Chest
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Cysts are commonly seen on CT scans of the lungs, and diagnosis can be challenging. Clinical and radiographic features combined with a multidisciplinary approach may help differentiate among various disease entities, allowing correct diagnosis. It is important to distinguish cysts from cavities because they each have distinct etiologies and associated clinical disorders. ⋯ Multifocal/diffuse cysts can occur with lymphoid interstitial pneumonia, Birt-Hogg-Dubé syndrome, tracheobronchial papillomatosis, or primary and metastatic cancers. Multifocal/diffuse cysts may be associated with nodules (lymphoid interstitial pneumonia, light-chain deposition disease, amyloidosis, and Langerhans cell histiocytosis) or with ground-glass opacities (Pneumocystis jirovecii pneumonia and desquamative interstitial pneumonia). Using the results of the high-resolution CT scans as a starting point, and incorporating the patient's clinical history, physical examination, and laboratory findings, is likely to narrow the differential diagnosis of cystic lesions considerably.
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COPD exacerbation incidence rates are often ascertained retrospectively through patient recall and self-reports. We compared exacerbation ascertainment through patient self-reports and single-physician chart review to central adjudication by a committee and explored determinants and consequences of misclassification. ⋯ www.ClinicalTrials.gov, NCT00706602.
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Of those patients hospitalized for an exacerbation of COPD, one in five will require rehospitalization within 30 days. Many developed countries are now implementing policies to increase care quality while controlling costs for COPD, known as value-based health care. In the United States, COPD is part of Medicare's Hospital Readmissions Reduction Program (HRRP), which penalizes hospitals for excess 30-day, all-cause readmissions after a hospitalization for an acute exacerbation of COPD, despite minimal evidence to guide hospitals on how to reduce readmissions. ⋯ It then identifies risk factors for early readmissions after acute exacerbation of COPD and discusses tested and emerging strategies to reduce these readmissions. Finally, we evaluate the current HRRP and future policy changes and their effect on the goal to deliver value-based COPD care. COPD remains a chronic disease with a high prevalence that has finally garnered the attention of health systems and policy makers, but we still have a long way to go to truly deliver value-based care to patients.
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Medically underserved areas are composed of vulnerable populations with reduced access to ambulatory care services. Our goal was to determine the association between residence in a medically underserved area and severe sepsis incidence and mortality. ⋯ Residence in a medically underserved area is associated with higher incidence and mortality rates of severe sepsis and represents a novel method of access-to-care adjustment. Traditional access-to-care surrogates, however, are poorly associated with sepsis mortality.
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A 43-year-old man was referred to our tertiary sleep center for the initiation of sleep apnea treatment. A prior diagnostic overnight polysomnography (Fig 1) had revealed an apnea-hypopnea index (AHI) of 22/h of sleep. The apneas were predominantly central (central AHI, 18.2/h; obstructive AHI, 3.8/h), more pronounced in the supine position (AHI supine, 36.6/h; AHI nonsupine, 11/h) and during non-rapid eye movement (non-REM) sleep (REM, 15.8/h; non-REM, 23.5/h). ⋯ He was not taking any medication but had noticed a slow decline in general physical performance in the last year, with dyspnea (New York Heart Association class I) after running distances of 1 to 2 km. He had never experienced syncope. His family history was unremarkable.