Junji Kumasawa

Comparative Effectiveness of Multivessel Coronary Artery Bypass Graft Surgery and Multivessel Percutaneous Coronary Intervention

TO THE EDITOR: Although we commend Hlatky and colleagues (1) for their attempts to assess the clinical characteristics that could modify the comparative effectiveness of coronary artery bypass graft (CABG) surgery versus percutaneous coronary intervention (PCI) in an unselected general population, the limitation of propensity score analysis when several unmeasured confounding factors are present should be emphasized. As the authors mentioned, medication and smoking status are critical confounding factors; however, there are several other unmeasured critical confounding factors, such as severe aortic calcification, immunosuppression, and systemic infection. McNulty and associates (2) explicitly identified that these factors contributed to the ineligibility for CABG in more than 50% of patients having PCI for left main coronary artery disease, and ineligible patients have a 5-fold risk for death compared with eligible patients. Thus, the association of reduced risk for death with CABG versus PCI would be overestimated by such residual confounding factors. Stukel and coworkers (3) reported that propensity score analysis could not reduce bias due to unmeasured confounding factors when such confounding was strong. They estimated the effectiveness of invasive cardiac management on the mortality rate among patients with acute myocardial infarction and showed a greater reduction in risk for death when using propensity score analysis than when using instrumental variable methods. If possible, Hlatky and colleagues should estimate average treatment effectiveness by using the instrumental variable method as a sensitivity analysis. The regional rate of performing CABG can be used as an instrumental variable as the regional cardiac catheterization rate was used in Stukel and coworkers’ study.

Erratum to: The cardiothoracic ratio and all-cause and cardiovascular disease mortality in patients undergoing maintenance hemodialysis: results of the MBD-5D study

In the original publication, under Abstract, in Results section, the sentence ‘‘Exploratory analysis .... binder.’’ should read as: ‘‘Exploratory analysis revealed that there were relationships between CTR and age, sex, body mass index, comorbidity of CVD, dialysis duration and intact parathyroid hormone, phosphorus, hemoglobin, and usage of phosphate binder’’. Under Results, in Exploratory analysis investigating the relationship between CTR and covariates section the sentence ‘‘Multivariable regression .... binder (Table 4).’’ should read as: ‘‘Multivariable regression analysis showed that there were relationships between CTR and age, sex, BMI, comorbidity of CVD, dialysis duration and level of iPTH, phosphorus, hemoglobin, and usage of phosphate binder (Table 4)’’. In Table 4, one row (Diabetes mellitus comorbidity) was duplicated and a row (Dialysis duration) was not included. The corrected Table 4 is given in this Erratum.

Effects of non-invasive ventilation in patients with acute respiratory failure excluding post-extubation respiratory failure, cardiogenic pulmonary edema and exacerbation of COPD: a systematic review and meta-analysis

BackgroundThis meta-analysis compared the effects of non-invasive ventilation (NIV) with invasive mechanical ventilation (InMV) and standard oxygen (O2) therapy on mortality and rate of tracheal intubation in patients presenting acute respiratory failure (ARF).MethodsWe searched the MEDLINE, EMBASE and Cochrane Central Register of clinical trials databases between 1949 and May 2015 to identify randomized trials of NIV for ARF. We excluded the ARF caused by extubation, cardiogenic pulmonary edema, and COPD.ResultsThe meta-analysis included 21 studies and 1691 patients, of whom 846 were assigned to NIV and 845 to control (InMV or standard O2 therapy). One hundred ninety-one patients (22.6%) in the NIV group and 261 patients (30.9%) in the control group died before discharge from hospital. The pooled odds ratio (OR) for short-term mortality (in-hospital mortality) was 0.56 (95% CI 0.40–0.78). When comparing NIV with standard O2 therapy, the short-term mortality was 155 (27.4%) versus 204 (36.0%), respectively. For this comparison, the pooled OR of short-term mortality was 0.56 (95% CI 0.36–0.85). When comparing NIV with InMV, the short-term mortality was 36 (12.9%) versus 57 (20.5%) patients, respectively. For this comparison, the pooled OR of short-term mortality was 0.56 (95% CI 0.34–0.90). Tracheal intubation was performed in 106 patients (22.7%) in the NIV and in 183 patients (39.4%) in the standard O2 group, representing a pooled OR of 0.37 (95% CI 0.25–0.55). There were publication biases and the quality of the evidence was graded as low.ConclusionCompared with standard O2 therapy or InMV, NIV lowered both the short-term mortality and the rate of tracheal intubation in patients presenting with ARF.

Detecting central-venous oxygen desaturation without a central-venous catheter: Utility of the difference between invasively and noninvasively measured blood pressure ☆ ☆☆ ☆☆☆ ★

OBJECTIVE The objective was to determine whether central-venous oxygen saturation (ScvO2<70%) can be detected from the difference between invasively and noninvasively measured systolic blood pressure (BP) (ie, ΔBP defined as arterial BP minus noninvasive BP). METHODS This is a cross-sectional study at a single medical and surgical intensive care unit in Japan. All hypotensive patients admitted to intensive care unit were eligible. Arterial BP was measured via a radial-artery catheter, and noninvasive BP on the same side was measured via a brachial cuff. ScvO2 was measured by gas analysis of blood sampled from a central-venous chatheter (CVC). We calculate the area under the curve for ΔBP as an indicator of ScvO2<70%. RESULTS Usable data were obtained from the records of 111 patients. The median and interquartile range of ΔBP and ScvO2 were -4mm Hg (-11, 6) and 67% (60.9, 73.9), respectively. The area under the curve of ΔBP as an indicator of ScvO2<70% was 0.81 (95% confidence interval [CI], 0.73-0.89). With a cutoff ΔBP of 0, sensitivity was 65.7% (95% CI, 53.1-76.8), specificity was 97.7% (95% CI, 88.0-99.8), and positive predictive value was 97.8 (95% CI, 88.2-99.9). CONCLUSIONS ΔBP can indicate whether ScvO2 is lower than 70%. When that difference is greater than 0, ScvO2 is very likely to be lower than 70%.

Does Influence of Maternal Smoking on Childhood Asthma Differ by Age and Personal Smoking Habit

We thank Dr Horita and colleagues for their interest in our article in CHEST. We agree with their views that adjunctive corticosteroid treatment may be indicated for severe community-acquired pneumonia (CAP) because of its beneficial effects on the length of hospital stay, the length of time to clinical stability, and the risk of acute respiratory distress syndrome. Allowing for the risk of infection escalation due to corticosteroid use before effective antimicrobial drugs are administered, and the negative results of early meta-analyses, current guidelines do not recommend the use of corticosteroids in CAP. More recently, with the publication of large-size randomized trials and meta-analyses, some benefits of corticosteroids have been found in the management of CAP, especially in patients with severe CAP.

156: WHAT IS ASSOCIATED WITH THE DISCREPANCY BETWEEN NIBP AND IBP?

than in patients with LVEF ≥40% (P <0.05). CFI had a better ability than cardiac output to detect cardiac dysfunction (LVEF <40%) (Area under the curve: 0.85 ± 0.02; P <0.001). A CFI value of <4.2 min-1 had a sensitivity of 82% and specificity of 84% for detecting LVEF <40%. The CFI <4.2 min-1 was associated with delayed cerebral ischemia (DCI) (odds ratio [OR], 2.14; 95% confidence interval [CI], 1.33-2.86; P = 0.004) and poor 3-month functional outcome on modified Rankin Scale of 4-6 (OR, 1.87; 95% CI, 1.06-3.29; P = 0.02). An ELWI >14 mL/kg after day 4 increased the risk of poor functional outcome at 3-month follow-up (OR, 2.10; 95% CI, 1.11-3.97; P = 0.04). Conclusions: Prolonged cardiac dysfunction and pulmonary edema increased the risk of DCI and poor 3-month functional outcome in patients with SAH suffering from TCM. Serial measurements of CFI and ELWI by transpulmonary thermodilution may provide an easy bedside method of detecting early changes of the cardiopulmonary function in directing proper post-SAH treatment.