Chest
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Heparin-induced thrombocytopenia (HIT) is associated with clinically significant morbidity and mortality. Patients who are critically ill are commonly thrombocytopenic and exposed to heparin. ⋯ If the patient is deemed as being at intermediate or high risk for HIT or if HIT is confirmed by means of the serotonin-release assay, heparin should be stopped, heparin-bonded catheters should be removed, and a direct antithrombin or fondaparinux should be initiated to reduce the risk of thrombosis. Warfarin is absolutely contraindicated in the acute phase of HIT; if administered, its effects must be reversed by using vitamin K.
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As marijuana smoking prevalence increases in the United States, concern regarding its potential risks to lung health has also risen, given the general similarity in the smoke contents between marijuana and tobacco. Most studies have found a significant association between marijuana smoking and chronic bronchitis symptoms after adjustment for tobacco. Although reports are mixed regarding associations between marijuana smoking and lung function, none have shown a relationship to decrements in FEV1 and few have found a relationship to a decreased ratio of FEV1/FVC, possibly related to an association between marijuana and an increased FVC. ⋯ Although bronchial biopsies from habitual marijuana smokers have shown precancerous histopathologic changes, a large cohort study and a pooled analysis of six well-designed case-control studies have not found evidence of a link between marijuana smoking and lung cancer. The immunosuppressive effects of delta-9 tetrahydrocannabinol raise the possibility of an increased risk of pneumonia, but further studies are needed to evaluate this potential risk. Several cases series have demonstrated pneumothoraces/pneumomediastinum and bullous lung disease in marijuana smokers, but these associations require epidemiologic studies for firmer evidence of possible causality.
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Randomized Controlled Trial
Can Patients With COPD Assimilate Disease-Specific Information During an Acute Exacerbation?: Results of a Pilot Randomized Controlled Trial.
The study aimed to determine the feasibility and effectiveness of an introductory disease-specific educational program delivered during an acute exacerbation of COPD (AECOPD) on objective measures of disease-specific knowledge. ⋯ A brief educational program delivered at the time of hospitalization for an AECOPD was feasible for a subset of patients, resulted in improved disease-specific knowledge, and may be a bridge to more active approaches.
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How Fragile Are Clinical Trial Outcomes That Support the CHEST Clinical Practice Guidelines for VTE?
VTE remains a health concern for global populations. Clinical practice guidelines are necessary to guide physicians in the prophylaxis and treatment of VTE. ⋯ Our conclusions parallel those of previous investigations of the fragility of RCT outcomes; we found that some outcomes used to support recommendations in AT10 are fragile. We recommend that the fragility index and fragility quotient be adopted as measures of robustness of clinical trial outcomes.
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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.