Umur Hatipoğlu

Inflammation and Obstructive Sleep Apnea Syndrome Pathogenesis: A Working Hypothesis

Obstructive sleep apnea syndrome (OSAS) afflicts about 5% of adults in Western countries and is thought to play an important role in the pathogenesis of cardiovascular disorders and diabetes mellitus. Although the etiology of OSAS is uncertain, intense local and systemic inflammation are present in these patients. In the upper airway, this process may promote oropharyngeal inspiratory muscle dysfunction and amplify upper airway narrowing and collapsibility thereby worsening the frequency and duration of apneas during sleep. The presence of systemic inflammation, characterized by elevated levels of certain potent pro-inflammatory mediators, such as C-reactive protein, leptin, TNF-α, IL-1β, IL-6, reactive oxygen species and adhesion molecules, may predispose to the development of cardiovascular complications observed in patients with OSAS. Treatment with nasal CPAP abrogates, in part, local and systemic inflammation in these patients. Whether therapeutic interventions aimed at abating inflammation could be a useful adjunct in the treatment of OSAS merits further investigation.

Sterically stabilized phospholipids attenuate human neutrophils chemotaxis in vitro

The purpose of this study was to determine whether sterically stabilized liposomes (SSL) and poly(ethylene glycol)-distearoylphosphatidylethanolamine (PEG-DSPE) attenuate polymorphonuclear neutrophils (PMNs) chemotaxis in vitro and, if so, whether incorporation of vasoactive intestinal peptide (VIP), a pleiotropic neuropeptide, on the surface of SSL amplifies SSL-induced responses. Using a modified blind-well chamber chemotaxis assay, we found that N-formyl-methionyl-leucyl-phenylalanine (FMLP; 0.1 microM) and zymosan opsonized with purified human complement (2 x 10(9) yeast wall particles/ml) elicit significant human PMNs chemotaxis (95+/-9 and 103+/-3 cells/high power field; p<0.05). These effects are significantly attenuated by SSL and PEG-DSPE (p<0.05). By contrast, aqueous VIP and VIP on SSL have no significant effects on FMLP- and zymosan-induced responses. We conclude that certain sterically stabilized liposomes and phospholipids attenuate human PMNs chemotaxis in vitro and that VIP does not modulate this response.

Utilization of Thoracic Ultrasound for Confirmation of Central Venous Catheter Placement and Exclusion of Pneumothorax: A Novel Technique in Real-Time Application

Aim: To evaluate the safety and utility of ultrasonography as a tool to confirm central venous catheter (CVC) position and to exclude insertion-related pneumothorax in place of chest radiography (CXR) in a tertiary medical intensive care unit (ICU). Methods: We randomized 60 consecutive medical ICU patients to conventional or ultrasound groups for CVC placement. Both groups had CVCs inserted under ultrasound guidance. The intervention group underwent real-time transthoracic echocardiography to assist in catheter positioning and chest ultrasonography for exclusion of pneumothorax. Our primary end point was reduction in CXR use. The secondary end point was time elapsed from the end of procedure to the availability of CVC for use. χ2 test was used to compare the 2 groups for the primary end point. T test was used to compare the 2 groups for the secondary end point. Results: Thirty patients were randomized to the conventional group and 30 were randomized to the ultrasound group. One patient was excluded in the control group since the procedure needed to be aborted. Patient characteristics were well matched for age, body mass index, and acute physiologic assessment and chronic health evaluation (APACHE III) scores. There was a 56.7% (P < .0001) reduction in CXR use in the ultrasound arm. Mean time to use was 53.6 minutes in the control group and 25 minutes in the ultrasound arm (P = .0015). Mean time required to complete the procedure was 27.7 minutes in the control group and 24.1 minutes in the ultrasound group (P = .2053). No pneumothorax was detected in either arm. Conclusion: Ultrasound-guided CVC placement and positioning with a minor modification in technique reduced the use of bedside CXR and reduced the time to use of the CVC.

Predicting 30-Day All-Cause Readmission Risk for Subjects Admitted With Pneumonia at the Point of Care

BACKGROUND: The pneumonia 30-d readmission rate has been endorsed by the National Quality Forum as a quality metric. Hospital readmissions can potentially be lowered by improving in-hospital care, transitions of care, and post-discharge disease management programs. The purpose of this study was to create an accurate prediction model for determining the risk of 30-d readmission at the point of discharge. METHODS: The model was created using a data set of 1,295 hospitalizations at the Cleveland Clinic Main Campus with pneumonia over 3 y. Candidate variables were limited to structured variables available in the electronic health record. The final model was compared with the Centers for Medicare and Medicaid Services (CMS) model among subjects 65 y of age and older (n = 628) and was externally validated. RESULTS: Three hundred thirty subjects (25%) were readmitted within 30 d. The final model contained 13 variables and had a bias-corrected C statistic of 0.74 (95% CI 0.71–0.77). Number of admissions in the prior 6 months, opioid prescription, serum albumin during the first 24 h, international normalized ratio and blood urea nitrogen during the last 24 h were the predictor variables with the greatest weight in the model. In terms of discriminative performance, the Cleveland Clinic model outperformed the CMS model on the validation cohort (C statistic 0.69 vs 0.60, P = .042). CONCLUSIONS: The proposed risk prediction model performed better than the CMS model. Accurate readmission risk prediction at the point of discharge is feasible and can potentially be used to focus post-acute care interventions in a high-risk group of patients.

Impact of a Post-Discharge Integrated Disease Management Program on COPD Hospital Readmissions

BACKGROUND: Readmission following a hospitalization for COPD is associated with significant health-care expenditure. METHODS: A multicomponent COPD post-discharge integrated disease management program was implemented at the Cleveland Clinic to improve the care of patients with COPD and reduce readmissions. This retrospective study reports our experience with the program. Groups of subjects who were exposed to different components of the program were compared regarding their readmission rates. Multivariate logistic regression analysis was performed to build predictive models for 30- and 90-d readmission. RESULTS: One hundred sixty subjects completed a 90-d follow-up, of which, 67 attended the exacerbation clinic, 16 subjects received care coordination, 51 subjects completed both, and 26 subjects did not participate in any component despite referral. Thirty- and 90-d readmission rates for the entire group were 18.1 and 46.2%, respectively. Thirty- and 90-d readmission rates for the individual groups were: exacerbation clinic, 11.9 and 35.8%; care coordination, 25.0 and 50.0%; both, 19.6 and 41.2%; and neither, 26.9 and 80.8%, respectively. The model with the best predictive ability for 30-d readmission risk included the number of hospitalizations within the previous year and use of noninvasive ventilation (C statistic of 0.84). The model for 90-d readmission risk included receiving any component of the post-discharge integrated disease management program, the number of hospitalizations, and primary care physician visits within the previous year (C statistic of 0.87). CONCLUSIONS: Receiving any component of a post-discharge integrated disease management program was associated with reduced 90-d readmission rate. Previous health-care utilization and lung function impairment were strong predictors of readmission.