Chest
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Pulmonary hypertension (PH) is a known risk factor for perioperative complications. Unlike in the case of cardiac surgery, PH is currently not listed as an independent risk factor for postoperative complications in guidelines for the management of noncardiac surgery. Despite the paucity of data, though, patients with PH are often counseled against having elective procedures because early and sudden postoperative deaths have been reported. ⋯ The two main principles of perioperative management are the prevention of systemic hypotension (risk of RV ischemia) and the prevention of acute elevations in pulmonary arterial pressure (risk of RV failure). Close monitoring, optimization of systemic BP, pain control, oxygenation and ventilation, avoidance of exacerbating factors, and use of vasopressors and pulmonary vasodilators as necessary are essential elements of management. Understanding the pathophysiology, cause, and severity of PH in the individual perioperative patient allows accurate risk assessment, optimization of PH and RV function prior to surgery, and appropriate intraoperative and postoperative management.
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A limited amount of data exist regarding the effect of intermittent pneumatic compression (IPC) and graduated compression stockings (GCS) on the incidence of VTE in the ICU setting. The objective of this study was to examine the association of mechanical thromboprophylaxis with IPC or GCS with the risk of VTE and hospital mortality among critically ill medical-surgical patients. ⋯ The use of IPC, but not GCS, was associated with a significantly lower VTE risk. This association was consistent regardless of the type of prophylactic heparin used and was not modified by trauma or surgical admission.
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New rules and methods for medical injury dispute resolution have been launched in New Hampshire and New York, and demonstration projects are underway elsewhere. This article describes major medical malpractice reforms undertaken and proposed in recent years. ⋯ In light of declining malpractice claim rates, heavier adverse impacts of damage caps on vulnerable groups (people who have severe injuries, who are elderly, and who are unemployed) and repeated findings of state law unconstitutionality, the rationale for nationwide damage caps is questioned. Attention to innovative reform proposals such as patient compensation funds, disclosure and early offer laws, safe harbor laws, enterprise insurance and no-fault compensation systems, is encouraged.
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Multicenter Study
Reference values for cardiorespiratory response and fitness on the treadmill in a 20- to 85-year-old population.
Existing reference values for clinical exercise testing have been derived from small nonrandom samples, lacking women and older individuals and some with poor or no maximal end criteria. The objective was to study the cardiorespiratory response during maximal exercise in a representative predominantly Caucasian sample of men and women. ⋯ This study establishes reference values for V.O2max (absolute, relative to body weight and fat-free weight), maximal HR, oxygen pulse, BP, ventilation, breathing reserve, respiratory exchange ratio, and blood lactate concentration during maximal exercise on treadmill in a large population.
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Long-term survival after lung transplant is limited by the development of chronic and progressive airflow obstruction, a condition known as bronchiolitis obliterans syndrome (BOS). While prior studies strongly implicate cellular rejection as a strong risk factor for BOS, less is known about the clinical significance of human leukocyte antigen (HLA) antibodies and donor HLA-specific antibodies in long-term outcomes. ⋯ Approximately one-third of lung transplant recipients have detectable HLA antibodies, which are associated with a worse prognosis regarding graft function and patient survival.