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827. Extracorporeal membrane oxygenation for ARDS in adults.
A 41-year-old woman presents with severe community-acquired pneumococcal pneumonia. Chest radiography reveals diffuse bilateral infiltrates, and hypoxemic respiratory failure develops despite appropriate antibiotic therapy. She is intubated and mechanical ventilation is initiated with a volume- and pressure-limited approach for the acute respiratory distress syndrome (ARDS). Over the ensuing 24 hours, her partial pressure of arterial oxygen (Pao2) decreases to 40 mm Hg, despite ventilatory support with a fraction of inspired oxygen (Fio2) of 1.0 and a positive end-expiratory pressure (PEEP) of 20 cm of water. She is placed in the prone position and a neuromuscular blocking agent is administered, without improvement in her Pao2. An intensive care specialist recommends the initiation of extracorporeal membrane oxygenation (ECMO).
828. Childhood adiposity, adult adiposity, and cardiovascular risk factors.
作者: Markus Juonala.;Costan G Magnussen.;Gerald S Berenson.;Alison Venn.;Trudy L Burns.;Matthew A Sabin.;Sathanur R Srinivasan.;Stephen R Daniels.;Patricia H Davis.;Wei Chen.;Cong Sun.;Michael Cheung.;Jorma S A Viikari.;Terence Dwyer.;Olli T Raitakari.
来源: N Engl J Med. 2011年365卷20期1876-85页
Obesity in childhood is associated with increased cardiovascular risk. It is uncertain whether this risk is attenuated in persons who are overweight or obese as children but not obese as adults.
838. Clinical practice. Treating smokers in the health care setting.
A 45 year-old overweight woman with a history of asthma and depression presents to her primary care physician with her third episode of acute bronchitis in the last 24 months. She began smoking at age 15 and now smokes 10 to 15 cigarettes per day, but every day she starts smoking immediately upon awakening, an indication of severe nicotine dependence. She has made multiple unsuccessful attempts to quit, once briefly using the nicotine patch, but relapsed due to strong urges to smoke and weight gain. She has not used cessation counseling or other medications. She is bothered by the cost of cigarettes, and is worried about smoking’s health effects on her two children and on herself. Importantly, she is reluctant to make a quit attempt now, in part, because she fears she won’t succeed. What would you advise?
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