American journal of respiratory and critical care medicine
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Am. J. Respir. Crit. Care Med. · Oct 2022
Randomized Controlled Trial Multicenter StudyThe Effect of a Liberal Approach to Glucose Control in Critically Ill Patients with Type 2 Diabetes: A multicenter, parallel-group, open-label, randomized clinical trial.
Rationale: Blood glucose concentrations affect outcomes in critically ill patients, but the optimal target blood glucose range in those with type 2 diabetes is unknown. Objectives: To evaluate the effects of a "liberal" approach to targeted blood glucose range during ICU admission. Methods: This mutlicenter, parallel-group, open-label randomized clinical trial included 419 adult patients with type 2 diabetes expected to be in the ICU on at least three consecutive days. ⋯ By Day 90, 62 of 210 (29.5%) in the intervention and 52 of 209 (24.9%) in the comparator group had died (absolute difference, 4.6 percentage points [95% CI, -3.9% to 13.2%]; P = 0.29). Conclusions: A liberal approach to blood glucose targets reduced incident hypoglycemia but did not improve patient-centered outcomes. Clinical trial registered with Australian New Zealand Clinical Trials Registry (ACTRN 12616001135404).
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Am. J. Respir. Crit. Care Med. · Oct 2022
Historical Redlining Impacts Contemporary Environmental and Asthma-Related Outcomes in Black Adults.
Rationale: Environmental threats and poorly controlled asthma disproportionately burden Black people. Some have attributed this to socioeconomic or biologic factors; however, racism, specifically historical redlining, a U. S. discriminatory mortgage lending practice in existence between the 1930s and the 1970s, may have actuated and then perpetuated poor asthma-related outcomes. ⋯ Furthermore, elevated exposure to filterable particulate matter <2.5 μm, sulfur dioxide, and volatile organic compound emissions (all P < 0.050) and risk of uncontrolled and/or severe asthma (relative risk [95% confidence interval], 2.30 [1.19, 4.43]; P = 0.009) demonstrated inequitable distributions within grade D neighborhood boundaries, disproportionately burdening Black registry participants. Conclusions: The racist practice of historical/HOLC redlining profoundly contributes to long-term environmental and asthma-related inequities in Black adults. Acknowledging the role racism has in these outcomes should empower more specific and novel interventions targeted at reversing these structural issues.
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Am. J. Respir. Crit. Care Med. · Oct 2022
The Contribution of Chest Radiography to the Clinical Management of Children Exposed to Tuberculosis.
Rationale: Although World Health Organization guidelines emphasize contact investigation for tuberculosis (TB)-exposed children, data that support chest radiography as a useful tool are lacking. Objectives: We evaluated the diagnostic and prognostic information of chest radiography in children exposed to TB and measured the efficacy of isoniazid preventive therapy (IPT) in those with relevant radiographic abnormalities. Methods: Between September 2009 and August 2012, we enrolled 4,468 TB-exposed children who were screened by tuberculin skin testing, symptom assessment, and chest radiography. ⋯ Among the 29 symptom-negative and CXR-abnormal child contacts, 20% (3/15) of the isoniazid recipients developed incident TB, compared with 57% (8/14) of those who did not receive IPT (82% IPT efficacy). Conclusions: Our results strongly support the use of chest radiography as a routine screening tool for the evaluation of child TB contacts, which is readily available. Radiographic abnormalities not usually considered suggestive of TB may indicate incipient or subclinical disease, although TB preventive treatment is adequate in most cases.
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Am. J. Respir. Crit. Care Med. · Oct 2022
Vasculopathy and Increased Vascular Congestion in Fatal COVID-19 and ARDS.
Rationale: The leading cause of death in coronavirus disease 2019 (COVID-19) is severe pneumonia, with many patients developing acute respiratory distress syndrome (ARDS) and diffuse alveolar damage (DAD). Whether DAD in fatal COVID-19 is distinct from other causes of DAD remains unknown. Objective: To compare lung parenchymal and vascular alterations between patients with fatal COVID-19 pneumonia and other DAD-causing etiologies using a multidimensional approach. ⋯ Alveolar-septal congestion was associated with a significantly shorter time to death from symptom onset (P = 0.03), length of hospital stay (P = 0.02), and increased ventilatory ratio [an estimate for pulmonary dead space fraction (Vd); p = 0.043] in all cases of ARDS. Conclusions: Severe COVID-19 pneumonia is characterized by significant vasculopathy and aberrant alveolar-septal congestion. Our findings also highlight the role that vascular alterations may play in Vd and clinical outcomes in ARDS in general.