Chest
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Cardiac tamponade is a medical emergency that can be readily reversed with timely recognition and appropriate intervention. The clinical diagnosis of cardiac tamponade requires synthesis of a constellation of otherwise nonspecific features based on an understanding of the underlying pathophysiological characteristics. Although echocardiographic examination is a central component of diagnosis, alone it is insufficient to establish the physiological diagnosis of hemodynamically significant cardiac tamponade. ⋯ Echocardiographic examination confirms the size, location, and other characteristics of the causal pericardial collection. Several echocardiographic features support the hemodynamic diagnosis of tamponade, including early diastolic collapse of the right ventricle, late diastolic collapse of the right atrium, respiratory variation in mitral valve inflow (akin to pulsus paradoxus), and decreased early filling (E wave) of mitral valve inflow (related to loss of the y descent). Echocardiographic examination then supports decisions about the early treatment and drainage of the tamponading effusion.
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Meta Analysis
Trial Duration and Risk Reduction in Combination Therapy Trials for Pulmonary Arterial Hypertension: A Systematic Review.
Relative risk (RR) and number needed-to-treat (NNT) are frequently time-dependant measures. We performed a systematic review and meta-analysis to assess whether trial duration influenced the relative and absolute risk of worsening in randomized controlled trials (RCTs) comparing combination therapy (CT) of pulmonary arterial hypertension (PAH)-specific therapies vs monotherapy (MT). ⋯ Absolute risk reduction of clinical worsening was relatively constant beyond 6 to 12 months of treatment in clinical trials comparing CT with MT in PAH. These results question the need for CT trials of very long duration in PAH.
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Nonthrombotic pulmonary embolism (NTPE) is a complete or partial occlusion of the pulmonary vasculature by various organic and inorganic materials. These materials include organic particulate matter (PM) such as adipocytes, tumor cells, bacteria, fungi, or gas and inorganic PM. Although NTPE due to organic PM has been extensively reported in the medical literature, there are no comprehensive reviews of inorganic material embolizing to the lungs. ⋯ In contrast to the "classic" pulmonary thromboembolism, the pathophysiologic effects of embolism by PM are not only mechanical but also a consequence of the nature of the offending material. NTPE caused by these substances can be relatively innocuous, life-threatening, or lead to chronic pulmonary disease, if left undetected. We hope that the heightened sense of awareness of this entity may allow earlier diagnosis and recognition of its complications.
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Meta Analysis
A Systematic Review and Meta-Analysis Comparing Pigtail Catheter and Chest Tube as the Initial Treatment for Pneumothorax.
The optimal initial treatment approach for pneumothorax remains controversial. This systemic review and meta-analysis investigated the effectiveness of small-bore pigtail catheter (PC) drainage compared with that of large-bore chest tube (LBCT) drainage as the initial treatment approach for all subtypes of pneumothorax. ⋯ Collectively, results of the meta-analysis suggest PC drainage may be considered as the initial treatment option for patients with primary or secondary spontaneous pneumothorax. Ideally, randomized controlled trials are needed to compare PC vs LBCT among different subgroups of patients with pneumothorax, which may ultimately improve clinical care and management for these patients.
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There is increasing interest in the therapeutic utility of vitamin D in asthma, which is supported by a significant body of evidence on epidemiologic associations between vitamin D insufficiency and worse asthma control. In support of a causal relationship, vitamin D beneficially modulates diverse immunologic pathways in heterogeneous asthma endotypes, regulating the actions of lymphocytes, mast cells, antigen-presenting cells, and structural cells to dampen excessive inflammatory responses. Allergic asthma is characterized by a failure of immune tolerance and the development of pathologic responses to inhaled aeroallergens, and vitamin D has been extensively shown to support immune regulation. ⋯ Increased understanding of the biological characteristics of vitamin D reveals methodological issues that might explain certain negative outcomes. Importantly, on systematic review of the trials to date, vitamin D is shown to be beneficial in asthma. The evidence discussed in this review supports the importance of optimizing vitamin D in holistic asthma care.