Free and paid medical assistance in the United States News : Part 7

Etiology and Outcomes of Pulmonary and Extrapulmonary Acute Lung Injury/ARDS in a Respiratory ICU in North India: Discussion

Etiology and Outcomes of Pulmonary and Extrapulmonary Acute Lung Injury/ARDS in a Respiratory ICU in North India: DiscussionIn our study, although patients with ALI/ARDSexp were younger and sicker (ie, higher baseline and maximum SOFA scores) than their ALI/ARDSp counterparts, we found no difference in the occurrence of new organ dysfunction/failure (ie, ASOFA scores), time to the development of the first organ dysfunction/organ failure, the duration of RICU stay, and length of hospital survival between the two categories of patients. Moreover, the classification of ARDS had no impact on the ultimate length of hospital survival after adjusting for various other risk factors like gender, baseline disease severity (ie, baseline SOFA scores), and the occurrence of new-onset organ dysfunction (ie, ASOFA scores). The lack of agreement among various studies can be explained by differences in baseline status, the prevalence of the disease precipitating ARDS in each center, the impact of therapy, and the overall distribution of these factors in the studied population. Another reason for the lack of agreement is probably the fact that the differentiation between direct and indirect insult is often straightforward only in patients with pneumonia or ARDS originating from intraabdominal sepsis, but a precise identification of the pathogenetic pathway is somewhat difficult to ascertain in other situations. Source
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Etiology and Outcomes of Pulmonary and Extrapulmonary Acute Lung Injury/ARDS in a Respiratory ICU in North India: Results

Patients with ALI/ ARDSexp had higher maximum SOFA scores, but the ASOFA (signifying the new-onset organ dysfunction and/or organ failure) scores were similar in the two groups (Table 2). Similarly, there was no difference between the two groups in terms of the length of time to the first development of nonpulmonary organ dysfunction and organ failure (Table 2).
Figure 1 shows the Pa02/Fl02 scores and PEEP levels, and Figure 2 shows Cstat and Pplat values over the course of the hospital stay. Although the initial Pplat values (ie, day 0 to day 3) were higher in ALI/ARDSp patients than in ALI/ARDSexp patients, there were no significant differences in the progression of lung mechanics and gas exchange variables over time. Ninety-four of the 180 patients with ALI/ARDS were discharged from the hospital; there was no difference in hospital survival between the two categories of ARDS patients (ALI/ARDSp, 70 of 123 [56.9%]; ALI/ARDSexp, 24 of 57 [42.1%]). review

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Etiology and Outcomes of Pulmonary and Extrapulmonary Acute Lung Injury/ARDS in a Respiratory ICU in North India: Statistical Analysis

Etiology and Outcomes of Pulmonary and Extrapulmonary Acute Lung Injury/ARDS in a Respiratory ICU in North India: Statistical AnalysisStatistical analyses were performed using a statistical software package (SPSS for Windows, version 10.0; SPSS Inc; Chicago IL). Descriptive frequencies were expressed using the mean (SD) and the median (range and interquartile range [IQR]). Differences between the means of continuous variables were compared using the Mann-Whitney U test, and those of categoric variables were compared with the x2 test. Levels of significance were expressed as p values and odds ratios (ORs) [95% confidence intervals (CIs)]. link
Stepwise multivariable logistic regression analysis was performed to study the effect of the type of ARDS on RICU mortality. Initially, the variables (ie, age, gender, etiology [ALI/ ARDSp vs ALI/ARDSexp], Pplat values, PEEP levels, SOFA scores, and ASOFA scores) were analyzed using univariate analysis to derive a crude OR. The variables that were found to be significant (ie, p < 0.1) on univariate analysis were then entered in a multivariate logistic regression model to derive the adjusted OR and CIs.
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Etiology and Outcomes of Pulmonary and Extrapulmonary Acute Lung Injury/ARDS in a Respiratory ICU in North India: Materials and Methods

This was a retrospective study conducted in the RICU of the Postgraduate Institute of Medical Education and Research between January 2001 and June 2005. All data in the RICU are entered prospectively into a computer program that is specifically designed for this purpose, with a continuous process of monitoring its completeness and correcting entries. Data are registered on RICU admission and every 24 h thereafter, using the lowest daily values for all variables of interest. Day 0 is defined as the interval from the time of RICU admission to 8:00 am on the next day; data from this time period are used to calculate the RICU admission sequential organ failure assessment (SOFA) scores. All remaining days are calendar days from 8:00 am to 8:00 am the following day. An informed consent form was obtained from all patients or their relatives as per the RICU protocol. The study was cleared by the institutional ethics committee. there
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Etiology and Outcomes of Pulmonary and Extrapulmonary Acute Lung Injury/ARDS in a Respiratory ICU in North India

Etiology and Outcomes of Pulmonary and Extrapulmonary Acute Lung Injury/ARDS in a Respiratory ICU in North IndiaAcute lung injury (ALI) and ARDS are characterized by refractory hypoxemia that develops secondary to high-permeability pulmonary edema. These syndromes can occur even without primary damage to the lung parenchyma, and thus they are now more often being classified as ALI/ARDS resulting from pulmonary causes (ALI/ARDSp) or extrapulmonary causes (ALI/ARDSexp) according to the mechanism of lung insult. Lung injuries of different origins may have possible differences in pathophysiology, lung morphology, radiology, respiratory mechanics, and response to different management strategies. Also, this distinction between a direct etiology of lung injury (ie, ALI/ARDSp) and an indirect etiology of lung injury (ie, ALI/ARDSexp) is gaining more attention as a means of better comprehending the pathophysiology of ARDS and possibly for modifying ventilatory management.

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Follow-up After an Asthma Hospitalization: Conclusion

Nevertheless, if we accept that the conclusions are correct, the study suggests that successful follow-up is determined not so much by who performs it than by what is done. First, the diagnosis should be confirmed. In the study Nathan et al, the diagnosis of nearly 10% of patients who were apparently hospitalized for asthma was not confirmed, although the correct diagnoses for those patients are not presented. Second, studies have documented that the following factors, which could be addressed on a follow-up appointment, are related to an increased risk of asthma-related emergency department visits or hospitalizations: inadequate asthma knowledge; not having an action plan; incorrect use of me-tered-dose inhalers; adverse environmental exposures, especially regarding environmental tobacco smoke and mites’; and adverse psychosocial circumstances.

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Follow-up After an Asthma Hospitalization: Discussion

Follow-up After an Asthma Hospitalization: DiscussionForty-seven intervention patients were randomized to follow-up by one pediatric respirologist, and 48 patients continued to receive regular care from their family physician or pediatrician. Intervention subjects had less school absenteeism than control subjects (mean, 10.7 vs 16.0 days, respectively; p = 0.04), but there were no significant differences in the rates of hospitalizations or emergency department visits during the study year. However, fewer days were spent in the hospital by the intervention patients compared to control patients (mean, 3.7 vs 11.2 days, respectively; p = 0.02). Castro et al reported the results of a nurse specialist intervention program in asthmatic patients with a history of frequent health-care use. The intervention group consisted of 50 patients, and 46 patients who continued their usual care with their private primary care physician were assigned to the control group. canadian health care mall

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Follow-up After an Asthma Hospitalization

Asthma caused an average of 467,000 hospitalizations per year between 1995 and 2002. Most asthma hospitalizations are preceded by an emergency department visit (Emergency Medicine Network; unpublished data), and asthma accounts for a total of nearly 1.8 million emergency department visits per year. Although exact figures are not available, many of these emergency asthma visits are preventable. Since a prior asthma hospitalization or emergency department visit is the strongest risk factor for subsequent emergency hospital utiliza-tion, follow-up after an asthma hospitalization or emergency department visit presents a golden opportunity for tertiary prevention. However, there are substantial knowledge gaps regarding the type of follow-up that will significantly improve asthma outcomes.

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Patient-Focused Care: Physician Benefits: Conclusion

Patient-Focused Care: Physician Benefits: ConclusionParticipants highlighted a number of points that they believed formed the basis of patient-focused care (Table 3). Patients are more likely to be motivated to follow treatment advice if they perceive the recommendations to be a common sense approach to maintaining health, and if they have a clear appreciation of the nature of their illness and an understanding of treatment risks and benefits. It is also important to consider that the management of chronic disease differs from that of an acute illness, so clinicians must be prepared to work in an ongoing partnership with patients to ensure that they are offered a clear rationale as to why inhaled corticosteroids are necessary, and to address their concerns about potential adverse effects. This approach, the basis of which is a detailed examination of patients’ perspectives on asthma and its treatment, and an open, nonjudgmental manner on the part of the clinician, is consistent with the idea of concordance. It also fits in with other recent initiatives, such as the “expert patient,” and shared decision making.

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Patient-Focused Care: Physician Benefits: Participant Feedback and Discussion

The effectiveness of this approach has been demonstrated in the development of an asthma center specifically developed to target patients with diffi-cult-to-control asthma. Adult patients with more than two emergency department visits within the last 6 months were referred by their primary care pro-vider. Interventions included an initial evaluation by asthma center personnel, spirometry and skin allergy testing, the development of treatment and follow-up plans after discussion of the patient by team members, extensive patient education, and establishment of a relationship with one of the asthma center nurses and physicians. Statistical analysis was not presented in this abstract report, but some of the results have obvious clinical and economic relevance. An analysis of 125 patients found that 90% rated their visit to the asthma center “very good” or “excellent.” Based on prescriptions filled, there was a reduction in the ratio of (3-agonist use vs inhaled corticosteroid use (ratio of 1.65 before vs 1.05 after). website

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