Chest
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Nosocomial pneumonia is the second most frequent nosocomial infection and represents the leading cause of death from infections that are acquired in the hospital. In the last decade, a large body of data has accumulated that points to the substantial impact of inadequate antibiotic treatment as a major risk factor for infection-attributed mortality in ventilator-associated pneumonia (VAP) patients. In most instances, high-risk pathogens (eg, highly resistant Gram-negative bacilli, such as Pseudomonas aeruginosa and Acinetobacter spp, as well as methicillin-resistant staphylococci) are the predominant microorganisms causing excess mortality. ⋯ Therefore, the best approach for reducing infection-related mortality seems to be the initial institution of an adequate and broad-spectrum antibiotic regimen in severely ill patients, which should be modified in a de-escalating strategy when the results from microbiologic testing become available. To circumvent the inherent danger of the emergence of resistance in ICU patients, additional measures have to be implemented and tested in clinical trials to reduce antibiotic consumption, shorten the duration of antibiotic treatment, and reduce the selection pressure on the ICU flora. This latter goal could be met by new antibiotic strategies including scheduled changes of recommended empiric antibiotic regimens at fixed intervals on a rotating basis.
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Review Case Reports
Subarachnoid pleural fistula due to penetrating trauma: case report and review of the literature.
We describe a case of a 30-year-old man who developed a recurrent pleural effusion after sustaining a gunshot wound to the left side of his chest with subsequent complete paralysis at the T2 level. Subarachnoid-pleural fistulas have rarely been reported as complications of penetrating and blunt trauma, thoracic surgery, as well as spinal surgery. Concomitant injuries may overshadow or complicate the diagnosis of subarachnoid-pleural fistulas. The diagnosis should be considered in any patient with a pleural effusion that is associated with severe neurologic injury, as the fistula rarely heals without surgical intervention and may lead to CNS infection or pneumocephalus.
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Angiogenesis, defined as the growth of new capillaries from preexisting vessels, is a pervasive biological phenomenon that is at the core of many physiologic and pathologic processes. An opposing balance of angiogenic and angiostatic factors regulates angiogenesis. ⋯ CXC chemokines comprise a unique cytokine family that contains members that exhibit on a structural/functional basis either angiogenic or angiostatic biological activity. In this review, we will discuss the role of CXC chemokines and angiogenesis in pulmonary fibrosis.
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Pulmonary fibrosis is a component of over 200 interstitial lung diseases. Some have known etiologies, however, for many diseases, the etiology remains unknown or obscure. This brief review examines the prevalence and classification of these diseases, the approach to be taken for the investigation of a patient suspected of having pulmonary fibrosis, the indications for the performance of lung biopsy, and current thoughts concerning the pathogenesis of the idiopathic forms of fibrotic lung disease. A brief review of established and emerging therapeutic strategies is included.
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Experimental methods to quantify alveolar fluid clearance have been adapted for our studies in patients with acute lung injury (ALI) or ARDS. We recently completed a study of 79 patients with ALI/ARDS that was designed to examine alveolar fluid clearance in the setting of alveolar epithelial injury from ALI/ARDS. Pulmonary edema fluid and plasma were sampled serially in the first 4 h after endotracheal intubation and the initiation of positive-pressure ventilation. ⋯ Patients with maximal alveolar fluid clearance had a significantly lower mortality rate and a shorter duration of mechanical ventilation. Several mechanisms may account for the decrease in the rate of alveolar fluid clearance in ALI/ARDS patients, including hypoxia, reactive oxygen species, reactive nitrogen species, and the loss of an intact epithelial barrier in the distal airspaces of the lung. Despite the epithelial injury in patients with ALI/ARDS, some experimental studies have suggested that alveolar fluid clearance could be increased with therapy using cyclic adenosine monophosphate agonists or other pharmacologic agents.