The Medical clinics of North America
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The majority of Americans die in hospitals where shortcomings in end-of-life care are endemic. Too often, patients die alone, in pain, their wishes unheeded by their physicians. Because hospitalists care for many of these dying patients, they can dramatically improve end-of-life care in hospitals. ⋯ In addition, they should communicate clearly with patients and families, and provide them psychosocial support. Hospitalists can increase the number and the timeliness of hospice referrals, thereby allowing more patients to die at home. Finally, all physicians must attend to their own senses of grief and loss to avoid burnout and to continue to reap the rewards end-of-life care provides.
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The hospitalized surgical patient requires a team approach. Because of increasing patient age and complexity of conditions, a comprehensive preoperative evaluation and medical optimization is often necessary to allow the anesthesiologist and surgeon to deliver the best surgical outcome. ⋯ Special surgical populations, such as those patients who need perioperative anticoagulation, further benefit from a surgical team that includes a medical specialist. Expertise and close supervision throughout the perioperative period will give the hospitalized surgical patient the greatest chance for a quick and successful recovery.
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Laboratory testing for B. burgdorferi infection is intended to substantiate a physician's clinical judgment of whether a patient has Lyme disease or not. Cultivation of B. burgdorferi from a patient's skin or blood is the gold standard for demonstration of active infection, but it is expensive and lacks clinical sensitivity. Detection of spirochetal DNA in clinical samples by PCR has better sensitivity, but PCR for B. burgdorferi has not yet been standardized for more routine diagnostic testing. ⋯ This estimate can serve to reassure patients who are at low risk of B. burgdorferi infection but are seeking a Lyme test for complaints of a more nonspecific nature. Although new subunit serologic assays based on recombinant proteins are becoming available commercially, the longstanding two-test approach, in which a positive or indeterminate result with a standardized, sensitive ELISA test is followed by verification with a more specific Western blot assay, still provides the physician with a reasonably accurate and reliable assessment of the presence of antibodies to B. burgdorferi. More recent challenges for serologic testing are seropositivity in the population as the result of immunization with the Lyme disease vaccine and the emergence of new Borrelia species that cause Lyme disease-like illnesses.
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Babesiosis is an emerging infection caused by protozoal parasites and transmitted by the same tick that transmits Lyme disease. Babesiosis is found throughout the world, but most cases have been described from the northeastern and northern midwestern United States. ⋯ Specific diagnosis is made through examination of a Giemsa-stained thin blood smear, DNA amplification using polymerase chain reaction, or detection of specific antibody. Treatment consists of clindamycin and quinine or atovaquone and azithromycin and, in severe cases, exchange transfusion.
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Naturopathic medicine is an eclectic form of primary health care that encompasses many complementary modalities in the treatment and prevention of disease. Treatment protocols are integrative in nature, combining the most suitable therapies to address the individual patient's needs. Although naturopathic physicians often are referred to as general practitioners of complementary medicine, practitioners share a common philosophical belief in the profession's founding principles. ⋯ As alternative therapies become more integrated in nature, conventional medicine will face new challenges. Licensed naturopathic physicians are trained sufficiently to play an active role in this new primary health care team. Although the exact role has yet to be determined, the eclectic approach taken by naturopathic physicians may be of benefit in this evolutionary process.