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COVID-19 , Neoplasias Pulmonares , Humanos , Neoplasias Pulmonares/epidemiologia , Pandemias , SARS-CoV-2RESUMO
PURPOSE: Long-term oxygen therapy (LTOT) is widely used to treat chronic obstructive pulmonary disease (COPD) and other conditions with severe hypoxemia, imposing a large financial burden on the American health care system. METHODS: To better understand oxygen prescription and its use in a multiethnic community hospital, we completed a prospective, observational study with a survey design in our multicultural population to better recognize patient understanding of oxygen indications and utilization. RESULTS: The survey was conducted at three outpatient pulmonary clinics. Among the 94 respondents (42% men and 58% women; age 71.8 ± 13 yr), 64% were current or former smokers. Sixty-one percent had primary diagnoses other than COPD, most commonly interstitial lung disease and congestive heart failure. One-third used oxygen for <12 hr daily. Oxygen use was variable among those to whom it was prescribed. Thirty-two percent of patients described themselves as noncompliant with their prescribed therapy due to poor equipment ergonomics, burdensome machine weight, and negative self-image and social stigma when using oxygen. CONCLUSIONS: Chronic obstructive pulmonary disease represented <50% of LTOT patients who were surveyed. Our data suggest that more structured prescribing practices and patient education should be studied if compliance is to be increased.
Assuntos
Oxigênio , Serviços Urbanos de Saúde , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Oxigenoterapia , Cooperação do Paciente , Estudos Prospectivos , Doença Pulmonar Obstrutiva Crônica/terapiaRESUMO
PURPOSE OF REVIEW: The current article reviews recent literature and summarizes the current understanding, diagnosis, risk, predictors, and management of radiation pneumonitis. RECENT FINDINGS: We discuss the different parameters that contribute to radiation toxicity, the potential biomarkers that predict the risk, and mitigators of radiation pneumonitis. SUMMARY: Radiotherapy aims to provide care and a better quality of life in cancer patients however with complications. Radiation pneumonitis is important to recognize to appropriately plan and care for this population.
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Neoplasias Pulmonares/radioterapia , Qualidade de Vida , Pneumonite por Radiação/diagnóstico , Humanos , Pneumonite por Radiação/epidemiologia , Pneumonite por Radiação/etiologia , Tomografia Computadorizada por Raios XRESUMO
PURPOSE OF REVIEW: This article reviews recent literature and experience in the diagnosis of nonresolving and slowly resolving pneumonia as it pertains to malignancy. RECENT FINDINGS: Malignancy must be considered as an important cause of pneumonia that resolves slowly or has incomplete resolution. Airway obstruction is more common than malignant infiltration as a cause of pneumonia that does not resolve appropriately. Infection due to resistant or unusual organisms must also be considered in the differential diagnosis. SUMMARY: Nonresolving pneumonia remains an important clinical challenge. Bronchoscopic evaluation in conjunction with computed tomography and PET scanning is still the most important technique for diagnosis.
Assuntos
Neoplasias Pulmonares , Pneumonia , Diagnóstico Diferencial , Humanos , Neoplasias Pulmonares/complicações , Neoplasias Pulmonares/diagnóstico , Pneumonia/diagnóstico , Pneumonia/etiologia , Pneumonia/terapia , Falha de TratamentoRESUMO
PURPOSE OF REVIEW: Multiple pulmonary nodules are a common finding especially with the implementation of lung cancer screening. Available guidelines address the management of solitary pulmonary nodules. The management of the multiple pulmonary nodules would differ based on the characteristic of the nodules, their distribution, and the history of the patients as well. RECENT FINDINGS: Most of the recent publications on multiple pulmonary nodules consist of individual case reports or case series. Robust population studies are lacking. SUMMARY: In this article, we propose an approach for management of multiple pulmonary nodules which needs to be validated.
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Neoplasias Pulmonares , Nódulos Pulmonares Múltiplos , Gerenciamento Clínico , Detecção Precoce de Câncer , Humanos , Neoplasias Pulmonares/patologia , Neoplasias Pulmonares/terapia , Nódulos Pulmonares Múltiplos/diagnóstico , Nódulos Pulmonares Múltiplos/terapiaRESUMO
PURPOSE OF REVIEW: This article reviews the current literature for the purpose of developing a practical approach for the diagnosis and management of primary tracheal tumors. RECENT FINDINGS: Because of nonspecific symptoms, tracheal tumors remain a diagnostic challenge. Currently available management strategies are not being optimally utilized due to lack of physician awareness and knowledge. The use of newer diagnostic modalities has increased diagnostic accuracy resulting in earlier detection in recent years. This review describes currently available diagnostic modalities along with relatively newer ones such as virtual bronchoscopy, anatomic Optical Coherence Tomography, spectroscopic techniques, and endobronchial ultrasonography. We will review and discuss management strategies including surgical options, adjuvant therapies, and interventional pulmonary techniques including their role in palliation. SUMMARY: Early detection along with improved surgical and interventional pulmonology techniques has led to a decline in the death rates from tracheal cancer in recent years. However, further studies are required to define the role of chemotherapeutic agents, combination therapies, and novel techniques such as tracheal transplantation, in the management of primary tracheal tumors. More robust evidence-based studies are needed to provide evidence for clinical practice guidelines for the treatment of primary tracheal tumors.
Assuntos
Neoplasias da Traqueia/diagnóstico , Neoplasias da Traqueia/terapia , Broncoscopia/métodos , Bases de Dados Factuais , Humanos , Pulmão/patologiaRESUMO
PURPOSE OF REVIEW: Despite the fact that primary pulmonary lymphoma (PPL) is a rare lung tumour, significant advances addressing clinical features, histological diagnosis, prognostic criteria and therapeutic management of this disease have been made within the past decade. RECENT FINDINGS: Monoclonality and phenotyping of alveolar lymphocytes are suggestive of mucosa-associated lymphoid tissue (MALT). Detection of MALT-1 gene rearrangements in bronchoalveolar fluid cells using fluorescence in-situ hybridization techniques helps to confirm the diagnosis of MALT PPL. Fine needle aspiration-computed tomography guided biopsies as well as transbronchial/cryobiopsies provide adequate tissue material for histological evaluation. Recent publications also provide a better appreciation of newer chemotherapeutic approaches, including fludarabine and mitoxantrone with or without ritubximab for the treatment of MALT, as well as complete surgical resection if local disease is present. Prognostic factors influencing survival and optimal therapy for MALT have not been well defined, but the use of tumour microvascular density appears promising. SUMMARY: This review outlines the implications of recent findings for clinical practice and research progress of PPL. Larger, multicentre and well designed studies are imperative to optimize the current diagnostic and therapeutic approach for this disease.
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Neoplasias Pulmonares/patologia , Linfoma , Biópsia por Agulha Fina , Humanos , Neoplasias Pulmonares/terapia , Linfoma/diagnóstico , Linfoma/terapia , PrognósticoAssuntos
Cuidados Críticos/economia , Unidades de Terapia Intensiva/tendências , Programas Médicos Regionais , Atitude do Pessoal de Saúde , Análise Custo-Benefício , Cuidados Críticos/métodos , Cuidados Críticos/normas , Recursos em Saúde , Mão de Obra em Saúde/economia , Humanos , Modelos Organizacionais , Transferência de Pacientes/economia , Transferência de Pacientes/normas , Gestão da Segurança , Telemedicina , Estados UnidosRESUMO
BACKGROUND: Prior case series have shown promising diagnostic sensitivity for CT scan-guided bronchoscopy. METHODS: This was a prospective randomized trial comparing CT scan-guided bronchoscopy vs conventional bronchoscopy for the diagnosis of lung cancer in peripheral lesions and mediastinal lymph nodes. All procedures were performed using a protocolized number of passes for forceps, transbronchial needles, and brushes. Cytologists and pathologists were blinded as to bronchoscopy type. Patients with negative results underwent open surgical biopsy (for nodules or lymph nodes) or were observed for > or = 2 years if they had a nodule < 1 cm in size. RESULTS: Fifty patients were enrolled into the study (CT scan-guided bronchoscopy, 26 patients; conventional bronchoscopy, 24 patients). Two patients, one from each arm, dropped out of the study. Ultimately, 36 patients were proven to have cancer, and 27 of these patients (75%) had their diagnosis made by bronchoscopy. The sensitivity for malignancy of CT scan-guided bronchoscopy vs conventional bronchoscopy for peripheral lesions was similar (71% vs 76%, respectively; p = 1.0). The sensitivity for malignancy of CT guided bronchoscopy vs conventional bronchoscopy for mediastinal lymph nodes was higher (100% vs 67%, respectively) but did not reach statistical significance (p = 0.26). On a per-lymph-node basis, there was a trend toward higher diagnostic accuracy with CT scan guidance (p = 0.09). The diagnostic yield was higher in larger lesions (p = 0.004) and when CT scanning confirmed target entry (p = 0.001). CONCLUSION: We failed to demonstrate a significant difference between CT scan-guided bronchoscopy and conventional bronchoscopy for the diagnosis of lung cancer in peripheral lesions and mediastinal lymph nodes. Further study of improved steering methods combined with CT scan guidance for the diagnosis of lung cancer in peripheral lesions is warranted.
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Adenocarcinoma/diagnóstico , Adenocarcinoma/patologia , Broncoscopia/métodos , Fluoroscopia , Neoplasias Pulmonares/diagnóstico , Neoplasias Pulmonares/patologia , Tomografia Computadorizada por Raios X , Idoso , Biópsia , Broncoscopia/tendências , Tumor Carcinoide/diagnóstico , Tumor Carcinoide/patologia , Carcinoma Pulmonar de Células não Pequenas/diagnóstico , Carcinoma Pulmonar de Células não Pequenas/patologia , Carcinoma de Células Pequenas/diagnóstico , Carcinoma de Células Pequenas/patologia , Carcinoma de Células Escamosas/diagnóstico , Carcinoma de Células Escamosas/patologia , Feminino , Humanos , Metástase Linfática , Masculino , Mediastino/patologia , Pessoa de Meia-Idade , Sensibilidade e EspecificidadeRESUMO
PURPOSE OF REVIEW: Community-acquired pneumonia is associated with significant morbidity and mortality and is the most common cause of death from infectious diseases in North America. The purpose of this review is to highlight recent advances in epidemiology, risk factors, severity criteria and antibiotic therapeutic regimens used for community-acquired pneumonia management. RECENT FINDINGS: All guidelines recommend early and appropriate empiric therapy directed against common typical organisms, such as Streptococcus pneumoniae, and other atypical organisms, but clinicians should be aware of newer emerging pathogens such as community-acquired methicillin-resistant Staphylococcus aureus and Gram-negative pathogens. SUMMARY: The optimum outcome in community-acquired pneumonia can be achieved by careful risk stratification using prediction rules together with appropriate antibiotic regimens. The mainstay of community-acquired pneumonia prevention is influenza and pneumococcal immunization. Promotion of smoking cessation will also help curtail the incidence of pneumococcal disease.
Assuntos
Antibacterianos/uso terapêutico , Infecções Comunitárias Adquiridas , Pneumonia , Guias de Prática Clínica como Assunto , Infecções Comunitárias Adquiridas/diagnóstico , Infecções Comunitárias Adquiridas/epidemiologia , Infecções Comunitárias Adquiridas/prevenção & controle , Humanos , Morbidade/tendências , América do Norte/epidemiologia , Pneumonia/diagnóstico , Pneumonia/epidemiologia , Pneumonia/prevenção & controle , Prevalência , Fatores de Risco , Abandono do Hábito de Fumar , Vacinação/métodosRESUMO
The use of tobacco can be traced back to ancient times. Its popularity grew exponentially during the twentieth century, surging during wartime and with the advent of mass media. The tobacco industry in the United States has been under constant legal pressure during the past 40 years. Despite the well-known and continually increasing morbidity and mortality related to smoking, it continues to be a prominent feature in worldwide culture and health.
Assuntos
Regulamentação Governamental , Indústria do Tabaco/legislação & jurisprudência , Tabagismo/epidemiologia , Publicidade , Humanos , Meios de Comunicação de Massa , Fumar/efeitos adversos , Fumar/epidemiologia , Prevenção do Hábito de Fumar , Abandono do Uso de Tabaco , Tabagismo/complicações , Tabagismo/prevenção & controle , Estados UnidosRESUMO
CONTEXT: Patients with venous thromboembolism (VTE) are susceptible to recurrent events, but whether prolonging anticoagulation is warranted in patients with VTE remains controversial. OBJECTIVE: To review the available evidence and quantify the risks and benefits of extending the duration of anticoagulation in patients with VTE. DATA SOURCES: PubMed, EMBase Pharmacology, the Cochrane database, clinical trial Web sites, and a hand search of reference lists. STUDY SELECTION: Included studies were randomized controlled trials with results published from 1969 through 2004 and evaluating the duration of anticoagulation in patients with VTE that measured recurrent VTE. Excluded studies were those enrolling only pure populations of high-risk patients. Two independent reviewers assessed each article for inclusion and exclusion criteria, with adjudication by a third reviewer in cases of disagreement. Fifteen of 67 studies were included in the analysis. DATA EXTRACTION: Two independent reviewers performed data extraction using a standardized form, with adjudication by the remainder of the investigators in cases of disagreement. Data regarding recurrent VTE, major bleeding, person-time at risk, and study quality were extracted. DATA SYNTHESIS: If patients in the long-term therapy group remained receiving anticoagulation, the risk of recurrent VTE with long- vs short-term therapy was reduced (weighted incidence rate, 0.020 vs 0.126 events/person-year; rate difference, -0.106 [95% confidence interval {CI}, -0.145 to -0.067]; P<.001; pooled incidence rate ratio [IRR], 0.21 [95% CI, 0.14 to 0.31]; P<.001). If anticoagulation in the long-term therapy group was discontinued, the risk reduction was less pronounced (weighted incidence rate, 0.052 vs 0.072 events/person-year; rate difference, -0.020 [95% CI, -0.039 to -0.001]; P = .04; pooled IRR, 0.69 [95% CI, 0.53 to 0.91]; P = .009). The risk of major bleeding with long- vs short-term therapy was similar (weighted incidence rate, 0.011 vs 0.006 events/person-year; rate difference, 0.005 [95% CI, -0.002 to 0.011]; P = .14; pooled IRR, 1.80 [95% CI, 0.72 to 4.51]; P = .21). CONCLUSIONS: Patients who receive extended anticoagulation are protected from recurrent VTE while receiving long-term therapy. The clinical benefit is maintained after anticoagulation is discontinued, but the magnitude of the benefit is less pronounced.
Assuntos
Anticoagulantes/administração & dosagem , Tromboembolia/tratamento farmacológico , Humanos , Medição de Risco , Prevenção Secundária , Fatores de TempoRESUMO
Plasma membrane wound repair is an important but poorly understood process. We used femtosecond pulses from a Ti-Sapphire laser to make multiphoton excitation-induced disruptions of the plasma membrane while monitoring the membrane potential and resistance. We observed two types of wounds that depolarized the plasma membrane. At threshold light levels, the membrane potential and resistance returned to prewound values within seconds; these wounds were not easily observed by light microscopy and resealed in the absence of extracellular Ca(2+). Higher light intensities create wounds that are easily visible by light microscopy and require extracellular Ca(2+) to reseal. Within a few seconds the membrane resistance is approximately 100-fold lower, while the membrane potential has depolarized from -80 to -30 mV and is now sensitive to the Cl(-) concentration but not to that of Na(+), K(+), or H(+). We suggest that the chloride sensitivity of the membrane potential, after wound resealing, is due to the fusion of chloride-permeable intracellular membranes with the plasma membrane.
Assuntos
Permeabilidade da Membrana Celular , Cloretos/metabolismo , Fusão de Membrana , Oócitos/metabolismo , Animais , Ânions , Cloreto de Cálcio/farmacologia , Cátions Bivalentes , Membrana Celular/metabolismo , Membrana Celular/efeitos da radiação , Permeabilidade da Membrana Celular/efeitos dos fármacos , Permeabilidade da Membrana Celular/efeitos da radiação , Técnicas In Vitro , Membranas Intracelulares/metabolismo , Transporte de Íons , Lasers , Potenciais da Membrana/efeitos dos fármacos , Potenciais da Membrana/efeitos da radiação , Oócitos/patologia , Oócitos/efeitos da radiação , Técnicas de Patch-Clamp , Estrelas-do-Mar , Membrana Vitelina/efeitos da radiaçãoRESUMO
BACKGROUND: While the optimal role of spiral CT angiography (CTA) in the diagnosis of pulmonary embolism (PE) remains controversial, this technology is already being widely utilized in the community setting. OBJECTIVES: To assess the impact CTA has had on angiography utilization rates and the overall diagnostic rate of PE. METHODS: All patients evaluated for PE during a 4-year period were studied. PE was defined as either a high-probability V/Q scan, a positive conventional angiogram, or a CTA with emboli in the segmental or larger pulmonary vessels. Diagnostic rates of PE per 1,000 hospital admissions were determined and analyzed for time periods before and after the introduction of CTA. CT reports were compared with their concurrent chest radiograph (CXR) reports and additional findings that were not apparent on CXR were abstracted. RESULTS: The diagnostic rate of PE per 1,000 hospital admissions was 1.8 prior to the introduction of CTA and increased to 2.8 per 1,000 admissions after the introduction of CTA (p < 0.0001). Total costs for diagnostic testing per PE diagnosis made went from US 2,518 dollars to US 2,572 dollars. While the number of PE diagnosed by V/Q scan remained constant, the number of PE diagnosed by conventional angiography decreased while the number diagnosed by CTA increased. In patients with intermediate probability V/Q scan results, the percentage of patients receiving subsequent angiography (conventional or CTA) increased from 17 to 26% (p = 0.043). When conventional angiography was performed, CT imaging of the chest still had to be ordered for other reasons 38% of the time. Additional information was obtained in 78% of cases when CTA was performed. CONCLUSIONS: Increased utilization of CTA was associated with an increase in angiography utilization rates and diagnostic rates of PE, was cost effective, and often provided additional, useful, and unanticipated diagnostic information.
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Angiografia , Hospitais Comunitários , Embolia Pulmonar/diagnóstico por imagem , Tomografia Computadorizada Espiral , Angiografia/economia , Angiografia/normas , Angiografia/estatística & dados numéricos , Análise Custo-Benefício , Custos de Cuidados de Saúde , Humanos , Embolia Pulmonar/fisiopatologia , Tomografia Computadorizada Espiral/economia , Tomografia Computadorizada Espiral/normas , Tomografia Computadorizada Espiral/estatística & dados numéricosRESUMO
The use of tobacco can be traced back to ancient times. Its popularity grew exponentially during the twentieth century, surging during wartime and with the advent of mass media. The tobacco industry in the United States has been under constant legal pressure during the past 40 years. Despite the well-known and continually increasing morbidity and mortality related to smoking, it continues to be a prominent feature in worldwide culture and health.
Assuntos
Fumar/tendências , Feminino , Humanos , Masculino , Fumar/efeitos adversos , Fumar/legislação & jurisprudência , Indústria do Tabaco/legislação & jurisprudência , Tabaco sem Fumaça/efeitos adversos , Estados UnidosRESUMO
STUDY OBJECTIVES: To evaluate the impact of a multifactorial intervention to improve the quality, efficiency, and patient understanding of care for community-acquired pneumonia. DESIGN: Times series cohort study. SETTING: Four academic health centers in the New York City metropolitan area. PATIENTS OR PARTICIPANTS: All consecutive adults hospitalized for pneumonia during a 5-month period before (n = 1,013) and after (n = 1,081) implementation of an inpatient quality improvement (QI) initiative. INTERVENTIONS: A multidisciplinary team of opinion leaders developed evidence-based treatment guidelines and critical pathways, conducted educational sessions with physicians, distributed pocket reminder cards, promoted standardized orders, and developed bilingual patient education materials. MEASUREMENTS AND RESULTS: The average age was 71.4 years, and 44.1% of cases were low risk, 36.8% were moderate risk, and 19.2% were high risk. The preintervention and postintervention groups were well matched on age, sex, race, nursing home residence, pneumonia severity, initial presentation, and most major comorbidities. The intervention increased the use of guideline-recommended antimicrobial therapy from 78.1 to 83.4% (p = 0.003). There was also a borderline decrease in the proportion of patients being discharged prior to becoming clinically stable, from 27.0 to 23.5% (p = 0.06). However, there were no improvements in the other targeted indicators, including time to first dose of antibiotics, proportion receiving antibiotics within 8 h, timely switch to oral antibiotics, timely discharge, length of stay, or patient education outcomes. CONCLUSIONS: This real-world QI program was able to improve modestly on some quality indicators, but not effect resource use or patient knowledge of their disease. Changing physician and organizational behavior in academic health centers will require the development and implementation of more intensive, system-oriented strategies.
Assuntos
Antibacterianos/uso terapêutico , Infecções Comunitárias Adquiridas/tratamento farmacológico , Hospitalização , Pneumonia/tratamento farmacológico , Garantia da Qualidade dos Cuidados de Saúde/métodos , Idoso , Infecções Comunitárias Adquiridas/classificação , Feminino , Humanos , Masculino , Cidade de Nova Iorque , Educação de Pacientes como Assunto , Pneumonia/classificação , Índice de Gravidade de DoençaRESUMO
PURPOSE OF REVIEW: The challenge of diagnosis and management of solitary pulmonary nodules is among the most common yet most important areas of pulmonary medicine. Ideally, the goal of diagnosis and management is to promptly bring to surgery all patients with operable malignant nodules while avoiding unnecessary thoracotomy in patients with benign disease. RECENT FINDINGS: Effective management of the solitary pulmonary nodule depends upon an understanding of decision analysis principles so that diverse technologies can be integrated into a systematic approach. SUMMARY: In almost all patients computed tomography (CT) is the best first step. Three key questions can then help guide the workup of the SPN. These are what is the pretest probability of cancer, what is the risk of surgical complications, and does the appearance of the nodule on CT scan suggest a benign or malignant etiology. In patients with average surgical risk, positron emission tomography (PET) scan is warranted when there is discordance between pretest probability of cancer and the appearance of the nodule on CT scan. Thus, when either the patient has a low risk of cancer and the CT suggests a malignant origin, or when there is high risk of cancer and the CT appears benign, PET scan will be cost effective. In most other situations, PET scanning is only marginally more effective than CT and fine needle aspiration strategies but costs much more.
Assuntos
Neoplasias Pulmonares/diagnóstico , Neoplasias Pulmonares/cirurgia , Nódulo Pulmonar Solitário/diagnóstico , Nódulo Pulmonar Solitário/cirurgia , Biópsia por Agulha , Técnicas de Apoio para a Decisão , Humanos , Radiografia Pulmonar de Massa , Tomografia por Emissão de Pósitrons , Probabilidade , Toracotomia , Tomografia Computadorizada por Raios XRESUMO
In acute exacerbation of chronic obstructive pulmonary disease (AECOPD), short-acting inhaled bronchodilators, such as salbutamol (albuterol) and ipratropium bromide, have proven useful. In patients who are refractory to these agents, intravenous aminophylline should be considered. Corticosteroids should also be used, either in the outpatient or inpatient setting. The duration of corticosteroids should probably not exceed 2 weeks and the optimum dosage is yet to be determined. Antibacterials, especially in patients with purulent or increased sputum, should be used, guided by the local antibiogram of the key microbes. Controlled oxygen therapy improves outcome in hypoxaemic patients and arterial blood gases should be performed to ensure hypercarbia is not becoming excessive. Should patients be in distress despite the above measures or if there is acidaemia or hypercarbia, noninvasive positive pressure ventilation could be used to improve outcomes without resorting to invasive mechanical ventilation. Mucous-clearing drugs and chest physiotherapy have no proven beneficial role in AECOPD.