Chest
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Physicians are often asked about complementary therapies by patients with cancer, and data show that the interest in and use of these therapies among patients with cancer is common. Therefore, it is important to assess the current evidence base on the benefits and risks of complementary therapies (modalities not historically used in modern Western medicine). ⋯ Several complementary therapy modalities can be helpful in improving the overall care of patients with lung cancer.
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For 2 decades, long-acting β-agonists (LABAs) have been associated with increased asthma-related death risks in several randomized trials, even when added to inhaled corticosteroids (ICSs). In reaction, the US Food and Drug Administration (FDA) recently mandated that the manufacturers of LABAs conduct five large, noninferiority, randomized trials of the LABA+ICS combination in 53,000 patients with asthma. Three methodologic issues in these trials could lead to masking of or falsely detecting elevated risks. ⋯ Second, the composite asthma outcome will be dominated by asthma hospitalization, possibly dwarfing an increased risk of asthma-related death, with differences as wide as seven deaths under the LABA+ICS combination vs one death under ICS alone remaining statistically uncertain. Finally, because of the multiple identical trials being requested from the different manufacturers of LABAs, even if each trial is powered at 90%, there is a 41% likelihood that at least one of the trials will not rule out a risk increase when, in truth, there is no risk increase. In view of these impediments, the FDA should preempt such complexities by establishing decision rules regarding the interpretation of the results from these momentous safety trials before their completion, expected in 2017.
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Case Reports
An opportunistic infection associated with ruxolitinib, a novel janus kinase 1,2 inhibitor.
We report a case of Cryptococcus neoformans pneumonia in a patient taking ruxolitinib, a janus kinase 1,2 inhibitor approved for the treatment of myelofibrosis. We hypothesize that ruxolitinib contributed to this infection through its effects on cell-mediated immunity. Clinicians should be aware of the potential for intracellular or opportunistic infections associated with this novel drug class.
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In 2013, the outpatient hospital payment from Medicare for a transbronchial needle aspiration more than doubled. At the same time, the recently updated American College of Chest Physicians guidelines for the diagnosis and management of lung cancer now recommend needle techniques, such as transbronchial needle aspiration, over surgical staging. The convergence of these two events will accelerate the existing forces of technology and economics that have been influencing both the practices of outpatient bronchoscopy and mediastinoscopy and the management of patients with lung cancer over the past 20 years.
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Hospitals are required to have a medical director of respiratory care as a condition of their participation in the Federal Medicare and Medicaid programs. This gives physicians opportunities to improve the quality of care for the patients in their community, to diversify income streams, and to assist hospitals to meet regulatory requirements for quality. The contracts for these positions are usually provided by the hospital, so it is imperative that physicians know how to protect their interests, what is expected of them, if they are being paid fairly, and that the contract is compliant with all regulatory issues. ⋯ Directorships are evolving to service line management as more of the hospital's reimbursement is linked to clinical quality and patient satisfaction. This article does not offer legal advice, nor is it meant to be all inclusive. Physicians should consult a health-care attorney for any questions before signing any contract.