American family physician
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Regional analgesia has become the most common method of pain relief used during labor in the United States. Epidural and spinal analgesia are two types of regional analgesia. With epidural analgesia, an indwelling catheter is directed into the epidural space, and the patient receives a continuous infusion or multiple injections of local anesthetic. ⋯ Rare serious complications include neurologic injury, epidural hematoma, or deep epidural infection. Regional analgesia increases the risk of instrument-assisted vaginal delivery, and family physicians should understand the contraindications and risks of complications. Continuous labor support (e.g., doula), systemic opioid analgesia, pudendal blocks, water immersion, sterile water injections into the lumbosacral spine, self-taught hypnosis, and acupuncture are other options for pain management during labor.
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Patients prepare advance directives in an effort to maintain autonomy during periods of incapacity or at the end of life. Advance directive documents are specific to the state in which the patient lives, but an effective strategy in the family physician's office involves more than filling out a form. Physician barriers to completing an advance directive include lack of time and discomfort with the topic. ⋯ Overcoming these barriers depends on effective communication at multiple visits, including allowing the patient the opportunity to ask questions. Involving the family or a proxy early and over time can help the process. It may be helpful to integrate advance directive discussions at selected stages of the patient's life and as health status changes.
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American family physician · Mar 2012
ReviewDiagnosis and management of upper gastrointestinal bleeding.
Upper gastrointestinal bleeding causes significant morbidity and mortality in the United States, and has been associated with increasing nonsteroidal anti-inflammatory drug use and the high prevalence of Helicobacter pylori infection in patients with peptic ulcer bleeding. Rapid assessment and resuscitation should precede the diagnostic evaluation in unstable patients with severe bleeding. Risk stratification is based on clinical assessment and endoscopic findings. ⋯ Although administration of proton pump inhibitors does not decrease mortality, risk of rebleeding, or need for surgery, it reduces stigmata of recent hemorrhage and the need for endoscopic therapy. Despite successful endoscopic therapy, rebleeding can occur in 10 to 20 percent of patients; a second attempt at endoscopic therapy is recommended in these patients. Arteriography with embolization or surgery may be needed if there is persistent and severe bleeding.
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Bipolar disorders are common, disabling, recurrent mental health conditions of variable severity. Onset is often in late childhood or early adolescence. Patients with bipolar disorders have higher rates of other mental health disorders and general medical conditions. ⋯ Maintenance therapy for patients involves screening for suicidal ideation and substance abuse, evaluating adherence to treatment, and recognizing metabolic complications of pharmacotherapy. Active management of body weight reduces complications and improves lipid control. Patients and their support systems should be educated about mood relapse, suicidal ideation, and the effectiveness of early intervention to reduce complications.