Follow-up with Telemedicine in Early Discharge for COPD Exacerbations: Randomized Clinical Trial (TELEMEDCOPD-Trial)

The results reported by different studies on telemonitoring in patients with chronic obstructive pulmonary disease (COPD) have been contradictory, without showing clear benefits to date. The objective of this study was to ascertain whether an early discharge and home hospitalization telehealth program for patients with COPD exacerbation is as effective as and more efficient than a traditional early discharge and home hospitalization program. A prospective experimental non-inferiority study, randomized into two groups (telemedicine/control) was conducted. The telemedicine group underwent monitoring and was required to transmit data on vital constants and ECGs twice per day, with a subsequent telephone call and 2 home visits by healthcare staff (intermediate and at discharge). The control group received daily visits. The main variable was time until first exacerbation. The secondary variables were: number of exacerbations; use of healthcare resources; satisfaction; quality of life; anxiety-depression; and therapeutic adherence, measured at one and 6 months of hospital discharge. A total of 116 patients were randomized (58 to each group) without significant differences in baseline characteristics or time until first exacerbation, i.e. median 48 days (pp. 25-75:23-120) in the control group, and 47 days (pp. 25-75:19-102) in the intervention group; p = 0.52). A significant decrease in the number of visits was observed in the intervention versus the control group, 3.8 ± 1 vs 5.1 ± 2(p = 0.001), without significant differences in the number of exacerbations. In conclusion follow-up via a telemedicine program in early discharge after hospitalization is as effective as conventional home follow up, being the cost of either strategy not significantly different.

Is gammaglobulin anti-CMV warranted in lung transplantation?

The usefulness of anti-CMV hyperimmune gammaglobulin (IgG-CMV, Cytotec) in lung transplant patients (LTx) is controversial. The objective of this study was to analyze the effectiveness of IgG-CMV in our LTx receptors.

PATIENTS AND METHODS

A retrospective study of LTx recipients treated with IgG-CMV as prophylaxis or as treatment for invasive disease. We used IgG-CMV associated with IV ganciclovir (GCV) as treatment for invasive disease. High-risk patients (CMV-negative recipients from CMV-positive donors; CMV-/+) were also with IgG-CMV prophylaxis during the first year. Other prophylactic uses of IgG-CMV were as an alternative to GCV in patients with related GCV toxicity, and as preemptive therapy in cases of persistent positive viral load (antigenemia > or = 1 cell and/or a PCR > or = 400) although oral GCV administration.

RESULTS

Between January 2000 and August 2003, 14 of the 74 lung transplant recipients (19%) received IgG-CMV as treatment for invasive disease (4 cases: 2 gastritis, 1 esophagitis, 1 hepatitis) and/or as prophylaxis (14 cases). All patients treated for invasive disease evolved favorably. No therapeutic failure were observed in CMV-/+ patients during treatment. Three of the six patients treated with IgG-CMV developed positive antigenemia despite treatment. The four patients treated for persistent antigenemia while receiving oral GCV achieved neutralization during the first month of treatment.

CONCLUSION

IgG-CMV associated with Gancyclovir is effective as treatment for invasive disease and as pre-emptive therapy in patients with persistent positive viral load. In CMV-/+ recipients, IgG-CMV prevents pneumonitis and delays the development of invasive disease after the first year.

Rapamycin in lung transplantation

INTRODUCTION

Rapamycin (RAPA) is a powerful immunosuppressant that also acts as an antiproliferative, which, therefore, could be useful in the treatment and prevention of bronchiolitis obliterans (BOS) in lung transplant recipients. We sought to report our experiences with RAPA in lung transplant patients with BOS that has not responded to the administration of other drugs.

MATERIALS AND METHODS

We performed a retrospective analysis of the clinical characteristics, pulmonary function, and complications among patients with BOS who received RAPA.

RESULTS

RAPA was administered to 11 patients, three single-lung transplant and eight bilateral lung transplant recipients, of whom five were women and six men, of mean age 48 years (26 to 65). The median posttransplant time to the initiation of RAPA for progressive BOS was 32 months (4 to 69) with a posttreatment follow-up of 15 months (3 to 34). RAPA was administered to all patients in association with a calcineurin inhibitor (tacrolimus in seven cases, and cyclosporine in four and steroids. Eight of the 11 patients (72%) with progressive deterioration of pulmonary function showed improved and/or stabilized FEV1 figures after introduction of RAPA. Eight patients developed adverse effects, which were possibly related to RAPA, leading to treatment withdrawal in two cases. The most frequent adverse effects were infections among 6 of the 12 cases, and myelosuppression in three.

CONCLUSIONS

RAPA may be useful to stabilize or improve pulmonary function in patients with BOS. Nevertheless, it was necessary for patients to be closely monitored so that possible adverse effects, and especially infections, may be detected early.

[Survival of lung transplant at the Puerta de Hierro Clinic]

The objective of this study was to analyze patient survival after lung transplants performed at the Puerta de Hierro clinic in Madrid (Spain) between 1991 and 1996. Survival probability was 65% after one year and 50% after three years. We found no significant differences in survival related to sex or type of transplant. Early survival tended to be higher for the last two years analyzed (71%) than for the first two (55%) (p < 0.00001). The rate was 100% for patients with cystic fibrosis and 0% for pulmonary hypertension and lymphangiomyomatosis. Short- and medium-term lung function results were good in surviving patients who did not develop obliterating bronchiolitis. We conclude that actuarial survival after lung transplant in our program is comparable to that reported in the literature. There are no significant differences related to sex, type of transplant or period. Survival varies greatly, however, depending on disease.

[Cholesterol in pleural fluid. Its usefulness in differentiating between exudates and transudates]

To analyze the usefulness of cholesterol levels in the differentiation of exudates and transudates. A 3.5-year prospective study of 170 patients with pleural discharge. Clinical microbiological and cyto-histological criteria were used for diagnosis. Exudates were classified by Light's criteria, by cholesterol > or = 45 mg/dl in pleural liquid, by a cholesterol in pleural liquid/cholesterol in serum quotient > or = 0.3 and by a finding of both LDH and cholesterol in pleural fluid. These criteria were compared with the final etiological diagnosis. Only pleural discharges with confirmed etiological diagnoses were analyzed. In the 130 pleural discharges for which certain etiological diagnoses were obtained, 33 were transudates and 97 were exudates. Light's criteria allowed accurate classification of 92 (95%) of the 97 exudates and 30 (91%) of the 33 transudates. The cholesterol in pleural liquid/cholesterol in serum quotient was the most productive and useful parameter (96% sensitivity, 97% specificity), better than pleural fluid cholesterol and the Light's criteria. The association of LDH and pleural fluid cholesterol classified 100% of the exudates, with efficacy similar to that of Light's criteria. The cholesterol in pleural fluid/serum quotient was the most useful biochemical variable. Cholesterol levels were about as useful as Light's criteria. The association of LDH and cholesterol allows us to bypass blood analyses for the diagnosis of exudates.