Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2023 Guidelines Reviewed

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) report is an essential resource for all clinicians who strive to provide optimal care to patients with chronic obstructive lung disease (COPD). The annual report of GOLD makes few revisions and updates besides including data from the preceding year. At an interval, GOLD comes up with a significant modification in its guidelines, which is generally a major overhaul of the pre-existing guidelines. According to the latest 2023 updates, published in November 2022, there have been significant advancements made in the field of COPD. These include the development of more precise definitions for COPD and its exacerbations, the introduction of a new set of parameters to measure exacerbation severity, and updating the COPD assessment tool. Additionally, revisions have been made to the initial and follow-up treatment guidelines. The report also simplifies the treatment algorithm and sheds light on new findings that suggest the use of pharmacological triple therapy can reduce mortality rates. Furthermore, the report includes discussions on inhaler device selection and adherence to COPD medications. These improvements demonstrate a continued effort to enhance COPD treatment and management. Although there are some areas that could benefit from more detailed guidance and explanation, such as the proper utilization of blood eosinophil counts for treatment decisions, and the establishment of treatment protocols post-hospitalization, the latest modifications to the GOLD recommendations will undoubtedly aid healthcare providers in addressing any gaps in patient care. We aim to highlight key changes in the GOLD 2023 report and present a viewpoint about their potential implications in a real-world clinical scenario.

The Use of POCUS-Obtained Optic Nerve Sheath Diameter in Intracerebral Hemorrhage

Background: Intracerebral hemorrhage (ICH) is associated with high morbidity and mortality. ICH causes increased intracranial pressure (ICP), leading to brain herniation as the disease progresses. Neurological physical exam and monitoring of the disease progression can be challenging due to the impaired consciousness and routine clinical management in this patient population. Given the continuity of the intracranial cavity with the optic nerve subarachnoid space, an increased ICH leads to distension of the optic nerve sheath. We herein examined the correlation between the ICH volume and the optic nerve sheath diameter (ONSD) measured by point of care ultrasound (POCUS). Methods: Patients with ICH diagnosed with a head computed tomography (CT) scan were prospectively enrolled in this study. A portable ultrasound was used to measure the (ONSD); the volume of ICH hematoma, the Acute Physiology And Chronic Health Evaluation IV score, and the Intracerebral Hemorrhage score were collected. A Spearman rank correlation coefficient test was used to assess the relationship between continuous variables. A Wilcoxon rank sum test was used to assess differences in continuous variables between two groups. A p-value less than 0.05 was deemed as statistically significant. Results: A total of 28 subjects were enrolled. A moderate positive correlation was detected between hemorrhage volume and the average ONSD (correlation = 0.4214, p = 0.0255). A weak positive correlation was detected between average ONSD and APACHE IV (correlation = 0.2347, p = 0.2294). A weak moderate positive correlation was detected between average ONSD and ICH score (correlation = 0.1160, p = 0.5566). Conclusions: In this study we demonstrate that ONSD is moderately correlated with hematoma size. A potential application may include serial measurements of the ONSD with ultrasound. This may offer a quick, non-invasive technique that can be used in an intracerebral hemorrhage to monitor the stability or expansion of a hematoma indirectly, and potentially catch a catastrophic event like cerebral herniation.

Video versus Direct Laryngoscopy for Tracheal Intubation of Critically Ill Adults

BACKGROUND

Whether video laryngoscopy as compared with direct laryngoscopy increases the likelihood of successful tracheal intubation on the first attempt among critically ill adults is uncertain.

METHODS

In a multicenter, randomized trial conducted at 17 emergency departments and intensive care units (ICUs), we randomly assigned critically ill adults undergoing tracheal intubation to the video-laryngoscope group or the direct-laryngoscope group. The primary outcome was successful intubation on the first attempt. The secondary outcome was the occurrence of severe complications during intubation; severe complications were defined as severe hypoxemia, severe hypotension, new or increased vasopressor use, cardiac arrest, or death.

RESULTS

The trial was stopped for efficacy at the time of the single preplanned interim analysis. Among 1417 patients who were included in the final analysis (91.5% of whom underwent intubation that was performed by an emergency medicine resident or a critical care fellow), successful intubation on the first attempt occurred in 600 of the 705 patients (85.1%) in the video-laryngoscope group and in 504 of the 712 patients (70.8%) in the direct-laryngoscope group (absolute risk difference, 14.3 percentage points; 95% confidence interval [CI], 9.9 to 18.7; P<0.001). A total of 151 patients (21.4%) in the video-laryngoscope group and 149 patients (20.9%) in the direct-laryngoscope group had a severe complication during intubation (absolute risk difference, 0.5 percentage points; 95% CI, -3.9 to 4.9). Safety outcomes, including esophageal intubation, injury to the teeth, and aspiration, were similar in the two groups.

CONCLUSIONS

Among critically ill adults undergoing tracheal intubation in an emergency department or ICU, the use of a video laryngoscope resulted in a higher incidence of successful intubation on the first attempt than the use of a direct laryngoscope. (Funded by the U.S. Department of Defense; DEVICE ClinicalTrials.gov number, NCT05239195.).

Effectiveness of the Ad26.COV2.S (Johnson & Johnson) Coronavirus Disease 2019 (COVID-19) Vaccine for Preventing COVID-19 Hospitalizations and Progression to High Disease Severity in the United States

Background . Adults in the United States (US) began receiving the adenovirus vector coronavirus disease 2019 (COVID-19) vaccine, Ad26.COV2.S (Johnson & Johnson [Janssen]), in February 2021. We evaluated Ad26.COV2.S vaccine effectiveness (VE) against COVID-19 hospitalization and high disease severity during the first 10 months of its use. Methods . In a multicenter case-control analysis of US adults (≥18 years) hospitalized 11 March to 15 December 2021, we estimated VE against susceptibility to COVID-19 hospitalization (VEs), comparing odds of prior vaccination with a single dose Ad26.COV2.S vaccine between hospitalized cases with COVID-19 and controls without COVID-19. Among hospitalized patients with COVID-19, we estimated VE against disease progression (VEp) to death or invasive mechanical ventilation (IMV), comparing odds of prior vaccination between patients with and without progression. Results . After excluding patients receiving mRNA vaccines, among 3979 COVID-19 case-patients (5% vaccinated with Ad26.COV2.S) and 2229 controls (13% vaccinated with Ad26.COV2.S), VEs of Ad26.COV2.S against COVID-19 hospitalization was 70% (95% confidence interval [CI]: 63-75%) overall, including 55% (29-72%) among immunocompromised patients, and 72% (64-77%) among immunocompetent patients, for whom VEs was similar at 14-90 days (73% [59-82%]), 91-180 days (71% [60-80%]), and 181-274 days (70% [54-81%]) postvaccination. Among hospitalized COVID-19 case-patients, VEp was 46% (18-65%) among immunocompetent patients. Conclusions . The Ad26.COV2.S COVID-19 vaccine reduced the risk of COVID-19 hospitalization by 72% among immunocompetent adults without waning through 6 months postvaccination. After hospitalization for COVID-19, vaccinated immunocompetent patients were less likely to require IMV or die compared to unvaccinated immunocompetent patients.

Effectiveness of mRNA Vaccines Against COVID-19 Hospitalization by Age and Chronic Medical Conditions Burden Among Immunocompetent US Adults, March-August 2021

Vaccine effectiveness (VE) against COVID-19 hospitalization was evaluated among immunocompetent adults (≥18 years) during March-August 2021 using a case-control design. Among 1669 hospitalized COVID-19 cases (11% fully vaccinated) and 1950 RT-PCR-negative controls (54% fully vaccinated), VE was 96% (95% confidence interval [CI], 93%-98%) among patients with no chronic medical conditions and 83% (95% CI, 76%-88%) among patients with ≥ 3 categories of conditions. VE was similar between those aged 18-64 years versus ≥65 years (P > .05). VE against severe COVID-19 was very high among adults without chronic conditions and lessened with increasing comorbidity burden.

Unilateral pulmonary edema and acute severe mitral regurgitation associated with operatively repaired aortic coarctation

Cardiogenic pulmonary edema classically presents bilaterally and with a symmetric distribution. Occasionally, cardiogenic pulmonary edema can present unilaterally, which carries an independent risk for mortality, possibly due to the delayed diagnosis. The most common cardiogenic cause of unilateral pulmonary edema is acute mitral regurgitation, frequently described in the setting of acute coronary syndrome. Here we describe a case of unilateral pulmonary edema caused by acute mitral regurgitation outside the setting of acute coronary syndrome.

Invasive diagnostic strategies in immunosuppressed patients with acute respiratory distress syndrome

Immunosuppression predisposes the host to development of pulmonary infections, which can lead to respiratory failure and the development of acute respiratory distress syndrome (ARDS). There are multiple mechanisms by which a host can be immunosuppressed and each is associated with specific infectious pathogens. Early invasive diagnostic modalities such as fiber-optic bronchoscopy with bronchoalveolar lavage, transbronchial biopsy, and open lung biopsy are complementary to serologic and noninvasive studies and assist in rapidly establishing an accurate diagnosis, which allows initiation of appropriate therapy and may improve outcomes with relative safety.

The role of self-expandable metallic stents for the treatment of airway complications after lung transplantation

BACKGROUND

Airway complications continue to be an important source of morbidity and mortality after lung transplantation (LTx). Different approaches have been used for their nonsurgical management. We describe our experience using self-expandable metallic stents (SEMSs) in patients with airway complications post-LTx.

METHODS

We present a retrospective analysis of stent related-data of all the LTx patients who received SEMSs to treat postoperative airway complications.

RESULTS

Between January 1992 and December 2001, 36 of 253 patients (14.2%) developed post-LTx airway complications involving 40 of 348 anastomoses (11.5%). A total of 15 SEMSs were placed in 12 patients (mean age 47.3+/-9.6 years) for tracheobronchomalacia, stenosis, and anastomotic dehiscence, including one patient referred from an outside hospital. Mean follow-up was 20.1+/-19.5 months (range 1.2-58 months). Patency and symptom improvement were achieved in 11 of 12 patients. Stenting of the airway led to successful weaning of two patients who were on prolonged mechanical ventilation. Suture dehiscence was effectively managed in two patients who were not candidates for surgical repair. Overall, the complication rate was 0.040 complications per patient per month (total number of complications and total number of months using the stent). Bacterial bronchitis (four patients) and obstructive granulomas (three patients) were the most frequent complications. The survival of LTx patients with airway SEMSs was similar when compared with the survival of all other LTx patients (P=0.74).

CONCLUSIONS

SEMSs are safe and effective in the management of airway complications in selected patients post-LTx. Weaning from mechanical ventilation and management of anastomotic dehiscence are the unique attributes of this device.

First-line chemotherapy with paclitaxel and platinum for advanced and recurrent cancer of the cervix--a phase II study

OBJECTIVE

The aim of this study was to assess the role of first-line chemotherapy with paclitaxel and platinum in the treatment of advanced or recurrent cervix cancer.

METHODS

Twenty patients with advanced or recurrent cancer of the cervix with no prior chemotherapy and measurable disease were entered in a phase II trial from September 1995 to September 1998. Seventeen patients were treated with paclitaxel at 135 mg/m(2) over 24 h followed by cisplatin at 75 mg/m(2) every 4 weeks. Three patients with impaired renal function were treated with paclitaxel at 135 mg/m(2) over 3 h with carboplatin at 300 mg/m(2).

RESULTS

A clinical response rate of 45% was noted (two complete responses and seven partial responses) with a median duration of 6 months (range: 1.5-9). The median progression-free interval and overall survival in patients with a clinical response was 10.5 and 13 months, respectively, compared to 4 (P = 0.015) and 6 months in the nonresponders (P = 0. 14). Seven of nine patients (77.8%) with a clinical response are alive. Patients with recurrences outside the radiation field had twice the response rate (60%) than that of those within the radiated field. The chemotherapy was well tolerated; the most significant toxicity was grade 3/4 neutropenia (55%). No patient had discontinuation of chemotherapy due to toxicity.

CONCLUSIONS

First-line chemotherapy with paclitaxel and platinum for advanced and recurrent cervix cancer is promising and deserves consideration for large phase III trials.

Role of salvage chemotherapy with topotecan and cisplatin in patients with paclitaxel- and platinum-resistant recurrent ovarian or primary peritoneal cancer: a phase II pilot study

BACKGROUND AND OBJECTIVES

We assessed the role of salvage chemotherapy with topotecan and cisplatin in patients with platinum- and paclitaxel-resistant advanced and recurrent ovarian or primary peritoneal cancer, based on the reported in vivo and in vitro synergism between these two drugs.

METHODS

Twenty patients were entered in this phase II trial from November 1997 to November 1998. They received cisplatin at 50 mg/m(2) on day 1 with topotecan at 0.6 mg/m(2) from day 1 to 5 every 28 days. In 70% of patients (14/20), this combination represented at least a third line of therapy.

RESULTS

A clinical response rate of 13.3% (two partial responses) was obtained in the 15 patients with evaluable disease. Sixty percent of patients (9/15) had stable disease and 26.7% (4/15) had progression. The median progression-free interval and survival were 4 months and 7 months, respectively. The 20 patients evaluable for toxicity received a mean of four chemotherapy cycles. Dose reductions were required in 45% of patients despite the administration of growth factors. The major dose-limiting toxicity was a 50% occurrence (10/20) of grade 4 thrombocytopenia and 30% (6/20) grade 4 neutropenia. There was one septic death.

CONCLUSIONS

These data suggest that combination therapy with topotecan and cisplatin has minimal activity in platinum- and paclitaxel-resistant advanced and recurrent ovarian or primary peritoneal cancer at the doses utilized in this trial.

Adenocarcinoma of the ileum with an enterotubal fistula presenting as an adnexal mass

Small bowel adenocarcinomas account for 3% of gastrointestinal malignancies, and 20 to 25% of these arise in the ileum. Clinical presentation is variable, and early diagnosis is difficult. A 56-year-old postmenopausal woman presented with crampy abdominal pain, anorexia, and weight loss. Pelvic examination and ultrasound revealed a 6 x 8-cm complex right adnexal mass. At laparotomy, en bloc resection of the right adnexa and the densely adherent ileal segment was performed along with a hysterectomy and a left salpingo-oophorectomy. The final pathology showed a moderately differentiated invasive adenocarcinoma of the ileum with a malignant enterotubal fistula. This is the first case reported in the literature of an ileal adenocarcinoma with a tubal fistula masquerading as an adnexal mass.

High levels of CA-125 in a case of a parasitic leiomyoma presenting as an abdominal mass

A 32-year-old woman presented with increasing abdominal girth and discomfort secondary to a 18-week-size mass and a CA-125 level of 1539. She underwent an exploratory laparotomy and resection of a parasitic fibroid following which the CA-125 levels decreased and normalized within a month. A review of English literature indicates that association of raised CA-125 levels with fibroids is inconsistent and very modest and such high levels have not been previously reported.

Mucinous adenocarcinomas of the vulva

An 80-year-old nullipara had a 2.0-cm cystic tumor of the right labium majus. Histologic diagnosis was mucinous eccrine carcinoma. Seventy-five percent of these rare skin adnexal tumors arise on the face, eyelid, or scalp; but none has been reported on the vulva. Indolent localized growth is usual with regional nodal spread in 11% and distant metastases in 3%. A 67-year-old multipara had a 1.2-cm polypoidal nodule of the posterior fourchette. Histologically, a colonic type mucinous carcinoma was arising within a villous adenoma. Mucicarmine and CEA stains were positive. Extensive workup failed to reveal other primary cancers in either patient. Both patients are well 19 and 17 months after radical vulvectomies and node-negative groin dissections. These cases illustrate further the diversity in cell type and biologic behavior of vulvar adenocarcinomas.