Top Ten List in Ventilator-Associated Pneumonia
Rello J, Lorente C, Bodi M, et al. Why do physicians not follow evidence-based guidelines for preventing ventilator-associated pneumonia?
The article reflects the need to improve medical and nursing staff adherence to guidelines. A total of 110 opinion leaders on VAP from 22 countries were interviewed for their personal opinions on different VAP prevention measures Dapoxetine online. Scientific evidence published alone has been shown to be ineffective in improving guideline implementation because the degree of adherence is independent of the strength of evidence and the grade of effectiveness, at least in part because of the disagreement of opinion leaders about the interpretation of reported trials. However, the most important reason why recommendations are not followed is the lack of technological availability, which has been cited by 78% of the interviewed opinion leaders. Pharmacologic strategies had worse adherence than nonpharmacologic ones, which were predominantly conditioned for excessive antibiotic employment. This report highlighted the great importance of educational measures in improving VAP prevention, remarking on the need for a multidisciplinary approach.
Zack JE, Garrison T, Trovillion E, et al. Effect of an education program aimed at reducing the occurrence of ventilator-associated pneumonia.
This interesting article confirms the huge importance of implementing scientific data with educational programs, and is directed to physicians and nurses in an effort to improve VAP prevention. The reduction in the VAP rate reported is 57.6% (range, 12.6 to 5.7 episodes per 1,000 ventilator days). The program included a theoretical module, with selfstudy and practice modifications, with staff meetings and didactic lectures. The authors reinforced the programs with continuous visual support throughout the ICU, contributing to the adherence to the guidelines. These strategies require constant reinforcement by continuous updating and feedback based on results. It is important to point out that the combination of different measures is an important way to reduce the incidence of VAP. As can be inferred from the study, not only the incidence of VAP can be reduced with educational programs, but also the costs and patient morbidity attributed to nosocomial infections.
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Effect of Emphysema on CT Scan Measures of Airway Dimensions in Smokers
COPD is incompletely reversible expiratory airflow obstruction attributed to a combination of emphysema and airway disease. CT imaging is increasingly being used to characterize and quantify these processes for genetic, epidemiologic, and therapeutic investigations with the premise that their relative balance may define unique subsets of disease. Although the quantification of emphysema by CT imaging has been well established and now validated in multiple histopathologic investigations, the quantification of airway disease Canadian Heath&Care Pharmacy has proven to be a greater challenge.
It is believed that the site of expiratory airflow obstruction in COPD is the small airways that are < 2 mm in diameter. Although direct examination of these structures is beyond the resolution of clinical CT scanning techniques, work by Nakano and colleagues demonstrated that dimensions of the central airways and their degree of remodeling on CT scan are correlated with the burden of distal small airways disease. It was subsequently discovered that the correlation between FEV1 % predicted and WA% is greater in subsegmental (and more peripheral) airways than in segmental airways. It has since become the standard in quantitative CT image analyses to study the most peripheral airways.
Previously, we and other groups demonstrated that with increasing disease severity and increasing burdens of emphysema, airways become less distensible. There may be several reasons for this observation, including mural fibrosis, which prevents dilation, and the disruption of the airway parenchymal interdependence in emphysematous lungs, which may reduce radial traction on the airway. In either case, an incompletely expanded airway may appear to have an elevated WA% on CT scan that could be falsely attributed to a greater burden of airway disease. Because the increase in WA% beyond the segmental airways is the basis of the increased correlation between lung function and airway disease, it is important to uncover whether this measure is related to emphysema. Using CT imaging, epidemiologic, and functional data from a large cohort of smokers in the COPDGene Study, we aimed to (1) examine the effect of emphysema on the relationship between WA% and FEV1 % predicted and (2) assess the relationships among lobar emphysema, segmental and subsegmental WA%, and total bronchial area (TBA) along six bronchial paths.