Chest
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Comment Review
The Last Beat: Contemporary Ethical Controversies Surrounding Determination of Cardiopulmonary Death.
Part one of this series tracked the evolution of the death examination, noting its stability over the last century despite changing diagnostic and therapeutic technologies and social contexts. In part two, we discuss the practical and ethical debates surrounding the exact timing of death. ⋯ The phenomenon of autoresuscitation highlights these issues because patients who meet all the criteria for circulatory death (sometimes for periods of observation well beyond the norm) apparently return to life. Were these patients resurrected (like Lazarus) or did we simply not wait long enough?
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Review Historical Article
The Last Breath: Historical Controversies Surrounding Determination of Cardiopulmonary Death.
Cardiopulmonary determination of death is a mainstay of the practice of internal medicine and pulmonary physicians. Despite this, there is considerable variability in death examinations. ⋯ The recognition of coma dépassé and brain death has further pushed the focus of the death examination onto the neurological system. Despite advancing diagnostics and legislative attempts to standardize the definition of death, cardiopulmonary death determination largely remains an ad hoc process.
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Interstitial lung abnormalities (ILA) may represent undiagnosed early-stage or subclinical interstitial lung disease (ILD). ILA are often observed incidentally in patients who subsequently develop clinically overt ILD. There is limited information on consensus definitions for, and the appropriate evaluation of, ILA. Early recognition of patients with ILD remains challenging, yet critically important. Expert consensus could inform early recognition and referral. ⋯ Guidance was established for identifying clinically relevant ILA, subsequent referral, and follow-up. These results lay the foundation for developing practical guidance on managing patients with ILA.
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Asthma-COPD overlap (ACO) is a heterogeneous condition that describes patients who show persistent airflow limitation with clinical features that support both asthma and COPD. Although no single consensus definition exists to diagnose this entity, common major criteria include a strong bronchodilator reversibility or bronchial hyperreactivity, a physician diagnosis of asthma, and a ≥ 10-pack-year cigarette smoking history. The prevalence of ACO ranges from 0.9% to 11.1% in the general population, depending on the diagnostic definition used. ⋯ For treatment options, the population with ACO historically has been excluded from therapeutic trials; therefore strong, evidence-based recommendations are lacking beyond first-line inhaler therapies. Advanced therapies in patients with ACO are selected according to disease phenotypes and are based on extrapolated data from asthma and COPD. Research focused on defining biomarkers and evidence-based treatment options for ACO is needed urgently.
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Meta Analysis
Risk Factors for Invasive Candida Infection in Critically Ill Patients: A Systematic Review and Meta-Analysis.
Current guidelines recommend empirical antifungal therapy in patients with sepsis with high risk of invasive Candida infection. However, many different risk factors have been derived from multiple studies. These risk factors lack specificity, and broad application would render most ICU patients eligible for empirical antifungal therapy. ⋯ Our systematic review and meta-analysis identified patient- and treatment-related factors that were associated with the risk for the development of invasive Candida infection in the ICU. Most of the factors identified were either related to medical interventions during intensive care or to comorbid conditions.