Clinics in chest medicine
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Given the varying histologic reactions and differ-ent mechanisms of action, it is not surprising that no uniform constellation of BAL changes is seen in drug-induced lung disease. BAL findings are not specific for any drug-induced lung disease and the definitive diagnosis cannot rely solely on the BAL findings. BAL findings can, however, contribute to the expected clinicopathologic pattern of a given drug-induced lung disease. BAL also is helpful in the differential diagnosis, primarily in the exclusion of an infective cause and of involvement of the lungs by the underlying disease (eg, metastatic cancer or malignant lymphoma).
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Pulmonary complications of therapy for RA or other benign conditions are often difficult to diagnose and treat. Clinical presentation of lung disease that is due to noncytotoxic drugs may vary from a mild, nonspecific cough to fulminant respiratory failure. The differential diagnosis of pulmonary disease should include drug toxicity, progression of the primary illness, and opportunistic infection. ⋯ Diagnostic work-up should include chest radiograph, repeat pulmonary function testing, and high-resolution CT of the chest. Bronchoscopy for tissue pathology or specific BAL cytokine markers also may yield useful information; occasionally, open-lung biopsy is required. If pulmonary disease that results from noncytotoxic drug therapy is suspected, the drug should be discontinued until the disease process is understood clearly.
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The lung has significant susceptibility to injury from a variety of chemotherapeutic agents. The clinician must be familiar with classic chemotherapeutic agents with well-described pulmonary toxicities and must also be vigilant about a host of new agents that may exert adverse effects on lung function. The diagnosis of chemotherapy-associated lung disease remains an exclusionary process, particularly with respect to considering usual and atypical infections, as well as recurrence of the underlying neoplastic process in these immune compromised patients. In many instances, chemotherapy-associated lung disease may respond to withdrawal of the offending agent and to the judicious application of corticosteroid therapy.
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Delirium is a frequent complication in older patients in the ICU and often persists beyond their ICU stay. Delirium in older persons in the ICU is a dynamic and complex process. ⋯ Given the high rates of delirium in the ICU that range from 50% to 80% (see references [27, 28, 34]), future studies are urgently needed to examine risk factors for delirium in the ICU setting, such as examining the impact of psychoactive medication use on delirium rates and persistence in the ICU setting. Moreover, studies that examine the impact of delirium prevention in the ICU on rates of delirium, duration and persistence of delirium, and long-term cognitive and functional outcomes post-ICU stay are greatly needed.
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The clinical spectrum of sepsis, severe sepsis, and septic shock is responsible for a growing number of deaths and excessive health care expenditures. Until recently, despite multiple clinical trials, no intervention provided a beneficial outcome in septic patients. Within the last 2 years, studies that involved drotrecogin alfa (activated), corticosteroid therapy, and early goal-directed therapy showed efficacy in those with severe sepsis and septic shock. These results have provided optimism for reducing sepsis-related mortality.