Publications by authors named "Guy W Soo Hoo"

58 Publications

Community-Acquired Pneumonia and Risk of Cardiovascular Events in People Living With HIV.

J Am Heart Assoc 2020 12 23;9(23):e017645. Epub 2020 Nov 23.

Department of Medicine Division of Pulmonary, Critical Care, and Sleep Medicine University of Washington Seattle WA.

Background Hospitalization with community-acquired pneumonia (CAP) is associated with an increased risk of cardiovascular disease (CVD) events in patients uninfected with HIV. We evaluated whether people living with HIV (PLWH) have a higher risk of CVD or mortality than individuals uninfected with HIV following hospitalization with CAP. Methods and Results We analyzed data from the Veterans Aging Cohort Study on US veterans admitted with their first episode of CAP from April 2003 through December 2014. We used Cox regression analyses to determine whether HIV status was associated with incident CVD events and mortality from date of admission through 30 days after discharge (30-day mortality), adjusting for known CVD risk factors. We included 4384 patients (67% [n=2951] PLWH). PLWH admitted with CAP were younger, had less severe CAP, and had fewer CVD risk factors than patients with CAP who were uninfected with HIV. In multivariable-adjusted analyses, CVD risk was similar in PLWH compared with HIV-uninfected (hazard ratio [HR], 0.89; 95% CI, 0.70-1.12), but HIV infection was associated with higher mortality risk (HR, 1.49; 95% CI, 1.16-1.90). In models stratified by HIV status, CAP severity was significantly associated with incident CVD and 30-day mortality in PLWH and patients uninfected with HIV. Conclusions In this study, the risk of CVD events during or after hospitalization for CAP was similar in PLWH and patients uninfected with HIV, after adjusting for known CVD risk factors and CAP severity. HIV infection, however, was associated with increased 30-day mortality after CAP hospitalization in multivariable-adjusted models. PLWH should be included in future studies evaluating mechanisms and prevention of CVD events after CAP.
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http://dx.doi.org/10.1161/JAHA.120.017645DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7763776PMC
December 2020

A Middle-Aged Man With a History of Asthma Presenting With Recurrent Episodes of Respiratory Distress.

Chest 2020 10;158(4):e205-e208

University of California, Los Angeles David Geffen School of Medicine, Los Angeles, CA; Pulmonary, Critical Care and Sleep Section, West Los Angeles VA Medical Center, Los Angeles, CA. Electronic address:

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http://dx.doi.org/10.1016/j.chest.2019.11.059DOI Listing
October 2020

The role of non-invasive ventilation in weaning and decannulating critically ill patients with tracheostomy: A narrative review of the literature.

Pulmonology 2021 Jan-Feb;27(1):43-51. Epub 2020 Jul 25.

Intensive Care Unit, Hospital Morales Meseguer, Av Marqués de los Vélez, s/n, 30008 Murcia, Spain.

Introduction: Invasive mechanical ventilation (IMV) is associated with several complications. Placement of a long-term airway (tracheostomy) is also associated with short and long-term risks for patients. Nevertheless, tracheostomies are placed to help reduce the duration of IMV, facilitate weaning and eventually undergo successful decannulation.

Methods: We performed a narrative review by searching PubMed, Embase and Medline databases to identify relevant citations using the search terms (with synonyms and closely related words) "non-invasive ventilation", "tracheostomy" and "weaning". We identified 13 publications comprising retrospective or prospective studies in which non-invasive ventilation (NIV) was one of the strategies used during weaning from IMV and/or tracheostomy decannulation.

Results: In some studies, patients with tracheostomies represented a subgroup of patients on IMV. Most of the studies involved patients with underlying cardiopulmonary comorbidities and conditions, and primarily involved specialized weaning centres. Not all studies provided data on decannulation, although those which did, report high success rates for weaning and decannulation when using NIV as an adjunct to weaning patient off ventilatory support. However, a significant percentage of patients still needed home NIV after discharge.

Conclusions: The review supports a potential role for NIV in weaning patients with a tracheostomy either off the ventilator and/or with its decannulation. Additional research is needed to develop weaning protocols and better characterize the role of NIV during weaning.
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http://dx.doi.org/10.1016/j.pulmoe.2020.07.002DOI Listing
July 2020

Underuse of Clinical Decision Rules and d-Dimer in Suspected Pulmonary Embolism: A Nationwide Survey of the Veterans Administration Healthcare System.

J Am Coll Radiol 2020 Mar 31;17(3):405-411. Epub 2019 Oct 31.

Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, California.

Purpose: The diagnosis of pulmonary embolism (PE) remains a challenge. CT pulmonary angiography (CTPA) for suspected PE has become the primary imaging modality, but concerns regarding overutilization, overdiagnosis, radiation, and costs have led to algorithms that combine a clinical decision rule (CDR) and highly sensitive d-dimer to identify patients in whom PE can be safely excluded without further studies. This has been identified as a top five Choosing Wisely recommendation in pulmonary medicine, but adherence is modest at best and actual utilization is unknown. Therefore, a survey was conducted to determine the prevalence of this approach in the Veterans Administration (VA) healthcare system.

Methods: A web-based questionnaire survey (SurveyGizmo.com) was developed and validated to query the utilization of CDR ± d-dimer in suspected PE. Key stakeholders identified from national VA mailing lists of radiology, pulmonary, and emergency medicine chiefs were sent an email describing the survey and provided a link for response. This study was reviewed and approved by our local institutional review board and accessing the link represented consent for participation. No personally identifiable data were collected and a drawing for a gift card was provided as an incentive.

Results: There were a total of 159 responses, with 120 fully completed surveys for analysis. The majority of respondents were chiefs (63%) with 11+ years of experience (80%), from hospitals with house staff (86%) and an emergency department (97%). Respondents were from emergency medicine (31%), pulmonary (27%), radiology (26%), and other departments (9%). The overwhelming majority of respondents (85%) did not require results of a CDR ± d-dimer before ordering a CTPA. Only 6.7% required a CDR + d-dimer, with others requiring either only a CDR (5.8%) or d-dimer (2.5%). The most common CDR was the Wells score, with only one using the Pulmonary Embolism Rule-Out Criteria. Nine of 18 (50%) regional Veterans Integrated Service Networks reported at least one site requiring a CDR before CTPA. An average of 9.6 CTPAs were estimated to be performed per week. Sorted by CDR and d-dimer use, 8 (CDR + d-dimer), 6.9 (CDR only), 8 (d-dimer only), 10.1 (no requirements) CTPA studies were performed weekly. The average CTPA yield for PE was estimated at 11.9% (CDR + d-dimer), 8% (CDR only), 2.5% (d-dimer only), and 7.6% (no requirements).

Conclusions: The vast majority of hospitals within the VA system do not use a CDR ± d-dimer in the evaluation of patients with suspected PE. Utilization of a CDR and d-dimer may decrease CTPA utilization and increase yield, but this assessment is limited by the scope of the survey.

Clinical Implications: CDR-guided strategies are recommended in the evaluation of suspected PE. Adherence within the VA healthcare system is very low. Further investigation is warranted to better characterize and improve the adherence to CDR-guided strategies and CTPA utilization.
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http://dx.doi.org/10.1016/j.jacr.2019.10.001DOI Listing
March 2020

ICU Utilization for Patients With Acute Exacerbations of Chronic Obstructive Pulmonary Disease Receiving Noninvasive Ventilation. Seeking Answers to the Questions of Utilization: Does Perception Reflect Reality?

Crit Care Med 2019 08;47(8):e725-e726

Pulmonary, Critical Care and Sleep Section, West Lost Angeles VA Healthcare Center (111Q), David Geffen School of Medicine at UCLA, Los Angeles, CA Department of Intensive Care, Cerrahpasa Faculty of Medicine, Istanbul University Cerrahpasa, Istanbul, Turkey Intensive Care Unit, Hospital Morales Meseguer, Murcia, Spain.

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http://dx.doi.org/10.1097/CCM.0000000000003798DOI Listing
August 2019

Medical Intensive Care Unit Admission Among Patients With and Without HIV, Hepatitis C Virus, and Alcohol-Related Diagnoses in the United States: A National, Retrospective Cohort Study, 1997-2014.

J Acquir Immune Defic Syndr 2019 02;80(2):145-151

Internal Medicine, Yale School of Medicine, New Haven, CT.

Background: HIV, hepatitis C virus (HCV), and alcohol-related diagnoses (ARD) independently contribute increased risk of all-cause hospitalization. We sought to determine annual medical intensive care unit (MICU) admission rates and relative risk of MICU admission between 1997 and 2014 among people with and without HIV, HCV, and ARD, using data from the largest HIV and HCV care provider in the United States.

Setting: Veterans Health Administration.

Methods: Annual MICU admission rates were calculated among 155,550 patients in the Veterans Aging Cohort Study by HIV, HCV, and ARD status. Adjusted rate ratios and 95% confidence intervals (CIs) were estimated with Poisson regression. Significance of trends in age-adjusted admission rates were tested with generalized linear regression. Models were stratified by calendar period to identify shifts in MICU admission risk over time.

Results: Compared to HIV-/HCV-/ARD- patients, relative risk of MICU admission decreased among HIV-mono-infected patients from 61% (95% CI: 1.56 to 1.65) in 1997-2009% to 21% (95% CI: 1.16 to 1.27) in 2010-2014, increased among HCV-mono-infected patients from 22% (95% CI: 1.16 to 1.29) in 1997-2009% to 54% (95% CI: 1.43 to 1.67) in 2010-2014, and remained consistent among patients with ARD only at 46% (95% CI: 1.42 to 1.50). MICU admission rates decreased by 48% among HCV-uninfected patients (P-trend <0.0001) but did not change among HCV+ patients (P-trend = 0.34).

Conclusion: HCV infection and ARD remain key contributors to MICU admission risk. The impact of each of these conditions could be mitigated with combination of treatment of HIV, HCV, and interventions targeting unhealthy alcohol use.
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http://dx.doi.org/10.1097/QAI.0000000000001904DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6701630PMC
February 2019

Electric Field-Induced Release and Measurement Liquid Biopsy for Noninvasive Early Lung Cancer Assessment.

J Mol Diagn 2018 11 8;20(6):738-742. Epub 2018 Oct 8.

School of Dentistry, University of California, Los Angeles, Los Angeles, California.

Previously, we detected circulating tumor DNA that contained two EGFR mutations (p.L858R and exon19 del) in plasma of patients with late-stage non-small-cell lung carcinoma (NSCLC) using the electric field-induced release and measurement (EFIRM) platform. Our aim was to determine whether EFIRM technology can detect these mutations in patients with early-stage NSCLC. Prospectively, 248 patients with radiographically determined pulmonary nodules were recruited. Plasma was collected before biopsy and histologic examination of the nodule. Inclusion criteria were histologic diagnosis of benign nodule (control) and stage I or II adenocarcinoma harboring either p.L858R or exon19 delEGFR mutations. Plasma samples were available from 44 patients: 23 with biopsy-proven benign pulmonary nodules and 21 with stage I or II adenocarcinoma (12 p.L858R and 9 exon19 delEGFR variants). Samples were analyzed for the EGFR mutations using the EFIRM platform. Assay sensitivity was 92% for p.L858R (11 of 12 samples positive) and 77% for exon19 del (7 of 9 samples positive). Specificity was 91% with two false-positive results in 23 patients with EGFR-positive nodules and 95% for the entire 44-patient series. Concordance was 100% with identical mutations discovered in plasma and nodule biopsy. The EFIRM platform is able to noninvasively detect two EGFR mutations in individuals with early-stage NSCLC.
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http://dx.doi.org/10.1016/j.jmoldx.2018.06.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6198245PMC
November 2018

Response.

Chest 2018 10;154(4):997-998

Department of Surgery, Yale University, New Haven, CT.

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http://dx.doi.org/10.1016/j.chest.2018.07.024DOI Listing
October 2018

Corticosteroids in the Management of Severe Coccidioidomycosis.

Am J Med 2019 01 2;132(1):110-113. Epub 2018 Oct 2.

Pulmonary, Critical Care and Sleep Section, Infectious Diseases Section, VA Greater Los Angeles Healthcare System, David Geffen School of Medicine at UCLA, Los Angeles, Calif.

Background: There is limited data suggesting that recovery from severe pulmonary infection with Coccidioides may be hastened by the addition of systemic corticosteroids.

Methods: We present a case report of 2 patients with persistent and progressive coccidioidomycosis who demonstrated a dramatic response to adjunctive corticosteroid therapy.

Results: Both patients had Coccidioides immitis cultured from respiratory samples. One was a 69-year-old man who had been treated with combination fluconazole and liposomal amphotericin for over 6 weeks, with persistent fever and pneumonia. The other was a 61-year-old man treated with fluconazole and then amphotericin for 3 weeks, with progression to acute respiratory distress syndrome and shock. Both received short courses of intravenous methylprednisolone and recovered to be discharged home.

Conclusions: As opposed to associated hypersensitivity, corticosteroid treatment in these cases was directed at modulating the ongoing destructive effects of unchecked inflammation. Rapid improvement was noted in both cases and raises the possibility that the addition of systemic corticosteroids may hasten recovery in patients with severe coccidioidomycosis.
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http://dx.doi.org/10.1016/j.amjmed.2018.09.020DOI Listing
January 2019

Response.

Chest 2018 09;154(3):716-717

Department of Surgery, Yale University, New Haven, CT.

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http://dx.doi.org/10.1016/j.chest.2018.06.025DOI Listing
September 2018

Tension hydropneumothorax as the initial presentation of Boerhaave syndrome.

Respir Med Case Rep 2018 31;25:100-103. Epub 2018 Jul 31.

Department of Medicine, Pulmonary & Critical Care Section, David Geffen School of Medicine at University of California, Los Angeles, USA.

Boerhaave syndrome, a rare yet frequently fatal diagnosis, is characterized by the spontaneous transmural rupture of the esophagus. The classic presentation of Boerhaave syndrome is characterized by Mackler's triad, consisting of chest pain, vomiting, and subcutaneous emphysema. However, Boerhaave syndrome rarely presents with all the features of Mackler's triad; instead, the common presentation of Boerhaave syndrome includes chest or epigastric pain, severe retching and vomiting, dyspnea, and shock. These symptoms are typically misdiagnosed as cardiogenic in origin. Due to its atypical presentation, rarity, and mimicry of emergent conditions, diagnosis of Boerhaave syndrome is often delayed, resulting in a high mortality rate at the time of diagnosis and with a subsequent exponential increase in mortality if treatment is delayed by greater than 48 hours. Here, we report two atypical presentations of Boerhaave syndrome presenting as tension hydropneumothorax and review ten previously reported cases of Boerhaave syndrome presenting as tension hydropneumothorax. This review serves to raise clinician awareness about the expansive and elusive ways by which esophageal perforation may present, and thereby facilitate timely and potentially life-saving diagnosis.
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http://dx.doi.org/10.1016/j.rmcr.2018.07.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6083431PMC
July 2018

Insight to the growing utilizations of high flow nasal oxygen therapy over non-invasive ventilation in community teaching hospital: alternative or complementary?.

Hosp Pract (1995) 2018 10 21;46(4):170-171. Epub 2018 Aug 21.

c Pulmonary and Critical Care Section (111Q) , West Los Angeles VA Healthcare Center , CA , USA.

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http://dx.doi.org/10.1080/21548331.2018.1510283DOI Listing
October 2018

High flow nasal cannulae versus non-invasive ventilation in moderate hypercapnic respiratory failure: Different roads, same destination but doubtful equality.

Clin Respir J 2018 Sep 22;12(9):2457-2458. Epub 2018 Aug 22.

Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Raipur, India.

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http://dx.doi.org/10.1111/crj.12942DOI Listing
September 2018

Non-invasive early detection of malignant pulmonary nodules by FISH-based sputum test.

Cancer Genet 2018 10 10;226-227:1-10. Epub 2018 May 10.

Department of Surgery, St. Luke's University Health Network, Bethlehem & Temple University Medical School, PA, USA.

Background: Early detection decreases lung cancer mortality. The Target-FISH Lung Cancer Detection (LCD) Test is a non-invasive test designed to detect chromosomal changes (deletion or amplification) via Fluorescence in situ Hybridization (FISH) in sputum specimens from persons suspected of having lung cancer. We evaluated the performance of the LCD test in patients with highly suspicious pulmonary nodules who were scheduled for a biopsy procedure.

Methods: Induced sputum was collected from patients who were scheduled for biopsy of a solitary pulmonary nodule (0.8-3 cm) in one of 6 tertiary medical centers in the US and Israel. The lung cancer detection (LCD) Test combined sputum cytology and Target-FISH analysis on the same target cells and the results were compared to the pathology. Participants with non-surgical negative biopsy results were followed for 2 years to determine their final diagnosis.

Results: Of the 173 participants who were evaluated, 112 were available for analysis. Overall, the LCD test had a sensitivity of 85.5% (95% CI, 76.1-92.3), specificity of 69% (95% CI, 49.2-84.7) and an accuracy of 81.3% (95% CI, 72.8-88). The positive and negative predictive values (PPV, NPV) were 88.8% and 62.5%, respectively. The LCD test was positive in 9 of 11 lung cancer patients who had an initial negative biopsy.

Conclusions: In a cohort of patients with highly suspicious lung nodules, the LCD test is a non-invasive option with good sensitivity and a high positive predictive value. A positive LCD test reinforces the need to aggressively pursue a definitive diagnosis of suspicious nodules.
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http://dx.doi.org/10.1016/j.cancergen.2018.04.118DOI Listing
October 2018

Accuracy of electronic health record data for the diagnosis of chronic obstructive pulmonary disease in persons living with HIV and uninfected persons.

Pharmacoepidemiol Drug Saf 2019 02 20;28(2):140-147. Epub 2018 Jun 20.

Department of Medicine, Veterans Affairs (VA) Connecticut Healthcare System and Yale University, West Haven, CT, USA.

Purpose: No prior studies have addressed the performance of electronic health record (EHR) data to diagnose chronic obstructive pulmonary disease (COPD) in people living with HIV (PLWH), in whom COPD could be more likely to be underdiagnosed or misdiagnosed, given the higher frequency of respiratory symptoms and smoking compared with HIV-uninfected (uninfected) persons.

Methods: We determined whether EHR data could improve accuracy of ICD-9 codes to define COPD when compared with spirometry in PLWH vs uninfected, and quantified level of discrimination using the area under the receiver-operating curve (AUC). The development cohort consisted of 350 participants who completed research spirometry in the Examinations of HIV Associated Lung Emphysema (EXHALE) study, a pulmonary substudy of the Veterans Aging Cohort Study. Results were externally validated in 294 PLWH who performed spirometry for clinical indications from the University of Washington (UW) site of the Centers for AIDS Research Network of Integrated Clinical Systems cohort.

Results: ICD-9 codes performed similarly by HIV status, but alone were poor at discriminating cases from non-cases of COPD when compared with spirometry (AUC 0.633 in EXHALE; 0.651 in the UW cohort). However, algorithms that combined ICD-9 codes with other clinical variables available in the EHR-age, smoking, and COPD inhalers-improved discrimination and performed similarly in EXHALE (AUC 0.771) and UW (AUC 0.734).

Conclusions: These data support that EHR data in combination with ICD-9 codes have moderately good accuracy to identify COPD when spirometry data are not available, and perform similarly in PLWH and uninfected individuals.
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http://dx.doi.org/10.1002/pds.4567DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6309326PMC
February 2019

Long-Term Experience With a Mandatory Clinical Decision Rule and Mandatory d-Dimer in the Evaluation of Suspected Pulmonary Embolism.

J Am Coll Radiol 2018 Dec 12;15(12):1673-1680. Epub 2018 Jun 12.

Department of Diagnostic Radiology, University of Texas MD Anderson Cancer Center, Houston, Texas.

Purpose: This study evaluated the long-term effectiveness of mandatory assignment of both a clinical decision rule (CDR) and highly sensitive d-dimer in the evaluation of patients with suspected pulmonary embolism (PE).

Materials And Methods: Institutional guidelines with a CDR and highly sensitive d-dimer were embedded in an order entry menu with mandatory assignment of key components before ordering a CT pulmonary angiogram (CTPA). Data were retrospectively extracted from the electronic health record.

Results: This was a retrospective review of 1,003 CTPA studies (905 patients, 845 male and 60 female patients, age 63.7 ± 13.5 years). CTPAs were positive for PE in 170 studies (17%), representing an average yield of 15% (year [average]; 2007 [15%], 2008 [18%], 2009 [15%], 2010 [15%], 2011 [17%], 2012 [15%], 2013 [23%]). The increased yield represented efforts of mandatory order entry assignments, educational sessions, and clinical champions. Different d-dimer thresholds with or without age adjustments in combination with the CDR identified about 10% of patients who may have been managed without CTPA.

Conclusion: Mandatory assignment of a CDR and highly sensitive d-dimer clinical decision pathway can be successfully incorporated into an order entry menu and produce a sustained increase in CTPA yield of patients with suspected PE.
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http://dx.doi.org/10.1016/j.jacr.2018.04.031DOI Listing
December 2018

Cerebral Artery Gas Embolism Following Navigational Bronchoscopy.

J Intensive Care Med 2018 Sep 3;33(9):536-540. Epub 2018 Apr 3.

2 David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.

Introduction: Cerebral artery gas embolism (CAGE) is a rare but serious adverse event with potentially devastating neurologic sequelae. Bronchoscopy is a frequently performed procedure but with only a few reported cases of CAGE.

Methods: We report the first documented case of CAGE associated with electromagnetic navigational bronchoscopy.

Results: A 61-year-old man with a left lower lobe nodule underwent electromagnetic navigational bronchoscopy. The target lesion underwent transbronchial biopsy, brushing and an end-procedure lavage. Following the procedure, he developed seizures, evidence of hypoxic injury and cerebral edema, and air emboli were seen on computed tomography imaging. He then underwent treatment with hyperbaric oxygen with a full and complete neurologic recovery. Review of other cases reported in the literature suggests improved neurologic outcomes with hyperbaric oxygen treatment.

Conclusions: Biopsy techniques performed during bronchoscopy and electromagnetic navigational bronchoscopy can result in CAGE. Comparison with other reported cases suggests improved neurologic outcomes in those treated with hyperbaric oxygen. Prompt recognition of this complication and timely treatment with hyperbaric oxygen are the cornerstones to recovery.
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http://dx.doi.org/10.1177/0885066618766838DOI Listing
September 2018

Markers of chronic obstructive pulmonary disease are associated with mortality in people living with HIV.

AIDS 2018 02;32(4):487-493

Department of Medicine, University of Washington, Seattle, Washington.

Objective: Aging people living with HIV (PLWH) face an increased burden of comorbidities, including chronic obstructive pulmonary disease (COPD). The impact of COPD on mortality in HIV remains unclear. We examined associations between markers of COPD and mortality among PLWH and uninfected study participants.

Design: Longitudinal analysis of the Examinations of HIV-Associated Lung Emphysema (EXHALE) cohort study.

Methods: EXHALE includes 196 PLWH and 165 uninfected smoking-matched study participants who underwent pulmonary function testing and computed tomography (CT) to define COPD and were followed. We determined associations between markers of COPD with mortality using multivariable Cox regression models, adjusted for smoking and the Veterans Aging Cohort Study (VACS) Index, a validated predictor of mortality in HIV.

Results: Median follow-up time was 6.9 years; the mortality rate was 2.7/100 person-years among PLWH and 1.7/100 person-years among uninfected study participants (P = 0.11). The VACS Index was associated with mortality in both PLWH and uninfected study participants. In multivariable models, pulmonary function and CT characteristics defining COPD were associated with mortality in PLWH: those with airflow obstruction (forced expiratory volume in 1 s/ forced vital capacity <0.7) had 3.1 times the risk of death [hazard ratio 3.1 (95% confidence interval 1.4-7.1)], compared with those without; those with emphysema (>10% burden) had 2.4 times the risk of death [hazard ratio 2.4 (95% confidence interval 1.1-5.5)] compared with those with ≤ 10% emphysema. In uninfected subjects, pulmonary variables were not significantly associated with mortality, which may reflect fewer deaths limiting power.

Conclusion: Markers of COPD were associated with greater mortality in PWLH, independent of the VACS Index. COPD is likely an important contributor to mortality in contemporary PLWH.
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http://dx.doi.org/10.1097/QAD.0000000000001701DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6366454PMC
February 2018

A Low Peripheral Blood CD4/CD8 Ratio Is Associated with Pulmonary Emphysema in HIV.

PLoS One 2017 25;12(1):e0170857. Epub 2017 Jan 25.

Department of Medicine, University of Washington, Seattle, Washington, United States of America.

Objectives: The prevalence of emphysema is higher among HIV-infected (HIV+) individuals compared to HIV-uninfected persons. While greater tobacco use contributes, HIV-related effects on immunity likely confer additional risk. Low peripheral blood CD4+ to CD8+ T-lymphocyte (CD4/CD8) ratio may reflect chronic inflammation in HIV and may be a marker of chronic lung disease in this population. Therefore, we sought to determine whether the CD4/CD8 ratio was associated with chronic obstructive pulmonary disease (COPD), particularly the emphysema subtype, in a cohort of HIV+ subjects.

Methods: We performed a cross-sectional analysis of 190 HIV+ subjects enrolled in the Examinations of HIV Associated Lung Emphysema (EXHALE) study. Subjects underwent baseline laboratory assessments, pulmonary function testing and chest computed tomography (CT) analyzed for emphysema severity and distribution. We determined the association between CD4/CD8 ratio and emphysema, and the association between CD4/CD8 ratio and pulmonary function markers of COPD.

Results: Mild or greater emphysema (>10% lung involvement) was present in 31% of subjects. Low CD4/CD8 ratio was associated with >10% emphysema in multivariable models, adjusting for risk factors including smoking, current and nadir CD4 count and HIV RNA level. Those with CD4/CD8 ratio <0.4 had 6.3 (1.1-39) times the odds of >10% emphysema compared to those with a ratio >1.0 in fully adjusted models. A low CD4/CD8 ratio was also associated with reduced diffusion capacity (DLCO).

Conclusions: A low CD4/CD8 ratio was associated with emphysema and low DLCO in HIV+ subjects, independent of other risk factors and clinical markers of HIV. The CD4/CD8 ratio may be a useful, clinically available, marker for risk of emphysema in HIV+ subjects in the antiretroviral therapy (ART) era.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0170857PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5266287PMC
August 2017

The Differential Impact of Emphysema on Respiratory Symptoms and 6-Minute Walk Distance in HIV Infection.

J Acquir Immune Defic Syndr 2017 01;74(1):e23-e29

*Department of Medicine, University of Washington, Seattle, WA; †Department of Internal Medicine, Veterans Affairs Connecticut Healthcare System, Yale University School of Medicine, New Haven, CT; ‡Department of Medicine, Michael E. DeBakey Veterans Affairs Medical Center, Baylor College of Medicine, Houston, TX; §Department of Radiology, University of Washington, Seattle, WA; ‖Department of Medicine, Atlanta Veterans Affairs Medical Center, Emory University School of Medicine, Atlanta, GA; ¶Department of Medicine, Veterans Affairs Greater Los Angeles Healthcare System, David Geffen School of Medicine at UCLA, Los Angeles, CA; #Department of Medicine, James J. Peters Veterans Affairs Medical Center, Bronx, NY; and **Department of Medicine, Icahn School of Medicine at Mt. Sinai, New York, NY.

Background: Emphysema is more prevalent in HIV-infected (HIV+) patients independent of smoking behavior. Nonetheless, health effects of emphysema in this population are poorly understood. We determined whether emphysema is associated with a greater burden of pulmonary symptoms and a lower 6-minute walk distance (6MWD) in HIV+ compared with HIV-uninfected (HIV-) subjects.

Methods: We performed a cross-sectional analysis of 170 HIV+ and 153 HIV- subjects in the Examinations of HIV-Associated Lung Emphysema (EXHALE) cohort study. Subjects completed a self-assessment of respiratory symptoms, pulmonary function testing, and 6MWD testing as well as a chest computed tomography to determine emphysema severity. We used regression models to determine the association of emphysema with respiratory symptoms and 6MWD in HIV+ subjects and compared this to HIV- subjects.

Results: Models stratified by HIV status demonstrated an association between >10% radiographic emphysema and chronic cough and/or phlegm and 6MWD in HIV+ subjects. These associations persisted among the subset without airflow obstruction: those with emphysema had 4.2 (95% confidence interval: 1.3 to 14) times the odds of chronic cough and/or phlegm and walked 60 m (95% confidence interval: 26 to 93) less distance than those without emphysema. There was no association between >10% emphysema and symptoms or 6MWD in HIV- subjects.

Conclusions: In our cohort, >10% radiographic emphysema was associated with chronic cough and/or phlegm and lower 6MWD in HIV+ but not HIV- subjects. These findings were robust even among HIV+ subjects with milder forms of emphysema and those without airflow obstruction, highlighting the clinical impact of emphysema in these patients.
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http://dx.doi.org/10.1097/QAI.0000000000001133DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5140705PMC
January 2017

Failure of Noninvasive Ventilation in Acute Exacerbations of Chronic Obstructive Pulmonary Disease: Need to Identify Borderline Patients.

Crit Care Med 2015 Nov;43(11):e530-1

Pulmonary and Critical Care Section, West Los Angeles VA Healthcare Center Intensive Care, Hospital Morales Meseguer, Murcia, Spain.

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http://dx.doi.org/10.1097/CCM.0000000000001212DOI Listing
November 2015

The Role of Noninvasive Ventilation in the Hospital and Outpatient Management of Chronic Obstructive Pulmonary Disease.

Authors:
Guy W Soo Hoo

Semin Respir Crit Care Med 2015 Aug 3;36(4):616-29. Epub 2015 Aug 3.

Pulmonary and Critical Care Section, West Los Angeles VA Healthcare Center, VA Greater Los Angeles Healthcare System, Geffen School of Medicine at UCLA, Los Angeles, California.

Positive pressure noninvasive ventilation (NIV) has become widely accepted in the treatment of both hospitalized and outpatient subjects with chronic obstructive pulmonary disease (COPD). The support has evolved over the past two decades to be part of first-line management in acute exacerbations of COPD and is also instrumental in discontinuing mechanical ventilation in COPD patients with acute respiratory failure. It is also suitable for treatment of COPD with other associated conditions including pneumonia, following lung resectional surgery, with concomitant obstructive sleep apnea and as part of end-of-life care. Short-term application can also facilitate some endoscopic procedures that may otherwise require endotracheal intubation. Outpatient use of NIV in COPD has garnered much attention, but the support has not been as robust as with NIV in hospitalized patients. However, an approach with higher pressures with a goal of significant reduction in daytime PaCO2 may be an effective strategy. NIV can also facilitate exercise training in pulmonary rehabilitation. A portable device which can augment tidal volume during ambulation and other activities of daily living may further expand the use of NIV in COPD patients.
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http://dx.doi.org/10.1055/s-0035-1556074DOI Listing
August 2015

Association of COPD With Risk for Pulmonary Infections Requiring Hospitalization in HIV-Infected Veterans.

J Acquir Immune Defic Syndr 2015 Nov;70(3):280-8

*Department of Medicine, University of Washington, Seattle, WA; †Veterans Affairs Connecticut Healthcare System, West Haven, CT; ‡Veterans Affairs Health Services Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA; §Department of Medicine, Veterans Affairs Connecticut Healthcare System, West Haven, CT, and Department of Medicine, Yale University School of Medicine, New Haven, CT; ‖Department of Medicine and Veterans Affairs Pittsburgh Healthcare System, University of Pittsburgh School of Medicine, Pittsburgh, PA, and Hamad Medical Corporation, Doha, Qatar; ¶Department of Medicine, Veterans Affairs Greater Los Angeles Healthcare System and David Geffen School of Medicine at UCLA, Los Angeles, CA; #Division of General Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA; **Infectious Diseases Section, Michael E. DeBakey Veterans Affairs Medical Center and Department of Medicine, Baylor College of Medicine, Houston, Texas; ††Department of Medicine, Yale University School of Medicine, New Haven, CT; ‡‡Department of Medicine, Vanderbilt University School of Medicine and Nashville Veterans Affairs Medical Center, Nashville, TN; §§James J. Peters Veterans Affairs Medical Center, Department of Medicine, Bronx and Department of Medicine, Icahn School of Medicine at Mt. Sinai, New York, NY; ‖‖Department of Medicine, Atlanta Veterans Affairs Medical Center and Emory University School of Medicine, Atlanta, GA; ¶¶Department of Medicine, Washington DC Veterans Affairs Medical Center and George Washington University School of Medicine, Washington, DC; and ##Department of Medicine, University of California San Francisco, San Francisco, CA.

Background: Pulmonary infections remain more common in HIV-infected (HIV+) compared with uninfected individuals. The increase in chronic lung diseases among aging HIV+ individuals may contribute to this persistent risk. We sought to determine whether chronic obstructive pulmonary disease (COPD) is an independent risk factor for different pulmonary infections requiring hospitalization among HIV+ patients.

Methods: We analyzed data from 41,993 HIV+ Veterans in the nationwide Veterans Aging Cohort Study Virtual Cohort from 1996 to 2009. Using International Classification of Diseases, Ninth Revision codes, we identified baseline comorbid conditions, including COPD, and incident community-acquired pneumonia (CAP), pulmonary tuberculosis (TB), and Pneumocystis jirovecii pneumonia (PCP) requiring hospitalization within 2 years after baseline. We used multivariable Poisson regression to determine incidence rate ratios (IRRs) associated with COPD for each type of pulmonary infection, adjusting for comorbidities, CD4 cell count, HIV viral load, smoking status, substance use, vaccinations, and calendar year at baseline.

Results: Unadjusted incidence rates of CAP, TB, and PCP requiring hospitalization were significantly higher among persons with COPD compared to those without COPD (CAP: 53.9 vs. 19.4 per 1000 person-years; TB: 8.7 vs. 2.8; PCP: 15.5 vs. 9.2; P ≤ 0.001). In multivariable Poisson regression models, COPD was independently associated with increased risk of CAP, TB, and PCP (IRR: 1.94, 95% confidence interval [CI]: 1.64 to 2.30; IRR: 2.60, 95% CI: 1.70 to 3.97; and IRR: 1.48, 95% CI: 1.10 to 2.01, respectively).

Conclusions: COPD is an independent risk factor for CAP, TB, and PCP requiring hospitalization among HIV+ individuals. As the HIV+ population ages, the growing burden of COPD may confer substantial risk for pulmonary infections.
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http://dx.doi.org/10.1097/QAI.0000000000000751DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4607625PMC
November 2015

Angiotensin-converting Enzyme Inhibitor Angioedema Requiring Admission to an Intensive Care Unit.

Am J Med 2015 Jul 10;128(7):785-9. Epub 2015 Mar 10.

Allergy and Immunology Section, Department of Medicine, Veterans Affairs Greater Los Angeles Healthcare System and David Geffen School of Medicine, University of California, Los Angeles.

Objective: The purpose of this study was to review consecutive cases of angiotensin-converting enzyme (ACE) inhibitor angioedema admitted to an intensive care unit.

Methods: Fifty subjects with ACE-inhibitor angioedema admitted from 1998-2011 were reviewed.

Results: All 50 subjects were men, 62.8 ± 8.4 years of age, 76% African Americans. Fifteen (30%) required ventilatory support and 2 (4%) required tracheostomy. Over half (56%) had taken ACE inhibitors for over a year. Logistic regression identified dyspnea and tongue involvement with the need for ventilatory support (P < .01). Hypercapnia (PaCO2 = 45.2 ± 6.7; P = 0.046) also identified patients needing ventilatory support.

Conclusions: Ventilatory support was provided for about one-third of those with ACE inhibitor-associated angioedema. Angioedema can occur even after extended use. Dyspnea and tongue involvement identified patients requiring ventilatory support.
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http://dx.doi.org/10.1016/j.amjmed.2015.02.006DOI Listing
July 2015

Increased risk of radiographic emphysema in HIV is associated with elevated soluble CD14 and nadir CD4.

Chest 2014 Dec;146(6):1543-1553

Department of Medicine, University of Washington, Seattle, WA. Electronic address:

Background: The association between HIV and emphysema remains incompletely understood. We sought to determine whether HIV is an independent risk factor for emphysema severity and whether markers of HIV severity and systemic biomarkers of inflammation (IL-6), altered coagulation (D-dimer), and immune activation (soluble CD14) are associated with emphysema.

Methods: We performed a cross-sectional analysis of 114 participants with HIV infection and 89 participants without HIV infection in the Examinations of HIV-Associated Lung Emphysema (EXHALE) study. Participants underwent chest CT imaging with blinded semiquantitative interpretation of emphysema severity, distribution, and type. We generated multivariable logistic regression models to determine the risk of HIV for radiographic emphysema, defined as > 10% lung involvement. Similar analyses examined associations of plasma biomarkers, HIV RNA, and recent and nadir CD4 cell counts with emphysema among participants with HIV infection.

Results: Participants with HIV infection had greater radiographic emphysema severity with increased lower lung zone and diffuse involvement. HIV was associated with significantly increased risk for > 10% emphysema in analyses adjusted for cigarette smoking pack-years (OR, 2.24; 95% CI, 1.12-4.48). In multivariable analyses restricted to participants with HIV infection, nadir CD4 < 200 cells/μL (OR, 2.98; 95% CI, 1.14-7.81), and high soluble CD14 level (upper 25th percentile) (OR, 2.55; 95% CI, 1.04-6.22) were associated with increased risk of > 10% emphysema. IL-6 and D-dimer were not associated with emphysema in HIV.

Conclusions: HIV is an independent risk factor for radiographic emphysema. Emphysema severity was significantly greater among participants with HIV infection. Among those with HIV, nadir CD4 < 200 cells/μL and elevated soluble CD14 level were associated with emphysema, highlighting potential mechanisms linking HIV with emphysema.
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http://dx.doi.org/10.1378/chest.14-0543DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4251616PMC
December 2014

Efficacy of noninvasive ventilation and hospital outcomes of acute chronic obstructive pulmonary disease in the ICU: a question of volume alone?

Crit Care Med 2014 Mar;42(3):e249

Intensive Care Unit and Non Invasive Ventilation Unit, Hospital Morales Meseguer, Murcia, Spain; Pulmonary and Critical Care, West LA VA Healthcare Center, Los Angeles, CA.

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http://dx.doi.org/10.1097/CCM.0000000000000074DOI Listing
March 2014

Findings in asymptomatic HIV-infected patients undergoing chest computed tomography testing: implications for lung cancer screening.

AIDS 2014 Apr;28(7):1007-14

aThe Icahn School of Medicine at Mount Sinai, New York, New York bUniversity of Washington School of Medicine, Seattle, Washington cJames J. Peters VA Medical Center, Bronx, New York dVA Connecticut Healthcare System, West Haven, Connecticut eYale University School of Medicine, New Haven, Connecticut fMichael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, Texas gAtlanta VA Medical Center and Emory University School of Medicine, Atlanta, Georgia hVA Greater Los Angeles Healthcare System and Geffen School of Medicine at UCLA, Los Angeles, California, USA.

Background: HIV-infected persons have a two-fold to five-fold increased unadjusted risk of lung cancer. In the National Lung Screening Trial (NLST), computed tomography (CT) screening was associated with a reduction in lung cancer mortality among high-risk smokers. These results may not generalize to HIV-infected persons, particularly if they are more likely to have false-positive chest CT findings.

Methods: We utilized data including standardized chest CT scans from 160 HIV infected and 139 uninfected Veterans enrolled between 2009 and 2012 in the multicenter Examinations of HIV Associated Lung Emphysema (EXHALE) Study. Abnormal CT findings were abstracted from clinical interpretations of the scans and classified as positive by NLST criteria vs. other findings. Clinical evaluations and diagnoses that ensued were abstracted from the medical record.

Results: There was no significant difference by HIV in the proportion of CT scans classified as positive by NLST criteria (29% of HIV infected and 24% of HIV uninfected, P=0.3). However, HIV-infected participants with CD4 cell counts less than 200 cells/μl had significantly higher odds of positive scans, a finding that persisted in multivariable analysis. Evaluations triggered by abnormal CT scans were also similar in HIV-infected and uninfected participants (all P>0.05).

Conclusion: HIV status was not associated with an increased risk of abnormal findings on CT or increased rates of follow-up testing in clinically stable outpatients with CD4 cell count more than 200. These data reflect favorably on the balance of benefits and harms associated with lung cancer screening for HIV-infected smokers with less severe immunodeficiency.
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http://dx.doi.org/10.1097/QAD.0000000000000189DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4018450PMC
April 2014