Cleveland Clinic journal of medicine
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Mortality from asthma is increasing, raising questions about the goals and adequacy of treatment. It is important to understand the pathophysiology of asthma and the rationale and options for treatment. ⋯ Appropriate medical therapy includes treatment with compounds that specifically suppress airway inflammation. The best approach to treatment may be an anti-inflammatory agent--preferably by inhalation--along with an inhaled direct bronchodilator, with objective measures of airflow limitation to assess disease severity.
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Valve repair is the best operation currently available for patients with mitral valve disease. However, repair is technically more difficult than valve replacement and has a risk of early and late failure. ⋯ Preoperative echocardiography, including Doppler color flow mapping to evaluate intracardiac flow, is used to assess the feasibility of repair. Intraoperatively, epicardial and transesophageal echocardiography are used to monitor surgical results immediately after repair, ensuring successful outcome of surgery.
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Advances in chemotherapy and surgery have significantly improved the outcome of infective endocarditis, but the disease remains a therapeutic challenge with an overall mortality of 20%. More cases of infective endocarditis seen today are associated with prosthetic heart valves, intravenous drug abuse, or complications of medical and surgical technology. Prosthetic valve endocarditis occurs in 1% to 4% of patients with prosthetic valves. ⋯ The principal indication for urgent surgical intervention is acute valvular dysfunction. Other considerations for surgery include evidence of myocardial invasion, infection by antibiotic-resistant organisms, and large vegetations. For patients at risk of infective endocarditis, antibiotic prophylaxis during invasive procedures is an accepted practice.
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Wheezing is a nonspecific manifestation of airway obstruction. Even though bronchial asthma is the most common cause of wheezing, a variety of pulmonary and nonpulmonary conditions can present with this symptom. In recent years methacholine provocation challenge has simplified detection of bronchial asthma; however, establishing accurate diagnosis of other causes of wheezing is important because each condition requires specific treatment. This article describes a methodical approach to the diagnosis of wheezing in patients who are not asthmatic.