The Journal of family practice
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Successful treatment of pain syndromes is one of the most common and most difficult problems facing family physicians. Frequently analgesics provide inadequate treatment, and clinicians are forced to consider alternatives. This article reviews the neurophysiologic similarities between depression and the chronic pain syndromes and describes several well-designed double-blinded studies that give evidence for the efficacy of antidepressants in chronic pain syndromes. ⋯ For chronic pain, antidepressants should be started at a low dosage and increased in a stepwise manner until an improvement in the pain occurs or intolerable side effects intervene. Side effects are a bothersome aspect of antidepressant therapy but are more tolerable at the doses generally needed for pain relief than at antidepressive doses. At least three weeks of antidepressant therapy is generally needed to gain significant relief of symptoms.
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The case presented here is typical of the localized fibrous mesotheliomas reviewed in the literature. It had a disastrous impact on an otherwise unremarkable pregnancy. There is no discussion in the literature of humeral factors related to localized fibrous mesotheliomas, but the fever, chills, and rheumatoid complaints in some patients may suggest such factors. ⋯ Anticoagulation led to hemorrhage from the thin-walled vascular areas of the tumor. This acute bleeding produced the hypovolemic shock on the third postpartum day, with a cascade of events leading to adult respiratory distress syndrome and the patient's ultimate death. This case underscores the importance of broad differential diagnosis as a continuing challenge in the practice of medicine.
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This is a report of the results of a study of all patients who received cardiopulmonary resuscitation (CPR) for an in-hospital cardiac arrest in a community hospital from July 1983 through June 1984. Out of 121 patients, 46 survived the initial arrest, but only 13 (11 percent) survived to leave the hospital. The patient's age or sex were not predictors of survival to leave the hospital. ⋯ Patients with acute myocardial infarctions or cardiac arrhythmias had better survival rates (26 percent and 19 percent, respectively) than with other diagnosis (5 percent), but this difference did not reach statistical significance. Patients who survived to leave the hospital did not suffer any mental loss from the arrest. General guidelines for withholding CPR based on the present study and a review of the literature are presented.
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Ectopic pregnancies are common, are increasing in incidence, and are preventable causes of reproductive morbidity and death. They are also frequently misdiagnosed, and are one of the most common causes for malpractice claims made against primary care physicians. The classic description of the presenting signs and symptoms of ectopic pregnancy was derived from a series of ruptured ectopic pregnancies. ⋯ The study confirmed the expected frequency of this condition in this population but findings disclosed that the classic presentation was, in fact, uncommon. Implications for decision making derived from these case reports are discussed. A high level of clinical suspicion for this problem must be maintained.
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A chart review of 37 hospitalized patients with diabetes mellitus who received burn therapy showed that ten (27 percent) had preventable lower-extremity burns related to sensory loss. Most of these ten burns occurred from heat applied for self-care of diabetes, namely, from hot tap water, a hot moist compress, or a heating pad. These ten patients, compared with the other 27 diabetic burn patients, were more likely to be men younger than 45 years old, to have insulin-dependent diabetes, and to have been burned during self-treatment. These findings underscore the importance of injury-prevention educational efforts by physicians in cautioning their diabetic patients, especially those with lower-extremity sensory losses, about potential burns from heat applied to the lower extremities for self-care.