Current opinion in pulmonary medicine
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Pleural effusions commonly occur in patients with left heart failure. However, there is increasing evidence that patients with pulmonary hypertension and isolated right heart failure frequently have pleural effusions. ⋯ Pleural effusions without an alternate explanation occur commonly in at least three subtypes of pulmonary arterial hypertension. The majority of patients with pleural effusions also have isolated right heart failure that is thought to be responsible for the development of the effusions. Patients presenting with pulmonary hypertension should be evaluated for pleural effusions, and if present, should receive a work-up for right heart failure.
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Immune reconstitution inflammatory syndrome (IRIS) is a common occurrence in HIV patients starting antiretroviral therapy (ART), and pulmonary involvement is an important feature of tuberculosis-IRIS and pneumocystis-IRIS. Pulmonologists need an awareness of the timing, presentation and treatment of pulmonary IRIS. ⋯ Tuberculosis-IRIS, nontuberculosis mycobacterial-IRIS and pneumocystis-IRIS occur within days to weeks of starting ART, causing substantial morbidity, but low mortality. Cryptococcal-IRIS usually occurs later in the course of ART, and may be associated with appreciable mortality. Early recognition of unmasking and paradoxical IRIS affecting the lung allows timely initiation of antimicrobial and/or immunomodulatory therapies.
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This review highlights the most important and salient recent developments with regards to invasive pulmonary aspergillosis (IPA), currently the most common opportunistic fungal pneumonia in patients with hematological malignancies. ⋯ Despite increasing knowledge of IPA and availability of newer antifungal agents, clinical management remains a challenge in the setting of a compromised host defense system that is unable to mount an appropriate immune response against the pathogen.
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Tuberculosis (TB) remains a global emergency and continues to kill 1.7 million people globally each year. Drug-resistant TB is now well established throughout the world and most TB patients are not being screened for drug resistance due to lack of laboratory resources and rapid accurate point-of-care tests. Accurate and rapid diagnosis of TB and drug-resistant TB is of paramount importance in establishing appropriate clinical management and infection control measures. During the past decade, there have been significant advances in diagnostic technologies for TB and drug-resistant TB. The purpose of this article is to review the current data, recommendations and evidence base for these tests. ⋯ In this review, we describe the phenotypic and genotypic methods currently available for the diagnosis of TB and drug-resistant forms of Mycobacterium tuberculosis and discuss future prospects for TB diagnostics. Current technologies for the detection of drug resistant M. tuberculosis vary greatly in terms of turnaround time, cost and complexity. Ultimately, the 'holy grail' diagnostic for TB must fulfil all technical specifications for a good point-of-care test, screen for drug resistance concurrently and be adaptable to the various health system levels and to countries with diverse economic status and TB burden.
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Ventilator-associated pneumonia (VAP) remains a frequent and severe complication in endotracheally intubated patients. Strict adherence to preventive measures reduces the risk of VAP. The objective of this paper is to review what has come forward in recent years in the nonpharmacological prevention of VAP. ⋯ New devices and strategies have been developed to prevent VAP. Some of these are promising but need further study. In addition, more attention is being given to factors that might facilitate the implementation process and the challenge of achieving high adherence rates.