Chest
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Review
Patient Centered Specialty Practice: Defining the Role of Specialists in Value-Based Healthcare.
Health care is at a crossroads and under pressure to add value by improving patient experience and health outcomes and reducing costs to the system. Efforts to improve the care model in primary care, such as the patient-centered medical home, have enjoyed some success. However, primary care accounts for only a small portion of total health-care spending, and there is a need for policies and frameworks to support high-quality, cost-efficient care in specialty practices of the medical neighborhood. ⋯ Evidence to support the model remains limited, and estimates of net costs and value to practices are not fully understood. The PCSP model holds promise for promoting value-based health care in specialty practices. The continued development of appropriate incentives is required to ensure widespread adoption.
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Harnessing the immune system to fight cancer is an exciting advancement in lung cancer therapy. Antitumor immunity can be augmented by checkpoint blockade therapy, which removes the inhibition/brakes imposed on the immune system by the tumor. Checkpoint blockade therapy with anti-programmed cell death protein 1 (anti-PD-1)/anti-programmed death ligand 1 (anti-PDL-1) antibodies causes tumor regression in about 25% of patients with lung cancer. ⋯ This latter approach has become feasible since the advent of next-generation sequencing technology, which allows identification of the specific mutations that each individual lung tumor bears. Indeed lung cancers are now known to have high mutation rates, making them logical targets for mutation-directed immune therapies. We review how sequencing of lung cancer mutations leads to better understanding of how the immune system recognizes tumors, providing improved opportunities to track antitumor immunity and ultimately leading to the development of personalized vaccine strategies aimed at unleashing the host immune system to attack mutations in the tumor.
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Right atrial pressure (Pra) is determined by the interaction of the function of the heart as a pump, which is called cardiac function, and the factors that determine the return of blood to the heart, which is called return function. Thus, monitoring Pra or its surrogate, central venous pressure (CVP), can give important insights into mechanisms behind changes in hemodynamic status, responses to interventions, and the likelihood of diagnoses. Examination of the components of the Pra tracing, especially during the ventilator cycle, can also give information about right-sided cardiac diastolic function, the status of the tricuspid valve, volume responsiveness, and the cardiac rhythm. Importantly, the pressure difference from the large venous reservoir to the heart is small, and thus great care must be taken with technical factors that affect the measurement.
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Randomized Controlled Trial
Improved cough and cough-specific quality of life in patients treated for scleroderma-related interstitial lung disease (SSc-ILD): Results of Scleroderma Lung Study II.
Cough is a common symptom of scleroderma-related interstitial lung disease (SSc-ILD), but its relationship to other characteristics of SSc-ILD, impact on cough-specific quality of life (QoL), and response to therapy for SSc-ILD have not been well studied. ⋯ FC occurs commonly in SSc-ILD, correlates with both the presence and severity of GERD and ILD at baseline, and declines in parallel with improvements in both ILD and GERD over a 2-year course of therapy. Frequent cough might serve as a useful surrogate marker of treatment response in SSc-ILD trials.
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Case Reports
A 46-Year-Old Man With Dyspnea, Hypoxemia, and Radiographic Asymmetry After Redo Bilateral Lung Transplantation.
A 46-year-old man underwent redo bilateral sequential lung transplantation for rapidly progressive bronchiolitis obliterans syndrome that developed 3.5 years after initial transplantation. In the operating room, he was sedated and intubated with a dual lumen endotracheal tube with subsequent single right-lung ventilation and left allograft implantation. His pulmonary arterial pressure became elevated with reperfusion of the newly implanted left lung, which required initiation of cardiopulmonary bypass to facilitate implantation of the right lung. ⋯ His chest was closed and he was transferred to the thoracic intensive care unit. On arrival to the intensive care unit, the patient was intubated, sedated, and had an oxygen saturation of 92% on a fraction of inspired oxygen of 100%, positive end-expiratory pressure of 10 cm H2O, and 20 parts per million of inhaled nitric oxide. He had a Swan-Ganz catheter in the right internal jugular vein that measured a mean pulmonary arterial pressure of 33 mm Hg and a pulmonary arterial systolic pressure of 63 mm Hg, which remained persistently elevated and prompted further diagnostic evaluation.