Chest
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A previously healthy 22-month-old girl presented to the ED with a 3-week history of dyspnea on exertion. A chest radiograph showed a right upper-lobe opacity suspicious for pneumonia (Fig 1A). The patient was prescribed amoxicillin but returned to the ED 7 days later with cough and persistent dyspnea and tachypnea. ⋯ Treatment with azithromycin and albuterol was initiated, and amoxicillin was discontinued. Her symptoms briefly improved; however, she returned to the ED 10 days later because of worsening cough and tachypnea, and a 2-day history of increased irritability, decreased oral intake, decreased urine output, and intermittent perioral cyanosis. She was afebrile throughout this period per parent report and vital sign documentation at each ED visit.
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Ultrasound studies to detect DVT are traditionally performed and interpreted by sonographers and radiologists, respectively, but the growth of point-of-care ultrasound is putting this powerful tool in the hands of front-line physicians. Literature from ambulatory patients in the ED suggests this tool performs well in the hands of nonconventional users, and it is now being commonly deployed to aid in the management of critically ill patients. This article presents an approach for incorporating these tools into bedside practice, including illustrative figures and narrated video presentations to demonstrate the techniques described.
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Approximately 300 million people worldwide are estimated to be affected by asthma, and the number of patients affected is growing exponentially-with potential for an additional 100 million people affected by the condition by 2025. With this increasing burden of disease, there is high motivation to discover effective prevention strategies. Strategies aimed at stalling the atopic progression, modifying the microbiome, preventing respiratory viral infections, and reducing the impact of toxin/pollutant exposure through dietary supplements have had limited success in the prevention of asthma. ⋯ Genes underlie a predisposition to asthma and allergic sensitization, whereas exposure to allergens, respiratory infections, and pollution may modify asthma pathogenesis and the variation in severity seen among individuals. Future advances in asthma prevention may include a more personalized approach: genetic variations among susceptible individuals with distinct asthma phenotypes or different biomarkers of disease may help individualize prevention strategies and render them more. In this article, we summarize interventions that have been studied for the prevention of asthma and identify some of the clinical trials that are actively underway in asthma prevention.
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Interventional pulmonology programs provide clinical benefit to patients and are financially sustainable. To appreciate and illustrate the economic value of interventional pulmonology programs to hospital systems, physicians must have an understanding of basic health-care finance. Total revenue, adjusted gross revenue, contribution margin, variable direct costs, and indirect costs are terms that are essential for understanding the finances of bronchoscopy. ⋯ Two significant features of an economically sustainable bronchoscopy program are high procedural volume and low direct cost per case. Interventional pulmonology programs are valuable to the patients being served and hospitals as a whole. Consideration of the various factors needed to maintain financial sustainability is essential to improve the quality of care for patients because the cost of care remains a critical driver in defining value.