- Email: [email protected]
Diet and Exercise-Induced Bronchoconstriction
post-salbutamol methacholine dose shift. Chest 1996; 110: 579 –580
Resource Allocation Issues and Clinical Practice Guidelines To the Editor: In their recent article in CHEST on “Resource Allocation Issues in Recommendations From Clinical Practice Guideline Panels” (January 2006),1 Guyatt and colleagues deliberated on the productive allocation of health-care resources to alternative management strategies. The authors stated, that “the annual cost of clopidogrel for 100 patients might equal the salary of one nurse in the United States, but the salaries of three nurses in Poland.” For the sake of everyone who would like to cite this example, we feel obliged to amend it. The authors cited inaccurate data provided bona fide by one of us (RJ). The appropriate data from the Polish General Statistical Bureau on the average salaries of nurses and the average cost to patients of clopidogrel indicate that the annual cost of clopidogrel for 100 patients would equal the salaries of at least 10 nurses in Poland. We apologize for these misleading statistics that we provided to authors and readers alike. Roman Jaeschke, MD McMaster University Hamilton, ON, Canada Jan Brozek, MD Jagiellonian University School of Medicine Krakow, Poland The authors have no conflict of interest regarding this topic. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal. org/misc/reprints.shtml). Correspondence to: Jan Brozek, CM UJ, Department of Medicine, Skawinska 8, Krakow 31066, Poland; e-mail: [email protected] DOI: 10.1378/chest.130.2.623
References 1 Guyatt G, Baumann M, Pauker S, et al. Addressing resource allocation issues in recommendations from clinical practice guideline panels: suggestions from an American College of Chest Physicians task force. Chest 2006; 129:182–187
Staphylococcus aureus in Community-Acquired Pneumonia To the Editor: We are concerned about the frequencies of bacterial pathogens in patients with culture-positive community-acquired pneumonia (CAP) that were reported by Kollef et al (December 2005).1 Among 2,221 such patients, Staphylococcus aureus was identified in 25.5% of patients, Streptococcus pneumoniae was identified in 16.6% of patients, and Haemophilus influenzae was identified in 16.6% of patients. From November 1999 to October 2003, 668 patients who were hospitalized in our department had a discharge code of pneumonia, chest radiograph infiltrates, and no hospitalization during the preceding month. Among 191 patients (median age, 68 years) with culture-positive CAP (ie, significant bacterial pathogens identified by blood culture [n ⫽ 60] and/or sputum culture), www.chestjournal.org
S pneumoniae was identified in 57% (n ⫽ 109; 46 bacteremic cases), H influenzae was identified in 27% (n ⫽ 51; 3 bacteremic cases), and S aureus was identified in 7.3% (n ⫽ 14; 5 bacteremic cases). This frequency of S aureus is consistent with the level of 2.9% in seven previous studies of hospitalized CAP patients that were summarized by Marrie.2 In our opinion, the frequencies of bacterial pathogens reported by Kollef et al1 are too odd to support the guideline recommendations for CAP. In the pneumonia population in the study by Kollef et al,1 S aureus was the only pathogen that was associated with increased mortality. Among our CAP patients detailed above, death within 30 days occurred in 29% of the 14 patients with S aureus identified (n ⫽ 4; one bacteremic case), compared with 5.1% of the 177 other patients with culture-positive CAP (n ⫽ 9; nine bacteremic cases; p ⫽ 0.009 [Fisher exact test]). Severe necrotizing pneumonia can be caused by S aureus carrying the Panton-Valentine leukocidin gene.3 However, S aureus isolates from three of our patients who died were tested and were negative for the Panton-Valentine leukocidin gene.4 Since S aureus is an uncommon cause of CAP, it does not need to be covered by the empirical CAP treatment. However, the severity associated with S aureus pneumonia reinforces the importance of performing routine blood and respiratory cultures in pneumonia patients. Kristoffer Strålin, MD, PhD Bo So¨derquist, MD, PhD ¨ rebro University Hospital O ¨ rebro, Sweden O Drs, Strålin and So¨derquist have no conflicts of interest to disclose. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal. org/misc/reprints.shtml). Correspondence to: Kristoffer Strålin, MD, PhD, Department of ¨ rebro University Hospital, SE-70185 O ¨ reInfectious Diseases, O bro, Sweden; e-mail, [email protected] DOI: 10.1378/chest.130.2.623a
References 1 Kollef MH, Shorr A, Tabak YP, et al. Epidemiology and outcomes of health-care-associated pneumonia: results from a large US database of culture-positive pneumonia. Chest 2005; 128:3854 –3862 2 Marrie TJ. Etiology of community-acquired pneumonia. In: Marrie TJ, ed. Community-acquired pneumonia. New York, NY: Kluwer Academic/Plenum Publishers, 2001; 131–141 3 Gillet Y, Issartel B, Vanhems P, et al. Association between Staphylococcus aureus strains carrying gene for PantonValentine leukocidin and highly lethal necrotising pneumonia in young immunocompetent patients. Lancet 2002; 359:753– 759 4 Johnsson D, Mo¨lling P, Strålin K, et al. Detection of PantonValentine leukocidin gene in Staphylococcus aureus by LightCycler PCR: clinical and epidemiological aspects. Clin Microbiol Infect 2004; 10:884 – 889
Diet and Exercise-Induced Bronchoconstriction To the Editor: We read with great interest the review article in CHEST by Parsons and Mastronarde (December 2005)1 on exercise-induced bronchoconstriction (EIB) in athletes. We believe that the discussion on nonpharmacologic therapy omitted to mention a CHEST / 130 / 2 / AUGUST, 2006
623
very promising area of research on the relationship between dietary factors and the severity of EIB. There is accumulating evidence that dietary modification has the potential to reduce the severity and incidence of asthma and EIB.2 It has repeatedly been shown that a low-sodium diet reduces postexercise airway narrowing2,3 and moderates airway inflammation3 in asthmatic subjects with EIB. It has also been shown that a 3-week fish oil diet, rich in omega-3 polyunsaturated fatty acids has a protective effect in suppressing EIB.4,5 In addition, antioxidant supplementation has also been shown to improve EIB to subclinical levels in significant numbers of individuals with EIB.2 The dietary factors mentioned above did not normalize postexercise pulmonary function in individuals with EIB. However, on average these dietary interventions did improve pulmonary function to below the clinical threshold of a 10% fall in postexercise FEV1, which is commonly used for diagnosis of EIB. This level of improvement is not unlike that attained with many pharmacologic treatments, which also do not necessarily normalize pulmonary function in EIB patients but do improve pulmonary function to subclinical levels. Thus, the potential for enhancing the quality of life for those individuals with EIB by dietary modification or supplementation is high. These findings point toward the prophylactic and acute therapeutic effects of selected dietary factors, which seem to be attainable by simple rearrangement of nutritional components, in patients with inflammatory diseases such as asthma and EIB.2 It is also possible that any beneficial effect of diet on asthma and EIB is mediated through the combined effect of a variety of nutrients, rather than through any single nutrient. Timothy D. Mickleborough, PhD Martin R. Lindley, PhD Indiana University Bloomington, IN The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal. org/misc/reprints.shtml). Correspondence to: Timothy D. Mickleborough, PhD, Indiana University, Bloomington, Department of Kinesiology, 1025 E 7th St, HPER 112, Bloomington, IN 47404; e-mail: [email protected] DOI: 10.1378/chest.130.2.623b
References 1 Parsons JP, Mastronarde JG. Exercise-induced bronchoconstriction in athletes. Chest 2005; 128:3966 –3974 2 Mickleborough TD, Gotshall RW. Dietary components with demonstrated effectiveness in decreasing the severity of exercise-induced asthma. Sports Med 2003; 33:671– 681 3 Mickleborough TD, Lindley MR, Ray S. Dietary salt, airway inflammation, and diffusion capacity in exercise-induced asthma. Med Sci Sports Exerc 2005; 37:904 –914 4 Mickleborough TD, Murray RL, Ionescu AA, et al. Fish oil supplementation reduces severity of exercise-induced bronchoconstriction in elite athletes. Am J Respir Crit Care Med 2003; 168:1181–1189 5 Mickleborough TD, Lindley MR, Ionescu AA, et al. Protective effect of fish oil supplementation on exercise-induced bronchoconstriction in asthma. Chest 2006; 129:39 – 49 To the Editor: We greatly appreciate the comments of Drs. Mickleborough and Lindley regarding our review of exercise-induced bronchoconstriction (EIB) in athletes. We agree that dietary modification is a promising new area of research in the management of EIB. 624
The studies cited by Drs. Mickleborough and Lindley highlight the need for further randomized clinical trials to determine the role of dietary modifications in the clinical management of EIB. Jonathan P. Parsons, MD John G. Mastronarde, MD, FCCP Columbus, OH The authors report that they have no conflict of interest related to this article. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal. org/misc/reprints.shtml). Correspondence to: Jonathan P. Parsons, MD, Ohio State University Medical Center, 473 W. 12th Ave, 201 HLRI, Columbus, OH 43210; e-mail: [email protected] DOI: 10.1378/chest.130.2.624
Shift Work in Intensive Care To the Editor: We read with great interest the study of Afessa et al (December 2005),1 which piloted a shift system for housestaff in a medical ICU. Although this represents a novel pattern of working among doctors in US training programs, this has become the accepted standard in the United Kingdom. The authors concluded that their study was insufficiently powered to detect significant differences in mortality, length of stay, or educational outcomes, and that a larger multicenter study may be required to address these issues.2 However, a possible confounding factor in this study was that the length and pattern of shifts may not have been optimal for reducing fatigue. While reduction to a 14-h shift represents a significant decrease both in the length of the duty period and the number of hours worked per week over the nonpilot period, in the United Kingdom this would, by current standards, be regarded as excessive. Although a decade or so ago the 100-h week was commonplace, national and European working-time legislation now limits doctors to working no ⬎ 56 h a week, with defined rest periods between shifts and days off between consecutive shifts. The optimal shift pattern for medical housestaff may be informed by data from the aviation industry, where safety is of paramount concern. Aviation accidents have a huge impact not only in financial cost but also in adverse public perception. This has focused the attention of aviation authorities on working patterns, fatigue, and error. The shift patterns of aircrew now consider circadian rhythms, quantity of sleep, and periods of wakefulness prior to duty periods in addition to length of shift.3 As a consequence, nighttime shifts are shorter than those during the day, and the number of consecutive night duty periods are restricted, with specific rest requirements before and after the shift in order to reduce the accumulated sleep deficit.4 In the study by Afessa et al,1 the shift pattern, and in particular working four consecutive 14-h night shifts, may abrogate the potential benefits of a shift system on patient outcome. Another possible reason why there was no demonstrable improvement in mortality or length of stay may have been the population of staff chosen for the implementation of a shift system. It seems more probable that the work patterns of senior doctors would be expected to have greater influence on patient outcomes than those of trainees. It is well-recognized that staffing ICUs with intensivists reduces morbidity, mortality, and costs.5–7 Unfortunately, in the United States a shortage of intensivists precludes the widespread adoption of this model of care.8 One solution, which increases senior input, is the development of telemedicine7; but this is unlikely to ever be the equivalent of the “hands-on” presence of an intensivist at the patient’s bedside. In Correspondence
Resource Allocation Issues and Clinical Practice Guidelines To the Editor: In their recent article in CHEST on “Resource Allocation Issues in Recommendations From Clinical Practice Guideline Panels” (January 2006),1 Guyatt and colleagues deliberated on the productive allocation of health-care resources to alternative management strategies. The authors stated, that “the annual cost of clopidogrel for 100 patients might equal the salary of one nurse in the United States, but the salaries of three nurses in Poland.” For the sake of everyone who would like to cite this example, we feel obliged to amend it. The authors cited inaccurate data provided bona fide by one of us (RJ). The appropriate data from the Polish General Statistical Bureau on the average salaries of nurses and the average cost to patients of clopidogrel indicate that the annual cost of clopidogrel for 100 patients would equal the salaries of at least 10 nurses in Poland. We apologize for these misleading statistics that we provided to authors and readers alike. Roman Jaeschke, MD McMaster University Hamilton, ON, Canada Jan Brozek, MD Jagiellonian University School of Medicine Krakow, Poland The authors have no conflict of interest regarding this topic. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal. org/misc/reprints.shtml). Correspondence to: Jan Brozek, CM UJ, Department of Medicine, Skawinska 8, Krakow 31066, Poland; e-mail: [email protected] DOI: 10.1378/chest.130.2.623
References 1 Guyatt G, Baumann M, Pauker S, et al. Addressing resource allocation issues in recommendations from clinical practice guideline panels: suggestions from an American College of Chest Physicians task force. Chest 2006; 129:182–187
Staphylococcus aureus in Community-Acquired Pneumonia To the Editor: We are concerned about the frequencies of bacterial pathogens in patients with culture-positive community-acquired pneumonia (CAP) that were reported by Kollef et al (December 2005).1 Among 2,221 such patients, Staphylococcus aureus was identified in 25.5% of patients, Streptococcus pneumoniae was identified in 16.6% of patients, and Haemophilus influenzae was identified in 16.6% of patients. From November 1999 to October 2003, 668 patients who were hospitalized in our department had a discharge code of pneumonia, chest radiograph infiltrates, and no hospitalization during the preceding month. Among 191 patients (median age, 68 years) with culture-positive CAP (ie, significant bacterial pathogens identified by blood culture [n ⫽ 60] and/or sputum culture), www.chestjournal.org
S pneumoniae was identified in 57% (n ⫽ 109; 46 bacteremic cases), H influenzae was identified in 27% (n ⫽ 51; 3 bacteremic cases), and S aureus was identified in 7.3% (n ⫽ 14; 5 bacteremic cases). This frequency of S aureus is consistent with the level of 2.9% in seven previous studies of hospitalized CAP patients that were summarized by Marrie.2 In our opinion, the frequencies of bacterial pathogens reported by Kollef et al1 are too odd to support the guideline recommendations for CAP. In the pneumonia population in the study by Kollef et al,1 S aureus was the only pathogen that was associated with increased mortality. Among our CAP patients detailed above, death within 30 days occurred in 29% of the 14 patients with S aureus identified (n ⫽ 4; one bacteremic case), compared with 5.1% of the 177 other patients with culture-positive CAP (n ⫽ 9; nine bacteremic cases; p ⫽ 0.009 [Fisher exact test]). Severe necrotizing pneumonia can be caused by S aureus carrying the Panton-Valentine leukocidin gene.3 However, S aureus isolates from three of our patients who died were tested and were negative for the Panton-Valentine leukocidin gene.4 Since S aureus is an uncommon cause of CAP, it does not need to be covered by the empirical CAP treatment. However, the severity associated with S aureus pneumonia reinforces the importance of performing routine blood and respiratory cultures in pneumonia patients. Kristoffer Strålin, MD, PhD Bo So¨derquist, MD, PhD ¨ rebro University Hospital O ¨ rebro, Sweden O Drs, Strålin and So¨derquist have no conflicts of interest to disclose. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal. org/misc/reprints.shtml). Correspondence to: Kristoffer Strålin, MD, PhD, Department of ¨ rebro University Hospital, SE-70185 O ¨ reInfectious Diseases, O bro, Sweden; e-mail, [email protected] DOI: 10.1378/chest.130.2.623a
References 1 Kollef MH, Shorr A, Tabak YP, et al. Epidemiology and outcomes of health-care-associated pneumonia: results from a large US database of culture-positive pneumonia. Chest 2005; 128:3854 –3862 2 Marrie TJ. Etiology of community-acquired pneumonia. In: Marrie TJ, ed. Community-acquired pneumonia. New York, NY: Kluwer Academic/Plenum Publishers, 2001; 131–141 3 Gillet Y, Issartel B, Vanhems P, et al. Association between Staphylococcus aureus strains carrying gene for PantonValentine leukocidin and highly lethal necrotising pneumonia in young immunocompetent patients. Lancet 2002; 359:753– 759 4 Johnsson D, Mo¨lling P, Strålin K, et al. Detection of PantonValentine leukocidin gene in Staphylococcus aureus by LightCycler PCR: clinical and epidemiological aspects. Clin Microbiol Infect 2004; 10:884 – 889
Diet and Exercise-Induced Bronchoconstriction To the Editor: We read with great interest the review article in CHEST by Parsons and Mastronarde (December 2005)1 on exercise-induced bronchoconstriction (EIB) in athletes. We believe that the discussion on nonpharmacologic therapy omitted to mention a CHEST / 130 / 2 / AUGUST, 2006
623
very promising area of research on the relationship between dietary factors and the severity of EIB. There is accumulating evidence that dietary modification has the potential to reduce the severity and incidence of asthma and EIB.2 It has repeatedly been shown that a low-sodium diet reduces postexercise airway narrowing2,3 and moderates airway inflammation3 in asthmatic subjects with EIB. It has also been shown that a 3-week fish oil diet, rich in omega-3 polyunsaturated fatty acids has a protective effect in suppressing EIB.4,5 In addition, antioxidant supplementation has also been shown to improve EIB to subclinical levels in significant numbers of individuals with EIB.2 The dietary factors mentioned above did not normalize postexercise pulmonary function in individuals with EIB. However, on average these dietary interventions did improve pulmonary function to below the clinical threshold of a 10% fall in postexercise FEV1, which is commonly used for diagnosis of EIB. This level of improvement is not unlike that attained with many pharmacologic treatments, which also do not necessarily normalize pulmonary function in EIB patients but do improve pulmonary function to subclinical levels. Thus, the potential for enhancing the quality of life for those individuals with EIB by dietary modification or supplementation is high. These findings point toward the prophylactic and acute therapeutic effects of selected dietary factors, which seem to be attainable by simple rearrangement of nutritional components, in patients with inflammatory diseases such as asthma and EIB.2 It is also possible that any beneficial effect of diet on asthma and EIB is mediated through the combined effect of a variety of nutrients, rather than through any single nutrient. Timothy D. Mickleborough, PhD Martin R. Lindley, PhD Indiana University Bloomington, IN The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal. org/misc/reprints.shtml). Correspondence to: Timothy D. Mickleborough, PhD, Indiana University, Bloomington, Department of Kinesiology, 1025 E 7th St, HPER 112, Bloomington, IN 47404; e-mail: [email protected] DOI: 10.1378/chest.130.2.623b
References 1 Parsons JP, Mastronarde JG. Exercise-induced bronchoconstriction in athletes. Chest 2005; 128:3966 –3974 2 Mickleborough TD, Gotshall RW. Dietary components with demonstrated effectiveness in decreasing the severity of exercise-induced asthma. Sports Med 2003; 33:671– 681 3 Mickleborough TD, Lindley MR, Ray S. Dietary salt, airway inflammation, and diffusion capacity in exercise-induced asthma. Med Sci Sports Exerc 2005; 37:904 –914 4 Mickleborough TD, Murray RL, Ionescu AA, et al. Fish oil supplementation reduces severity of exercise-induced bronchoconstriction in elite athletes. Am J Respir Crit Care Med 2003; 168:1181–1189 5 Mickleborough TD, Lindley MR, Ionescu AA, et al. Protective effect of fish oil supplementation on exercise-induced bronchoconstriction in asthma. Chest 2006; 129:39 – 49 To the Editor: We greatly appreciate the comments of Drs. Mickleborough and Lindley regarding our review of exercise-induced bronchoconstriction (EIB) in athletes. We agree that dietary modification is a promising new area of research in the management of EIB. 624
The studies cited by Drs. Mickleborough and Lindley highlight the need for further randomized clinical trials to determine the role of dietary modifications in the clinical management of EIB. Jonathan P. Parsons, MD John G. Mastronarde, MD, FCCP Columbus, OH The authors report that they have no conflict of interest related to this article. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal. org/misc/reprints.shtml). Correspondence to: Jonathan P. Parsons, MD, Ohio State University Medical Center, 473 W. 12th Ave, 201 HLRI, Columbus, OH 43210; e-mail: [email protected] DOI: 10.1378/chest.130.2.624
Shift Work in Intensive Care To the Editor: We read with great interest the study of Afessa et al (December 2005),1 which piloted a shift system for housestaff in a medical ICU. Although this represents a novel pattern of working among doctors in US training programs, this has become the accepted standard in the United Kingdom. The authors concluded that their study was insufficiently powered to detect significant differences in mortality, length of stay, or educational outcomes, and that a larger multicenter study may be required to address these issues.2 However, a possible confounding factor in this study was that the length and pattern of shifts may not have been optimal for reducing fatigue. While reduction to a 14-h shift represents a significant decrease both in the length of the duty period and the number of hours worked per week over the nonpilot period, in the United Kingdom this would, by current standards, be regarded as excessive. Although a decade or so ago the 100-h week was commonplace, national and European working-time legislation now limits doctors to working no ⬎ 56 h a week, with defined rest periods between shifts and days off between consecutive shifts. The optimal shift pattern for medical housestaff may be informed by data from the aviation industry, where safety is of paramount concern. Aviation accidents have a huge impact not only in financial cost but also in adverse public perception. This has focused the attention of aviation authorities on working patterns, fatigue, and error. The shift patterns of aircrew now consider circadian rhythms, quantity of sleep, and periods of wakefulness prior to duty periods in addition to length of shift.3 As a consequence, nighttime shifts are shorter than those during the day, and the number of consecutive night duty periods are restricted, with specific rest requirements before and after the shift in order to reduce the accumulated sleep deficit.4 In the study by Afessa et al,1 the shift pattern, and in particular working four consecutive 14-h night shifts, may abrogate the potential benefits of a shift system on patient outcome. Another possible reason why there was no demonstrable improvement in mortality or length of stay may have been the population of staff chosen for the implementation of a shift system. It seems more probable that the work patterns of senior doctors would be expected to have greater influence on patient outcomes than those of trainees. It is well-recognized that staffing ICUs with intensivists reduces morbidity, mortality, and costs.5–7 Unfortunately, in the United States a shortage of intensivists precludes the widespread adoption of this model of care.8 One solution, which increases senior input, is the development of telemedicine7; but this is unlikely to ever be the equivalent of the “hands-on” presence of an intensivist at the patient’s bedside. In Correspondence