Search

Editorial. Comments on the medical challenges of sarcoidosis. Unknown etiology; Nature of the disease; Relationship between pulmonary hypertension and sarcoidosis.

Background: COVID-19 has disrupted the care of all patients, and little is known about its impact on the utilization and short-term mortality of percutaneous coronary intervention (PCI) patients, particularly nonemergency patients., Methods: New York State's PCI registry was used to study the utilization of PCI and the presence of COVID-19 in four patient subgroups ranging in severity from ST-elevation myocardial infarction (STEMI) to elective patients before (December 01, 2018-February 29, 2020) and during the COVID-19 era (March 01, 2020-May 31, 2021), as well as to examine the impact of different COVID severity levels on the mortality of different types of PCI patients., Results: Decreases in the mean quarterly PCI volume from the prepandemic period to the first quarter of the pandemic ranged from 20% for STEMI patients to 61% for elective patients, with the other two subgroups having decreases in between these values. PCI quarterly volume rebounds from the prepandemic period to the second quarter of 2021 were in excess of 90% for all patient subgroups, and 99.7% for elective patients. Existing COVID-19 was rare among PCI patients, ranging from 1.74% for STEMI patients to 3.66% for elective patients. PCI patients with COVID-19 and acute respiratory distress syndrome (ARDS) who were not intubated, and PCI patients with COVID-19 and ARDS who were either intubated or were not intubated because of Do Not Resuscitate//Do Not Intubate status had higher risk-adjusted mortality ([adjusted ORs = 10.81 [4.39, 26.63] and 24.53 [12.06, 49.88], respectively]) than patients who never had COVID-19., Conclusions: There were large decreases in the utilization of PCI during COVID-19, with the percentage of decrease being highly sensitive to patient acuity. By the second quarter of 2021, prepandemic volumes were nearly restored for all patient subgroups. Very few PCI patients had current COVID-19 throughout the pandemic period, but the number of PCI patients with a COVID-19 history increased steadily during the pandemic. PCI patients with COVID-19 accompanied by ARDS were at much higher risk of short-term mortality than patients who never had COVID-19. COVID-19 without ARDS and history of COVID-19 were not associated with higher mortality for PCI patients as of the second quarter of 2021., (© 2023 Wiley Periodicals LLC.)

Objectives: To develop an enhanced understanding of factors that influence providers' views about end-of-life care, we examined the contributions of provider, hospital, and country to variability in agreement with consensus statements about end-of-life care., Design and Setting: Data were drawn from a survey of providers' views on principles of end-of-life care obtained during the consensus process for the Worldwide End-of-Life Practice for Patients in ICUs study., Subjects: Participants in Worldwide End-of-Life Practice for Patients in ICUs included physicians, nurses, and other providers. Our sample included 1,068 providers from 178 hospitals and 31 countries., Interventions: None., Measurements and Main Results: We examined views on cardiopulmonary resuscitation and withholding/withdrawing life-sustaining treatments, using a three-level linear mixed model of responses from providers within hospitals within countries. Of 1,068 providers from 178 hospitals and 31 countries, 1% strongly disagreed, 7% disagreed, 11% were neutral, 44% agreed, and 36% strongly agreed with declining to offer cardiopulmonary resuscitation when not indicated. Of the total variability in those responses, 98%, 0%, and 2% were explained by differences among providers, hospitals, and countries, respectively. After accounting for provider characteristics and hospital size, the variance partition was similar. Results were similar for withholding/withdrawing life-sustaining treatments., Conclusions: Variability in agreement with consensus statements about end-of-life care is related primarily to differences among providers. Acknowledging the primary source of variability may facilitate efforts to achieve consensus and improve decision-making for critically ill patients and their family members at the end of life.

Great differences in end-of-life practices in treating the critically ill around the world warrant agreement regarding the major ethical principles. This analysis determines the extent of worldwide consensus for end-of-life practices, delineates where there is and is not consensus, and analyzes reasons for lack of consensus. Critical care societies worldwide were invited to participate. Country coordinators were identified and draft statements were developed for major end-of-life issues and translated into six languages. Multidisciplinary responses using a web-based survey assessed agreement or disagreement with definitions and statements linked to anonymous demographic information. Consensus was prospectively defined as >80% agreement. Definitions and statements not obtaining consensus were revised based on comments of respondents, and then translated and redistributed. Of the initial 1,283 responses from 32 countries, consensus was found for 66 (81%) of the 81 definitions and statements; 26 (32%) had >90% agreement. With 83 additional responses to the original questionnaire (1,366 total) and 604 responses to the revised statements, consensus could be obtained for another 11 of the 15 statements. Consensus was obtained for informed consent, withholding and withdrawing life-sustaining treatment, legal requirements, intensive care unit therapies, cardiopulmonary resuscitation, shared decision making, medical and nursing consensus, brain death, and palliative care. Consensus was obtained for 77 of 81 (95%) statements. Worldwide consensus could be developed for the majority of definitions and statements about end-of-life practices. Statements achieving consensus provide standards of practice for end-of-life care; statements without consensus identify important areas for future research.

Background: The provision of effective palliative care is of great importance to patients awaiting lung transplantation. Although the prospect of lung transplantation provides hope to patients and their families, these patients are usually very symptomatic from their underlying disease., Methods: An e-mail questionnaire was sent to members of the American College of Chest Physicians' Transplant NetWork and the Pulmonary Council of the International Society for Heart and Lung Transplantation (ISHLT). The survey included questions about barriers to providing palliative care, the availability of palliative care services, and recommended strategies to improve palliative care for lung transplant candidates., Results: The 158 respondents represented approximately 65% of transplant programs in the ISHLT registry. Respondents were in practice a mean of 11.3 (± 9) years, 70% were pulmonologists, 17% were surgeons, and 13% were other care providers. Barriers were classified into domains including patient factors, family factors, physician factors, and institutional/transplant program/lung allocation system factors. Significant patient/family barriers included unrealistic patient/family expectations about survival, unwillingness to plan end-of-life care, concerns about abandonment or inappropriate care after enrollment in a palliative care program, and family disagreements about care goals. For institutional/program/allocation system barriers, only the requirement for weight loss or gain to meet program-specific BMI requirements was identified. Significant physician barriers included competing time demands and the seemingly contradictory goals of transplant vs palliative care. Strategies recommended to improve palliative care included routine advance care planning for patients awaiting transplantation, access to palliative care specialists, training of transplant physicians in symptom management, and regular meetings among transplant physicians, nurses, patients, and families., Conclusions: Physicians providing care to lung transplant candidates reported considerable barriers to the delivery and acceptance of palliative care and identified specific strategies to improve palliative care for lung transplant candidates.

Objective: This project sought to evaluate the impact of a hospital-based Palliative Care Consultation (PCC) service utilizing a common practice: the resident mortality review conference., Method: Internal Medicine residents used a revised chart audit tool during the mortality review conference, which included domains described in the Clinical Practice Guidelines for Quality Palliative Care (2004). This study attempted to transform the common practice into a methodology for collecting data that could be used as a platform to assess the quality of hospital care near the end of life. In this review, the residents were asked not only "what care was delivered appropriately?" but "what could we have done?" to relieve the patient's and family's suffering., Results: The results showed that the mortality review process could be used to assess care at the end of life. It also showed that those patients who received a PCC received better care. Symptoms were addressed at a significantly higher rate for those patients who received a PCC than for those who did not. Specifically, these were symptoms of pain (75% vs. 51%, p < .0001), dyspnea (75% vs. 59%, p < 0.0001), nausea (28% vs. 18%, p < 0.0001), and agitation (53% vs. 33%, p < 0.0001)., Significance of Results: The mortality review process was found to be valuable in assessing care delivery for patients near the end of life. The tool yielded results that were consistent with findings of other studies looking at pain and symptom management, advance care planning, and the rate of palliative care consults across major diagnostic categories, supporting the face validity of the mortality review process.

Post-extubation stridor is a potential complication of endotracheal intubation. The incidence, risk factors, and outcome in adult patient populations are poorly defined. It was our clinical impression that the occurrence of post-extubation stridor in our medical intensive care unit was more frequent than generally reported. We therefore monitored all intubated patients to determine the incidence of post-extubation stridor and to identify any predisposing factors. All adult patients requiring endotracheal intubation and medical intensive care admission were prospectively observed over a 5-month period in a university-affiliated medical intensive care unit. Sixty-seven patients requiring intubation and medical intensive care admission were evaluated. Twenty-two patients were excluded from analysis because no extubation was attempted. The remaining 45 patients were divided into two groups: 8 with and 37 without post-extubation stridor. Of the parameters analyzed, cuff pressure, treatment with corticosteroids at the time of extubation, and the presence of a primary neurologic process necessitating intubation differed significantly between groups. Six of the 8 patients who developed post-extubation stridor required reintubation. Four of these patients were subsequently successfully extubated, one required tracheostomy, and one patient died after a 2-week deteriorating clinical course. The incidence of significant stridor in our population was 17.8%. Medical management was successful in the majority of patients with post-extubation stridor. Routine tracheostomy following a single episode of post-extubation stridor is not indicated. Further investigation regarding risk factors and a placebo-controlled trial evaluating the efficacy of systemic corticosteroids before extubation in individuals at risk for developing post-extubation stridor are needed.

Recent efforts to reestablish control of tuberculosis have resulted in some success. However, deaths from tuberculosis continue to increase worldwide. Molecular techniques have dominated investigators' efforts to improve diagnostic methods and therapeutic options. Unfortunately, no significant advances in the development of new drugs have occurred. Ongoing attempts to develop more effective vaccines hold some preliminary promise, but delineation of the protective antigens on Mycobacterium tuberculosis and the development of a vaccine for use in humans is considered decades away from clinical use. The lack of political commitment worldwide and the potential loss of support nationally remain major obstacles to the establishment of effective and long-lasting tuberculosis control.

The resurgence of tuberculosis and the emergence of multidrug resistant tuberculosis have led to renewed interest in this ancient disease. Advances in the field of molecular biology have increased our understanding of the epidemiology and transmission of infection. This has had a particular impact on the documentation of, and the subsequent development of guidelines to prevent, the nosocomial transmission of tuberculosis. Molecular techniques have dominated the efforts of investigators to improve diagnostic methods and therapeutic options. Recent information regarding the mechanism of developing protective immunity to tuberculosis may lead to the development of more effective vaccines and a role for immunotherapy in treatment. National and international organizations have formulated guidelines for the diagnosis and treatment of disease and infection. The development of a global response to the problem of tuberculosis in order to ensure the establishment of long-lasting control is needed.

Purpose: Pulmonary infection is a frequent cause of morbidity and mortality in patients with acquired immunodeficiency syndrome (AIDS), and Pneumocystis carinii pneumonia (PCP) is the predominant infection in these patients. In those patients who experience progression to respiratory failure from PCP, the reported mortality rate has been between 87% to 100%. This, in addition to the ultimately fatal outcome of patients with AIDS, has led many physicians to question the advisability of instituting mechanical support for respiratory failure in the setting of PCP. It had been our impression that the outcome of patients on our service was not as poor as was generally reported. We therefore undertook a retrospective analysis of our clinical experience., Patients and Methods: We reviewed the clinical course of patients admitted to our service between December 1984 and June 1988 who required intubation and mechanical ventilation for PCP or presumed PCP., Results: Thirty-three cases were identified with 18 survivors (54.5%) and 15 non-survivors (45.5%). Twenty-five of the 33 patients were intubated for their first episode of PCP, with 16 survivors (64%), whereas the remaining eight patients were intubated for their second episode of PCP, with two survivors (25%). We were not able to identify any parameters that predicted survival, although the serum lactate dehydrogenase level was useful in following the response to treatment., Conclusion: It is our belief that there is a reasonable chance of survival for patients requiring mechanical ventilation for PCP. We question the wisdom of avoiding intubation and mechanical ventilation altogether in patients with PCP due to the presumption of fatality in this clinical situation.