European Respiratory Society guidelines for the management of adult bronchiectasis

Bronchiectasis in adults is a chronic disorder associated with poor quality of life and frequent exacerbations in many patients. There have been no previous international guidelines.The European Respiratory Society guidelines for the management of adult bronchiectasis describe the appropriate investigation and treatment strategies determined by a systematic review of the literature.A multidisciplinary group representing respiratory medicine, microbiology, physiotherapy, thoracic surgery, primary care, methodology and patients considered the most relevant clinical questions (for both clinicians and patients) related to management of bronchiectasis. Nine key clinical questions were generated and a systematic review was conducted to identify published systematic reviews, randomised clinical trials and observational studies that answered these questions. We used the GRADE approach to define the quality of the evidence and the level of recommendations. The resulting guideline addresses the investigation of underlying causes of bronchiectasis, treatment of exacerbations, pathogen eradication, long term antibiotic treatment, anti-inflammatories, mucoactive drugs, bronchodilators, surgical treatment and respiratory physiotherapy.These recommendations can be used to benchmark quality of care for people with bronchiectasis across Europe and to improve outcomes.

Predicting mortality in hospitalized patients with 2009 H1N1 influenza pneumonia.

BACKGROUND: Community-acquired pneumonia (CAP) severity scores can identify patients at low risk for mortality who may be suitable for ambulatory care. Here, we follow the clinical course of hospitalized patients with CAP due to 2009 H1N1 influenza. OBJECTIVE: To evaluate the role of CAP severity scores as predictors of mortality. METHODS: This was a secondary data analysis of patients hospitalized with CAP due to 2009 H1N1 influenza confirmed by reverse transcriptase polymerase chain reaction enrolled in the CAPO (Community-Acquired Pneumonia Organization) international cohort study. CAP severity scores PSI (Pneumonia Severity Index), CURB-65 (confusion, urea, respiratory rate, blood pressure, age ≥ 65 years) and CRB-65 (confusion, respiratory rate, blood pressure, age ≥ 65 years) were calculated. Actual and predicted mortality rates were compared. A total of 37 predictor variables were evaluated to define those associated with mortality. RESULTS: Data from 250 patients with CAP due to 2009 H1N1 influenza were analyzed. Patients with low predicted mortality rates (0-1.5%) had actual mortality rates ranging from 2.6% to 17.5%. Obesity and wheezing were the only novel variables associated with mortality. CONCLUSIONS: The decision to hospitalize a patient with CAP due to 2009 H1N1 influenza should not be based on current CAP severity scores, as they underestimate mortality rates in a significant number of patients. Patients with obesity or wheezing should be considered at an increased risk for mortality.

What hope for Haiti?

PIP: The population, environmental, and economic problems of Haiti must be solved through a national change in attitude, an emphasis on the individual value of children, a social concern for urgent action on sustainable development, and shared responsibility in the international community. The impact of colonialism was to lay waste to subsistence practices which were ecologically balanced. This first nation of self-liberated slaves has problems deeply rooted in the past, which have been worsened by the ruling elite's exploitation. There is extreme poverty, boat people, deforestation, environmental degradation, civil liberty abuses, and a struggle for democracy. Population growth as well as, indirectly, death, hunger, and disease, have contributed to the immigration of Haitians to the US, Canada, France, and neighboring islands. Fertility has been high for the past 20 years. The family planning challenges are discussed in light of the 10% acceptance rate and met demand. The host country's ability to cope with the burden of supplying employment, social services, and legal protection accounts for the reluctance to accept greater numbers of Haitians. Rural-to-urban migration has created nightmares within Haiti. Cite Soleil has a population density of 25,000 people/sq. kilometer, and more than 33% of rural areas is unfit for habitation. The urban slums offer a substandard quality of life due to infiltration of sea water into the soil which prohibits vegetative growth, due to sanitation deficits, and due to inadequate clean water supplies. The example of a small sugar merchant with an income of $40/month reflects the ability to survive but with no provision for empowerment or betterment for the future for the grandchildren in her care. Captain Jacques-Yves Cousteau attests to the difficulties and, maybe, impossibilities of turning around the process of environmental devastation and overpopulation. The ecological problems are primarily due to salinization and deforestation; the pressure for fuelwood has increased since the trade embargo, which prevents importation of butane and propane. Tree planting of 20 million/year yields 2-3 million actually surviving. Destructive fishing, quarrying, and agricultural techniques continue to waste resources.^ieng