Chest
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Cavities occasionally are encountered on thoracic images. Their differential diagnosis is large and includes, among others, various infections, autoimmune conditions, and primary and metastatic malignancies. ⋯ A chronic process (≥ 12 weeks) suggests mycobacterial, fungal, viral, or parasitic infections; malignancy (primary lung cancer or metastases); or autoimmune disorders (rheumatoid arthritis and granulomatosis with polyangiitis). Although a number of radiographic features can suggest a diagnosis, their lack of specificity requires that imaging findings be combined with the clinical context to make a confident diagnosis.
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As seen in this CME online activity (available at http://journal.cme.chestnet.org/copd-hot-hmv), acute exacerbations of COPD are associated with significant levels of morbidity and mortality. Acute noninvasive ventilation has been demonstrated its clinical efficacy and cost-effectiveness in reducing intubation rate and mortality and in patients with acute decompensated hypercapnic exacerbations of COPD. However, those patients with evidence of chronic hypercapnic respiratory failure have worse long-term outcomes compared with patients who have only transient hypercapnia during the acute phase returning to eucapnia in the recovery stage. ⋯ The addition of home noninvasive ventilation to home oxygen therapy in patients with persistent hypercapnia led to improved admission-free survival. The noninvasive ventilation was titrated to overnight measures of transcutaneous CO2 to achieve control of nocturnal hypoventilation, which improved daytime chronic respiratory failure. Home noninvasive ventilation is a complex intervention requiring a multidisciplinary team and long-term patient follow-up to maximize the clinical benefit to the patient.
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Frailty is a strong indicator of vulnerability among older persons, but its association with ICU outcomes has not been evaluated prospectively (ie, with objective measurements obtained prior to ICU admission). Our objective was to prospectively evaluate the relationship between frailty and post-ICU disability, incident nursing home admission, and death. ⋯ Pre-ICU frailty status was associated with increased post-ICU disability and new nursing home admission among ICU survivors, and death among all admissions. Pre-ICU frailty status may provide prognostic information about outcomes after a critical illness.
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Randomized Controlled Trial
Vitamin C Pharmacokinetics in Critically Ill Patients: A Randomized Trial of Four IV Regimens.
Early high-dose IV vitamin C is being investigated as adjuvant therapy in patients who are critically ill, but the optimal dose and infusion method are unclear. The primary aim of this study was to describe the dose-plasma concentration relationship and safety of four different dosing regimens. ⋯ The 2 g/d dose was associated with normal plasma concentrations, and the 10 g/d dose was associated with supranormal plasma concentrations, increased oxalate excretion, and metabolic alkalosis. Sustained therapy is needed to prevent hypovitaminosis.
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As seen in this CME online activity (available at http://journal.cme.chestnet.org/sv-sleep-disorder), central sleep apnea (CSA) is associated with increased mortality in patients with heart failure (HF), and it has been thought that treatment of CSA may improve underlying HF. Positive airway pressure therapy, specifically auto-servoventilation (ASV), can not only suppress abnormal breathing patterns but has been reported to improve cardiac function in HF patients with CSA. In patients with HF and with CSA unsuppressed with CPAP, newer ASV use has been associated with significant CSA improvement; in addition, several studies have reported efficacy of ASV in the treatment of underlying cardiac dysfunction in HF patients with CSA. ⋯ However, until this is done, there is an urgent educational need for review of the approved labeling and validated clinical use of ASV within the medical community. The purpose of this educational activity is to review the appropriate use of ASV for the treatment of sleep-disordered breathing, including Cheyne-Stokes respiration, treatment-emergent central apnea, and opioid-induced periodic breathing. Emphasis will be placed on proper patient and therapy selection, especially in patients with HF.