Chest
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Review Case Reports
How We Do It: Using Sotatercept in the Care of Patients with Pulmonary Arterial Hypertension.
Pulmonary arterial hypertension (PAH) is a rare disease of the pulmonary microvasculature leading to elevated precapillary pulmonary hypertension. Pulmonary vascular remodeling, a characteristic of PAH, is driven by dysfunctions in the signaling between the pulmonary smooth muscle and endothelial cells with abnormalities that affect cell proliferation and immune dysregulation. ⋯ Often, recommendations from these data are unclear or too general, due to remaining gaps in knowledge. In this edition of "How I Do It," we provide a case-based discussion of common clinical decisions regarding diagnostic testing, choice of first-line agents, escalation of therapy, potential timing of sotatercept, safety awareness, practical use, potential management changes, and the future use of sotatercept in other pulmonary hypertension cohorts.
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Lung cancer screening (LCS) has the potential to decrease mortality from lung cancer by 20%. Yet, more than a decade since LCS was established as an evidence-based practice, < 20% of the eligible population in the United States has been screened. This review focuses on critically appraising interventions that have been designed to increase the initial uptake of LCS, including how they address known barriers to LCS and their effectiveness in overcoming these barriers. ⋯ Improving uptake of LCS requires learning from prior interventions to design multilevel interventions that address barriers to LCS at key steps and identifying which components of these interventions are effective and generalizable.
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Artificial intelligence (AI) is increasingly being used in health care. Without an ethically supportable, standard approach to knowing when patients should be informed about AI, hospital systems and clinicians run the risk of fostering mistrust among their patients and the public. Therefore, hospital leaders need guidance on when to tell patients about the use of AI in their care. ⋯ To determine which AI technologies fall into each of the identified categories (no notification or no informed consent [IC], notification only, and formal IC), we propose that AI use-cases should be evaluated using the following criteria: (1) AI model autonomy, (2) departure from standards of practice, (3) whether the AI model is patient facing, (4) clinical risk introduced by the model, and (5) administrative burdens. We take each of these in turn, using a case example of AI in health care to illustrate our proposed framework. As AI becomes more commonplace in health care, our proposal may serve as a starting point for creating consensus on standards for notification and IC for the use of AI in patient care.
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Observational Study
Veno-venous Extracorporeal Membrane Oxygenation (VV ECMO) Candidacy Decision-Making: Lessons and Hypotheses from a Single Center Observational Analysis.
Use of venovenous extracorporeal membrane oxygenation (ECMO) is increasing, but candidacy selection processes are variable and subject to bias. ⋯ ECMO candidacy decisions are inconsistent. We identified four patterns of inconsistency in our center and propose a three-domain model for understanding and categorizing contraindications, yielding five lessons that may improve candidacy decision processes until further research can guide practice more definitively.
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A 76-year-old male Vietnam veteran with a medical history of OSA on CPAP, mild COPD, Parsonage-Turner syndrome (a rare neurologic syndrome manifesting with shoulder and arm pain), hypertension, gastroesophageal reflux, hiatal hernia, and prior endocarditis presented with 1 year duration progressive exertional dyspnea with minimal activity by referral from an outside pulmonologist. The patient reported possible exposure to Agent Orange during his service but was otherwise without significant occupational or environmental exposures. ⋯ Aside from marginal cigarette use, he denied any recreational drug use or any anorectic use. The patient provided records from a recent right heart catheterization (RHC) months earlier for review.