The relative attention from researchers to bronchiectasis due to cystic fibrosis compared with other causes (non-cystic fibrosis bronchiectasis, NCFBE) has been heavily weighted towards the former. ...However, there has been a significant expansion of research and funding in NCFBE in recent years. Despite this, there have been limited advances in patient care. Current approaches in bronchiectasis research have limitations, as the lung can respond to injury in different ways, leading to different disease mechanisms and treatment responses. Similar to other lung diseases, such as interstitial lung disease and asthma, bronchiectasis has different pathways and presentations. Pooling different clinical phenotypes together in research studies has been a major failing, and there is a need for large collaborative groups to address this. Longitudinal studies are also needed to understand the progression and key determinants of NCFBE. Multicenter paradigms and a refashioning of research agendas are necessary to address the complexity of NCFBE and improve patient care.
Background Pulmonary embolism (PE) remains a significant cause of hospital admission and health-care costs. Estimates of PE incidence came from the 1990s, and data are limited to describe trends in ...hospital admissions for PE over the past decade. Methods We analyzed Nationwide Inpatient Sample data from 1993 to 2012 to identify patients admitted with PE. We included admissions with International Classification of Diseases, 9th revision, codes listing PE as the principal diagnosis as well as admissions with PE listed secondary to principal diagnoses of respiratory failure or DVT. Massive PE was defined by mechanical ventilation, vasopressors, or nonseptic shock. Outcomes included hospital lengths of stay, adjusted charges, and all-cause hospital mortality. Linear regression was used to analyze changes over time. Results Admissions for PE increased from 23 per 100,000 in 1993 to 65 per 100,000 in 2012 ( P < .001). The percent of admissions meeting criteria for massive PE decreased (5.3% to 4.4%, P = .002), but the absolute number of admissions for massive PE increased (from 1.5 to 2.8 per 100,000, P < .001). Median length of stay decreased from 8 (interquartile range IQR, 6-11) to 4 (IQR, 3-6) days ( P < .001). Adjusted hospital charges increased from $16,475 (IQR, $10,748-$26,211) in 1993 to $25,728 (IQR, $15,505-$44,493) in 2012 ( P < .001). All-cause hospital mortality decreased from 7.1% to 3.2% ( P < .001), but population-adjusted deaths during admission for PE increased from 1.6 to 2.1 per 100,000 ( P < .001). Conclusions Total admissions and hospital charges for PE have increased over the past two decades. However, the population-adjusted admission rate has increased disproportionately to the incidence of patients with severe PE. We hypothesize that these findings reflect a concerning national movement toward more admissions of less severe PE.
Community-Acquired Pneumonia Wunderink, Richard G; Waterer, Grant W
The New England journal of medicine,
02/2014, Letnik:
370, Številka:
6
Journal Article
Recenzirano
Treatment of community-acquired pneumonia typically involves either a respiratory fluoroquinolone or a combination of cephalosporin and a macrolide. Initial broad-spectrum antibiotic therapy should ...be targeted to patients selected according to risk factors or existing disease.
Foreword
This
Journal
feature begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, when they exist. The article ends with the authors' clinical recommendations.
Stage
A 67-year-old woman with mild Alzheimer's disease who has a 2-day history of productive cough, fever, and increased confusion is transferred from a nursing home to the emergency department. According to the transfer records, she has had no recent hospitalizations or recent use of antibiotic agents. Her temperature is 38.4°C (101°F), the blood pressure is 145/85 mm Hg, the respiratory rate is 30 breaths per minute, the heart rate is 120 beats per minute, and the oxygen saturation is 91% while she is breathing ambient air. Crackles are heard in both lower lung fields. She is oriented to person . . .
This document provides evidence-based clinical practice guidelines on the management of adult patients with community-acquired pneumonia.
A multidisciplinary panel conducted pragmatic systematic ...reviews of the relevant research and applied Grading of Recommendations, Assessment, Development, and Evaluation methodology for clinical recommendations.
The panel addressed 16 specific areas for recommendations spanning questions of diagnostic testing, determination of site of care, selection of initial empiric antibiotic therapy, and subsequent management decisions. Although some recommendations remain unchanged from the 2007 guideline, the availability of results from new therapeutic trials and epidemiological investigations led to revised recommendations for empiric treatment strategies and additional management decisions.
The panel formulated and provided the rationale for recommendations on selected diagnostic and treatment strategies for adult patients with community-acquired pneumonia.
Coronavirus disease 2019 (COVID-19) has produced an extraordinary amount of literature in a short time period. This review focuses on what the new literature has provided in terms of more general ...information about the management of community-acquired pneumonia (CAP).
Measures taken to reduce the spread of COVID-19 have caused a significant drop in influenza worldwide. Improvements in imaging, especially ultrasound, and especially in the application of rapid molecular diagnosis are likely to have significant impact on the management of CAP. Therapeutic advances are so far limited.
COVID-19 has taught us that we can do far more to prevent seasonal influenza and its associated mortality, morbidity and economic cost. Improvements in imaging and pathogen diagnosis are welcome, as is the potential for secondary benefits of anti-COVID-19 therapies that may have reach effect on respiratory viruses other than severe acute respiratory syndrome coronavirus 2. As community-transmission is likely to persist for many years, recognition and treatment of severe acute respiratory syndrome coronavirus 2 will need to be incorporated into CAP guidelines moving forward.
Background. Existing severity assessment tools, such as the pneumonia severity index (PSI) and CURB-65 (tool based on confusion, urea level, respiratory rate, blood pressure, and age <65 years), ...predict 30-day mortality in community-acquired pneumonia (CAP) and have limited ability to predict which patients will require intensive respiratory or vasopressor support (IRVS). Methods. The Australian CAP Study (ACAPS) was a prospective study of 882 episodes in which each patient had a detailed assessment of severity features, etiology, and treatment outcomes. Multivariate logistic regression was performed to identify features at initial assessment that were associated with receipt of IRVS. These results were converted into a simple points-based severity tool that was validated in 5 external databases, totaling 7464 patients. Results. In ACAPS, 10.3% of patients received IRVS, and the 30-day mortality rate was 5.7%. The features statistically significantly associated with receipt of IRVS were low systolic blood pressure (2 points), multilobar chest radiography involvement (1 point), low albumin level (1 point), high respiratory rate (1 point), tachycardia (1 point), confusion (1 point), poor oxygenation (2 points), and low arterial pH (2 points): SMART-COP. A SMART-COP score of <3 points identified 92% of patients who received IRVS, including 84% of patients who did not need immediate admission to the intensive care unit. Accuracy was also high in the 5 validation databases. Sensitivities of PSI and CURB-65 for identifying the need for IRVS were 74% and 39%, respectively. Conclusions. SMART-COP is a simple, practical clinical tool for accurately predicting the need for IRVS that is likely to assist clinicians in determining CAP severity.
COVID-19: First Do No Harm Waterer, Grant W; Rello, Jordi; Wunderink, Richard G
American journal of respiratory and critical care medicine,
06/2020, Letnik:
201, Številka:
11
Journal Article
Recenzirano
Odprti dostop
Waterer et al. discuss the COVID-19 pandemic. Faced with a new disease, numbers of patients that have in many cases vastly overwhelmed healthcare resources, and no available effective treatment, an ...extraordinary array of experimental therapies have been given to critically ill patients, often in combination. Whether this approach has harmed more patients that it has helped remains to be seen. Desperate times are felt to justify desperate measures. However, the case series by Du et al. demonstrates that access to basic critical care support, not experimental therapies, is the most important determinant of the high mortality reported in some SARS-CoV-2 series. Despite acute respiratory distress syndrome in 74% and shock in 81%, only 21% of cases received invasive mechanical ventilation.
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