Cleveland Clinic journal of medicine
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It is often unclear when and how to wean patients from mechanical ventilation. We have devised an evidence-based protocol in which patients undergo a 30-minute trial of spontaneous breathing with a T tube or pressure support of 7 cm H2O. Those who can tolerate the trial are extubated, while those who cannot are reconnected to mechanical ventilation but undergo another trial every day until they can be extubated. More study is needed to improve the criteria to predict successful spontaneous breathing and extubation, and to clarify the role of non-invasive ventilation to avoid reintubation.
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The management of pulmonary arterial hypertension (PAH) should aim to provide vasodilation of the pulmonary arteries, treat right ventricular failure, improve functional capacity and quality of life, and improve survival, if possible. Data from right heart catheterization and an estimation of vasoresponsiveness together guide treatment for PAH. ⋯ Coumarin derivatives, epoprostenol, and, in selected patients, calcium channel blockers are the only drugs associated with improved survival, and only epoprostenol has been shown to improve survival in a prospective randomized trial. Knowledge of the supportive therapies, indications for surgical intervention, and emerging drug therapies should provide the working armamentarium for clinicians treating this rare but devastating disease.
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With 64-ounce sodas and "supersized" fast food on nearly every street corner, America has become the land of the obese. Despite disheartening statistics regarding the success of weight-loss plans, patients are more likely to take steps to lose weight if encouraged to do so by their primary care physician.
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The recommendation for HIV antiretroviral therapy is changing from "treat early, treat hard" to "treat a little later, treat hard" as more toxicities of the drugs are recognized. Drug-resistant HIV is becoming a serious problem, even in treatment-naive patients. For HIV patients with organ failure, transplantation is increasingly an option.