Chest
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Multicenter Study Observational Study
Management of Pulmonary Nodules by Community Pulmonologists: A Multicenter Observational Study.
Pulmonary nodules (PNs) are a common reason for referral to pulmonologists. The majority of data for the evaluation and management of PNs is derived from studies performed in academic medical centers. Little is known about the prevalence and diagnosis of PNs, the use of diagnostic testing, or the management of PNs by community pulmonologists. ⋯ A substantial fraction of intermediate-sized nodules referred to pulmonologists ultimately prove to be lung cancer. Despite advances in imaging and nonsurgical biopsy techniques, invasive sampling of low-risk nodules and surgical resection of benign nodules remain common, suggesting a lack of adherence to guidelines for the management of PNs.
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As lung cancer screening with low-dose CT scanning is implemented, an increasing number of people will be diagnosed with pulmonary nodules. Primary care clinicians care for the vast majority of these patients, but their experiences with communication and managing distress in this population are not well understood. ⋯ PCPs often lack systemic resources to optimize patient-centered approaches when discussing incidental pulmonary nodules with patients. With the advent of lung cancer screening, pulmonologists can assist primary care colleagues by providing accurate information to counsel patients and assisting in managing conversations about the risk of cancer. Pulmonologists should support efforts to implement reliable systems to ensure adherence to follow-up.
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Indwelling arterial catheters (IACs) are used extensively in the ICU for hemodynamic monitoring and for blood gas analysis. IAC use also poses potentially serious risks, including bloodstream infections and vascular complications. The purpose of this study was to assess whether IAC use was associated with mortality in patients who are mechanically ventilated and do not require vasopressor support. ⋯ In hemodynamically stable patients who are mechanically ventilated, the presence of an IAC is not associated with a difference in 28-day mortality. Validation in other datasets, as well as further analyses in other subgroups, is warranted.
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Selecting a strategy (surveillance, biopsy, resection) for pulmonary nodule evaluation can be complex given the absence of high-quality data comparing strategies and the important tradeoffs among strategies. Guidelines recommend a three-step approach: (1) assess the likelihood of malignancy, (2) evaluate whether the patient is a candidate for invasive intervention, and (3) elicit the patient's preferences and engage in shared decision-making. We sought to characterize how pulmonologists select a pulmonary nodule evaluation strategy and the extent to which they report following the guideline-recommended approach. ⋯ Although pulmonologists appear to routinely personalize pulmonary nodule evaluation strategies based on the individual patient's risk-benefit tradeoffs, they may not consistently take patient preferences into account during the decision-making process. In the absence of high-quality evidence regarding the optimal methods of pulmonary nodule evaluation, physicians should strive to ensure that management decisions are consistent with patients' values.
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Randomized Controlled Trial
Targeted Fluid Minimization Following initial Resuscitation in Septic Shock: A Pilot Study.
IV fluid represents a basic therapeutic intervention for septic shock. Unfortunately, the optimal administration of IV fluid to maximize patient outcomes and prevent complications is largely unknown. ⋯ This pilot study suggests that TFM in patients with septic shock can be performed using protocol-guided assessments of fluid responsiveness. Larger trials of TFM in septic shock are needed.