Chest
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Randomized Controlled Trial Multicenter Study Comparative Study
Is it possible to identify exacerbations of mild to moderate COPD that do not require antibiotic treatment?
Anthonisen criteria are widely used to guide the use of antibiotics in exacerbations of COPD. We evaluated the best predictors of outcomes in exacerbations of mild to moderate COPD not treated with antibiotics. ⋯ Among the Anthonisen criteria, only an increase in sputum purulence is a significant predictor of failure without antibiotics. The use of a point-of-care CRP test significantly increases the predictive accuracy of failure. Both of these easy-to-obtain factors may help clinicians to identify patients with exacerbated mild to moderate COPD who can be safely treated without antibiotics in an ambulatory setting.
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Randomized Controlled Trial Multicenter Study Comparative Study
The Clinical Impact and Preventability of Ventilator-Associated Conditions in Critically Ill Mechanically Ventilated Patients.
Ventilator-associated conditions (VACs) and infection-related ventilator-associated complications (iVACs) are the Centers for Disease Control and Prevention's new surveillance paradigms for patients who are mechanically ventilated. Little is known regarding the clinical impact and preventability of VACs and iVACs and their relationship to ventilator-associated pneumonia (VAP). We evaluated these using data from a large, multicenter, quality-improvement initiative. ⋯ VACs and iVACs are associated with significant morbidity and mortality. Although the agreement between VAC, iVAC, and VAP is poor, a higher adoption of measures to prevent VAP was associated with lower VAP and VAC rates.
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Unilateral medical futility policies, which allow health-care providers to limit or withdraw life-sustaining treatment over patient or surrogate objections, are increasingly designed around a procedural approach. Medical or ethics committees follow a prespecified process, the culmination of which is a justified decision about whether ongoing treatment should be withheld or withdrawn. These procedures have three stages. ⋯ We review the available data on procedure-based futility policies, arguing that there is limited information on their potential harms and how these harms are distributed. We consider the ethical implications of policy-making under informational uncertainty, invoking the precautionary principle--in the absence of clear data, if a policy has significant risk of significant harm, the burden of proof that it is not harmful falls on those recommending the policy--as the guiding moral standard for hospitals and professional organizations considering whether to adopt a procedural approach to medical futility. On the basis of this principle, we argue that any new futility guideline must include a significant commitment to collecting prospective data on its application.
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Critical care pharmacy services in the ICU have expanded from traditional dispensing responsibilities to being recognized as an essential component of multidisciplinary care for critically ill patients. Augmented by technology and resource utilization, this shift in roles has allowed pharmacists to provide valuable services in the form of assisting physicians and clinicians with pharmacotherapy decision-making, reducing medication errors, and improving medication safety systems to optimize patient outcomes. ⋯ Partnering with physician and nursing champions can garner support from hospital administrators for the addition of clinical pharmacy critical care services. The addition of a pharmacist to an interprofessional critical care team should be encouraged as health-care systems focus on improving the quality and efficiency of care delivered to improve patient outcomes.