The Medical clinics of North America
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Med. Clin. North Am. · Sep 1988
Review Randomized Controlled Trial Clinical TrialDiagnosis of pulmonary infections in immunocompromised patients.
In an immunocompromised patient with fever and pulmonary infiltrates, it frequently is difficult to decide which invasive procedure, if any, to use to obtain a definitive diagnosis. Because most lung infiltrates in immunosuppressed patients are caused by bacteria and sputum usually is readily available for examination, empiric therapy with potent, safe, broad spectrum, antibacterial drugs often is successful. Invasive procedures that prove a diagnosis may result in substantive changes in therapy in perhaps as few as 10 to 20 per cent of patients, and the procedure itself may harm the patient. ⋯ New diagnostic and therapeutic developments may change decision analysis in the near future. At present, cultures for viruses and fungi and serologic techniques have little application at most medical centers, and decisions on data from invasive procedures pivot on interpretation of histology and smears. Development of assays for antigen (for example, Aspergillus) and rapid culture techniques (for example, cytomegalovirus and the shell vial method), coupled with new, effective antimicrobials, may demand maximum effort for a definitive diagnosis in every patient.
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Before any more progress is made in reducing the incidence of sudden cardiac death, our ability to identify those at risk must be refined further. The close association with coronary artery disease necessitates that the first step must be the identification of those with underlying coronary artery disease. This is underscored by the disturbing fact that, in many, sudden death is the first sign of coronary disease. ⋯ At the present time, we can identify certain subsets that warrant aggressive therapy: survivors of sudden death events or sustained ventricular tachycardia, obstructive cardiomyopathies, aortic stenosis, left main coronary artery disease, and congenital QT prolongation. Less aggressive but also less specific therapies, such as beta-blockers in myocardial infarction survivors, can be given more indiscriminately. Ultimately, of course, the greatest impact will come from prevention of coronary artery disease.