Chest
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Multicenter Study Clinical Trial
Management of Low-Risk Pulmonary Embolism Patients Without Hospitalization: The Low-Risk Pulmonary Embolism Prospective Management Study.
The efficacy and safety of managing patients with low-risk pulmonary embolism (PE) without hospitalization requires objective data from US medical centers. We sought to determine the 90-day composite rate of recurrent symptomatic VTE, major bleeding events, and all-cause mortality among consecutive patients diagnosed with acute low-risk PE managed without inpatient hospitalization; and to measure patient satisfaction. ⋯ Treatment of carefully selected patients with acute PE and low risk by PESI < 86, echocardiography, and CUS without inpatient hospitalization is safe and acceptable to patients. Results must be viewed with caution because of the small sample size relative to the end point and the generalizability surrounding availability of emergent echocardiography.
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A growing body of evidence supports a bidirectional relationship between posttraumatic stress disorder (PTSD) and sleep disturbances. Fragmented sleep induced by sleep-related breathing disorders, insomnia, and nightmares impacts recovery and treatment outcomes and worsens PTSD symptoms. Despite recent attention, management of these disorders has been unrewarding in the setting of PTSD. ⋯ Imagery rehearsal therapy has shown significant reduction in nightmare intensity and frequency. The success of noradrenergic blocking agents has not been consistent among studies, with one-half reporting treatment failure. An integrated stepped care approach that includes components of both behavioral and pharmacologic interventions customized to patients' sleep-maladaptive behaviors may offer a solution to delivering accessible, effective, and efficient services for individuals with PTSD.
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Refractory shock is a lethal manifestation of cardiovascular failure defined by an inadequate hemodynamic response to high doses of vasopressor medications. Approximately 7% of critically ill patients will develop refractory shock, with short-term mortality exceeding 50%. Refractory vasodilatory shock develops from uncontrolled vasodilation and vascular hyporesponsiveness to endogenous vasoconstrictors, causing failure of physiologic vasoregulatory mechanisms. ⋯ Novel vasopressor agents, such as synthetic human angiotensin II, can increase BP and reduce the need for high doses of catecholamine vasopressors in severe or refractory vasodilatory shock. Few effective rescue therapies exist for established refractory shock, which emphasizes the importance of aggressive intervention before refractory shock develops, including the earlier initiation of rational combination vasopressor therapy. The present review discusses the diagnosis and management of refractory shock to offer guidance for management of this important clinical problem and to provide a framework for future research.
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In specialty clinics, a staff physician is often required to direct patient flow through the clinic and performs all documentation for coding/billing. In response to the workload created by increased patient volume, many specialty clinics have implemented protocols for both disease treatment and coordination of clinic flow. In this article, we review the literature on using mobile technology to assist with patient care, clinic flow, disease treatment, and documentation/billing. We also describe the development and implementation of a mobile application in our pulmonary clinic designed to automate patient flow, assist the physician in documentation/billing, and gather research data including review of initial user data and lessons learned.
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Tobacco exposure results in various changes to the airways and lung parenchyma. Although emphysema represents the more common injury pattern, in some individuals, cigarette smoke injures alveolar epithelial cells and other lung cells, resulting in diffuse infiltrates and parenchymal fibrosis. Smoking can trigger interstitial injury patterns mediated via recruitment and inappropriate persistence of myeloid and other immune cells, including eosinophils. ⋯ Although respiratory bronchiolitis-interstitial lung disease, desquamative interstitial pneumonia, pulmonary Langerhans cell histiocytosis, and acute eosinophilic pneumonia have a well-established association with tobacco use, its role and impact on idiopathic pulmonary fibrosis, combined pulmonary fibrosis and emphysema, and connective tissue disease-related interstitial lung diseases is still ambiguous. Smoking-related interstitial fibrosis is a relatively newly appreciated entity with distinct histopathologic features but with unclear clinical ramifications. Increased implementation of lung cancer screening programs and utilization of CT scans in thoracic imaging have also resulted in increased identification of "incidental" or "subclinical" interstitial lung changes in smokers, the ensuing impact of which remains to be studied.