Clinical Briefs

By Louis Kuritzky, MD

Generalist and Pulmonologist Care for Patients Hospitalized with Severe COPD

Copd is the fourth leading cause of death in the United States. Comparison of generalist with specialist care of COPD has focused on ambulatory settings, but much of the cost of COPD and mortality is located in hospital settings. The current study is the first to specifically compare the care of these two professional groups in reference to inpatient COPD management.

Five academic medical centers enrolled 866 adults with severe COPD. The Therapeutic Intervention Scoring System score was used to assess intervention use on days 1, 3, 7, 14, and 25 of patient care; this system scores minor interventions like an IV or pulse oximetry 1 point, and 2-4 points for greater intensity interventions, such as arterial lines, intubation, or surgical procedures. Additionally, expenses were recorded from hospital billing records.

Both adjusted average resource intensity scores and estimated hospital costs were the same for patients treated by pulmonologists as those treated by generalists. Regueiro and associates conclude there is not a significant difference in resource use, cost, or survival of COPD patients between pulmonologists and generalists.

Regueiro CR, et al. Am J Med 1998; 105:366-372.

Microalbuminuria Screening in Patients with Hypertension

Increased urinary excretion of protein is a marker for future development of cardiovascular disease among hypertensive patients and correlates with the risk of mortality in diabetics. Traditional office testing materials for albumin requires at least 300-500 mg/d albumin excretion to indicate a positive test; since much lower levels of urinary albumin excretion (UAE) are abnormal (normal is < 30 mg/d), there has been a window wherein abnormal UAE may be missed in typical outpatient practice, unless the clinician resorts to the somewhat cumbersome and expensive 24-hour urine analysis.

In diabetics, interventions addressed at improving microalbuminuria with ACE inhibitors have shown less progression to overt nephropathy. Hence, it has been felt that early detection of even modest levels of UAE above normal is desirable. For this purpose, the Micral-Test (Boehringer Manheim, Indianapolis, IN) has been developed. The current study is the first to evaluate its efficacy in hypertensive patients.

In a patient population of 171 hypertensives, Micral-Test was compared with 24-hour urine collection. The sensitivity of random urine sampling was 92%. Equally valuable as the high sensitivity, Gerber and colleagues acknowledge a small (£ 5%) false-positive rate. Gerber et al conclude that Micral-Test is a valuable screening tool for microalbuminuria.

Gerber LM, et al. Am J Hypertens 1998;11:1321-1327.

Mortality Results for Early Elective Surgery or Ultrasonographic Surveillance for Small Abdominal Aortic Aneurysms

Although elective repair of large abdominal aortic aneurysms (AAA) reduces mortality, small aneurysms are often followed by observation with repeat ultrasonographic measurement. Unheralded rupture of an AAA is always associated with a high mortality rate, hence, the potential for elective early intervention is theoretically attractive. This study compared, in patients older than 60 years (n = 1090), elective surgical repair of small AAA (4.0-5.5 cm) vs. ultrasonographic surveillance for 4-6 years. Ultrasound was performed every six months for AAA 4.0-4.9 cm, and every three months for AAA 5.0-5.5. Additionally, if growth rate was greater than 1 cm/yr or if AAA became tender or symptomatic, surgery was offered to the patient. Statistical analysis of overall mortality by intention-to-treat methodology was performed.

In the first 30 days of the trial, the 5.8% mortality rate seen in the surgical group provided a statistical disadvantage. At all end point times, the surgical group enjoyed no advantage over ultrasonographic surveillance. The authors conclude that early surgical intervention is not advantageous over ultrasonographic surveillance in terms of mortality for AAA less than 5.5 cm.

The UK Small Aneurysm Trial Participants. Lancet 1998;352:1649-1655.