Chest 2015


1. Chest. 2015 Sep 10. doi: 10.1378/chest.15-0666. [Epub ahead of print]

Prediction of Mortality in Pulmonary Embolism Based on Left Atrial Volume
Measured on CT Pulmonary Angiography.

Aviram G, Soikher E, Bendet A, Shmueli H, Ziv-Baran T, Amitai Y, Friedensohn L,
Berliner S, Meilik A, Topilsky Y.

BACKGROUND: Preliminary reports suggest that a small left atrium (LA) is
associated with severe acute pulmonary embolisms (PE). This study used data
derived from volumetric analyses of computerized tomographic pulmonary
angiography (CTPA) to investigate whether a reduced LA volume can predict adverse
outcome in a large series of patients with acute PE.
METHODS: We retrospectively analyzed 756 consecutive patients diagnosed with
acute PE by non-gated CTPA between 1/2007-12/2010. Each CTPA was investigated
with volumetric analysis software which automatically provides the volumes of the
LA, right atrium (RA), right ventricle (RV), and left ventricle (LV). A
classification tree divided the cardiac chamber volumes and ratios into
categories according to mortality. Cox regression assessed the association
between these categories and 30-day mortality after adjustment for age, gender
and clinical background.
RESULTS: The final study group consisted of 636 patients who had successful
volumetric segmentation and complete outcome data. Eighty-four patients (13.2%)
died within 30 days of PE diagnosis. There was a higher mortality rate among
patients with an LA volume ≤62 ml compared to those with LA volume >62 ml (19.6% 
vs 8.9%, respectively, hazard ratio [HR]=2.44, P < .001), an LV volume ≤67 ml
(16.4% vs 8.3%, HR=1.8, P = .024) and an RA/LA volume ratio >1.2 (17% vs 9.4%,
HR=2.1, P = .002). A reduced LA volume was the best predictor of adverse outcome.
CONCLUSIONS: Decreased LA volume is associated with higher mortality and is the
first among the various cardiac compartments to predict mortality in patients
with acute PE.

PMID: 26356029  [PubMed - as supplied by publisher]

2. Chest. 2015 Oct 22. doi: 10.1378/chest.15-1733. [Epub ahead of print]

Efficacy and Safety of Corticosteroids for Community-Acquired Pneumonia: A
Systematic Review and Meta-Analysis.

Wan YD, Sun TW, Liu ZQ, Zhang SG, Wang LX, Kan QC.

Background: Corticosteroids are an option in the treatment of community-acquired
pneumonia (CAP). However, the benefits and adverse effects of corticosteroids,
especially in severe CAP, have not been well assessed.
Methods: Pubmed, Embase, and Cochrane library databases from inception to May
2015 were searched. Randomized controlled trials (RCTs) and cohort studies that
evaluated use of corticosteroids in adult patients with CAP were included. The
quality of outcomes was evaluated using GRADE methodology. The Mantel-Haenszel
method with random-effects modeling was used to calculate pooled relative risks
(RRs) and 95% confidence intervals(CIs).
Results: Nine eligible RCTs (1667 patients) and six cohort studies(4095
patients), were identified. The mean corticosteroid dose and treatment duration
were 30 mg/day methylprednisolone for 7 days. Corticosteroids did not have a
statistically significant effect on mortality (RR, 0.72; 95% CI: 0.43-1.21;
evidence rank: low) in CAP patients, and severe CAP patients (RCTs; RR, 0.72; 95%
CI: 0.43-1.21; evidence rank: low; cohort studies; RR, 1.00; 95% CI, 0.86-1.17 ).
Corticosteroids treatment was associated with an decreased risk of adult
respiratory distress syndrome (RR, 0.21; 95% CI, 0.08-0.59), and may reduce the
lengths of hospital and intensive care unit stay, the duration of intravenous
antibiotic treatment, and the time to clinical stability. Corticosteroid were not
associated with increased rates of adverse events.
Conclusions: Short-term treatment with corticosteroids is safe, and may reduce
the risk of adult respiratory distress syndrome, shorten the length of the
disease in CAP patients.

PMID: 26501852  [PubMed - as supplied by publisher]

3. Chest. 2015 Nov 5. doi: 10.1378/15-2065. [Epub ahead of print]

Children with chronic wet or productive cough - treatment and investigations: a
systematic review.

Chang AB, Oppenheimer JJ, Weinberger M, Rubin BK, Irwin RS.

Background: We undertook systematic reviews to examine key questions (KQs)
related to pediatric chronic wet cough. In children with chronic (>4-weeks)
wet/productive cough not related to bronchiectasis; (KQ1)-how effective are
antibiotics in improving the resolution of cough? If so, what and for how long?
and; (KQ2)-when should they be referred for further investigations?
Methods: We used the CHEST expert cough panel's protocol. Two authors screened
searches, selected and extracted data. Systematic reviews, randomized controlled
trials (RCTs), cohort (prospective and retrospective) and cross-sectional studies
published in English were included.
Results: Data were presented in PRISMA flowcharts and summaries tabulated.
Fifteen studies were included in KQ1 (systematic reviews=3, RCTs=3, prospective
studies=5, retrospective studies=4) and 17 in KQ2 (RCT=1, prospective=11,
retrospective=5). Combining data from RCTs (KQ1), the number needed to treat for
benefit was 3 (95%CI 2.0-4.3) in achieving cough resolution. In general, findings
from prospective and retrospective studies were consistent but there were minor
Conclusion: There is high quality evidence that in children aged ≤14-years with
chronic (>4-weeks duration) wet or productive cough, the use of appropriate
antibiotics improves cough resolution. There is also high quality evidence that
when specific cough pointers (e.g. digital clubbing) are present in children with
wet cough, further investigations (e.g. flexible bronchoscopy, chest CTs and
immunity tests) should be undertaken. When the wet cough does not improve by
4-weeks of antibiotics, there is moderate quality evidence that children should
be referred to a major center for consideration of further investigations to
determine whether an underlying lung or other disease are present.

PMID: 26539649  [PubMed - as supplied by publisher