Chest
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Time-limited trials (TLTs) are used in the management of critical care patients undergoing potentially nonbeneficial interventions to improve prognostication and build trust and consensus between family and intensivists. When these trials are not well defined and executed, discordant views of the patient's prognosis, conflict, and continuation of nonbeneficial care can arise. ⋯ This framework allows physicians and families to deal more effectively with the inherent uncertainty and required flexibility needed in caring for complex critical care patients. This can lead to patient-centered decision-making that improves patient-physician relationships and goal-concordant care and also potentially reduces nonbeneficial treatments at the end of life.
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Randomized Controlled Trial
Reboxetine Plus Oxybutynin for OSA Treatment: A 1-Week, Randomized, Placebo-Controlled, Double-Blind Crossover Trial.
The recent discovery that a combination of noradrenergic and antimuscarinic drugs improved upper airway muscle function during sleep and reduced OSA severity has revitalized interest in pharmacologic therapies for OSA. ⋯ ClinicalTrials.gov; No.: NCT04449133; URL: www.clinicaltrials.gov.
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Considering the COVID-19 pandemic where concomitant occurrence of ARDS and severe acute brain injury (sABI) has increasingly coemerged, we synthesize existing data regarding the simultaneous management of both conditions. Our aim is to provide readers with fundamental principles and concepts for the management of sABI and ARDS, and highlight challenges and conflicts encountered while managing concurrent disease. Up to 40% of patients with sABI can develop ARDS. ⋯ In this narrative review, we discuss the physiological basis and risks involved during simultaneous management of ARDS and sABI, summarize evidence for treatment decisions, and demonstrate these principles using hypothetical case scenarios. Use of invasive or noninvasive monitoring to assess brain and lung physiology may facilitate goal-directed treatment strategies with the potential to improve outcome. Understanding the pathophysiology and key treatment concepts for comanagement of these conditions is critical to optimizing care in this high-acuity patient population.
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A 71-year-old man with history of gastroesophageal reflux disease, chronic sinusitis, arthritis, hypothyroidism, and anemia of chronic disease initially sought treatment with a recurrent left pleural effusion along with other abnormal lung findings on chest CT scan. Before his referral, he was being managed for 3 years at his local hospital for waxing and waning fevers, fatigue, productive cough, chills, and night sweats. He did not report any hemoptysis or chest pain, but reported weight loss of 13 kgs in 15 months. ⋯ At that time, his chronic sinusitis was suspected to be the cause of his symptoms and he underwent balloon sinuplasty. He was receiving daily sublingual immunotherapy for inhaled respiratory allergens for the previous year after showing positive test results for 17 inhaled allergens. The patient had no other known immunologic workup before our evaluation.
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An 84-year-old woman with a medical history of hypertension, hypothyroidism, and transient ischemic attacks presented with right-sided upper and lower extremity weakness for 1 day. She was a lifetime nonsmoker with no known heart disease or chronic lung disease. ⋯ She denied any fevers, chills, rashes, or shortness of breath. There was no history of recent travel.