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Computerised clinical decision support for suspected PE

This study aimed to determine the effect of an evidence-based clinical decision support (CDS) algorithm on the use and yield of CT pulmonary angiography (CTPA) and on outcomes of patients evaluated in the emergency department (ED) for suspected PE.

The study included 1363 consecutive patients evaluated for suspected PE in an ED during 12 months before and 12 months after initiation of CDS use. Introduction of CDS was associated with decreased CTPA use (55% vs 49%; absolute difference (AD), 6.3%; 95% CI 1.0% to 11.6%; p=0.02).

The use of CDS was associated with fewer symptomatic venous thromboembolic events during follow-up in patients with an initial negative diagnostic evaluation for PE (0.7% vs 3.2%; AD 2.5%; 95% CI 0.9% to 4.6%; p<0.01).

Keeping up appearances: the importance of maintaining health status in COPD

One of the real strengths of the Evaluation of COPD Longitudinally to Identify Predictive Surrogate Endpoints (ECLIPSE) study was that it confirmed something that seemed so obvious that no one ever felt the need to say it! So, we now know that if the patient with COPD sitting in front of you in the outpatient clinic has frequent exacerbations then, guess what?

Over time, chances are they will continue to exacerbate. In the same way, it seems pretty obvious that maintaining or improving the health status of a patient with COPD over the course of any given year would be associated with a better outcome in subsequent years.

Well, despite the fact that we have been measuring health status in some shape or form in patients with COPD for almost 30 years, it surprised me that we had no real proof that this was indeed the case.

Childhood pneumonia: the role of viruses

The development and availability of improved vaccines, particularly the pneumococcal (PCV) and Haemophilus influenzae type b (Hib) conjugate vaccines have substantially reduced the incidence of childhood pneumonia and severe pneumonia associated with these pathogens over the last decade. However, despite a declining pneumonia incidence and high rates of immunisation, pneumonia remains the leading cause of childhood mortality globally and a major cause of hospitalisation.

Defining the aetiology of pneumonia has become crucial to develop appropriate management strategies, and guide development of new vaccines. Further, the development of better methods for specimen collection and of molecular diagnostics has provided more sensitive techniques to define potential aetiological agents.

However, assigning aetiology may be challenging as it can be difficult to distinguish colonising from pathogenic organisms in respiratory specimens, blood culture rarely is positive and pneumonia, especially severe disease, may frequently be due to multiple copathogens....

Nosocomial pneumonia in non-invasive ventilation patients: incidence, characteristics, and outcomes.

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BACKGROUND: Nosocomial pneumonia occasionally occurs in non-invasive ventilation (NIV) patients.

AIM: To report the incidence, characteristics, and outcomes of nosocomial pneumonia in NIV patients.

METHODS: A prospective observational study was performed in a respiratory intensive care unit (ICU). After admission, patients who received NIV for more than 48h were enrolled. Pneumonia was considered nosocomial when it occurred after at least 48h of NIV.

FINDINGS: Between January 2012 and August 2014, we enrolled 520 NIV patients. Nosocomial pneumonia occurred in 16 patients (3.1%). The nosocomial pneumonia rate was 4.5 cases per 1000 NIV-days. The most common pathogen was Acinetobacter baumannii (81%). At the initiation of NIV, there were no differences in age, gender, diagnosis, disease severity, or arterial blood gas findings between patients with and without nosocomial pneumonia. Compared to patients without nosocomial pneumonia, nosocomial pneumonia patients had a longer duration of NIV (8.4 vs 5.0 days, P < 0.01), a longer ICU stay (10.8 vs 7.9 days, P = 0.01), a longer hospital stay (25.9 vs 15.3 days, P = 0.04), a higher intubation rate (63% vs 21%, P < 0.01), and higher hospital mortality (75% vs 25%, P < 0.01). Nosocomial pneumonia was an independent risk factor for intubation (OR: 6.74; 95% CI: 2.24-20.28) and death (7.65; 1.34-43.72).

CONCLUSION: The incidence of nosocomial pneumonia in NIV patients in this population was 3.1%. Nosocomial pneumonia increased the time that NIV was required, length of ICU stay, length of hospital stay, intubation rate, and hospital mortality.

The Role of Noninvasive Ventilation in the Hospital and Outpatient Management of Chronic Obstructive Pulmonary Disease.

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Positive pressure noninvasive ventilation (NIV) has become widely accepted in the treatment of both hospitalized and outpatient subjects with chronic obstructive pulmonary disease (COPD). The support has evolved over the past two decades to be part of first-line management in acute exacerbations of COPD and is also instrumental in discontinuing mechanical ventilation in COPD patients with acute respiratory failure.

It is also suitable for treatment of COPD with other associated conditions including pneumonia, following lung resectional surgery, with concomitant obstructive sleep apnea and as part of end-of-life care. Short-term application can also facilitate some endoscopic procedures that may otherwise require endotracheal intubation.

Outpatient use of NIV in COPD has garnered much attention, but the support has not been as robust as with NIV in hospitalized patients. However, an approach with higher pressures with a goal of significant reduction in daytime PaCO2 may be an effective strategy. NIV can also facilitate exercise training in pulmonary rehabilitation.

A portable device which can augment tidal volume during ambulation and other activities of daily living may further expand the use of NIV in COPD patients.

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