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ABSTRACT: Guidelines recommend detection of early chronic obstructive pulmonary disease (COPD), but evidence on the diagnostic work-up for COPD only concerns advanced and established COPD.
To quantify the accuracy of symptoms and signs for early COPD, and the added value of C-reactive protein (CRP), in primary care patients presenting with cough.
Cross-sectional diagnostic study of 73 primary care practices in the Netherlands Method: Four hundred primary care patients (182 males, mean age 63 years) older than 50 years, presenting with persistent cough (>14 days) without established COPD participated, of whom 382 completed the study. They underwent a systematic diagnostic work-up of symptoms, signs, conventional laboratory CRP level, and hospital lung functions tests, including body plethysmography, and an expert panel decided whether COPD was present (reference test). The independent value of all items was estimated by multivariable logistic regression analysis.
According to the expert panel, 118 patients had COPD (30%). Symptoms and signs with independent diagnostic value were age, sex, current smoking, smoking more than 20 pack-years, cardiovascular comorbidity, wheezing complaints, diminished breath sounds, and wheezing on auscultation. Combining these items resulted in an area under the receiver operating characteristic curve (ROC area) of 0.79 (95% confidence interval = 0.74 to 0.83) after internal validation. The proportion of subjects with elevated CRP was higher in those with early COPD, but CRP added no relevant diagnostic information above symptoms and signs.
In subjects presenting with persistent cough, the CRP level has no added value for detection of early COPD.
British Journal of General Practice 09/2012; 62(602):632-8. · 1.83 Impact Factor
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ABSTRACT: Acute asthma severity scores facilitate assessment and implementation of timely and appropriate therapy for pediatric patients but are complex and challenging for clinicians to use at the bedside.
To assess whether a simple, bedside acute asthma severity score comprising 3 standard clinical measures performs as well as more comprehensive asthma scores.
We prospectively enrolled participants 5 to 17 years of age with acute asthma exacerbations. We recorded 3 asthma scores at baseline and after 2 hours of treatment: the Pediatric Asthma Severity Score (PASS), the Pediatric Respiratory Assessment Measure (PRAM), and the RAD score (Respiratory rate; Accessory muscle use; Decreased breath sounds). We assessed each score for criterion validity in predicting baseline percent forced expiratory volume in 1 second (%FEV(1)) and for responsiveness in predicting change of %FEV(1) after 2 hours of treatment using multiple linear regression models adjusted for age, race, sex, and Global Initiative for Asthma chronic control.
Of 536 participants included for analyses, median age was 8.8 years, 60% were male, and 58% were African American. The 3 acute asthma scores demonstrated similar criterion validity to explain variation of baseline %FEV(1) (R(2): 0.434 [PASS]; 0.462 [PRAM]; 0.426 [RAD]), but none demonstrated clinically significant responsiveness to change in %FEV(1) (R(2): 0.109 [PASS]; 0.106 [PRAM]; 0.139 [RAD]).
The RAD score, comprising 3 routinely measured bedside clinical parameters, is a simple and easily used instrument for assessing the severity of an acute asthma exacerbation and has comparable criterion validity and improved responsiveness when compared with 2 more complex acute asthma scores.
Annals of allergy, asthma & immunology: official publication of the American College of Allergy, Asthma, & Immunology 07/2011; 107(1):22-8. · 2.83 Impact Factor
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Anesthesiology 03/2011; 114(3):485-7. · 5.36 Impact Factor
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ABSTRACT: Treatment of surgical patients in intensive care unit (ICU) comes along with major disadvantages, which have to be justified by some acceptable short- and long-term outcomes. Short-term effects of treatment in ICU have been well-documented. The aims of this study were to quantify the long-term survival of more than 10 years' follow-up of a large cohort of patients admitted to a surgical ICU and to investigate the effects of age, gender, and underlying disease on this long-term survival.
Of all surgical patients admitted to the ICU of the St Elisabeth Hospital between 1995 and 2000, patient characteristics, disease category, APACHE II score, and survival were prospectively registered. A follow-up with a mean of 8 years after discharge was achieved. The independent association of multiple covariates was done using cox proportional hazard analysis.
Of the 1822 patients included, 936 (51%) had died within 11 years and 52 patients were lost to follow-up. Overall ICU and in-hospital mortality were 11% and 16%, respectively. Age, gender, APACHE II score, the need for dialysis, and surgical classification were independently associated with long-term survival. Mortality increased with age of admittance to the ICU (hazard ratio, 1.058), whereas female patients had a lower chance to die (hazard ratio, 0.793). However, the preadmission disease did not influence long-term outcome. Long-term mortality rates in various surgical classification groups varied between 29% for trauma and 80% for gastrointestinal patients. In gastrointestinal, oncological, general surgical, and/or high-aged patients, a negative effect on mortality persisted beyond 5 years. The mortality ratio was increased twofold in comparison to the general population (51% vs 27%).
Ten years after ICU discharge, survival was only 50%. After ICU treatment, survival follows distinct patterns in which age, gender, surgical classification, the need of dialysis, and APACHE II score are independent determinants, and long lasting.
Annals of surgery 01/2011; 253(1):151-7. · 7.90 Impact Factor
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ABSTRACT: In drug development, clinical medicine, or health policy making, basing one's decisions on a selective part of the available evidence can pose a major threat to the health of patients and the society. If, for example, primarily positive research reports are taken into account, one could wrongfully conclude that a harmful drug is safe. The systematic error introduced by summarizing evidence that is not representative of the available evidence is commonly referred to as "publication bias." Some, however, prefer other terms to refer to the same concept. In this article, we explore the terminology and concepts relevant to this bias and propose a more systematic nomenclature than what is currently used.
Journal of clinical epidemiology 12/2010; 64(5):459-62. · 2.96 Impact Factor
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ABSTRACT: Several experimental studies have suggested that early exposure to anesthetic agents, i.e., before completion of synaptogenesis, can result in widespread apoptotic neuronal degeneration and late cognitive impairment, but human data are lacking. The authors performed a retrospective pilot study to test the feasibility and calculate sample sizes for a larger epidemiologic study of disturbed neurobehavioral development as a function of age at the time of first anesthetic exposure. Pediatric urological procedures were selected because the timing of surgery depends mainly on the age at which a diagnosis is made.
Neurobehavioral development was assessed using the validated 120-item parental Child Behavior CheckList/4-18 in 314 children who were operated for pediatric urological procedures between the ages of 0 and 6 yr.
Of 243 questionnaires returned, the total problem score was clinically deviant in 41 (23%) of children aged less than 24 months at the time of first surgery and 13 (20%) aged greater than 24 months. Crude and adjusted odds ratios for a clinically deviant Child Behavior CheckList/4-18 score increased with younger age at the time of surgery, but the confidence intervals were very wide. Adjusted odds ratio was 1.38 (0.59-3.22) when operated at age less than 6 months, 1.19 (0.45-3.18) when operated between 6 and 12 months of age, and 1.20 (0.45-3.20) when operated between 12 and 24 months (using operated at greater than 24 months of age as reference category). A properly powered cohort study would require at least 2,268 children.
Children undergoing urologic surgery at age less than 24 months showed more behavioral disturbances than children in whom surgery was performed after age 2 yr, although the results were not statistically significant. To confirm or refute an effect of anesthesia on cognitive development, at least 2,268 children need to be studied. With retrospective study designs, residual confounding remains an issue that can only be solved in prospective randomized studies.
Anesthesiology 05/2009; 110(4):805-12. · 5.36 Impact Factor
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ABSTRACT: Background: Several experimental studies have suggested that early exposure to anesthetic agents, i.e., before completion of synaptogenesis, can result in widespread apoptotic neuronal degeneration and late cognitive impairment, but human data are lacking. The authors performed a retrospective pilot study to test the feasibility and calculate sample sizes for a larger epidemiologic study of disturbed neurobehavioral development as a function of age at the time of first anesthetic exposure. Pediatric urological procedures were selected because the timing of surgery depends mainly on the age at which a diagnosis is made.
Anesthesiology 03/2009; 110(4):805-812. · 5.36 Impact Factor
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ABSTRACT: Although cardiovascular magnetic resonance imaging (CMR) is well established, its diagnostic accuracy in identifying chronic heart failure (CHF) in patients with chronic obstructive pulmonary disease (COPD) has not yet been quantified.
Participants were recruited from a cohort of 405 patients aged >or=65 years, with mild to moderate and stable COPD. In this population, 83 (20.5%) patients had a new diagnosis of CHF, all left-sided, established by an expert panel using all available diagnostic information, including echocardiography. In a nested case-control study design, 37 consecutive COPD patients with newly detected CHF (cases) and a random sample of 41 of the remaining COPD patients (controls) received additional CMR measurements. The value of CMR in diagnosing heart failure was quantified using univariable and multivariable logistic modeling in combination with area under the receiver operating characteristic curves (ROC-area).
Combination of CMR measurements of left ventricular ejection fraction, indexed left and right atrial volume, and left ventricular end-systolic dimensions provided high added diagnostic value beyond clinical items (ROC-area 0.91) for identifying CHF. Left-sided measurements of CMR and echocardiography correlated well, including ejection fraction. Right ventricular mass divided by right ventricular end-diastolic volume was higher in COPD patients with CHF than in those without concomitant CHF.
Easily assessable morphologic and volume-based CMR measurements have excellent capacities to identify previously unknown left-sided chronic heart failure in mild to moderate COPD patients. There seems to be an adaptive tendency to concentric right ventricular hypertrophy in COPD patients with left-sided CHF.
American heart journal 10/2008; 156(3):506-12. · 4.65 Impact Factor
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Anesthesiology 11/2007; 107(4):678-9. · 5.36 Impact Factor
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ABSTRACT: The authors assessed the willingness to pay (WTP) for "perfect" prophylactic antiemetics and analgesics in patients who were scheduled to undergo surgery during general anesthesia. Furthermore, they determined whether postoperative experiences of pain and nausea and vomiting (PONV) changed patients' WTP.
Data were collected alongside a randomized clinical trial that investigated the incidence of PONV in patients anesthetized with either inhalation anesthesia or total intravenous anesthesia. A subset of 808 consecutive patients participating in the trial completed WTP questionnaires 1 day before and 2 weeks after surgery. The outcome measure was the maximum amount of money that patients were willing to pay for "perfect" antiemetics and analgesics. Preoperative WTP and individual WTP changes after surgery were analyzed in relation to baseline characteristics and postoperative pain and PONV experiences.
Prevention of postoperative pain was valued higher than prevention of PONV. The median preoperative WTP for analgesics was US dollar 35 (interquartile range, dolalr 7-69) vs. US dollar 17 (interquartile range, dollar 7-69) for antiemetics. Individual WTP changes for antiemetics were not related to PONV experience, whereas severe postoperative pain (numerical rating score > or = 8) was associated with an increase in the WTP for analgesics.
Severe postoperative pain experiences increased patients' WTP for analgesics, but PONV did not increase WTP for antiemetics. The elicited WTP values were lower than those reported in previous studies, which is possibly related to differences in market culture or patients' attitudes toward postoperative pain, nausea, and vomiting.
Anesthesiology 06/2006; 104(5):1033-9. · 5.36 Impact Factor
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ABSTRACT: Preoperative anxiety has been suggested as a predictor of postoperative nausea and vomiting (PONV), but supporting data are lacking. We quantified the added predictive value of preoperative anxiety to established predictors of PONV in 1389 surgical inpatients undergoing various procedures, by using multivariate logistic regression analysis. Investigated predictors were a history of PONV or motion sickness, smoking, sex, age, ethnicity, body mass index, ASA physical status, surgery type, duration of anesthesia, anesthetic technique, and postoperative opioid analgesia. Anxiety was measured by the Spielberger State-Trait Anxiety Inventory and the Amsterdam Preoperative Anxiety and Information Scale. The outcome was the occurrence of PONV in the first 24 h after surgery. The area under the receiver operating characteristic curve of a multivariate (logistic regression) model including sex, age, smoking, history of PONV or motion sickness, surgery type, and anesthetic technique was 0.72 (95% confidence interval, 0.70-0.74). There was a weak but significant association of anxiety with PONV, but the addition of anxiety to the model did not further increase the area under the receiver operating characteristic curve. Therefore, routine preoperative measurement of anxiety does not seem warranted, provided that the other predictors are already considered.
Anesthesia & Analgesia 06/2005; 100(5):1525-32, table of contents. · 3.29 Impact Factor
