Chest
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Pulmonary exacerbations in cystic fibrosis (CF) contribute to the burden of disease, with a negative impact on quality of life, costs, and lung function. Our aim was to evaluate whether exacerbations, defi ned by antibiotic use, were triggered by daily fl uctuations in air pollution. ⋯ In patients with CF and exacerbations, ambient concentrations of ozone, PM 10 , and NO 2 play a role in triggering an exacerbation.
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We explore some philosophical and scientific underpinnings of clinical research and evidence at the patient-clinician encounter scale. Insufficient evidence and a common failure to use replicable and sound research methods limit us. Both patients and health care may be, in part, complex nonlinear chaotic systems, and predicting their outcomes is a challenge. ⋯ Obtaining a benefit at the patient-clinician encounter scale requires human (clinician) behavior modification. We believe that serious rethinking and restructuring of the clinical research and care delivery systems is necessary to assure the profession and the public that we continue to do more good than harm. We need to evaluate whether, and how, detailed decision-support tools may enable reproducible clinician behavior and beneficial use of evidence.
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Compounding pharmacies serve a critical role in modern health care to meet special patient care needs. Although the US Food and Drug Administration (FDA) has clearly delineated jurisdiction over drug companies and products manufactured under Good Manufacturing Practice (GMP) regulations to ensure quality, potency, and purity, compounding pharmacies are regulated by the State Boards and are not registered by the FDA. In recent years, some compounding pharmacies acted like a manufacturer, preparing large amounts of injectable drugs with interstate activities. ⋯ Moreover, compliance with the Institute for Safe Medication Practices 2011 recommendations that any type of sterile compounding must be in compliance with the United States Pharmacopoeia chapter 797 guidelines will reduce the risk of patient harm from microbial contamination. Finally, other critical factors that require close attention include addressing injectable products compounded in hospitals and other outpatient health-care centers. The FDA and State Boards of Pharmacy must be adequately funded to exercise the oversight effectively.
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Catamenial pneumothorax (CP) is a cause of recurrent pneumothorax in women of child-bearing age. Surgical treatment has been associated with high recurrence rates. We report our experience with a totally videothoracoscopic approach involving diaphragmatic repair, pleurectomy/abrasion, and hormonal treatment in patients with proven CP. ⋯ A totally videothoracoscopic approach to CP including diaphragmatic cover with a mesh and pleurectomy/pleural abrasion is feasible, safe, and highly effective. Routine hormonal treatment (gonadotropin-releasing hormone analog) may also help reduce recurrences.
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Diaphragmatic muscle contractions triggered by ventilator insuffl ations constitute a form of patient-ventilator interaction referred to as “entrainment,” which is usually unrecognized in critically ill patients. Our objective was to review tracings, which also included muscular activity, obtained in sedated patients who were mechanically ventilated to describe the entrainment events and their characteristics. The term “reverse triggering” was adopted to describe the ventilator-triggered muscular efforts. ⋯ To our knowledge, this is the fi rst time that the presence of respiratory entrainment in sedated, critically ill adult patients who are mechanically ventilated has been documented. The “reverse-triggered” breaths illustrate a new form of neuromechanical coupling with potentially important clinical consequences.