The Mount Sinai journal of medicine, New York
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Patient refusal of indicated medical treatment, especially when the treatment would be life sustaining, presents all physicians, especially emergency physicians, with the responsibility of determining whether the patient has the capacity to refuse treatment, and whether the patient's refusal is informed. These two crucial questions present a number of dilemmas for physicians who may have no prior relationship with that particular patient. The ethical and legal principles for determining decision-making capacity and assuring that refusal is informed are described, and an algorithm for responding to patient refusals is presented.
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In 1996, the federal government published regulations that allow investigators to obtain a waiver of informed consent for emergency research when certain very specific criteria are met. The participants must be unable to give consent as a result of their medical condition, and the intervention involved in the research must be administered before consent from the participants' legally authorized representative is feasible. ⋯ The author reviews the development of these regulations, often referred to as "The Final Rule," the ethical basis for the waiver, and the specific provisions of the federal regulations that govern research without consent in emergency situations. Reactions of proponents, critics and the lay public are discussed.
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"Triage" is a term generally referring to the social practice of sorting or categorizing. While it originally had an innocent, commercial meaning referring to sorting crops according to quality, the term quickly took on a more ominous meaning referring to classifying battlefield casualties into three groups: those too well-off to be treated and then, among those more seriously wounded, one group that will get medical attention and another that will not. The moral problem is how to distinguish between the latter two groups. ⋯ Two organ transplant examples--tissue typing for kidneys and geographical priority for allocating livers--show that American social policy, when forced to choose between allocating on the basis of efficiency or allocating on the basis of justice, will consider both principles, but give equal or dominant priority to justice--even though this priority is understood to be relatively inefficient. Since health care professionals have a recognized preference for efficiency over justice and lay people are inclined towards justice, leaving mass disaster triage policy in the hands of health professionals will predictably structure the policy in a way that conflicts with the moral priorities of the lay population. Formal public debate that recognizes the conflict between efficiency and equity--professional and lay priorities--is therefore essential.
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Although a patent foramen ovale (PFO) is often found in younger patients with transient ischemic attacks or stroke, paradoxical embolization through PFO is rarely considered as a cause of acute limb ischemia. We report a single-center experience of 5 consecutive patients with limb-threatening ischemia due to paradoxical embolization within a one-year period. All patients were treated by catheter thrombectomy and long-term oral anticoagulation after surgery. The fact that the 5 embolectomies made up 10% of all embolectomies performed in our center during this time interval may indicate that the role of paradoxical embolization is still underestimated in peripheral embolic disease.
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Review
Thrombotic microangiopathy: differential diagnosis, pathophysiology and therapeutic strategies.
Several disease states manifest as thrombotic microangiopathies (TMA), most prominently thrombotic thrombocytopenic purpura (TTP) and hemolytic uremic syndrome (HUS). The recent discovery of the von Willebrand factor cleaving protease ADAMTS-13 (a disintegrin and metalloprotease with thrombospondin type 1 motif), found to be deficient in TTP, has helped separate these entities. ⋯ Although enormous progress has been made towards understanding these syndromes, the diagnostic tools and therapies used have hardly changed in the last 20 years, with the standard of care remaining plasma exchange in most cases. In this review, we will cover the multiple etiologic factors for TMAs, with the resultant differential diagnoses, as well as provide insight into the latest pathophysiologic findings and possible implications for treatment.