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Sepsis Order Set Use Associated With Increased Care Value. 败血症医嘱集的使用与护理价值的提高有关。
IF 9.5 1区 医学 Q1 CRITICAL CARE MEDICINE Pub Date : 2024-11-01 Epub Date: 2024-06-19 DOI: 10.1016/j.chest.2024.05.032
Christopher R Dale, Shih-Ting Chiu, Shelley Schoepflin Sanders, Caleb J Stowell, Tessa L Steel, Joshua M Liao, James I Barnes

Background: Sepsis is common and expensive, and evidence suggests that sepsis order sets may help to improve care. Very incomplete evidence exists regarding the effects of sepsis order sets on the value of care produced by hospitals or the societal costs of sepsis care.

Research question: In patients hospitalized for sepsis, is the receipt a of a sepsis order set vs no order set associated with improved value of care, defined as decreased hospital mortality, decreased hospital direct variable costs, and decreased societal spending on hospitalizations?

Study design and methods: This retrospective cohort study included patients discharged with sepsis International Classification of Diseases, Tenth Revision, codes over 2 years from a large integrated delivery system. Using a propensity score, sepsis order set users were matched to nonusers to study the association between sepsis order set use and the value of care from the hospital and societal perspective. The association between order set receipt and hospital mortality, direct variable cost, and hospital revenue also were examined in a priori defined subgroups of sepsis severity and hospital mortality.

Results: The study included 97,249 patients, with 52,793 patients (54%) receiving the sepsis order set. The propensity score match analysis included 55,542 patients, with 27,771 patients in each group. Recipients of the sepsis order set showed a 3.3% lower hospital mortality rate and a $1,487 lower median direct variable total cost (P < .01 for both). Median payer-neutral reimbursement (ie, PNR), a proxy for hospital revenue and thus societal costs, was $465 lower for sepsis order set users (P < .01). Receipt of the sepsis order set was associated with a $1,022 increase in contribution margin, the difference between direct variable costs and PNR per patient.

Interpretation: Receipt of the sepsis order set was associated with improved value of care, from both a hospital and societal perspective.

背景:败血症既常见又昂贵,有证据表明败血症医嘱集可能有助于改善护理。关于脓毒症医嘱集对医院产生的护理价值或脓毒症护理的社会成本的影响,目前还没有完整的证据:研究问题:在因脓毒症住院的患者中,接受脓毒症医嘱集与不接受医嘱集是否与提高护理价值(即降低住院死亡率、降低医院直接可变成本和降低住院的社会支出)有关?对一家大型综合医疗服务系统两年内使用败血症 ICD-10 编码出院的患者进行回顾性队列研究。采用倾向评分法将脓毒症医嘱集使用者与非使用者进行匹配,从医院和社会角度研究脓毒症医嘱集的使用与医疗价值之间的关联。此外,还根据事先定义的败血症严重程度和医院死亡率分组,研究了接收医嘱集与医院死亡率、直接可变成本和医院收入之间的关系:97,249 名患者参与了研究,其中 52,793 人(54%)接受了败血症医嘱集。55542 名患者被纳入倾向得分匹配分析,每组 27771 人。接受败血症医嘱集的患者住院死亡率降低了 3.3%,直接可变总成本中位数降低了 1487 美元(两者的 P < 0.01)。作为医院收入和社会成本的代表,脓毒症医嘱集使用者的支付方中立补偿(PNR)中位数降低了 465 美元(P < 0.01)。脓毒症医嘱集的使用与贡献率(每位患者的直接可变成本与 PNR 之间的差额)增加 1022 美元有关:从医院和社会的角度来看,脓毒症医嘱集的使用与护理价值的提高有关。
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引用次数: 0
"My Mom Is a Fighter": A Qualitative Analysis of the Use of Combat Metaphors in ICU Clinician Notes. "我妈妈是个斗士":对重症监护室临床医生笔记中使用战斗隐喻的定性分析。
IF 9.5 1区 医学 Q1 CRITICAL CARE MEDICINE Pub Date : 2024-11-01 Epub Date: 2024-08-26 DOI: 10.1016/j.chest.2024.07.178
Shannen Kim, Hunter Mills, Teva Brender, Samuel McGowan, Eric Widera, Allyson C Chapman, Krista L Harrison, Sei Lee, Alex K Smith, David Bamman, Oksana Gologorskaya, Julien Cobert

Background: A metaphor conceptualizes one, typically abstract, experience in terms of another, more concrete, experience with the goal of making it easier to understand. Although combat metaphors have been well described in some health contexts, they have not been well characterized in the setting of critical illness.

Research question: How do clinicians use combat metaphors when describing critically ill patients and families in the electronic health record?

Study design and methods: We included notes written about patients aged 18 years or older admitted to ICUs within a large hospital system from 2012 through 2020. We developed a lexicon of combat words and isolated note segments that contained any combat mentions. Combat mentions were defined systematically as a metaphor or not across two coders. Among combat metaphors, we used a grounded theory approach to construct a conceptual framework around their use.

Results: Across 6,404 combat-related mentions, 5,970 were defined as metaphors (Cohen κ, 0.84). The most common metaphors were "bout" (26.2% of isolated segments), "combat" (18.5%), "confront" (17.8%), and "struggle" (17.5%). We present a conceptual framework highlighting how combat metaphors can present as identity ("mom is a fighter") and process constructs ("struggling to breathe"). Identity constructs usually were framed around: (1) hope, (2) internal strength, (3) contextualization of current illness based on prior experiences, or (4) a combination thereof. Process constructs were used to describe: (1) "fighting for" (eg, working toward) a goal, (2) "fighting against" an unwanted force, or (3) experiencing internal turmoil.

Interpretation: We provide a novel conceptual framework around the use of combat metaphors in the ICU. Further studies are needed to understand intentionality behind their use and how they impact clinician behaviors and patient and caregiver emotional responses.

背景:隐喻将一种典型的抽象经验概念化为另一种更具体的经验,目的是使其更容易理解。尽管战斗隐喻在某些健康环境中已经得到了很好的描述,但在危重病环境中还没有得到很好的描述:研究设计和方法:我们纳入了 2012-2020 年间一家大型医院系统内重症监护病房收治的年龄大于等于 18 岁患者的病历。我们开发了战斗词汇词典,并分离出包含任何战斗提及的笔记片段。两名编码员系统地定义了战斗隐喻与否。在战斗隐喻中,我们使用了基础理论方法,围绕其使用构建了一个概念框架:在 6,404 次与战斗有关的提及中,5,970 次被定义为隐喻(科恩卡帕 0.84)。最常见的隐喻是 "bout"(占孤立片段的 26.2%)、"combat"(18.5%)、"confront"(17.8%)和 "struggle"(17.5%)。我们提出了一个概念框架,强调了战斗隐喻如何表现为身份建构("妈妈是个斗士")和过程建构("挣扎着呼吸")。身份建构通常围绕:(1) 希望,(2) 内在力量,和/或 (3) 基于先前经历的当前疾病的背景。过程建构用于描述:(1)"为......而战"(如为实现目标而努力),(2)"对抗 "不想要的力量,或(3)经历内部动荡:我们围绕重症监护室中战斗隐喻的使用提供了一个新颖的概念框架。需要进一步研究,以了解使用这些隐喻背后的意图,以及它们如何影响临床医生的行为和患者/护理人员的情绪反应。
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引用次数: 0
Two Birds With One Stone: Cross-Registry Analysis of Women Undergoing Lung Cancer and Breast Cancer Screening. 一石二鸟:对接受肺癌和乳腺癌筛查的女性进行交叉登记分析。
IF 9.5 1区 医学 Q1 CRITICAL CARE MEDICINE Pub Date : 2024-11-01 Epub Date: 2024-07-10 DOI: 10.1016/j.chest.2024.06.3798
John Michael Sweetnam, Lenka Goldman, Lars Grimm, Gerard A Silvestri, Nichole T Tanner
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引用次数: 0
A New Dawn for Bronchoscopy for Peripheral Lung Lesions? 支气管镜检查周围肺部病变的新曙光?
IF 9.5 1区 医学 Q1 CRITICAL CARE MEDICINE Pub Date : 2024-11-01 DOI: 10.1016/j.chest.2024.06.004
Ley T Chan, Christopher M Orton, Pallav L Shah
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引用次数: 0
Improving Diagnosis and Management of Pulmonary Hypertension in Interstitial Lung Disease. 改善间质性肺病肺动脉高压的诊断和管理。
IF 9.5 1区 医学 Q1 CRITICAL CARE MEDICINE Pub Date : 2024-11-01 DOI: 10.1016/j.chest.2024.06.3806
Lu Hao, Jisu Xue
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引用次数: 0
Reflections on the Recent Study on Minocycline for Delirium Prevention in Patients in the ICU. 关于米诺环素预防重症监护病房患者谵妄的最新研究的思考。
IF 9.5 1区 医学 Q1 CRITICAL CARE MEDICINE Pub Date : 2024-11-01 DOI: 10.1016/j.chest.2024.05.048
Xiaozhen Zhao, Caifeng Li
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引用次数: 0
Response. 回应。
IF 9.5 1区 医学 Q1 CRITICAL CARE MEDICINE Pub Date : 2024-11-01 DOI: 10.1016/j.chest.2024.06.3825
Felipe Dal-Pizzol, Cristiane Ritter
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引用次数: 0
Sex Differences After Treatment With Ivacaftor in People With Cystic Fibrosis. 囊性纤维化患者接受伊伐卡夫托治疗后仍存在性别差异。
IF 9.5 1区 医学 Q1 CRITICAL CARE MEDICINE Pub Date : 2024-11-01 Epub Date: 2024-06-11 DOI: 10.1016/j.chest.2024.05.019
Melanie Holtrop, Sophia Cosmich, MinJae Lee, Ashley Keller, Raksha Jain

Background: Historically, studies show that female patients with cystic fibrosis (CF) have worse pulmonary outcomes than male patients, including decreased life expectancy. It is unknown whether this disparity persists in the new era of highly effective modulator therapies. Ivacaftor has been available in the United States for > 10 years, allowing for the opportunity to understand the impact this therapy may have on sex disparities in CF. We hypothesized that female patients will continue to show worse outcomes because we suspect that the disparity is not driven solely by ion channel dysfunction.

Research question: Does a difference in outcomes between male and female patients persist after the initiation of ivacaftor in people with CF?

Study design and methods: We conducted a retrospective cohort study using the CF Foundation Patient Registry comparing changes in pulmonary exacerbation rate, lung function (FEV1 % predicted), and presence of Pseudomonas aeruginosa among male patients vs female patients before and after initiation of treatment with the highly effective modulator ivacaftor.

Results: The cohort comprised 1,900 people with CF who were treated with ivacaftor between 2010 and 2017; 928 patients (48.84%) were male and 972 patients (51.16%) were female with a mean age of 33.09 years. Male patients showed a significant decrease in pulmonary exacerbations after ivacaftor treatment (from 0.38 to 0.34; adjusted rate ratio, 0.89; P = .028), whereas female patients did not (from 0.48 to 0.45; adjusted rate ratio, 0.95; P = .174). FEV1 % predicted similarly decreased in both male and female patients before vs after ivacaftor treatment. P aeruginosa prevalence decreased to a similar extent in both male and female patients after ivacaftor treatment.

Interpretation: Our findings demonstrate that sex disparities in CF persist in those treated with ivacaftor because of differences in pulmonary exacerbations. More research is needed to determine the specific pathophysiologic drivers of this disparity.

背景:历史研究表明,囊性纤维化(CF)女性患者的肺部治疗效果比男性患者差,包括预期寿命缩短。在使用高效调节剂疗法(HEMTs)的新时代,这种差异是否依然存在尚不得而知。伊伐卡夫托(Ivacaftor)在美国上市已超过十年,因此我们有机会了解这种疗法对 CF 性别差异的影响。我们假设女性的预后将继续恶化,因为我们怀疑这种差异并不完全是由离子通道功能障碍造成的:研究设计和方法:我们利用CF基金会患者登记处(CFFPR)进行了一项回顾性队列研究,比较了开始使用高效调节剂伊伐卡夫托治疗前后男性与女性在肺部恶化率、肺功能(ppFEV1)和铜绿假单胞菌存在情况方面的变化:我们的队列包括2010-2017年间接受伊伐卡夫托治疗的1900名CF患者,其中男性928人(48.84%),女性972人(51.16%),平均年龄33.09岁。ivacaftor治疗后,男性的肺部恶化率明显降低(从0.38降至0.34,调整后比率为0.89,p = 0.028),而女性则没有明显降低(从0.48降至0.45,调整后比率为0.95,p = 0.174)。ivacaftor治疗后,男性和女性铜绿假单胞菌感染率的下降程度相似:我们的研究结果表明,在接受伊伐卡夫托治疗的患者中,由于肺部恶化的不同,CF患者的性别差异依然存在。要确定造成这种差异的具体病理生理学因素,还需要进行更多的研究。
{"title":"Sex Differences After Treatment With Ivacaftor in People With Cystic Fibrosis.","authors":"Melanie Holtrop, Sophia Cosmich, MinJae Lee, Ashley Keller, Raksha Jain","doi":"10.1016/j.chest.2024.05.019","DOIUrl":"10.1016/j.chest.2024.05.019","url":null,"abstract":"<p><strong>Background: </strong>Historically, studies show that female patients with cystic fibrosis (CF) have worse pulmonary outcomes than male patients, including decreased life expectancy. It is unknown whether this disparity persists in the new era of highly effective modulator therapies. Ivacaftor has been available in the United States for > 10 years, allowing for the opportunity to understand the impact this therapy may have on sex disparities in CF. We hypothesized that female patients will continue to show worse outcomes because we suspect that the disparity is not driven solely by ion channel dysfunction.</p><p><strong>Research question: </strong>Does a difference in outcomes between male and female patients persist after the initiation of ivacaftor in people with CF?</p><p><strong>Study design and methods: </strong>We conducted a retrospective cohort study using the CF Foundation Patient Registry comparing changes in pulmonary exacerbation rate, lung function (FEV<sub>1</sub> % predicted), and presence of Pseudomonas aeruginosa among male patients vs female patients before and after initiation of treatment with the highly effective modulator ivacaftor.</p><p><strong>Results: </strong>The cohort comprised 1,900 people with CF who were treated with ivacaftor between 2010 and 2017; 928 patients (48.84%) were male and 972 patients (51.16%) were female with a mean age of 33.09 years. Male patients showed a significant decrease in pulmonary exacerbations after ivacaftor treatment (from 0.38 to 0.34; adjusted rate ratio, 0.89; P = .028), whereas female patients did not (from 0.48 to 0.45; adjusted rate ratio, 0.95; P = .174). FEV<sub>1</sub> % predicted similarly decreased in both male and female patients before vs after ivacaftor treatment. P aeruginosa prevalence decreased to a similar extent in both male and female patients after ivacaftor treatment.</p><p><strong>Interpretation: </strong>Our findings demonstrate that sex disparities in CF persist in those treated with ivacaftor because of differences in pulmonary exacerbations. More research is needed to determine the specific pathophysiologic drivers of this disparity.</p>","PeriodicalId":9782,"journal":{"name":"Chest","volume":" ","pages":"951-962"},"PeriodicalIF":9.5,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141316810","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Association of Age at Smoking Initiation, Age at Smoking Cessation, and Lower Respiratory Mortality: Prospective Study of 500,000 Adults in the United States. 开始吸烟年龄、戒烟年龄与下呼吸道死亡率的关系:对 50 万美国成年人的前瞻性研究。
IF 9.5 1区 医学 Q1 CRITICAL CARE MEDICINE Pub Date : 2024-11-01 Epub Date: 2024-05-25 DOI: 10.1016/j.chest.2024.04.022
Blake Thomson, Ahmedin Jemal, Farhad Islami
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引用次数: 0
A 54-Year-Old Man With High-Grade Fever, Cough, Dyspnea, and Vesiculobullous Skin Eruptions. 一名 54 岁的男性,伴有高烧、咳嗽、呼吸困难和膀胱皮肤溃烂。
IF 9.5 1区 医学 Q1 CRITICAL CARE MEDICINE Pub Date : 2024-11-01 DOI: 10.1016/j.chest.2024.05.034
Anna Oppliger, Patrick M Meyer Sauteur, Robert Dahmen, Adrian Schibli, Bertram Feil, Mattia Arrigo, Lars C Huber

Case presentation: A 54-year-old Egyptian man with a 5-day history of worsening cough, high-grade fever, and progressive dyspnea was referred to our hospital. A 3-day course of ceftriaxone provided in an outpatient setting showed no clinical improvement. Medical history was unremarkable, except for bilateral pulmonary embolism diagnosed 3 years earlier. The patient actively smoked and denied the use of alcohol and illicit drugs. The patient worked as cook and had lived in Switzerland for the past 10 years. Five weeks before the actual presentation, he had traveled to Egypt. One of his children showed symptoms of a respiratory infection approximately 2 weeks before that. His only regular medication was rivaroxaban.

病例介绍:一名 54 岁的埃及男子因咳嗽、高烧和进行性呼吸困难恶化 5 天,被转诊到我院。他在门诊接受了为期 3 天的头孢曲松治疗,但临床症状未见好转。除三年前诊断出双侧肺栓塞外,病史无异常。患者经常吸烟,但否认酗酒和使用违禁药物。患者从事厨师工作,过去10年一直住在瑞士。实际发病前五周,他曾前往埃及旅行。大约两周前,他的一个孩子出现了呼吸道感染症状。他唯一经常服用的药物是利伐沙班。
{"title":"A 54-Year-Old Man With High-Grade Fever, Cough, Dyspnea, and Vesiculobullous Skin Eruptions.","authors":"Anna Oppliger, Patrick M Meyer Sauteur, Robert Dahmen, Adrian Schibli, Bertram Feil, Mattia Arrigo, Lars C Huber","doi":"10.1016/j.chest.2024.05.034","DOIUrl":"https://doi.org/10.1016/j.chest.2024.05.034","url":null,"abstract":"<p><strong>Case presentation: </strong>A 54-year-old Egyptian man with a 5-day history of worsening cough, high-grade fever, and progressive dyspnea was referred to our hospital. A 3-day course of ceftriaxone provided in an outpatient setting showed no clinical improvement. Medical history was unremarkable, except for bilateral pulmonary embolism diagnosed 3 years earlier. The patient actively smoked and denied the use of alcohol and illicit drugs. The patient worked as cook and had lived in Switzerland for the past 10 years. Five weeks before the actual presentation, he had traveled to Egypt. One of his children showed symptoms of a respiratory infection approximately 2 weeks before that. His only regular medication was rivaroxaban.</p>","PeriodicalId":9782,"journal":{"name":"Chest","volume":"166 5","pages":"e141-e145"},"PeriodicalIF":9.5,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142615789","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
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Chest
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