Barry Merriman

Effect of Early versus Deferred Antiretroviral Therapy for HIV on Survival

BACKGROUND The optimal time for the initiation of antiretroviral therapy for asymptomatic patients with human immunodeficiency virus (HIV) infection is uncertain. METHODS We conducted two parallel analyses involving a total of 17,517 asymptomatic patients with HIV infection in the United States and Canada who received medical care during the period from 1996 through 2005. None of the patients had undergone previous antiretroviral therapy. In each group, we stratified the patients according to the CD4+ count (351 to 500 cells per cubic millimeter or >500 cells per cubic millimeter) at the initiation of antiretroviral therapy. In each group, we compared the relative risk of death for patients who initiated therapy when the CD4+ count was above each of the two thresholds of interest (early-therapy group) with that of patients who deferred therapy until the CD4+ count fell below these thresholds (deferred-therapy group). RESULTS In the first analysis, which involved 8362 patients, 2084 (25%) initiated therapy at a CD4+ count of 351 to 500 cells per cubic millimeter, and 6278 (75%) deferred therapy. After adjustment for calendar year, cohort of patients, and demographic and clinical characteristics, among patients in the deferred-therapy group there was an increase in the risk of death of 69%, as compared with that in the early-therapy group (relative risk in the deferred-therapy group, 1.69; 95% confidence interval [CI], 1.26 to 2.26; P<0.001). In the second analysis involving 9155 patients, 2220 (24%) initiated therapy at a CD4+ count of more than 500 cells per cubic millimeter and 6935 (76%) deferred therapy. Among patients in the deferred-therapy group, there was an increase in the risk of death of 94% (relative risk, 1.94; 95% CI, 1.37 to 2.79; P<0.001). CONCLUSIONS The early initiation of antiretroviral therapy before the CD4+ count fell below two prespecified thresholds significantly improved survival, as compared with deferred therapy.

Complete Cytoreduction Offers Longterm Survival in Patients with Peritoneal Carcinomatosis from Appendiceal Tumors of Unfavorable Histology

BACKGROUND Cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) is a rapidly evolving treatment for metastatic appendiceal neoplasms. The aim of this study was to show the effect of complete cytoreduction (CC) on survival in patients undergoing CRS and HIPEC for high-grade appendiceal neoplasm. STUDY DESIGN A retrospective study of a prospective database of 56 patients (from 1999 to 2007) with appendiceal neoplasms treated with CRS and HIPEC was carried out. Histology of the disease, CC score, and peritoneal cancer index (PCI) score were assessed independently and collectively for each group of patients. Survival analysis was performed using the Cox proportional hazard model. RESULTS Three-year overall survival was 60%. The median peritoneal cancer index score was 25 or higher. Survival analysis by tumor histology was 80% for patients with low-grade tumors and 52% for patients with high-grade tumors (p = 0.024). Survival by completeness of cytoreduction was 78% for patients with a low CC score (0 to 1) and 28% in patients with a high CC score (2 to 3; p = 0.01). There was no statistically significant difference in survival between the low-grade and high-grade tumors when a complete cytoreduction was performed in both groups of patients: 80% versus 68% (p = 0.69). CONCLUSIONS CRS and HIPEC is an effective treatment for patients with disseminated appendiceal tumors. High-grade tumors also benefit from this approach and should not be excluded from CRS and HIPEC. Every effort should be made to achieve a complete cytoreduction regardless of the tumor histology.

Do high-resolution CT findings of usual interstitial pneumonitis obviate lung biopsy? : Views of pulmonologists

Background: High-resolution CT (HRCT) of the lungs has become an essential component to evaluate patients with diffuse lung disease. Little is known, however, about the current practices of pulmonologists caring for patients with these complex conditions, and, in particular, whether HRCT can obviate the need for surgical lung biopsy. Objectives: To investigate the practices of pulmonologists concerning the acceptability of a HRCT diagnosis in lieu of lung biopsy in diffuse lung disease. Methods: We asked practicing pulmonologists among membership of the American College of Chest Physicians whether HRCT results could replace lung biopsy in 16 diffuse lung diseases. Responses were examined in light of published evidence, practice guidelines, and certain practice parameters. Results: Two hundred and thirty (52.6%) of 437 eligible physicians responded. Sixty-seven percent (67%) of respondents accepted HRCT diagnosis for idiopathic pulmonary fibrosis/usual interstitial pneumonia (IPF/UIP) despite their awareness of guidelines recommending histological diagnosis. Most would not accept a radiologic diagnosis for lymphangioleiomyomatosis (LAM; 37%) or eosinophilic granuloma (Langerhans’ cell histiocytosis, LCH; 19%), even though CT findings are frequently characteristic. Responses were similar by type of clinical practice and recency of fellowship training. Chest physicians who referred patients for HRCT more frequently were more likely to accept HRCT diagnosis (p = 0.008) and those who had higher self-ratings of proficiency in reading HRCT (p = 0.004) were more likely to believe HRCT often suggests specific diagnosis. Conclusions: Most US pulmonologists will accept an HRCT diagnosis of IPF/UIP without lung biopsy, but are reluctant to do so for most other diffuse lung conditions including LAM and LCH.

Are Physician Estimates of Asthma Severity Less Accurate in Black than in White Patients

BackgroundRacial differences in asthma care are not fully explained by socioeconomic status, care access, and insurance status. Appropriate care requires accurate physician estimates of severity. It is unknown if accuracy of physician estimates differs between black and white patients, and how this relates to asthma care disparities.ObjectiveWe hypothesized that: 1) physician underestimation of asthma severity is more frequent among black patients; 2) among black patients, physician underestimation of severity is associated with poorer quality asthma care.Design, Setting and PatientsWe conducted a cross-sectional survey among adult patients with asthma cared for in 15 managed care organizations in the United States. We collected physicians’ estimates of their patients’ asthma severity. Physicians’ estimates of patients’ asthma as being less severe than patient-reported symptoms were classified as underestimates of severity.MeasurementsFrequency of underestimation, asthma care, and communication.ResultsThree thousand four hundred and ninety-four patients participated (13% were black). Blacks were significantly more likely than white patients to have their asthma severity underestimated (OR = 1.39, 95% CI 1.08–1.79). Among black patients, underestimation was associated with less use of daily inhaled corticosteroids (13% vs 20%, p < .05), less physician instruction on management of asthma flare-ups (33% vs 41%, p < .0001), and lower ratings of asthma care (p = .01) and physician communication (p = .04).ConclusionsBiased estimates of asthma severity may contribute to racially disparate asthma care. Interventions to improve physicians’ assessments of asthma severity and patient–physician communication may minimize racial disparities in asthma care.

The Asthma Control and Communication Instrument: A clinical tool developed for ethnically diverse populations

BACKGROUND Lower levels of quality asthma care among racially diverse populations might be due to inaccurate disease status assessments. The Asthma Control and Communication Instrument (ACCI) is a new tool that captures patient report of disease status during routine care. OBJECTIVE We sought to test the ACCIs psychometric properties in a racially diverse population. METHODS We performed a cross-sectional study. Subjects were recruited from specialist and generalist urban outpatient clinics. The ACCI and measures of asthma control, quality of life, lung function, and specialist rating of asthma status were collected. Four ACCI domains were separately validated: Acute Care, Bother, Control, and Direction. Principal component analysis, internal consistency, concurrent, discriminative, known-groups validity, and accuracy were evaluated. RESULTS Two hundred seventy asthmatic patients (77% female subjects, 55% black) participated. ACCI Control domain internal consistency was 0.80. ACCI Bother, Control, and Direction domains showed strong concurrent validity with asthma control and quality-of-life measures (all P < .001). ACCI Acute Care and Direction domains showed strong concurrent validity with individual validation items (all P < .001). The ACCI Control domain discriminated clinically important levels of disease status measured by asthma control, quality of life (both P < .001), and percent predicted peak expiratory flow rate (P = .005) and was associated with specialist rating of disease status (P < .001), confirming known-groups validity. The accuracy of the ACCI Control domain in classifying patients with uncontrolled asthma was very good (area under the curve, 0.851; 95% CI, 0.742-0.95870). Results were similar for both black and white subjects. CONCLUSION The ACCI is a promising clinical tool that measures asthma disease status during routine health care and is valid for use in both black and white populations.

Patient Factors Used by Pediatricians to Assign Asthma Treatment

OBJECTIVE. Although asthma is often inappropriately treated in children, little is known about what information pediatricians use to adjust asthma therapy. The purpose of this work was to assess the importance of various dimensions of patient asthma status as the basis of pediatrician treatment decisions. PATIENTS AND METHODS. We conducted a cross-sectional, random-sample survey, between November 2005 and May 2006, of 500 members of the American Academy of Pediatrics using standardized case vignettes. Vignettes varied in regard to (1) acute health care use (hospitalized 6 months ago), (2) bother (parent bothered by the childs asthma status), (3) control (frequency of symptoms and albuterol use), (4) direction (qualitative change in symptoms), and (5) wheezing during physical examination. Our primary outcome was the proportion of pediatricians who would adjust treatment in the presence or absence of these 5 factors. RESULTS. Physicians used multiple dimensions of asthma status other than symptoms to determine treatment. Pediatricians were significantly more likely to increase treatment for a recently hospitalized patient (45% vs 18%), a bothered parent (67% vs 18%), poorly controlled symptoms (4–5 times per week; 100% vs 18%), or if there was wheezing on examination (45% vs 18%) compared with patients who only had well-controlled symptoms. Pediatricians were significantly less likely to decrease treatment for a child with well-controlled symptoms and recent hospitalization (28%), parents who reported being bothered (43%), or a child whose symptoms had worsened since the last doctor visit (10%) compared with children with well-controlled symptoms alone. CONCLUSIONS. Pediatricians treat asthma on the basis of multiple dimensions of asthma status, including hospitalization, bother, symptom frequency, direction, and wheezing but use these factors differently to increase and decrease treatment. Tools that systematically assess multiple dimensions of asthma may be useful to help further improve pediatric asthma care.

Utility of high-resolution CT for management of diffuse lung disease: results of a survey of U.S. pulmonary physicians.

RATIONALE AND OBJECTIVES This study was performed to determine how U.S. pulmonologists rate the clinical contributions of high-resolution computed tomography (CT) in patients with diffuse lung disease, to ascertain how the technique affects management decisions, and to determine the effect of three physician characteristics on these attitudes. MATERIALS AND METHODS The authors surveyed 450 practicing pulmonologists. The questionnaire explored perceptions of the efficacy of high-resolution CT for achieving five clinical objectives, the importance of high-resolution CT in 17 diseases, and the effects of the CT results on management decisions. Responses were examined by type of clinical practice, monthly referral volume, and year of completion of pulmonary fellowship. RESULTS The response rate was 52.6%. High-resolution CT was rated most helpful for determining the extent of diffuse lung disease and least helpful for assessing disease activity and prognosis. Pulmonologists believed that high-resolution CT was most important in the idiopathic interstitial pneumonias and least important in Pneumocystis carinii pneumonia and emphysema. High-resolution CT results frequently increased the physicians confidence in a presumptive diagnosis. Recently trained pulmonologists were more likely to report that high-resolution CT results altered their management plan. There were no significant differences related to type of practice. CONCLUSION U.S. pulmonologists in a variety of practice settings value the contributions of high-resolution CT in patients with diffuse lung disease and find it particularly important in the chronic interstitial pneumonias. High-resolution CT results have their greatest effect in confirming a presumptive clinical diagnosis and less frequently alter the management plan.