Chest
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The FEV3/FVC ratio is not discussed in the American Thoracic Society/European Respiratory Society (ATS/ERS) guidelines for lung function interpretation in spite of narrow confidence limits of normal and its association with smoking. We sought to determine whether a reduction in only the FEV3/FVC ratio was associated with physiologic changes compared with subjects with normal FEV1/FVC and FEV3/FVC ratios. ⋯ The FEV3/FVC ratio should be routinely reported on spirometry. An isolated reduction may indicate an early injury pattern of hyperinflation, air trapping, and loss of Dlco.
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COPD is an important global health problem. In addition to pulmonary impairment, systemic inflammation, musculoskeletal abnormalities, and cardiovascular comorbidity influence disease burden and mortality risk. Body weight and body composition are important discriminants in classifying disease heterogeneity. ⋯ For maintenance of muscle and bone tissue, appropriately timed, high-quality protein intake and addressing vitamin D deficiency must be considered. Specific nutrients (eg, n-3 polyunsaturated fatty acids and polyphenolic compounds) may have the pharmacologic potential to boost decreased muscle mitochondrial metabolism and enhance impaired physical performance, particularly when the metabolic stimulus of physical activity alone is limited. At this stage, evidence is insufficient to support an intake of high doses of single nutritional supplements to modulate respiratory pathology, but some small studies have identified micronutrient modulation via the diet as a promising intervention.
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The high costs of American health care, the related problem of the uninsured, and the grim fiscal prognosis of Medicare and Medicaid are among the most pressing challenges facing the United States today. A solution to the cost problem that does not reduce access or quality is sought by those at all points on the political spectrum. ⋯ Higher performing primary care, supported by changes in payment, has driven a sustainable business model that preserves the option of independent practice for physicians. We are now testing competencies developed for Medicare Advantage in the Pioneer Accountable Care Organization program, which preserves the broad patient choice that is an important feature of traditional Medicare.
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Physicians are moving increasingly from self-employed, private practices to at-will employment relationships. This historic change in the organizational administration of medical services is likely to accelerate as the Affordable Care Act is implemented and as accountable care organizations permeate the medical marketplace. Physicians vow an ascendant oath to safeguard patients' welfare, but as they become employees, they may sign legal contracts that also oblige obedience to the institutions that hire them. What happens when an employer makes a decision that is not in the best interests of patients and the physicians fulfill their Hippocratic obligation to voice dissent on their patients' behalf rather than abiding by their contractual obligation to obey their employer? This article explores the philosophical and legal ramifications of this potential collision of obligations to patients and to employers.