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Chest Jun 2024Acute pulmonary embolism (PE) is a common disease encountered by pulmonologists, cardiologists, and critical care physicians throughout the world. For patients with... (Review)
Review
TOPIC IMPORTANCE
Acute pulmonary embolism (PE) is a common disease encountered by pulmonologists, cardiologists, and critical care physicians throughout the world. For patients with high-risk acute PE (defined by systemic hypotension) and intermediate high-risk acute PE (defined by the absence of systemic hypotension, but the presence of numerous other concerning clinical and imaging features), intensive care often is necessary. Initial management strategies should focus on optimization of right ventricle (RV) function while decisions about advanced interventions are being considered.
REVIEW FINDINGS
We reviewed the existing literature of various vasoactive agents, IV fluids and diuretics, and pulmonary vasodilators in both animal models and human trials of acute PE. We also reviewed the potential complications of endotracheal intubation and positive pressure ventilation in acute PE. Finally, we reviewed the data of venoarterial extracorporeal membrane oxygenation (ECMO) use in acute PE. The above interventions are discussed in the context of the underlying pathophysiologic features of acute RV failure in acute PE with corresponding illustrations.
SUMMARY
Norepinephrine is a reasonable first choice for hemodynamic support with vasopressin as an adjunct. IV loop diuretics may be useful if evidence of RV dysfunction or volume overload is present. Fluids should be given only if concern exists for hypovolemia and absence of RV dilatation. Supplemental oxygen administration should be considered even without hypoxemia. Positive pressure ventilation should be avoided if possible. venoarterial ECMO cannulation should be implemented early if ongoing deterioration occurs despite these interventions.
PubMed: 38830402
DOI: 10.1016/j.chest.2024.04.032 -
Journal of Managed Care & Specialty... Jun 2024Health plan coverage is central to patient access to care, especially for rare, chronic diseases. For specialty drugs, coverage varies, resulting in barriers to access....
BACKGROUND
Health plan coverage is central to patient access to care, especially for rare, chronic diseases. For specialty drugs, coverage varies, resulting in barriers to access. Pulmonary arterial hypertension (PAH) is a rare, progressive, and fatal disease. Guidelines suggest starting or rapidly escalating to combination therapy with drugs of differing classes (phosphodiesterase 5 inhibitors [PDE5is], soluble guanylate cyclase stimulators [sGC stimulators], endothelin receptor antagonists [ERAs], and prostacyclin pathway agents [PPAs]).
OBJECTIVE
To assess the variation in commercial health plan coverage for PAH treatments and how coverage has evolved. To examine the frequency of coverage updates and evidence cited in plan policies.
METHODS
We used the Tufts Medical Center Specialty Drug Evidence and Coverage database, which includes publicly available specialty drug coverage policies. Overall, and at the drug and treatment class level, we identified plan-imposed coverage restrictions beyond the drug's US Food and Drug Administration label, including step therapy protocols, clinical restrictions (eg, disease severity), and prescriber specialty requirements. We analyzed variation in coverage restrictiveness and how coverage has changed over time. We determined how often plans update their policies. Finally, we categorized the cited evidence into 6 different types.
RESULTS
Results reflected plan coverage policies for 13 PAH drugs active between August 2017 and August 2022 and issued by 17 large US commercial health plans, representing 70% of covered lives. Coverage restrictions varied mainly by step therapy protocols and prescriber restrictions. Seven plans had step therapy protocols for most drugs, 9 for at least one drug, and 1 had none. Ten plans required specialist (cardiologist or pulmonologist) prescribing for at least one drug, and 7 did not. Coverage restrictions increased over time: the proportion of policies with at least 1 restriction increased from 38% to 73%, and the proportion with step therapy protocols increased from 29% to 46%, with generics as the most common step. The proportion of policies with step therapy protocols increased for every therapy class with generic availability: 18% to 59% for ERAs, 33% to 77% for PDE5is, and 33% to 43% for PPAs. The proportion of policies with prescriber requirements increased from 24% to 48%. Plans updated their policies 58% of the time annually and most often cited the 2019 CHEST clinical guidelines, followed by randomized controlled trials.
CONCLUSIONS
Plan use of coverage restrictions for PAH therapies increased over time and varied across both drugs and plans. Inconsistency among health plans may complicate patient access and reduce the proportion who can persist on PAH treatments.
Topics: Humans; United States; Antihypertensive Agents; Pulmonary Arterial Hypertension; Insurance Coverage; Phosphodiesterase 5 Inhibitors; Hypertension, Pulmonary; Insurance, Pharmaceutical Services
PubMed: 38824632
DOI: 10.18553/jmcp.2024.30.6.541 -
Clinics in Chest Medicine Jun 2024The pericardium comprises a double-walled fibrous-serosal sac that encloses the heart. Reflections of the serosal layer form sinuses and recesses. With advances in... (Review)
Review
The pericardium comprises a double-walled fibrous-serosal sac that encloses the heart. Reflections of the serosal layer form sinuses and recesses. With advances in multidetector computed tomography (CT) technology, pericardial recesses are frequently detected with thin-section CT. Knowledge of pericardial anatomy on imaging is crucial to avoid misinterpretation of fluid-filled pericardial sinuses and recesses as adenopathy/pericardial metastasis or aortic dissection, which can impact patient management and treatment decisions. The authors offer a comprehensive review of pericardial anatomy and its variations observed on CT, potential pitfalls in image interpretation, and implications for the pulmonologist with respect to unnecessary diagnostic procedures or interventions.
Topics: Humans; Pericardium; Tomography, X-Ray Computed; Pulmonologists; Multidetector Computed Tomography
PubMed: 38816085
DOI: 10.1016/j.ccm.2024.02.002 -
Respirology Case Reports May 2024Primary tracheal tumours are extremely rare, that originate from Schwann cells. We report a case of a primary tracheal schwannoma. A 60-year-old male who presented with...
Primary tracheal tumours are extremely rare, that originate from Schwann cells. We report a case of a primary tracheal schwannoma. A 60-year-old male who presented with noisy breathing, shortness of breath, and blood streaked phlegm. Chest CT scan showed an endotracheal mass which was resected bronchoscopically using Rigid bronchoscopy, electrocautery snare and cryoextraction. Biopsy confirmed the diagnosis of schwannoma.
PubMed: 38808151
DOI: 10.1002/rcr2.1390 -
PeerJ 2024During the COVID-19 pandemic, universal mask-wearing became one of the main public health interventions. Because of this, most physical examinations, including lung...
OBJECTIVE
During the COVID-19 pandemic, universal mask-wearing became one of the main public health interventions. Because of this, most physical examinations, including lung auscultation, were done while patients were wearing surgical face masks. The aim of this study was to investigate whether mask wearing has an impact on pulmonologist assessment during auscultation of the lungs.
METHODS
This was a repeated measures crossover design study. Three pulmonologists were instructed to auscultate patients with previously verified prolonged expiration, wheezing, or crackles while patients were wearing or not wearing masks (physician and patients were separated by an opaque barrier). As a measure of pulmonologists' agreement in the assessment of lung sounds, we used Fleiss kappa (K).
RESULTS
There was no significant difference in agreement on physician assessment of lung sounds in all three categories (normal lung sound, duration of expiration, and adventitious lung sound) whether the patient was wearing a mask or not, but there were significant differences among pulmonologists when it came to agreement of lung sound assessment.
CONCLUSION
Clinicians and health professionals are safer from respiratory infections when they are wearing masks, and patients should be encouraged to wear masks because our research proved no significant difference in agreement on pulmonologists' assessment of auscultated lung sounds whether or not patients wore masks.
Topics: Humans; Masks; COVID-19; Cross-Over Studies; Auscultation; Male; Respiratory Sounds; Female; SARS-CoV-2; Middle Aged; Adult; Pandemics; Pulmonologists; Aged
PubMed: 38803582
DOI: 10.7717/peerj.17368 -
Journal of Clinical Medicine May 2024Diagnostic and therapeutic decision-making in pregnancy with suspected pulmonary embolism (PE) is challenging. European and other international professional societies... (Review)
Review
Diagnostic and therapeutic decision-making in pregnancy with suspected pulmonary embolism (PE) is challenging. European and other international professional societies have proposed various recommendations that are ambiguous, probably due to the unavailability of randomized controlled trials. In the following sections, we discuss the supporting diagnostic steps and treatments. We suggest a standardized diagnostic work-up in pregnant patients presenting with symptoms of PE to make evidence-based diagnostic and therapeutic decisions. We strongly recommend that clinical decisions on treatment in pregnant patients with intermediate- or high-risk pulmonary embolism should include a multidisciplinary team approach involving emergency physicians, pulmonologists, angiologist, cardiologists, thoracic and/or cardiovascular surgeons, radiologists, and obstetricians to choose a tailored management option including an interventional treatment. It is important to be aware of the differences among guidelines and to assess each case individually, considering the specific views of the different specialties. This review summarizes key concepts of the diagnostics and acute management of pregnant women with suspected PE that are supportive for the clinician on duty.
PubMed: 38792409
DOI: 10.3390/jcm13102863 -
Lung Cancer (Amsterdam, Netherlands) Jun 2024Radiation pneumonitis (RP) is a dose-limiting toxicity for patients undergoing radiotherapy (RT) for lung cancer, however, the optimal practice for diagnosis,...
PURPOSE
Radiation pneumonitis (RP) is a dose-limiting toxicity for patients undergoing radiotherapy (RT) for lung cancer, however, the optimal practice for diagnosis, management, and follow-up for RP remains unclear. We thus sought to establish expert consensus recommendations through a Delphi Consensus study.
METHODS
In Round 1, open questions were distributed to 31 expert clinicians treating thoracic malignancies. In Round 2, participants rated agreement/disagreement with statements derived from Round 1 answers using a 5-point Likert scale. Consensus was defined as ≥ 75 % agreement. Statements that did not achieve consensus were modified and re-tested in Round 3.
RESULTS
Response rate was 74 % in Round 1 (n = 23/31; 17 oncologists, 6 pulmonologists); 82 % in Round 2 (n = 19/23; 15 oncologists, 4 pulmonologists); and 100 % in Round 3 (n = 19/19). Thirty-nine of 65 Round 2 statements achieved consensus; a further 10 of 26 statements achieved consensus in Round 3. In Round 2, there was agreement that risk stratification/mitigation includes patient factors; optimal treatment planning; the basis for diagnosis of RP; and that oncologists and pulmonologists should be involved in treatment. For uncomplicated radiation pneumonitis, an equivalent to 60 mg oral prednisone per day, with consideration of gastroprotection, is a typical initial regimen. However, in this study, no consensus was achieved for dosing recommendation. Initial steroid dose should be administered for a duration of 2 weeks, followed by a gradual, weekly taper (equivalent to 10 mg prednisone decrease per week). For severe pneumonitis, IV methylprednisolone is recommended for 3 days prior to initiating oral corticosteroids. Final consensus statements included that the treatment of RP should be multidisciplinary, the uncertainty of whether pneumonitis is drug versus radiation-induced, and the importance risk stratification, especially in the scenario of interstitial lung disease.
CONCLUSIONS
This Delphi study achieved consensus recommendations and provides practical guidance on diagnosis and management of RP.
Topics: Humans; Radiation Pneumonitis; Consensus; Delphi Technique; Lung Neoplasms; Disease Management
PubMed: 38788551
DOI: 10.1016/j.lungcan.2024.107822 -
Archives of Rheumatology Mar 2024The aim of this study was to identify differences and similarities between connective tissue disease (CTD) patients with and without progressive pulmonary fibrosis (PPF)...
OBJECTIVES
The aim of this study was to identify differences and similarities between connective tissue disease (CTD) patients with and without progressive pulmonary fibrosis (PPF) by applying the new guidelines.
PATIENTS AND METHODS
Patient characteristics and disease courses from medical records of 50 CTD-associated Interstitial lung disease (ILD) patients (33 females, 17 males; mean age: 60.1±12.9 years) were longitudinally studied between January 2018 and May 2022. Respiratory involvement in CTD patients was described, and differences in CTD patients who developed PPF compared to those who did not were identified by the 2022 ATS (American Thoracic Society)/ERS (European Respiratory Society)/JRS (Japanese Respiratory Society)/ALAT (Asociación Latinoamericana de Thórax) Guidelines on Idiopathic Pulmonary Fibrosis and Progressive Pulmonary Fibrosis in Adults.
RESULTS
In the majority (74%) of patients, CTD was diagnosed before ILD onset. Nonspecific interstitial pneumonia was the most common high resolution computer tomography pattern, followed by the usual interstitial pneumonia pattern. On pulmonary function test, 38% had a restrictive pattern at baseline. Patients without PPF tended to have worse lung function at baseline and increased macrophage count in bronchoalveolar lavage than patients with PPF.
CONCLUSION
In patients without PPF, disease progression may be missed, resulting in inadequate management. Interdisciplinary management of patients with CTD with the participation of pulmonologists and precise lung function diagnostics is recommended.
PubMed: 38774704
DOI: 10.46497/ArchRheumatol.2024.10105 -
BMC Health Services Research May 2024The inappropriate and excessive use of antibiotics during the coronavirus pandemic has become an important issue.
BACKGROUND
The inappropriate and excessive use of antibiotics during the coronavirus pandemic has become an important issue.
OBJECTIVE
Our primary aim is to ascertain the attitudes of physicians toward the antibiotics prescribing for the treatment of COVID-19 in Turkey. Our secondary aim was to identify factors affecting to physicians' decisions regarding antibiotic therapy for the treatment of COVID-19 and risk factors associated with antibiotic overprescribing.
METHODS
It was a multicenter cross-sectional survey. Physicians from 63 different cities were invited to survey through social media (Facebook, Instagram, WhatsApp). Data were collected from respondents through an online questionnaires during November-December 2021.
RESULTS
The survey was completed by 571 participants from 63 cities. Pulmonologists comprised the majority (35.20%), followed by internal medical specialists (27.85%) and general practitioners (23.29%). The rates of participants who started empirical antibiotics in the outpatient, ward, and ICU (intensive care unit) were 70.2%, 85.5%, and 74.6%, respectively. When the practice of prescribing antibiotics by physicians for the treatment of COVID-19 in outpatients was compared according to the healthcare setting (primary, secondary, tertiary care hospitals) no significant difference was found. Sputum purulence (68.2%) was recognized as the most important factor for the decision of antibiotic therapy, followed by procalcitonin levels (64.9%) and abnormal radiological findings (50.3%). The most prescribed antibiotics were respiratory quinolones. (48%, 65.9%, 62.7% outpatient, ward, ICU respectively) CONCLUSIONS: In this study, we found that physicians frequently had irrational attitudes toward antibiotic prescription to COVID-19 patients, including those with minor diseases. Our findings underline that the necessity of particular, workable interventions to guarantee the prudent use of antibiotics in COVID-19.
Topics: Humans; Turkey; Cross-Sectional Studies; Anti-Bacterial Agents; Male; Female; Practice Patterns, Physicians'; Adult; Attitude of Health Personnel; Middle Aged; COVID-19; Surveys and Questionnaires; Inappropriate Prescribing; COVID-19 Drug Treatment; SARS-CoV-2; Physicians; Pandemics
PubMed: 38773553
DOI: 10.1186/s12913-024-11110-z -
The Journal of Asthma : Official... Jun 2024In this document, 9 Indian experts have evaluated the factors specific to LMICs when it came to Severe Asthma (SA) diagnosis, evaluation, biologic selection,... (Review)
Review
OBJECTIVE
In this document, 9 Indian experts have evaluated the factors specific to LMICs when it came to Severe Asthma (SA) diagnosis, evaluation, biologic selection, non-biologic treatment options, and follow-up.
DATA SOURCES
A search was performed using 50 keywords, focusing on the Indian/LMICs perspective, in PubMed, Cochrane Library, and Google Scholar. The key areas of the search were focused on diagnosis, phenoendotyping, non-biological therapies, selecting a biologic, assessment of treatment response, and management of exacerbation.
STUDY SELECTIONS
The initial search revealed 1826 articles, from these case reports, observational studies, cohort studies, non-English language papers, etc., were excluded and we short-listed 20 articles for each area. Five relevant articles were selected by the experts for review.
RESULTS
In LMICs, SA patients may be referred to the specialist for evaluation a little late for Phenoendotyping of SA. While biologic therapy is now a standard of care, pulmonologists in LMICs may not have access to all the investigations to phenoendotype SA patients like fractional exhaled nitric oxide (FeNO), skin prick test (SPT), etc., but phenotyping of SA patients can also be done with simple blood investigations, eosinophil count and serum immunoglobulin E (IgE). Choosing a biologic in the overlapping phenotype of SA and ACO patients is also a challenge in the LMICs.
CONCLUSIONS
Given the limitations of LMIC, it is important to select the right patient and explain the potential benefits of biological therapy. Non-biologic add-on therapies can be attempted in a resource-limited setting where biological therapy is not available/feasible for patients.
PubMed: 38767570
DOI: 10.1080/02770903.2024.2349614