Search

Mobile (m) Health technology is well-suited for Remote Patient Monitoring (RPM) in a patient's habitual environment. In recent years there have been fast-paced developments in mHealth-enabled pediatric RPM, especially during the COVID-19 pandemic, necessitating evidence synthesis. To this end, we conducted a scoping review of clinical trials that had utilized mHealth-enabled RPM of pediatric asthma. MEDLINE, Embase and Web of Science were searched from September 1, 2016 through August 31, 2021. Our scoping review identified 25 publications that utilized synchronous and asynchronous mHealth-enabled RPM in pediatric asthma, either involving mobile applications or via individual devices. The last three years has seen the development of evidence-based, multidisciplinary, and participatory mHealth interventions. The quality of the studies has been improving, such that 40% of included study reports were randomized controlled trials. In conclusion, there exists high-quality evidence on mHealth-enabled RPM in pediatric asthma, warranting future systematic reviews and/or meta-analyses of the benefits of such RPM. Copyright © 2022 Elsevier Ltd. All rights reserved.

International audience; Chronic Obstructive Pulmonary Disease (COPD) is a common disease associated with significant morbidity and mortality that is both preventable and treatable. However, a major challenge in recognizing, preventing, and treating COPD is understanding its complexity. While COPD has historically been characterized as a disease defined by airflow limitation, we now understand it as a multi-component disease with many clinical phenotypes, systemic manifestations, and associated co-morbidities. Evidence is rapidly emerging in our understanding of the many factors that contribute to the pathogenesis of COPD and the identification of "early" or "pre-COPD" which should provide exciting opportunities for early treatment and disease modification. In addition to breakthroughs in our understanding of the origins of COPD, we are optimizing treatment strategies and delivery of care that are showing impressive benefits in patient-centered outcomes and healthcare utilization. This special issue of Respiratory Medicine, "COPD: Providing the Right Treatment for the Right Patient at the Right Time" is a summary of the proceedings of a conference held in Stresa, Italy in April 2022 that brought together international experts to discuss emerging evidence in COPD and Pulmonary Rehabilitation in honor of a distinguished friend and colleague, Claudio Ferdinando Donor (1948-2021). Claudio was a true pioneer in the field of pulmonary rehabilitation and the comprehensive care of individuals with COPD. He held numerous leadership roles in in the field, provide editorial stewardship of several respiratory journals, authored numerous papers, statement and guidelines in COPD and Pulmonary Rehabilitation, and provided mentorship to many in our field. Claudio's most impressive talent was his ability to organize spectacular conferences and symposia that highlighted cutting edge science and clinical medicine. It is in this spirit that this conference was conceived and planned. These proceedings are divided into 4 sections which highlight crucial areas in the field of COPD: (1) New concepts in COPD pathogenesis; (2) Enhancing outcomes in COPD; (3) Non-pharmacologic management of COPD; and (4) Optimizing delivery of care for COPD. These presentations summarize the newest evidence in the field and capture lively discussion on the exciting future of treating this prevalent and impactful disease. We thank each of the authors for their participation and applaud their efforts toward pushing the envelope in our understanding of COPD and optimizing care for these patients. We believe that this edition is a most fitting tribute to a dear colleague and friend and will prove useful to students, clinicians, and researchers as they continually strive to provide the right treatment for the right patient at the right time. It has been our pleasure and a distinct honor to serve as editors and oversee such wonderful scholarly work.

Background: Some patients with coronavirus disease 2019 (COVID-19) experience prolonged fatigue and dyspnoea without objective impairment of pulmonary or cardiac function. This study determined diaphragm function and its central voluntary activation as a possible pathophysiological correlate after severe COVID-19 acute respiratory distress syndrome (ARDS). Methods:Ten patients with severe COVID-19 ARDS treated with invasive mechanical ventilation (IMV) (6 female, age 56±14 years, 63±45 days of IMV) and ten matched healthy controls underwent pulmonary function tests (PFTs), 6-minute walk test, echocardiography, diaphragm ultrasound, and invasive recording of twitch transdiaphragmatic pressure (twPdi) following magnetic diaphragm stimulation. Twitch interpolation was used to determine the diaphragm voluntary activation index (DVAI); reflecting central diaphragm activation. Findings: One year post discharge, neither PFTs nor echocardiography were indicative of significant abnormalities in severe COVID-19 survivors. However, six patients reported persisting dyspnoea on exertion (severe in two, moderate in four). On ultrasound, the diaphragm thickening ratio was lower in patients versus controls (1.87±0.37 vs. 2.76±0.72; p

This report is a summary of a workshop focusing on using telemedicine to facilitate the integrated care of chronic obstructive pulmonary disease (COPD). Twenty-five invited participants from 8 countries met for one and one-half days in Stresa, Italy on 7-8 September 2017, to discuss this topic. Participants included physiotherapists, nurses, a nurse practitioner, and physicians. While evidence-based data are always at the center of sound inference and recommendations, at this point in time the science behind telemedicine in COPD remains under-developed; therefore, this document reflects expert opinion and consensus. While telemedicine has great potential to expand and improve the care of our COPD patients, its application is still in its infancy. While studies have demonstrated its effectiveness in some patient-centered outcomes, the results are by no means consistently positive. Whereas this tool may potentially reduce health care costs by moving some medical interventions from centralized locations in to patient's home, its cost-effectiveness has had mixed results and telemonitoring has yet to prove its worth in the COPD population. These discordant results should not be unexpected in view of patient complexity and the heterogeneity of telemedicine. This is reflected in the very limited support offered by the National Health Services to a wider application of telemedicine in the integrated care of COPD patients. However, this situation should challenge us to develop the necessary science to clarify the role of telemedicine in the medical management of our patients, providing a better and definitive scientific basis to this approach.

Introduction Sarcoidosis is a chronic inflammatory disease often associated with chronic fatigue. Prevalence of fatigue can be measured via neuropsychological testing. Its pathophysiology is insufficiently understood. Structural analysis might help with the development of novel treatment methods. Methods We recruited 30 sarcoidosis patients whose fatigue severity and depressive symptom presence was measured through validated neuropsychological self-assessment. T1-weighted structural images were acquired and VBM preprocessing was conducted. Total scores of these tests and subscales were correlated through multiple regression analysis to the brain morphometry. Results Fatigue severity positively correlated with gray matter volumes in the striatum, the cingulate cortex and the cerebellum and negatively in the parietal and temporal lobe and posterior insula. Subscale analysis indicated a correlation between cognitive fatigue and striatum involvement as well as between physical and psychosocial fatigue and cerebellar alterations. Discussion Structural analysis delineated two structural patterns associated with the presence of fatigue. One such pattern mainly seemed to involve structures with a focus on decision-making processes while the other indicated alterations in regions vital for perception. Fatigue seems to be a heterogeneous disease, where varying dimensions of reported symptoms correlate with different patterns of structural changes.

Background Inhaled agents are widely used in the treatment of chronic airway diseases. Correct technique is required to ensure appropriate drug deposition, but poor technique is common. This study investigated whether inhalation technique could be improved by patient training using short videos from the German Airway League. Methods Outpatients from a university hospital respiratory clinic who had incorrect inhalation technique were asked to demonstrate this again immediately after viewing the training videos, and after 4–8 weeks' follow-up. Inhalation technique was rated by a study nurse using specific checklists. Results One hundred and twelve patients with obstructive lung disease treated with inhaled bronchodilators or corticosteroids were included. More than half (51.8%) had at least one mistake in inhalation technique at baseline. Of these, most (88%) understood the training videos, 76% demonstrated correct device use immediately after training, and 72% were still able to demonstrate correct inhalation technique at follow-up (p = 0.0008 for trend). In addition, the number of mistakes decreased significantly after video training (by 1.82 [95% confidence interval 1.39–2.25]; p Conclusions German Airway League inhalation technique training videos were easy to understand and effectively improved inhalation technique in patients with airway diseases.

Background: Identifying preventive strategies in Covid-19 patients will help to improve resource-allocation and reduce mortality. In this Journal, we recently demonstrated in a post-mortem cohort that SARS-CoV-2 renal tropism was associated with kidney injury, disease severity and mortality. We also proposed an algorithm to predict the risk of adverse outcomes in Covid-19 patients harnessing urinalysis and protein/coagulation parameters on admission for signs of kidney injury. Here, we aimed to validate this hypothesis in a multicenter cohort. Methods: Patients hospitalized for Covid-19 at four tertiary centers were screened for an available urinalysis, serum albumin (SA) and antithrombin-III activity (AT-III) obtained prospectively within 48h upon admission. The respective presumed risk for an unfavorable course was categorized as “low”, “intermediate” or “high”, depending on a normal urinalysis, an abnormal urinalysis with SA ≥2 g/dl and AT-III ≥70%, or an abnormal urinalysis with at least one SA or AT-III abnormality. Time to ICU or death within ten days served as primary, in-hospital mortality and required organ support served as secondary endpoints. Findings: Among a total of N=223 screened patients, N=145 were eligible for enrollment, falling into the low (N=43), intermediate (N=84), and high risk (N=18) categories. The risk for ICU transfer or death was 100% in the high risk group and significantly elevated in the composite of high and intermediate risk as compared to the low risk group (63·7% vs. 27·9%; HR 2·6; 95%-CI 1·4 to 4·9; P=0·0020). Having an abnormal urinalysis was associated with mortality, need for mechanical ventilation, extra-corporeal membrane oxygenation (ECMO) or renal replacement therapy (RRT). Interpretation: Our data confirm that Covid-19-associated urine abnormalities on admission predict disease aggravation. This supports the conceptual relevance of Covid-19-associated kidney injury. By engaging a simple urine dipstick our algorithm allows for early preventive measures and appropriate patient stratification. Trial Registration: (ClinicalTrials.gov number NCT04347824) Funding Statement: This work was supported by the DFG (GR 1852/6-1 to OG; CRC1192 to JET, EH and TBH), (HU 1016/8-2, HU 1016/11-1, HU 1016/ 12-1 to TBH) and (GR 1852/6-1 to OG); by the BMBF (STOP-FSGS-01GM1518C and NephrESA-031L0191E to TBH), by the Else-Kroner Fresenius Foundation (Else Kroner-Promotionskolleg –iPRIME to TBH), and by the H2020-IMI2 consortium BEAt-DKD (115974 to TBH). In addition, the UMG Gottingen applied for Government funding (Covid-19 program) by The German Federal Ministry of Education and Research and the application currently is under consideration. Declaration of Interests: All authors report no conflict of interest in relation to this observational cohort-study. Ethics Approval Statement: According to the German Medicines Act, the study was approved by the leading institutional review board (IRB) of the UMG Gottingen (41/4/20), and all others.

Highlights • The sensitivity and specificity of the new Roche SARS-CoV-2 Rapid Antigen Test was evaluated. • We found a specificity of 96 %. • The sensitivity with samples with a Ct of < 25 was 100 % and gradually decreases to 22.2 % with cycle thresholds > = 35. • The new test might be useful to rapidly identify contagious individuals., There is an ongoing need for reliable antigen assays for timely and easy detection of individuals with acute SARS-CoV-2 infection. Using 75 swabs from patients previously tested positive by SARS-CoV-2 PCR and 75 swabs from patients previously tested negative by SARS-CoV-2 PCR, we investigated the sensitivity and specificity of the SARS-CoV-2 Rapid Antigen Test (Roche). We determined a specificity of 96 %. The assay’s sensitivity with samples with a cycle threshold of < 25, 25 - = 35 was 100 %, 95 %, 44.8 % and 22.2 %, respectively. We conclude that sensitivity and specificity of the antigen assay is inferior to the PCR assay. However, the antigen assay may be a quick and easy to perform alternative for differentiation of individuals contagious for SARS-CoV-2 from non-contagious individuals.

Background Facing the ongoing pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), there is an urgent need for serological assays identifying individuals with past coronavirus disease 2019 (COVID-19). Study design Our study is the first to compare four new commercially available assays using 75 sera from patients tested positive or negative by SARS-CoV-2 PCR: the anti SARS-CoV-2 ELISA (IgG) (Euroimmun, Germany), the EDI New Coronavirus COVID-19 IgG ELISA, (Epitope diagnostics (EDI), USA), the recomWell SARS-CoV-2 IgG ELISA (Mikrogen, Germany), and the SARS-CoV-2 Virachip IgG (Viramed, Germany). Results We found a sensitivity of 86.4 %, 100 %, 86.4 %, and 77.3 % and a specificity of 96,2 %, 88,7 %, 100 %, and 100 % for the Euroimmun assay, the EDI assay, the Mikrogen assay, and the Viramed assay, respectively. Conclusions Commercially available SARS-CoV-2 IgG assays have a sufficient specificity and sensitivity for identifying individuals with past SARS-CoV-2 infection.

Noninvasive positive pressure ventilation (NPPV) using effective pressure levels to reduce chronic hypercapnia improves survival in stable hypercapnic COPD. However, the underlying mechanisms remain unclear. This study investigated the influence of effective NPPV on a panel of cytokines and established cardiovascular biomarkers.Peripheral blood samples were drawn before and three months after the initiation of NPPV and analyzed by flow cytometric bead array and ELISA.Twenty COPD patients (forced expiratory volume in 1 s 31 ± 17% predicted) were included. NPPV (inspiratory positive airway pressure 23 ± 4 mbar; breathing frequency 17 ± 2/min) significantly improved arterial carbon dioxide pressure (PaCO2), both during daytime spontaneous breathing (p = 0.005) and nighttime ventilation (p0.001). Serum interleukin (IL)-10 levels were slightly reduced (p = 0.016), whereas IL-1 (p = 0.073) and IL-12 (p = 0.089) showed only a tendency towards change over time. Pro-brain natriuretic peptide (proBNP) significantly decreased by a mean of 578 ± 1332 ng/L after three months' NPPV (p = 0.017 vs baseline). No other significant changes in cardiovascular biomarkers occurred. The decrease in PaCO2 during daytime spontaneous breathing was positively correlated with the reduction in proBNP (correlation coefficient 0.613; p = 0.0197).Effective NPPV impacts on systemic inflammation in COPD patients. Furthermore, reductions in PaCO2 during NPPV were associated with decreases in proBNP levels. Future studies are needed to clarify these findings in a larger cohort of COPD patients.DRKS00007644 (German Clinical Trials Register; https://drks-neu.uniklinik-freiburg.de/drks_web/navigate.do?navigationId=resultsExt).

We investigate the viscous model of quantum hydrodynamics, which describes the charge transport in a certain semiconductor. Quantum mechanical effects lead to third order derivatives, turning the stationary system into an elliptic system of mixed order in the sense of Douglis–Nirenberg. In the case most relevant to applications, the semiconductor device features a piecewise constant barrier potential. In the case of thermodynamic equilibrium, we obtain asymptotic expansions of interfacial layers of the particle density in neighbourhoods of the jump points of this barrier potential, and we present rigorous proofs of uniform estimates of the remainder terms in these asymptotic expansions.

As seen in this CME online activity (available at http://journal.cme.chestnet.org/copd-hot-hmv), acute exacerbations of COPD are associated with significant levels of morbidity and mortality. Acute noninvasive ventilation has been demonstrated its clinical efficacy and cost-effectiveness in reducing intubation rate and mortality and in patients with acute decompensated hypercapnic exacerbations of COPD. However, those patients with evidence of chronic hypercapnic respiratory failure have worse long-term outcomes compared with patients who have only transient hypercapnia during the acute phase returning to eucapnia in the recovery stage. Indeed, there are limited options available to improve the clinical outcome in these COPD patients with persistent hypercapnia. The Home Oxygen Therapy-Home Mechanical Ventilation (HOT-HMV) trial investigated admission-free survival in patients with persistent hypercapnia following a life-threatening exacerbation requiring acute noninvasive ventilation. Phenotyping patients to ensure chronic hypercapnia enriched the trial population to identify those patients at highest risk of readmission or death following an exacerbation. The addition of home noninvasive ventilation to home oxygen therapy in patients with persistent hypercapnia led to improved admission-free survival. The noninvasive ventilation was titrated to overnight measures of transcutaneous CO2 to achieve control of nocturnal hypoventilation, which improved daytime chronic respiratory failure. Home noninvasive ventilation is a complex intervention requiring a multidisciplinary team and long-term patient follow-up to maximize the clinical benefit to the patient.

This article reports on a national study of doctoral nursing faculty, including both PhD and Doctor of Nursing Practice (DNP) faculty. Using a national sample of 624 doctoral nursing faculty, we surveyed individuals on a variety of issues, including succession planning, retirement, quality of life as a doctoral faculty member, their views on the new DNP degree, and how they view the future of doctoral nursing education. Study implications for both DNP and PhD faculty are explored and the meaning of the findings of the study for the future are discussed, including new items that will be investigated in a repeat survey in 2012.

We study a singularly perturbed elliptic second order system in one space variable as it appears in a stationary quantum drift–diffusion model of a semiconductor. We prove the existence of solutions and their uniqueness as minimizers of a certain functional and determine rigorously the principal part of an asymptotic expansion of a boundary layer of those solutions. We prove analytical estimates of the remainder terms of this asymptotic expansion, and confirm by means of numerical simulations that these remainder estimates are sharp.

A strong compactness result in the spirit of the Lions–Aubin–Simon lemma is proven for piecewise constant functions in time ( u τ ) with values in a Banach space. The main feature of our result is that it is sufficient to verify one uniform estimate for the time shifts u τ − u τ ( ⋅ − τ ) instead of all time shifts u τ − u τ ( ⋅ − h ) for h > 0 , as required in Simon’s compactness theorem. This simplifies significantly the application of the Rothe method in the existence analysis of parabolic problems.

We investigate the linear system of thermoelasticity, consisting of an elasticity equation and a heat conduction equation, in a waveguide Ω = ( 0 , 1 ) × R n − 1 , with certain boundary conditions. We consider the cases of homogeneous and inhomogeneous systems and prove decay estimates of the solutions, which are a key ingredient to showing the global existence of solutions to non-linear thermoelasticity, after having decomposed the solutions into various parts. We also give a simplified proof to the representation of the solutions to the Cauchy problem of thermoelasticity.

Several thermomechanical models have been proposed from a heuristic point of view. A mathematical analysis should help to clarify the applicability of these models, among those recent thermal or viscoelastic models. Single-phase-lag and dual-phase-lag heat conduction models can be interpreted as formal expansions of delay equations. The delay equations are shown to be ill-posed, as are the formal expansions of higher order in contrast to lower-order expansions leading to Fourier's or Cattaneo's law. The ill-posedness is proved, showing the lack of continuous dependence on the data, and thus showing that these models (delay or higher-order expansion ones) are highly explosive. In this note we shall present conditions for when this happens.

Despite attention given to the nursing shortage and now the nursing faculty shortage, what is perhaps less visible but equally critical are the pending retirements of most of the current cadre of academic nursing administrators in the next decade. With only 2.1% of current deans, directors, and department chairs in 2006 aged 45 years or younger, there may be a pending crisis in leadership development and succession planning in our nursing schools and colleges. This article describes an innovative leadership development program for largely new nursing academic administrators, which combined a formal campus-based leadership symposia and executive coaching. This article is particularly useful and practical in that actual case studies are described (albeit modified slightly to protect the identity of the individual administrator), providing a real-life narrative that rarely makes its way into the nursing academic administration literature. The executive coaching focus is very sparsely used in nursing academia, and this college's success using this professional development strategy is likely to become a template for other institutions to follow.

Background Average volume-assured pressure support (AVAPS) has been introduced as a new additional mode for a bilevel pressure ventilation (BPV) device (BiPAP; Respironics; Murrysville, PA), but studies on the physiologic and clinical effects have not yet been performed. There is a particular need to better define the most efficient ventilatory treatment modality for patients with obesity hypoventilation syndrome (OHS). Methods In OHS patients who did not respond to therapy with continuous positive airway pressure, the effects of BPV with the spontaneous/timed (S/T) ventilation mode with and without AVAPS over 6 weeks on ventilation pattern, gas exchange, sleep quality, and health-related quality of life (HRQL) assessed by the severe respiratory insufficiency questionnaire (SRI) were prospectively investigated in a randomized crossover trial. Results Ten patients (mean [± SD] age, 53.5 ± 11.7 years; mean body mass index, 41.6 ± 12.1 kg/m 2 ; mean FEV 1 /FVC ratio, 79.4 ± 6.5%; mean transcutaneous P co 2 [Ptc co 2 ], 58 ± 12 mm Hg) were studied. Ptc co 2 nonsignificantly decreased during nocturnal BPV-S/T by −5.6 ± 11.8 mm Hg (95% confidence interval [CI], −14.7 to 3.4 mm Hg; p = 0.188), but significantly decreased during BPV-S/T-AVAPS by −12.6 ± 12.2 mm Hg (95% CI, −22.0 to −3.2 mm Hg; p = 0.015). Pneumotachographic measurements revealed a higher individual variance of peak inspiratory pressure (p Conclusion BPV-S/T substantially improved oxygenation, sleep quality, and HRQL in patients with OHS. AVAPS provided additional benefits on ventilation quality, thus resulting in a more efficient decrease of Ptc co 2 . However, this did not provide further clinical benefits regarding sleep quality and HRQL.

We discuss evolution operators of Schrödinger type which have a non-self-adjoint lower order term and give a necessary condition for the Cauchy problem to such operators to be well-posed in Gevrey spaces. Under an additional assumption, this necessary condition is sharp.

With reports of high rates of sleep disruption in Human Immunodeficiency Virus (HIV) + persons, this study tested whether there were differences in sleep quality and well-being between a group of HIV+ persons who reduced their caffeine intake from baseline by 90% or greater for 30 days (n=44) versus a group of HIV+ persons who continued their usual caffeine consumption (n=44).Subjects were administered pre- and post-Pittsburgh Sleep Quality Index (PSQI), Perceived Well-being Scale-Revised (PWB-R) and MOS-HIV Health Survey instruments, with MOS-HIV summary scores used as a covariate.On ANCOVA analysis for sleep quality (F=14.032, P.001), a 35% improvement in sleep among experimental subjects was identified. There was no significant difference between the two groups on ANCOVA analysis for well-being (F=0.111. P=.739).High levels of caffeine consumption may have an exacerbating effect on already prevalent HIV-related sleep pattern disturbances, and significant reductions of caffeine may improve sleep quality.

Narcolepsy is a chronic disorder of EDS. All patients experience EDS. Other symptoms include cataplexy, sleep paralysis, hypnagogic hallucinations, and disrupted nocturnal sleep. Treatment, usually with stimulants and low-doses of antidepressant medications, can dramatically improve the patient's quality of life. Although only advanced practice nurses may be actively involved in the diagnosis and treatment of this disorder, all nurses can encourage their patients who complain of EDS to consult a specialist in sleep disorders medicine, provide emotional support after diagnosis, and educate patients and their families about narcolepsy and its treatment.

As seen in this CME online activity (available at http://journal.cme.chestnet.org/home-niv-copd), COPD is a common and debilitating disease and is currently the third leading cause of death in the United States. The role of noninvasive ventilation (NIV) in the management of severe, hypercapnic COPD has been controversial. However, it was concluded that current data would support the following recommendations. Patients with COPD with a waking Paco2 > 50 to 52 mm Hg, an overnight Paco2 > 55 mm Hg, or both who are symptomatic and compliant with other therapies should be eligible for NIV. In addition, multiple previous hospital admissions for COPD exacerbation, requiring noninvasive/invasive mechanical ventilation, strongly suggest a need for chronic NIV. Patients with COPD with a BMI > 30 kg/m2 respond particularly well to this therapy. When the decision is made to start NIV, this treatment is probably best initiated during a short hospitalization, although this can be accomplished in the clinic, home, or sleep laboratory if well-trained clinicians are available. Newer modes of NIV such as volume-assured pressure support, particularly with autotitrating expiratory positive airway pressure (EPAP), may create the opportunity for home NIV initiation easier for less experienced physicians. Regardless of the mode selected, inspiratory pressures must be in the 20 to 25 cm H2O range to meaningfully increase tidal volume, reduce work of breathing, and, importantly, reduce waking arterial Paco2. EPAP is currently set at 4 to 5 cm H2O, although future technologies may allow this to be individualized to maximally reduce auto-positive end expiratory pressure. The NIV device should have a backup rate although it is controversial as to whether this should be set at a high (18-20 breaths/min) vs a low (8-10 breaths/min) rate. The proper use of NIV in appropriately chosen patients with COPD can improve quality of life and increase survival. Ongoing studies are assessing if the frequency of future hospitalizations can be reduced with NIV. Thus, NIV should be strongly considered in any patients with COPD meeting the criteria described here.

Clinical inference is part of the clinical decision-making process and precedes judgment and action. It is an integrated response to patient cues and other evidence and a necessary skill for all nurses. The purpose of this study was to compare undergraduate and graduate nursing students' use of clinical inference in rating harmful outcomes for patients occurring after medication errors. The Medication Error Outcome Scale, a simulation methodology using medication error vignettes, was used to compare undergraduate and graduate students' use of clinical inference. Kruskal-Wallis analysis of variance showed that there was a statistically significant difference (P = .04) among freshman, junior, senior, baccalaureate, and Master's students' use of clinical inference in regard to perceived harm occurring after a medication errors. Post hoc Mann-Whitney U tests indicated that senior and baccalaureate students' use of clinical inference differed significantly (P = .005). This study suggests that clinical experience shapes clinical inference.

The role of noninvasive positive pressure ventilation (NPPV) has been well established in the treatment of acute hypercapnic respiratory failure due to COPD. However, evidence for a sustained improvement in blood gas levels and survival in patients with stable hypercapnic COPD following NPPV is still lacking. There is concern that this might be due to low inspiratory pressures of18 cm H2O used in previous studies, which thereby did not achieve a reduction of Pa(CO2). Therefore, the 2-year survival and changes in lung function and blood gas levels were analyzed in patients with stable hypercapnic COPD in whom controlled pressure-limited NPPV was titrated to achieve a maximal improvement in Pa(CO2).Retrospective study between March 1997 and September 2003.General ward of a university hospital.Thirty-four consecutive patients with stable (mean pH 7.40 +/- 0.03) hypercapnic COPD (mean age, 63.4 +/- 9.7 years [+/- SD]; mean body mass index, 28.3 +/- 7.3 kg/m2).Daytime Pa(CO2) during spontaneous breathing decreased by 6.9 +/- 8.0 (95% confidence interval, - 9.9 to - 3.9), from 53.3 +/- 4.8 to 46.4 +/- 7.0 mm Hg (p0.001); while daytime Pa(O2) increased by 5.8 +/- 9.4 (95% confidence interval, 2.3 to 9.3), from 51.7 +/- 8.8 to 57.5 +/- 9.3 mm Hg (p = 0.002); and FEV1 increased by 0.14 +/- 0.16 (95% confidence interval, 0.08 to 0.20), from 1.03 +/- 0.54 to 1.17 +/- 0.59 L (p0.001) after 2 months of NPPV. This was achieved with mean inspiratory pressures of 27.7 +/- 5.9 cm H2O (range, 17 to 40 cm H2O) at a mean respiratory rate of 20.8 +/- 2.5 breaths/min (range, 14 to 24 breaths/min). The 2-year survival rate was 86%.Controlled NPPV using a mean inspiratory pressure of 28 cm H2O is well tolerated over longer periods and can improve blood gas levels and lung function. Prospective, randomized controlled trials of high-intensity NPPV are required to evaluate its role in patients with stable hypercapnic COPD.