SAGE open medicine
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Medical assistance in dying opens up uncharted professional territory for Canadian physicians extending their practices to include assisting and hastening death for eligible patients. ⋯ Medical assistance in dying is markedly different from other physicians' practices in that it has an enriched capacity for caring. The process brings deep satisfaction characterized by intimate, personalized contact with patients and families. The professional rewards of providing medical assistance in dying outweigh the challenges, offering an alternative narrative to more publicly accepted views of assisting someone to die.
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Review
Targeted muscle reinnervation for the management of pain in the setting of major limb amputation.
The life altering nature of major limb amputations may be further complicated by neuroma formation in up to 60% of the estimated 2 million major limb amputees in the United States. This can be a source of pain and functional limitation of the residual limb. Pain associated with neuromas may limit prosthetic limb use, require reoperation, lead to opioid dependence, and dramatically reduce quality of life. ⋯ Targeted muscle reinnervation has been shown to reduce phantom limb and neuroma pain for patients with upper and lower extremity amputations. It may be performed at the time of initial amputation to prevent pain development or secondarily for the treatment of established pain. Encouraging outcomes have been reported, and targeted muscle reinnervation is emerging as a leading surgical technique for pain prevention in patients undergoing major limb amputations and pain management in patients with pre-existing amputations.
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Cardiovascular disease remains the leading cause of death in the United States, and cardiopulmonary bypass is a cornerstone in the surgical management of many related disease states. Pathophysiologic changes associated both with extracorporeal circulation and shock can beget a syndrome of low systemic vascular resistance paired with relatively preserved cardiac output, termed vasoplegia. ⋯ The introduction of a second non-catecholamine vasopressor, angiotensin II, and non-specific nitric oxide scavengers offers potential means by which to manage this challenging phenomenon. This narrative review addresses both the definition, risk factors, and pathophysiology of vasoplegia and potential therapeutic interventions.
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Central venous access using peripherally inserted central catheters is frequently used for patients receiving intravenous medications in the hospital or outpatients. Although there are several benefits of peripherally inserted central catheters, such as ease of insertion, low procedure-related risk and higher patient satisfaction, there are complications associated with peripherally inserted central catheter use. Despite some studies evaluating peripherally inserted central catheter line-related complications, the factors associated with peripherally inserted central catheter-related deep venous thrombosis in critically ill medical-surgical patients are poorly described. The objective of this case-control study was to identify the risk factors associated with peripherally inserted central catheter line-related deep venous thrombosis in critically ill medical-surgical intensive care unit patients in a community hospital. ⋯ Our study indicates that the catheter size relative to the diameter of the vein could be an important risk factor for the development of peripherally inserted central catheter-related deep venous thrombosis. The study findings should be confirmed in a larger study designed to identify risk factors of peripherally inserted central catheter-related deep venous thrombosis. In the meantime, the peripherally inserted central catheter lines should be used judiciously in critically ill patients.
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Clostridioides (formerly Clostridium) difficile infection recurrence in patients re-exposed to antibiotics for treatment of a non-Clostridioides difficile infection is high at approximately 33%. Low-dose per os vancomycin (e.g. 125 mg q12 h) or metronidazole (e.g. 500 mg intravenous/per osq8 h) may help prevent recurrences, but study of secondary prophylaxis in critically ill patients is needed. ⋯ There was no difference in Clostridioides difficile infection recurrence between prophylaxis groups, however, given the low recurrence rate, prospective evaluation with a larger sample of critically ill patients is necessary.