Annals of the American Thoracic Society
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RATIONALE/OBJECTIVE: In the context of increasing survivorship from critical illness, many studies have documented persistent sequelae among survivors. However, few evidence-based therapies exist for these problems. Support groups have proven efficacy in other populations, but little is known about their use after an intensive care unit (ICU) stay. Therefore, we surveyed critical care practitioners regarding their hospital's practice regarding discussing post-ICU problems for survivors with patients and their loved ones, communicating with primary care physicians, and providing support groups for current or former patients and families. ⋯ Despite growing awareness of the problems faced by ICU survivors, in this statewide quality improvement collaborative, hospital-based support groups are rarely available, and deficiencies in transitions of care exist. Practice innovations and formal research are needed to provide ways to translate awareness of the problems of survivorship into improved outcomes for patients.
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The Affordable Care Act was intended to address systematic health inequalities for millions of Americans who lacked health insurance. Expansion of Medicaid was a key component of the legislation, as it was expected to provide coverage to low-income individuals, a population at greater risk for disparities in access to the health care system and in health outcomes. Several studies suggest that expansion of Medicaid can reduce insurance-related disparities, creating optimism surrounding the potential impact of the Affordable Care Act on the health of the poor. ⋯ Moreover, relative to many private plans, Medicaid is an imperfect program suffering from lower reimbursement rates, fewer covered services, and incomplete acceptance by preventive and specialty care providers. These constraints will reduce the potential impact of the expansion for patients with respiratory and sleep conditions or critical illness. Despite its imperfections, the more than 10 million low-income individuals who gain insurance as a result of Medicaid expansion will likely have increased access to health care, reduced out-of-pocket health care spending, and ultimately improvements in their overall health.
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Due to growing interest in management of central airway obstruction, rigid bronchoscopy is undergoing a resurgence in popularity among pulmonologists. Performing rigid bronchoscopy requires use of deep sedation or general anesthesia to achieve adequate patient comfort, whereas maintaining oxygenation and ventilation via an uncuffed and often open rigid bronchoscope requires use of ventilation strategies that may be unfamiliar to most pulmonologists. Available approaches include apneic oxygenation, spontaneous assisted ventilation, controlled ventilation, manual jet, and high-frequency jet ventilation. ⋯ Despite a patient population that often suffers from significant respiratory compromise, major complications with rigid bronchoscopy are uncommon and are similar among modern ventilation approaches. Choice of ventilation technique should be determined by local expertise and equipment availability. Appropriate patient selection and recognition of limitations associated with a given ventilation strategy are critical to avoid procedural-related complications.
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Minority patients with lung cancer are less likely to receive stage-appropriate treatment. Along with access to care and provider-related factors, cultural factors such as patients' lung cancer beliefs, fatalism, and medical mistrust may help explain this disparity. ⋯ Negative surgical beliefs, fatalism, and mistrust are more prevalent among minorities and appear to explain almost one-third of the observed disparities in lung cancer treatment among black patients. Interventions targeting cultural factors may help reduce undertreatment of minorities.
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Pulmonary arterial hypertension (PAH) is a pulmonary vasculopathy that leads to failure of the right ventricle and premature death. ⋯ Patients with PAH showed lower sublingual microvasculature flow index and higher tortuosity compared with healthy age- and sex-matched control subjects. Further investigations are needed to assess whether this methodology can provide information on disease prognosis and/or response to therapy in this condition.