The Medical clinics of North America
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In this article, we have shown that almost all "routine" laboratory tests before surgery have limited clinical value. Clinicians should order only a small number of routine tests based on age as noted in Table 13. Selective use of other preoperative tests should be based on history and physical examination findings that identify subgroups of patients who are more likely to have abnormal results. ⋯ For this reason, clinicians can have a low threshold for ordering these tests in patients for whom the frequency of abnormalities is increased compared with a healthy population. We believe that physicians should not be criticized for selective test ordering before surgery. Physicians and institutions recommending routine preoperative testing for all patients provide no clinical value to their patients at considerable cost.
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Med. Clin. North Am. · Jan 2003
ReviewEvaluation and management of anemia and bleeding disorders in surgical patients.
The perioperative period offers a unique hemostatic and physiologic challenge. Evaluation of anemia and the decision to transfuse play an important role in the perioperative period. ⋯ A bleeding-oriented history and physical, along with some baseline tests, may help alert the physician to the possibility of a bleeding disorder. Finally, some patients may need correction of their bleeding disorder before surgery or careful monitoring in the perioperative period.
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Preventing postoperative ARF, especially in subjects with pre-existing chronic kidney disease, and caring for ESRD patients undergoing surgery are challenging and best accomplished by a team comprised of primary care physician, nephrologist, cardiologist, surgeon, anesthesiologist, endocrinologist, and nutritionist. Elimination of risk factors for ARF whenever possible, as well as early diagnosis, may improve the outcome of this devastating illness. Drugs capable of preventing or changing the course of postoperative ARF may be available soon. For uremic patients, a comprehensive approach is necessary to minimize morbidity and mortality imposed by numerous comorbid conditions.
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Med. Clin. North Am. · Nov 2002
ReviewBarrett's esophagus and esophageal adenocarcinoma: pathogenesis, diagnosis, and therapy.
Gastric juice that refluxes into the esophagus can injure esophageal squamous epithelium. When the injury heals through a metaplastic process in which an abnormal columnar epithelium replaces the injured squamous one, the resulting condition is called Barrett's esophagus. ⋯ This article examines such issues as the treatment, endoscopic surveillance, and chemoprevention of Barrett's esophagus. Also included are published guidelines and recommendations.
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This study demonstrates many of the important features and challenges of improving hospital care. The unique confluence of software technology advances and increasingly complex clinical needs have made possible a redesign of the process by which discharge documentation is generated and disseminated. Using knowledge of the patients' experience of hospital care, a multidisciplinary team identified communication at the time of discharge as a key interaction point in the system of care. ⋯ Will the quality of care improve? Probably, although that remains to be seen. Improvements in care do not need to be sophisticated, they do not need to be elaborate, and they do not need to involve new devices or new technologies. Improvements start with thinking about the way work is done and reflecting on how the work might be done differently to meet and exceed patients' needs and expectations.