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The role of leukotriene receptor antagonists in asthma

This study assessed the effectiveness of a leukotriene receptor antagonist (LTRA) in two pragmatic randomised controlled trials over a 2-year period in primary care practices across the UK.

The first trial compared LTRAs with inhaled glucocorticoids as the first-line treatment in asthma.

The second trial compared the addition of LTRAs versus the addition of long-acting β2-agonists in patients already using inhaled glucocorticoids with asthma.

All treatments led to significant improvements in the primary outcome measure: the mini Asthma Quality of Life Questionnaire. At 2 months, the LTRA was found to be equivalent in both studies. At 2 years, there was a trend towards equivalence between treatment groups although scores fell outside of their pretest definition of equivalence...

Muscle mass and strength in obstructive lung disease: a smoking gun?

Over the past 2 decades, there has been increasing interest in the extrapulmonary manifestations of chronic obstructive pulmonary disease (COPD). This is supported by the clinical observation that patients show significant improvements in functional performance and health-related quality of life with pulmonary rehabilitation in the absence of lung function changes.1 Furthermore, the forced expiratory volume in 1 s is an imperfect predictor of mortality in severe patients with COPD,2 and when forced expiratory volume in 1 s is corrected after double lung transplantation, peak exercise remains only approximately 50% of predicted up to 1–2 years after surgery.3 This limitation in exercise and functional capacity has led to a particular focus upon the skeletal muscle ...

Treatment of tuberculosis and optimal dosing schedules

Intermittent tuberculosis treatment regimens have been developed to facilitate treatment supervision. Their efficacy has been substantiated by clinical trials and tuberculosis control programmes, notwithstanding the lack of head-to-head comparison between daily and intermittent regimens. Recently, there has been opposing evidence from observational studies, pharmacokinetic-pharmacodynamic studies and animal models that intermittent treatment increases the risk of relapse, treatment failure or acquired rifamycin resistance, especially among HIV-infected patients. Systematic reviews have been conflicting. PubMed, Ovid MEDLINE and EMBASE were systematically searched for publications in English to evaluate the evidence about dosing schedules and treatment efficacy. Levels of evidence and grade...

Risk Factors Associated with Delayed Diagnosis of Acute Pulmonary Embolism.

Prompt diagnosis and treatment of acute pulmonary embolism (PE) is essential to reduce mortality. Risk factors for PE are well known, but factors associated with delayed diagnosis are less clear.

OBJECTIVE: Our objective was to identify clinical factors associated with delayed diagnosis of patients with acute PE presenting to a tertiary-care emergency department (ED).

METHODS: We studied 400 consecutive adults who presented to our ED with acute, symptomatic PE. All patients were diagnosed by computed tomography (CT) angiography. Early diagnosis was defined as CT diagnosis<12h from ED arrival, and delayed diagnosis as CT diagnosis>12h. Univariate and multiple logistic regression models were used to identify factors associated with delayed diagnosis. Odds ratios with 95% confidence intervals are reported.

RESULTS: The median time from arrival to diagnosis was 2.4h (interquartile range 1.4-7.6), and 73 (18.3%) patients had delayed diagnosis. Patients aged>65 years and those with coronary artery disease or congestive heart failure had longer times from ED arrival to CT diagnosis, whereas patients with recent immobility had shorter times. Patients diagnosed>12h were older and had higher rates of morbid obesity and coronary artery disease, whereas patients diagnosed<12h had higher rates of tachycardia. In multiple regression modeling, tachycardia and recent immobility remained associated with early diagnosis, whereas morbid obesity remained associated with delayed diagnosis.

CONCLUSIONS: Older patients with cardiovascular comorbidities had longer times from ED arrival to CT diagnosis. Our data suggest that these patients represent more of a diagnostic challenge than those presenting with traditional risk factors for PE, such as tachycardia and recent immobilization. Physicians should consider these factors to diagnosis acute PE promptly in the ED.

Pulmonary embolism: ct signs and cardiac biomarkers for predicting right ventricular dysfunction.

To prospectively evaluate the accuracy of quantitative cardiac CT parameters and two cardiac biomarkers (NT-pro-Brain Natriuretic Peptide (NT-pro-BNP); troponin I), alone and in combination, for predicting right ventricular dysfunction (RVD) in patients with acute pulmonary embolism (PE).

557 consecutive patients with suspected PE underwent pulmonary CTA. Patients with PE also underwent echocardiography and NT-pro-BNP/troponin I serum level measurements. 3 different CT measurements were obtained (RV/LVaxial, RV/LV4-CH), and RV/LVvolume). CT measurements and NT-pro-BNP/troponin I serum levels were correlated with RVD at echocardiography.Patients with RVD (n=77) showed significantly higher RV/LV ratios and NT-pro-BNP/troponin I levels compared to those without RVD (RV/LVaxial 1.68±0.84 vs. 1.00±0.21; RV/LV4ch 1.52±0.45 vs. 1.01±0.21; RV/LVvolume 1.97±0.53 vs. 1.07±0.52; serum NT-pro-BNP 6372±2319 vs. 1032±1559 ng·L(-1); troponin I 0.18±0.41 vs. 0.06±0.18). The area under the curve for the detection of RVD of RV/LVaxial, RV/LV4Ch, RV/LVvolume, NT-pro-BNP and troponin I were 0.84, 0.87, 0.93, 0.83 and 0.70 respectively. The combination of biomarkers and RV/LVvolume increased the AUC to 0.95 (RV/LVvolume with NT-pro-BNP) and 0.93 (RV/LVvolume with troponin I).

RV/LVvolume is the most accurate CT parameter for identifying patients with RVD. A combination of RV/LVvolume with NT-pro-BNP or troponin I measurements improves the diagnostic accuracy of either test alone.

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