysis withheld.

A prospective comparison of fiberoptic transbronchial needle aspiration and bronchial biopsy for bronchoscopically visible lung carcinoma.

BACKGROUND: Fiberoptic bronchoscopy is the most common modality used to diagnose endobronchial carcinoma. The authors prospectively compared the sensitivity of endobronchial needle aspiration (EBNA) and immediate cytologic assessment with bronchial biopsy and bronchial washing in the diagnosis of endobronchial malignancy. METHODS: A prospective trial comparing the sensitivity of EBNA, bronchial biopsy, and bronchial washings during fiberoptic bronchoscopy for endobronchially visible lung tumor was conducted. The authors enrolled 65 consecutive patients with endobronchial abnormalities identified during bronchoscopy. All patients in the study underwent fiberoptic bronchoscopy that included EBNA, bronchial biopsy, and bronchial wash. The sensitivities of the individual techniques were compared. The sensitivities of bronchoscopy were also prospectively compared when multiple sampling techniques were employed. RESULTS: Malignancy was present in 57 of 65 study patients. Cancer was diagnosed in 47 patients by EBNA, 42 patients by bronchial biopsy, and 36 patients by bronchial washing. The sensitivity of a strategy employing bronchial biopsy and bronchial washings was 0.82 (95% CI, 0.70-0.90). The addition of EBNA to bronchial biopsy and bronchial washings significantly increased the sensitivity to 0.95 (95% CI, 0.85-0.98; McNemar P = 0.02). Subset analysis revealed that this strategy was especially useful in cases in which lesions were submucosal or causing extrinsic compression. CONCLUSIONS: There is a modest increase in the sensitivity of fiberoptic bronchoscopy in diagnosing endobronchial cancer with the addition of EBNA to bronchial biopsy and bronchial washings, especially for patients with submucosal abnormalities. Collection of EBNA, followed by biopsy and washings only if immediate interpretation of EBNA is negative or inadequate, may be the most effective bronchoscopy strategy for evaluating visible endobronchial abnormalities.

Outcomes, preferences for resuscitation, and physician-patient communication among patients with metastatic colorectal cancer. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments.

PURPOSE: To describe characteristics, outcomes, and decision making in patients with colorectal cancer metastatic to the liver, and to examine the relationship of doctor-patient communication with patient understanding of prognosis and physician understanding of patients' treatment preferences. PATIENTS AND METHODS: The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT) was a prospective cohort study conducted at five teaching hospitals in the United States between 1989 and 1994. Participants in this study were hospitalized patients 18 years of age or older with known liver metastases who had been diagnosed with colorectal cancer at least 1 month earlier. Data were collected by patient interview and chart review at study entry; patients were interviewed again at 2 and 6 months. Data collected by physician interview included estimates of survival and impressions of patients' preferences for cardiopulmonary resuscitation (CPR). Patients and physicians were also asked about discussions about prognosis and resuscitation preferences. RESULTS: We studied 520 patients with metastatic colorectal cancer (median age 64, 56% male, 80% white, 2-month survival 78%, 6-month survival 56%). Quality of life (62% "good" to "excellent") and functional status (median number of disabilities = 0) were high at study entry and remained so among interviewed survivors at 2 and 6 months. Of 339 patients with available information, 212 (63%) of 339 wanted CPR in the event of a cardiopulmonary arrest. Factors independently associated with preference for resuscitation included younger age, better quality of life, absence of lung metastases, and greater patient estimate of 2-month prognosis. Of the patients who preferred not to receive CPR, less than half had a do-not-resuscitate note or order written. Patients' self-assessed prognoses were less accurate than those of their physicians. Physicians incorrectly identified patient CPR preferences in 30% of cases. Neither patient prognostication nor physician understanding of preferences were significantly better when discussions were reported between doctors and patients. CONCLUSIONS: A majority of patients with colorectal cancer have preferences regarding end of life care. The substantial misunderstanding between patients and their physicians about prognosis and treatment preferences appears not to be improved by direct communication. Future research focused on enhancing the effectiveness of communication between patients and physicians about end of life issues is needed.

Relationship between cancer patients' predictions of prognosis and their treatment preferences.

CONTEXT: Previous studies have documented that cancer patients tend to overestimate the probability of long-term survival. If patient preferences about the trade-offs between the risks and benefits associated with alternative treatment strategies are based on inaccurate perceptions of prognosis, then treatment choices may not reflect each patient's true values. OBJECTIVE: To test the hypothesis that among terminally ill cancer patients an accurate understanding of prognosis is associated with a preference for therapy that focuses on comfort over attempts at life extension. DESIGN: Prospective cohort study. SETTING: Five teaching hospitals in the United States. PATIENTS: A total of 917 adults hospitalized with stage III or IV non-small cell lung cancer or colon cancer metastatic to liver in phases 1 and 2 of the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT). MAIN OUTCOME MEASURES: Proportion of patients favoring life-extending therapy over therapy focusing on relief of pain and discomfort, patient and physician estimates of the probability of 6-month survival, and actual 6-month survival. RESULTS: Patients who thought they were going to live for at least 6 months were more likely (odds ratio [OR], 2.6; 95% confidence interval [CI], 1.8-3.7) to favor life-extending therapy over comfort care compared with patients who thought there was at least a 10% chance that they would not live 6 months. This OR was highest (8.5; 95% CI, 3.0-24.0) among patients who estimated their 6-month survival probability at greater than 90% but whose physicians estimated it at 10% or less. Patients overestimated their chances of surviving 6 months, while physicians estimated prognosis quite accurately. Patients who preferred life-extending therapy were more likely to undergo aggressive treatment, but controlling for known prognostic factors, their 6-month survival was no better. CONCLUSIONS: Patients with metastatic colon and lung cancer overestimate their survival probabilities and these estimates may influence their preferences about medical therapies.

Virtual bronchoscopy for directing transbronchial needle aspiration of hilar and mediastinal lymph nodes: a pilot study.

OBJECTIVE: We conducted a preliminary investigation of virtual bronchoscopy as a guide for transbronchial needle aspiration of hilar or mediastinal lymph nodes to assess the usefulness of this technique. CONCLUSION: Virtual bronchoscopic images derived from routine helical CT scans were useful for directing transbronchial needle aspiration in a clinical setting. In addition, virtual bronchoscopy may have been responsible for improving the yield of transbronchial needle aspirations done by our bronchoscopists when 22-gauge needles were used.

Lung transplantation for Williams-Campbell syndrome.

Williams-Campbell syndrome is a rare disorder characterized by a deficiency of cartilage in subsegmental bronchi leading to distal airway collapse and bronchiectasis. We report the first case of lung transplantation in a patient with end-stage lung disease secondary to Williams-Campbell syndrome. Although the patient did not have proximal airway collapse prior to transplantation, his posttransplant course was complicated by the development of bronchomalacia of the right and left mainstem bronchi. The patient experienced recurrent pulmonary infections and died of bacterial pneumonia 1 year after transplantation. Autopsy revealed cartilage deficiency in both right and left mainstem bronchi. A hypothesis may be made that a combination of proximal cartilage deficiency and posttransplant airway ischemia led to the development of bronchomalacia after lung transplantation. Thus, in contrast to previous reports, the cartilage deficiency in Williams-Campbell syndrome can involve both proximal and distal airways. Consequently, bilateral sequential lung transplantation may not be an effective therapeutic option in patients with this syndrome.

Relationship of body mass index to subsequent mortality among seriously ill hospitalized patients. SUPPORT Investigators. The Study to Understand Prognoses and Preferences for Outcome and Risks of Treatments.

OBJECTIVE: To determine if body mass Index (BMI = weight [kg]/height [m]2), predictive of mortality in longitudinal epidemiologic studies, was also predictive of mortality in a sample of seriously ill hospitalized subjects. DESIGN: Prospective, multicenter study. SETTING: Five tertiary care medical centers in the United States. PATIENTS: Patients > or = 18 yrs of age who had one of nine illnesses of sufficient severity to anticipate a 6-month mortality rate of 50% were enrolled at five participating sites in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Patients were asked their current height and weight as part of the demographic data. Stratifying body mass index by percentile rank (< or = 15, 15 to 85, and > or = 85th percentiles), risk ratios for mortality were calculated by Cox Proportional Hazards using the 15th to 85th percentile of body mass index as the reference group while controlling for multiple variables such as prior weight loss, albumin, and Acute Physiology Score. A body mass index in the < or = 15th percentile was associated with an excess risk of mortality (risk ratio = 1.23; p < .001) within 6 months. High body mass index (> or = 85th percentile) was not significantly related to risk of mortality. CONCLUSIONS: Body mass index, a simple anthropometric measure of nutrition employed in community epidemiologic studies, has now been demonstrated to be a predictor of mortality in an acutely ill population of adults at five different tertiary centers. Even when controlling for multiple disease states and physiologic variables and removing from the analysis all patients with significant prior weight loss, a body mass index below the 15th percentile remained a significant and independent predictor of mortality. Examination of patient vs. proxy data did not change the results. Future studies examining variables predictive of mortality should include body mass index, even in acutely ill populations with a poor probability of survival.

Outcomes following acute exacerbation of severe chronic obstructive lung disease. The SUPPORT investigators (Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments)

In order to describe the outcomes of patients hospitalized with an acute exacerbation of severe chronic obstructive pulmonary disease (COPD) and determine the relationship between patient characteristics and length of survival, we studied a prospective cohort of 1,016 adult patients from five hospitals who were admitted with an exacerbation of COPD and a PaCO2 of 50 mm Hg or more. Patient characteristics and acute physiology were determined. Outcomes were evaluated over a 6 mo period. Although only 11% of the patients died during the index hospital stay, the 60-d, 180-d, 1-yr, and 2-yr mortality was high (20%, 33%, 43%, and 49%, respectively). The median cost of the index hospital stay was $7,100 ($4,100 to $16,000; interquartile range). The median length of the index hospital stay was 9 d (5 to 15 d). After discharge, 446 patients were readmitted 754 times in the next 6 mo. At 6 mo, only 26% of the cohort were both alive and able to report a good, very good, or excellent quality of life. Survival time was independently related to severity of illness, body mass index (BMI), age, prior functional status, PaO2/FI(O2), congestive heart failure, serum albumin, and the presence of cor pulmonale. Patients and caregivers should be aware of the likelihood of poor outcomes following hospitalization for exacerbation of COPD associated with hypercarbia.

High-dose, hyperfractionated, accelerated radiotherapy using a concurrent boost for the treatment of nonsmall cell lung cancer: unusual toxicity and promising early results.

PURPOSE: The treatment of nonsmall cell lung cancer (NSCLC) with conventional radiotherapy (RT) results in inadequate local tumor control and survival. We report results of a Phase II trial designed to treat patients with a significantly increased total dose administered in a reduced overall treatment time using a hyperfractionated, accelerated treatment schedule with a concurrent boost technique. METHODS AND MATERIALS: A total of 49 patients with unresectable Stage IIIA/IIIB (38 patients) or medically inoperable Stage I/II (11 patients) NSCLC were prospectively enrolled in this protocol. Radiation therapy was administered twice daily, 5 days/week with > 6 h between each treatment. The primary tumor and adjacent enlarged lymph nodes were treated to a total dose of 73.6 Gy in 46 fractions of 1.6 Gy each. Using a concurrent boost technique, electively irradiated nodal regions were simultaneously treated with a dose of 1.25 Gy/fraction for the first 36 fractions to a total dose of 45 Gy. RESULTS: Median survival for the entire group of 49 patients is 15.3 months. Actuarial survival at 2 years is 46%: 60% for 11 Stage I/II patients, 55% for 21 Stage IIIA patients, and 26% for 17 Stage IIIB patients. The actuarial rate of freedom from local progression at 2 years is 64% for the entire group of 49 patients: 62% for Stage I/II patients, 70% for Stage IIIA patients, and 55% for Stage IIIB patients. Patients who underwent serial bronchoscopic reevaluation (4 Stage I/II, 8 Stage IIIA, and 6 Stage IIIB) have an actuarial rate of local control of 71% at 2 years. The median total treatment time was 32 days. Nine of 49 patients (18%) experienced Grade III acute esophageal toxicity. The 2-year actuarial risk of Grade III or greater late toxicity is 30%. The 2-year actuarial rate of severe-late pulmonary and skin-subcutaneous toxicity is 20% and 15%, respectively. CONCLUSION: This treatment regimen administers a substantially higher biologically effective dose compared with conventional and pure hyperfractionation treatment schedules. The overall rate of acute and late toxicity was acceptable. Preliminary rates of overall survival and local control and freedom from local progression compare favorably to results reported with pure hyperfractionated radiotherapy and chemoradiotherapy.

Cost-effectiveness of collecting routine cytologic specimens during fiberoptic bronchoscopy for endoscopically visible lung tumor.

STUDY OBJECTIVE: Fiberoptic bronchoscopy is the most common modality used to diagnose endobronchial carcinoma. Collection of brushing and washing specimens for cytology is common during bronchoscopy for endobronchial abnormality, but it is unknown if collection of these specimens is cost-effective. DESIGN: Retrospective review of a computerized database with cost-effectiveness analysis. SETTING: Tertiary care medical center. PATIENTS: Two hundred one patients undergoing bronchoscopy for endobronchial lung tumor. INTERVENTION: All patients in the study underwent fiberoptic bronchoscopy that included forceps biopsies, washings, and brushings. In addition to analyzing the sensitivity of forceps-biopsy, washings, and brushings at diagnosing malignancy, we analyzed the cost-effectiveness of three potential specimen collection strategies. These strategies were (1) collection of both washings and brushings in addition to forceps biopsy specimen, (2) collection of either washings or brushings in addition to forceps biopsy specimen, and (3) collection of forceps biopsy specimen only. MEASUREMENTS AND RESULTS: The sensitivity of bronchoscopy, including biopsy, washing, and brushing is 85.3% (95% confidence interval [CI], 80.1 to 90.5%). The sensitivity of forceps biopsy is 80.8% (95% CI, 75.0 to 86.6%). The addition of washings and brushings increases the sensitivity of bronchoscopy from 80.8 to 85.3% (McNemar's p = 0.01). Cost-effectiveness analysis reveals that forceps biopsy plus washing or brushing has a marginal cost-effectiveness ratio of $308 per reduced-quality day avoided compared with forceps alone. Adding an additional cytology specimen has a marginal cost-effectiveness ratio of $5,500 per reduced-quality day avoided. CONCLUSIONS: There is a modest but definite increase in the sensitivity of bronchoscopy in diagnosing endobronchial cancer with the addition of washings and brushings for cytology. Cost-effectiveness analysis reveals that collection of either washings or brushings is probably the best strategy.

The rising tide of asthma. Trends in the epidemiology of morbidity and mortality from asthma.

The increase in the asthma mortality rate seen in the past decade has stimulated much discussion, research, and controversy. The epidemiology of asthma morbidity is reviewed, with special attention to the roles of demographics, socioeconomic status, and iatrogenesis in the rising tide of asthma mortality.

Pathophysiology and management of life-threatening asthma.

With sound medical management and good patient education, only a small minority of patients with asthma ever experience a life-threatening episode. The pathophysiology, clinical presentation, and management of life-threatening asthma are reviewed. Special emphasis is placed on identification of the fatality-prone asthmatic patient and on avoidance of complications of treatment that significantly add to morbidity and mortality rates.

Identification of comatose patients at high risk for death or severe disability. SUPPORT Investigators. Understand Prognoses and Preferences for Outcomes and Risks of Treatments.

OBJECTIVE: To develop and validate a simple prognostic scoring system to identify patients in nontraumatic coma at high risk for poor outcomes using data available early in the hospital course. DESIGN: Prospective cohort study. SETTING: Five geographically diverse academic medical centers. PATIENTS: A total of 596 patients in nontraumatic coma enrolled in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT), including 247 in the model derivation set and 349 in the model validation set. MAIN OUTCOME MEASURES: Death and severe disability by 2 months. MAIN RESULTS: For the 596 patients studied (median age, 67 years; 52% female), the primary cause of coma was cardiac arrest in 31% and cerebral infarction or intracerebral hemorrhage in 36%. At 2 months 69% had died, 20% had survived with known severe disability, 8% were known to have survived without severe disability, and 3% survived with unknown functional status. Five clinical variables available on day 3 after enrollment were associated independently with 2-month mortality: abnormal brain stem response (adjusted odds ratio [OR] = 3.2; 95% confidence interval [CI], 1.3 to 8.1), absent verbal response (OR = 4.6; 95% CI, 1.8 to 11.7), absent withdrawal response to pain (OR = 4.3; 95% CI, 1.7 to 10.8), creatinine level greater than or equal to 132.6 mumol/L (1.5 mg/dL) (OR = 4.5; 95% CI, 1.8 to 11.0), and age of 70 years or older (OR = 5.1; 95% CI, 2.2 to 12.2). Mortality at 2 months for patients with four or five of these risk factors was 97% (58/60; 95% CI, 88% to 100%) in the validation set. Brain stem and motor responses best predicted death or severe disability by 2 months. For patients with either an abnormal brain stem response or absent motor response to pain, the rate of death or severe disability at 2 months was 96% (185/193; 95% CI, 92% to 98%) in the validation set. CONCLUSIONS: Five readily available clinical variables identify a large subgroup of patients in nontraumatic coma at high risk for poor outcomes. This risk stratification approach offers physicians, patients, and patients' families information that may prove useful in patient care decisions and resource allocation.

Recurrence of diffuse panbronchiolitis after lung transplantation.

Diffuse panbronchiolitis (DBP) is characterized by chronic inflammation of the upper and lower respiratory tract. DPB has been found almost exclusively in oriental populations. We describe the occurrence of a case of DPB in an African American patient who underwent bilateral sequential lung transplantation. Ten weeks after transplantation, DPB recurred in the lung allograft, with rapid and significant deterioration in graft function. Allograft function improved within a few weeks after beginning treatment with erythromycin. This early recurrence is suggestive of a systemic etiology of DPB. Although recurrence of other systemic diseases has been reported after lung transplantation, no previous patients have been reported with early functional deterioration based solely on disease recurrence.