Current opinion in pulmonary medicine
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This review discusses the most recent clinical and basic research literature on pulmonary alveolar proteinosis (PAP) as it relates to pathogenesis, diagnosis, and management. ⋯ Understanding of the pathogenesis of PAP has greatly increased in the last decade; study has brought better comprehension of lung biology and recognition of the critical role for GM-CSF and alveolar macrophage in surfactant clearance. Balance between resident immune cell population and normal lung function still needs further study. Resident alveolar macrophages have an essential role in surfactant homeostasis. With this knowledge more effective diagnostic tests (e.g. anti-GM-CSF antibody) and therapies for PAP are under investigation.
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Venous thromboembolism represents a potentially threatening complication in surgical and medical patients. Thromboprophylaxis showed a significant reduction of venous thromboembolic events, and low-molecular-weight heparins have been considered the standardized prophylactic regimen for a long time. The purpose of this review is to provide updated evidence on the use of low-molecular-weight heparins for prevention of venous thromboembolism after the publication of the latest American College of Chest Physicians Evidence-Based Clinical Practice Guidelines on antithrombotic and thrombolytic therapy. ⋯ Low-molecular-weight heparins are expanding their application, but progressively they will be replaced by other new antithrombotics for the prophylaxis of venous thromboembolism. Surgical patients undergo a more concerted approach to thromboprophylaxis than medical patients. Future research should aim at improving prophylaxis in the latter setting in order to significantly reduce the rate of venous thromboembolic events.
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The potential impact of helical computerized tomography (CT) on earlier diagnosis and earlier treatment of pulmonary embolism and improved health outcomes is significant. The purpose of this review is to summarize the state-of-the-art of radiographic pulmonary embolism detection and consider future directions to reduce this significant public health problem. ⋯ CT of the lung is an evolving technology that is improving medical decision making and health outcomes for individuals who sustain pulmonary embolism, one of the leading causes of in-hospital death. Future approaches include reducing cost and radiation risk, and promoting anticoagulation prophylaxis and provider and consumer awareness. The time is ripe to ensure evolving technology equates with long-term healthier outcomes.
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To summarize recent studies that have quantified the incidence of death due to late thromboembolic disease among patients initially diagnosed with acute unprovoked pulmonary embolism. These findings will aid clinicians who must weigh the risk versus the benefits of long-term anticoagulant therapy. ⋯ The incidence of death due to recurrent pulmonary embolism or significantly debilitating or fatal thromboembolic pulmonary hypertension in the first 3 years after anticoagulant treatment is discontinued is approximately 1-3%. In patients in whom the risk of fatal or disabling hemorrhage is lower, the benefits of chronic anticoagulation may outweigh the risks.
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The purpose of this review is to critique and summarize clinical literature relevant to thromboprophylaxis in critically ill patients with renal insufficiency. The specific objectives are to discuss factors that increase the risks for bleeding and venous thromboembolism in critically ill patients, with a focus on patients with renal insufficiency, and to consider prophylaxis management options and the rationale for their use. ⋯ We provide some considerations for practice in the conclusion section.