Chest
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Rheumatoid arthritis (RA) is a systemic inflammatory disorder affecting approximately 1.3 million adults in the United States. Approximately 10% of these individuals with RA have clinically evident interstitial lung disease (RA-ILD), and an additional one-third demonstrate subclinical ILD on chest CT scan. The risk of death for individuals with RA-ILD is three times higher than for patients with RA without ILD, with a median survival after ILD diagnosis of only 2.6 years. ⋯ At present, we lack a standard validated approach to the definition, diagnosis, risk stratification, and management of RA-ILD. In this perspective, we discuss the importance of clinical and translational research and how ongoing research efforts can address important gaps in our knowledge over the next few years. Furthermore, recommendations are made to design multicenter collaborative studies that will expedite the development of clinical trials designed to decrease the significant morbidity and mortality associated with RA-ILD.
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Successfully designing a new ICU requires clarity of vision and purpose and the recognition that the patient room is the core of the ICU experience for patients, staff, and visitors. The ICU can be conceptualized into three components: the patient room, central areas, and universal support services. Each patient room should be designed for single patient use and be similarly configured and equipped. ⋯ This coordination helps establish efficient and safe patient throughput and care and fosters physical and social cohesiveness within the ICU. A balanced approach to centralized and decentralized monitoring and logistics also offers great flexibility. Synchronization of the universal support services in the ICU with the hospital's existing systems maintains unity of purpose and continuity across the enterprise and avoids unnecessary duplication of efforts.
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The use of mechanical circulatory support (MCS) devices has increased sixfold since 2006. Although there is an established legal and ethical consensus that patients have the right to withdraw and withhold life-sustaining interventions when burdens exceed benefits, this consensus arose prior to the widespread use of MCS technology and is not uniformly accepted in these cases. ⋯ Our center recently encountered the challenge of an awake and functionally improving patient with a total artificial heart (TAH) who requested its deactivation. We present a narrative description of this case with discussion of the following questions: (1) Is it ethically permissible to deactivate this particular device, the TAH? (2) Are there any particular factors in this case that are ethical contraindications to proceeding with deactivation? (3) What are the specific processes necessary to ensure a compassionate and respectful deactivation? (4) What proactive practices could have been implemented to lessen the intensity of this case's challenges? We close with a list of recommendations for managing similar cases.
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The modern medical record is not only used by providers to record nuances of patient care, but also is a document that must withstand the scrutiny of insurance payers and legal review. Medical documentation has evolved with the rapid growth in the use of electronic health records (EHRs). The medical software industry has created new tools and more efficient ways to document patient care encounters and record results of diagnostic testing. ⋯ Policies to guide provider documentation in EHRs have been developed by institutions and payers with the goal of reducing patient care risks as well as preventing fraud and abuse. In this article, we describe the major content-importing technologies that are commonly used in EHR documentation as well as the benefits and risks associated with their use. We have also reviewed a number of institutional policies and offer some best practice recommendations.