Cleveland Clinic journal of medicine
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The use of HS solutions has been shown to reduce ICP both in animal models and in human studies in a variety of underlying disorders, even in cases refractory to treatment with hyperventilation and mannitol. There are several possible mechanisms of action, and important complications such as central pontine myelinolysis and intracranial hemorrhage have not been reported in the human studies. Different types of HS solutions with different methods of infusion (bolus and continuous) have been used in the past, and so far there are not enough data to recommend one concentration over another. Many issues remain to be clarified, including the exact mechanism of action of HS, the best mode of administration and HS concentration to be given, and the relative efficacy of HS vis-à-vis available treatments, particularly mannitol.
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Any patient age 50 or older with distorted vision or vision loss may have age-related macular degeneration and should be immediately referred to an ophthalmologist. Early diagnosis and treatment are essential to preserve the current level of vision. We outline risk factors, clinical signs, what happens to the retina, and what treatments are currently available, as well as recommendations about vitamin and mineral supplementation.
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When interpreting pulmonary function tests, one should first try to determine the pattern of abnormality: is it obstructive, restrictive, or normal? Pulmonary function tests cannot by themselves distinguish among the potential causes of abnormalities, and must be interpreted in light of the patient's history, physical examination, and ancillary studies. Once a pattern is recognized, the diagnosis will often follow.
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Echocardiography can help distinguish simple and uncomplicated bacteremias from true cases of infective endocarditis and guide the type and duration of antibiotic therapy in a more precise and cost-effective manner. Empiric long-term antibiotic therapy is no longer uniformly recommended for all cases of S aureus bacteremia, although experts disagree about the optimal length of therapy.
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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.