Disparities in asthma prevalence, severity, quality of care, and outcomes have been widely documented across racial/ethnic communities, among privately insured vs publicly insured patients, and according to patients' socioeconomic status, among other patient characteristics. In order to effectively address asthma disparities, changes will need to be made across all systems of care in which these subpopulations receive health-care services. The majority of current trends in private insurance, Medicaid/State Children's Health Insurance Program, and the safety net are likely to further exacerbate asthma disparities rather than help to reduce these disparities. Asthma cannot be effectively managed unless individuals have affordable access to a full range of services and receive coordinated, quality health care. Multiple policy levers will need to be simultaneously employed to ensure access to the full range of services needed for effective asthma management, especially among low-income and minority persons with asthma in order to reduce the gap in disparities. The needs of these patients must be thoughtfully addressed and strategically advocated for within all systems of care in which these subpopulations receive health services. This overall strategy must necessarily include consideration of the capacity of safety-net providers to meet the needs of uninsured and underinsured persons with asthma. This article reviews trends in health-care financing, in clinical management, and the health-care safety net, and assesses their likely impact on asthma disparities. It concludes with a discussion of key policy arenas that will have significant influence on the eventual success of efforts to reduce asthma disparities.

Asthma is a common, chronic illness with substantial morbidity, especially for racial and ethnic minorities in the United States. The care of the patient with asthma is complex and depends ideally on excellent communication between patients and health-care providers. Communication is essential for the patient to communicate the severity of his or her illness, as well as for the health-care provider to instruct patients on pharmacologic and nonpharmacologic care. This article describes evidence for poor provider/patient communication as a contributor to health-care disparities for minority patients with asthma. Communication problems stem from issues with patients, health-care providers, and health-care systems. It is likely that asthma disparities can be improved, in part, by improving patient/provider communication. While much is known presently about the problem of patient/provider communication in asthma, there is a need to improve and extend the evidence base on the role of effective communication of asthma care and the links to outcomes for minorities. Additional studies are needed that document the extent to which problems with doctor/patient communication lead to inadequate care and poor outcomes for minorities with asthma, as well as mechanisms by which these disparities occur.

The National Workshop To Reduce Asthma Disparities assembled a multidisciplinary group comprised of scientists, clinicians, and community representatives to examine factors related to asthma disparities. Attention was given to the importance of discerning family, social, and behavioral factors that facilitate or impede the use of health-care services suitable to the medical status of an individual. This review highlights select biopsychosocial factors that contribute to these disparities, the manner in which they may contribute or protect persons affected by asthma, and recommended directions for future research.

Poor, minority children living in US inner cities have increased rates of asthma morbidity and mortality. Factors that contribute to these increased rates are varied and complex, with current evidence suggesting that the environment is an important causative factor. Respiratory morbidity is often the result of allergens and air pollutants. Additionally, for children living in urban environments, underlying societal susceptibility factors specific to the inner city serve to increase asthma morbidity. Even though ambient pollutants have been declining in US cities, asthma morbidity and mortality rates have been increasing. Indoor pollutants are closely linked to increased asthma prevalence and morbidity. While the understanding of environmental influences is still relatively limited, we can say that indoor exposures are more important than ambient pollutants, and we know that bioaerosols containing allergenic proteins are especially important. Additionally, certain particulate aerosols and ozone cause inflammation individually and may act synergistically to enhance the acute and chronic IgE-mediated inflammation. The purpose of this article is to review the data relating exposure to environmental pollutants and airborne allergens, and the relationship of this exposure to asthma prevalence and morbidity in order to inform plans for public health programs to reduce an asthma burden.

Although genetic factors may partly explain the differences in asthma prevalence, morbidity, and mortality among ethnic groups in the United States, few studies of the genetics of asthma have included members of ethnic minority groups. Only one genome-wide linkage analysis of asthma and/or asthma-related phenotypes (conducted by the Collaborative Study on the Genetics of Asthma) has included any members of ethnic minority populations. The interpretation of the findings of genetic association studies of asthma in ethnic minority groups is complicated by reduced statistical power due to small sample sizes; the failure to correct for multiple comparisons; a lack of homogeneity of the populations studied with regard to area of residence, ancestral background, and/or country of origin; a lack of measurement of relevant environmental exposures; and (for case-control studies of genetic association) a lack of detection and control of potential population stratification. Genetic studies may improve our understanding of asthma and lead to new methods to prevent, diagnose, and treat this disease. Limited study of asthma genetics in ethnic minority populations is unacceptable, as it may prevent these groups from benefiting from future developments in asthma management and thus widen existing disparities in asthma care. Future genetic association studies of asthma among ethnic minorities in the United States should include large samples of populations that have been adequately defined with regard to area of residence, self-designated ancestry, and country of origin. These studies should also include an adequate assessment of potentially relevant environmental exposures and (for case-control association studies) population stratification.

When fluid administration fails to restore an adequate arterial pressure and organ perfusion in patients with septic shock, therapy with vasopressor agents should be initiated. The ultimate goals of such therapy in patients with shock are to restore effective tissue perfusion and to normalize cellular metabolism. Although arterial pressure is the end point of vasopressor therapy, and the restoration of adequate pressure is the criterion of effectiveness, BP does not always equate to blood flow; so, the precise BP goal to target is not necessarily the same in all patients. There has been longstanding debate about whether one catecholamine vasopressor agent is superior to another, but different agents have different effects on pressure and flow. The argument about which catecholamine is best in a given situation is best transformed into a discussion about which agent is best suited to implement the therapeutic strategy chosen. Despite the complex pathophysiology of sepsis, an underlying approach to its hemodynamic support can be formulated that takes both pressure and perfusion into account when choosing therapeutic interventions. The efficacy of hemodynamic therapy in sepsis should be assessed by monitoring a combination of clinical and hemodynamic parameters. How to optimize regional blood and microcirculatory blood flow remains uncertain. Thus, specific end points for therapy are debatable and are likely to evolve. Nonetheless, the idea that clinicians should define specific goals and end points, titrate therapies to those end points, and evaluate the results of their interventions on an ongoing basis remains a fundamental principle.

The use of portable monitors (PM) devices has been demonstrated in a wide variety of investigational settings with varying results. While most devices correlate very well with in-laboratory polysomnography, some still misclassify a significant numbers of patients and have lower sensitivity. In addition, the failure rate of PM devices is higher than that of in-laboratory polysomnography, requiring repeated investigations. Nonetheless, these devices may reduce the waiting time for diagnosis and could potentially decrease costs. Cost-effectiveness studies have yet to demonstrate an advantage to using PM devices, although their employed modeling techniques may not accurately reflect prevailing practices. The majority of third-party payers do not reimburse unattended studies and consider them still to be investigational. Some health maintenance organizations have begun to recognize PM-based studies in their diagnostic algorithms and will cover their cost; others may do so on a case-by-case basis. There continues to be a dearth of evidence to support widespread implementation of PM devices for use within the general population. Larger-scale validation studies in patients with lower pretest probabilities and a wide range of comorbidities are needed.

Obstructive sleep apnea (OSA) is a common disorder associated with serious health consequences, increased health-care utilization, and economic burden. With greater public and medical attention to sleep disorders, the volume of referrals for sleep studies over the last decade has increased by approximately 12-fold. Despite the steep growth of infrastructure to diagnose and treat OSA, access to such services remains a sizeable problem, and demand overwhelms capacity. To expedite diagnosis of sleep apnea and prescription of treatment, one strategy adopted by sleep specialists is to employ split-night polysomnography, a strategy that encompasses both diagnosis of OSA and initiation of positive pressure therapy in a single night. This article reviews the literature examining this combined diagnostic/therapeutic strategy and discusses the applicable third-party issues of procedural coding and reimbursement.

The clinical course of patients with idiopathic pulmonary fibrosis (IPF) is generally marked by a decline in pulmonary function over time. Increasingly, patients have been recognized as having an acute, and often fatal, clinical deterioration, termed an acute exacerbation of IPF (AE-IPF).

Since the first successful single-lung transplant in 1983 and double-lung transplant in 1986, thousands of patients have benefited from the procedures. Until 1995, allocation of donor lungs was based purely on time on the waiting list. In 1995, a 90-day credit was given to patients with idiopathic pulmonary fibrosis, while still maintaining allocation based on waiting list time. In 2005, the lung allocation score (LAS) was implemented, dramatically changing the way lungs are allocated. This article will explore the reasons for the creation of the LAS, the design of the score, early experience with transplant results under the new system, and further changes that may be made to the system of lung allocation. As surgical techniques and medical management evolve, so to will the management of potential donors and the allocation of their organs, with the aim of benefiting patients needing lung transplantation in the United States.

Preoperative pulmonary evaluation is important in the management of patients with lung disease who are undergoing elective cardiothoracic or noncardiothoracic surgery. In some instances, preoperative pulmonary evaluations may also contribute to the management of patients being considered for urgent surgery. The incidence of postoperative pulmonary complications (PPCs) is high and is associated with substantial morbidity and mortality, and prolonged hospital stays. Perioperative pulmonary complications in patients undergoing elective noncardiothoracic surgery can be more accurately predicted than in patients undergoing elective cardiothoracic surgery. Effective strategies to prevent complications in the postoperative period are few. Incentive spirometry and continuous positive airway pressure are the only modalities of proven benefit. Identifying patients who are at risk for the development of PPCs and managing their underlying modifiable risk factors aggressively prior to surgery is essential.

The epithelial sodium channel (ENaC) represents the rate-limiting step of sodium absorption across airway epithelia and thereby constitutes the major pathway for volume absorption from the airway surface liquid compartment. ENaC dysregulation leads to dehydration of airway surfaces in patients with cystic fibrosis, which in turn disrupts the primary innate lung defense mechanism, mucus clearance. The development of treatment strategies that address this defect is a logical and promising means of preventing or delaying the onset of this lethal lung disease.

Poverty has deepened the crisis in health-care delivery in developing countries, particularly sub-Saharan Africa, which is a region facing a disease burden that is unmatched in the world. Whether access to proven and powerful information and communication technologies (ICTs) can improve health indicators is an ongoing debate. However, this brief review shows that in the last decade there has been significant growth in Internet access in urban areas; health-care workers now use it for communication, access to relevant health-care information, and international collaboration. The central message learned during this period about the application of ICTs is that infrastructural and cultural contexts vary and require different models and approaches. Thus, to harness the full potential of ICTs to the benefit of health systems, health workers, and patients will demand an intricate mix of old and new technologies.

This article reviews the research on the relation between indoor air pollution exposure and acute respiratory infection (ARI) in children in developing countries. ARI is a cause of death globally, causing approximately 19% of all deaths before the age of 5 years, according to a World Health Organization estimate. Indoor air pollution from biomass fuels, which is strongly poverty related, has long been regarded as an important risk factor for ARI morbidity and mortality. The empirical base for this view is comparatively narrow, with few empirical studies in relation to the magnitude of the global public health importance of the problem. Most existing reports consistently indicate that indoor air pollution is indeed a risk factor for ARI, but studies are generally small and use indirect indicators of pollution, such as use of biomass fuel or type of stove. Exposure assessment for indoor air pollution in developing countries is recognized as a major obstacle because of high cost and infrastructural limitations to chemical pollution sampling. Use of proxy indicators without measurement support may increase the risk of both misclassification of exposure and of confounding by other poverty-related factors. The issue of sufficient sample size further underlines the need for decisions to invest in this research field. Areas where further research is needed also include exploring qualitatively options for interventions that are culturally and economically acceptable to local communities.

Poverty is a major social problem in the United States and throughout much of the world. Poverty and the broader term socioeconomic status (SES) are important determinants of overall health status and many pulmonary diseases. The purpose of this study was to review the medical literature from the past 20 years addressing the relationship between SES and lung function in both children and adults. There is a significant negative correlation between lung function (primarily FEV1 and FVC) and SES. This relationship exists even after adjusting for smoking status, occupational exposures, and race. The magnitude of the effect of low SES on lung function is variable, but FEV1 reductions of >300 mL in men and >200 mL in women have been reported. SES is an important determinant of lung function and an underrecognized contributor to pulmonary disease.

ARDS can occur from the following two pathogenetic pathways: a direct pulmonary injury (ARDSp); and an indirect injury (ARDSexp). The predisposing clinical factor can influence the pathogenesis and clinical outcome of ARDS. This metaanalysis was aimed at evaluating whether there is any difference in mortality between the two groups.

Recent studies have documented the efficacy and safety of sublingual immunotherapy (SLIT) in patients with rhinitis, but the value of this treatment in those with asthma is still debated. We evaluated the efficacy of SLIT in the treatment of allergic asthma in children by a metaanalysis of randomized, double-blind, and placebo-controlled (DBPC) clinical trials.

Acute renal failure (ARF) with the concomitant need for renal replacement therapy (RRT) is a common complication of critical care medicine that is still associated with high mortality. Different RRT strategies, like intermittent hemodialysis, continuous venovenous hemofiltration, or hybrid forms that combine the advantages of both techniques, are available and will be discussed in this article. Since a general survival benefit has not been demonstrated for either method, it is the task of the nephrologist or intensivist to choose the RRT strategy that is most advantageous for each individual patient. The underlying disease, its severity and stage, the etiology of ARF, the clinical and hemodynamic status of the patient, the resources available, and the different costs of therapy may all influence the choice of the RRT strategy. ARF, with its risk of uremic complications, represents an independent risk factor for outcome in critically ill patients. In addition, the early initiation of RRT with adequate doses is associated with improved survival. Therefore, the "undertreatment" of ARF should be avoided, and higher RRT doses than those in patients with chronic renal insufficiency, independent of whether convective or diffusive methods are used, are indicated in critically ill patients. However, clear guidelines on the dose of RRT and the timing of initiation are still lacking. In particular, it remains unclear whether hemodynamically unstable patients with septic shock benefit from early RRT initiation and the use of increased RRT doses, and whether RRT can lead to a clinically relevant removal of inflammatory mediators.

Patients experiencing acute elevations of ammonia present to the ICU with encephalopathy, which may progress quickly to cerebral herniation. Patient survival requires immediate treatment of intracerebral hypertension and the reduction of ammonia levels. When hyperammonemia is not thought to be the result of liver failure, treatment for an occult disorder of metabolism must begin prior to the confirmation of an etiology. This article reviews ammonia metabolism, the effects of ammonia on the brain, the causes of hyperammonemia, and the diagnosis of inborn errors of metabolism in adult patients.