Annals of the American Thoracic Society
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Treatment of pleural infection with instillation of intrapleural tissue plasminogen activator (tPA) and human recombinant DNase (DNase) has been proven to decrease the length of hospital stay, decrease surgical referral, and improve drainage. The optimal dosage, administration, timing, and frequency of the regimen remain unclear. It is unknown if the two drugs can be administered immediately one after the other (referred to as concurrent) instead of instilling them separately with a 1- to -2-hour interval in between. ⋯ This cohort study shows that early administration of concurrent tPA/DNase in patients with pleural infection is relatively safe and effective. Given the high cost of therapy, it is feasible to guide therapy on the basis of clinical and radiographic response.
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Transitions to outpatient care are crucial after critical illness, but the documentation practices in discharge documents after critical illness are unknown. ⋯ In the discharge documents of survivors of ARDS, ARDS itself is rarely mentioned, but mechanical ventilation and ICU stay frequently are. The low rates of documentation of ARDS appear to be concordant with low rates of documentation during the hospital stay, consistent with known underrecognition in the ICU. Natural language processing tools can be used to effectively analyze large numbers of discharge documents of patients with critical illness.
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Nontuberculous mycobacteria (NTM) cause an increasingly important chronic and debilitating lung disease in older adults. Diagnosis is often delayed, although awareness among clinicians and patients is increasing. When necessary, treatment often lasts 18-24 months and consists of three or four antibiotics that can have serious side effects. ⋯ Patients expressed frustration with the number of people who have endured years of missed diagnoses or inadequate treatment of NTM. Participants identified as top research priorities the prevention of NTM infection; approval of more effective treatments with fewer side effects and easier administration; understanding the best chest physiotherapy methods; validating and using tools to measure quality of life; and developing a disease-specific activity and severity assessment tool. Workshop participants agreed that two complementary objectives are critical to ensure the best achievable outcomes for patients: (1) additional clinician education to improve screening and diagnosis of NTM infections; and (2) development of a geographically distributed network of experts in NTM disease to offer consultation or direct therapy after a diagnosis is made.
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Dr. Leroy Hood promotes a paradigm to advance medical care that he calls P4 medicine. The four Ps are: personalized, predictive, preventative, and participatory. ⋯ The final P-participatory-is ideally suited to OSA, with technology to obtain extensive data remotely from continuous positive airway pressure machines. Providing adherence data directly to patients increases their use of continuous positive airway pressure. Thus, the concept of P4 medicine is very applicable to obstructive sleep apnea and can be the basis for future research efforts.
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Primary ciliary dyskinesia (PCD) is a rare, heterogeneous, recessive, genetic disorder of motile cilia, leading to chronic upper and lower respiratory symptoms. Prevalence is estimated at around 1:10,000, but many patients remain undiagnosed, whereas others receive the label incorrectly. Proper diagnosis is complicated by the fact that the key symptoms, such as wet cough, chronic rhinitis, and recurrent upper and lower respiratory infection, are common and nonspecific. ⋯ However, they have been developed in tertiary care settings, where 10 to 50% of tested patients have PCD. The sensitivity and specificity of the tools are reasonable, but positive and negative predictive values may be poor in primary or secondary care settings. Although these studies are an important step toward an earlier diagnosis of PCD, more remains to be done before we have tools tailored to different health care settings.