Chest
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Proton pump inhibitors (PPIs) and histamine type 2 receptor blockers (H2Bs) are used for stress ulcer prophylaxis. Although the PPIs have greater potency for acid suppression, their relative effectiveness for preventing clinically important GI bleeding (CIGIB) has not been established. The goal of this study was to determine whether prophylactic PPIs were associated with lower risk of CIGIB than H2Bs among critically ill adults. ⋯ H2Bs were robustly and consistently associated with significantly lower CIGIB risk compared with PPIs in this population.
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Evidence supporting adjunctive corticosteroids during the treatment of Pneumocystis jirovecii pneumonia (PcP) in adults without HIV is minimal and controversial. ⋯ The addition of early corticosteroids to anti-Pneumocystis therapy in patients without HIV was not associated with improved respiratory outcomes.
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Renal disease is a well-recognized manifestation of cystic fibrosis (CF) and people with CF are at increased risk of nephrolithiasis. Lithotripsy is the preferred treatment but has occasionally been associated with pulmonary complications. Here we report the case of a person with CF who developed a pneumothorax soon after lithotripsy and discuss the potential mechanism of injury. We hope this case highlights some of the additional considerations clinicians should take into account when managing patients with advanced pulmonary disease in CF.
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Case Reports
A 47-Year-Old Man With Progressive Mental Deterioration During Ventilator Management of Asthma in the ICU.
A 47-year-old man was admitted to the ICU with acute hypercapnic respiratory failure caused by a severe asthma attack. He had a history of asthma, atrial septal defect, chronic heart failure, and atrial fibrillation. He underwent surgical closure of the atrial septal defect at 7 years of age and was asymptomatic until 38 years of age when he developed congestive heart failure because of structural cardiac abnormalities, including left ventricular systolic dysfunction, biatrial enlargement, and mild mitral and tricuspid regurgitation. ⋯ Despite the recovery from the initial respiratory failure, he became inactive and lethargic on the fourth day in the ICU. ICU-acquired delirium was suspected, and administration of sedatives and analgesics was discontinued. On the following day, he was unresponsive to stimuli.
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Combined intrapleural therapy with tissue plasminogen activator (tPA) and deoxyribonuclease (DNase) has been shown to reduce the need for surgical intervention for complicated pleural effusion/empyema (CPE/empyema). For patients in whom tPA/DNase is likely to fail, however, receipt of this therapy may simply delay the inevitable. The goal of this study was to identify risk factors for failure of combined intrapleural therapy. ⋯ Our analysis found that the presence of pleural thickening and the presence of an abscess/necrotizing pneumonia helps to triage patients in whom combined intrapleural therapy is likely to fail. The results warrant further study and validation in a prospective multicenter study.