Diffuse alveolar hemorrhage (DAH) is characterized by the presence of hemoptysis, anemia, and the presence of diffuse parenchymal infiltrates on imaging studies. Idiopathic pulmonary hemosiderosis (IPH) is an uncommon cause of diffuse alveolar hemorrhage (DAH) and is classically known to present in childhood. Adult-onset IPH is extremely rare. We report the case of a 48-year-old female patient who presented with hemoptysis and acute hypoxic respiratory failure, requiring intubation and mechanical ventilation. Imaging studies showed diffuse bilateral patchy infiltrates. Bronchoalveolar lavage (BAL) confirmed the diagnosis of DAH. Extensive workup including video-assisted thoracoscopic surgical lung biopsy (VATS) failed to reveal any vasculitis, infectious, immunological or connective tissue disorder, as the underlying cause for DAH. The patient was successfully treated with high-dose steroid therapy.
Learning Objectives: The purpose of this study was to evaluate the efficacy of using an EMR-based decision-support tool to order serum lactate levels in a population of potentially septic hospitalized adults. We previously developed an automated alert system to detect vital sign and laboratory abnormalities indicative of systemic inflammatory response syndrome (SIRS) and organ dysfunction that triggers a real-time clinical alert when both occur within 8 hours. It was hypothesized that if this alert system also triggered an automated lactate order, it might identify a subgroup of hyperlactemic patients with a high risk for mortality and potential to benefit from urgent clinical attention. Methods: A cohort study was performed over four months during which all patients who satisfied criteria for SIRS and organ dysfunction had an automated lactate order resulted, unless the clinician had already ordered a lactate or cancelled the automated order. Results: 4981 adult patients admitted during the trial had a discharge mortality rate of 1.78% (95%CI: 1.42-2.15). 1400 patients satisfied criteria for SIRS/ organ dysfunction, triggering the alert system. 479/1400 had a clinician-ordered lactate with a mortality rate of 12.1% (95%CI:9.2-15.0), which rose to 36.7% (95%CI:24.5-48.9) in the 60-patient subgroup with lactate >4.0 mmol/L. 584/1400 patients had an alert-ordered lactate with a mortality rate of 12.2% (95%CI: 9.6-14.9), which rose to 51.4% (34.8-68.0%) in the 35-patient subgroup with lactate >4.0 mmol/L. In 337/1400 cases, the automated lactate order was cancelled by clinicians. Patients in this subgroup had a mortality of 2.7% (95%CI:1.0-4.4%). Conclusions: The automated alert was able to identify a subgroup of patients with SIRS, organ dysfunction and hyperlactemia in real time -patients for whom the clinician had either not thought to order lactate, or were unable to before the alert ordered it. Patients with this dangerous triad of findings had similarly high mortality rates no matter how the lactate was ordered. Clinicians effectively identified a subgroup of patients with SIRS, organ dysfunction and low morta Learning Objectives: ICU rounding is a combination of care management, medical education, and patient-family encounters with multidisciplinary teams. Because of resident duty hour restrictions, nurse practitioners (NPs) have recently become more actively engaged patient care. However, the impact of these changes on team workflow during morning rounds remains unknown. The purpose of this study was to understand how providers spend their time during morning rounds. Methods:A prospective observational time study was conducted in a
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