The American journal of medicine
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Comparative Study
The clinical spectrum of early Lyme borreliosis in patients with culture-confirmed erythema migrans.
The diagnosis of erythema migrans (EM), the characteristic rash of early Lyme borreliosis, is based primarily on its clinical appearance since it often occurs prior to the development of a specific antibody response. Other skin disorders, however, may be confused with EM. ⋯ We describe the largest group of culture-positive patients with EM from the United States to date. Although systemic symptoms were present in most patients, objective evidence of advanced disease was uncommon. Our patients with culture-confirmed EM were less sick than those described in the days before culture confirmation was possible. The ability to isolate B burgdorferi from lesional skin of large numbers of patients with EM should make culture-positive patients the standard by which to define manifestations of early Lyme borreliosis associated with this rash. Microbiologic documentation of Lyme borreliosis will help delineate the manifestations of this illness, and should form the framework for research directed at pathophysiology, diagnosis, treatment, and prevention.
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Randomized Controlled Trial Clinical Trial
A randomized, controlled trial of a clinical pharmacist intervention to improve inappropriate prescribing in elderly outpatients with polypharmacy.
To evaluate the effect of sustained clinical pharmacist interventions involving elderly outpatients with polypharmacy and their primary physicians. ⋯ This study demonstrates that a clinical pharmacist providing pharmaceutical care for elderly primary care patients can reduce inappropriate prescribing and possibly adverse drug effects without adversely affecting health-related quality of life.
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Case Reports Comparative Study
Evaluation of a medical ethics consultation service: opinions of patients and health care providers.
To study the perceived effectiveness of bioethics consultation as evaluated by both professional staff and patients and their families. ⋯ Patients or family members and professional staff have different perceptions regarding the value of bioethics consultation. When asked for comments, patients/family members cite lack of communication with professional staff as their primary reason for responding negatively. Earlier mobilization of consultative staff, rigorous training of consultants in techniques of conflict resolution, and education of primary caregivers regarding recognition of communication problems may serve to narrow this perceptual divergence.
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To determine the patterns of chronic outpatient management in urban patients with moderate and severe asthma, and to assess medical practice adherence to the Guidelines for the Diagnosis and Management of Asthma from the National Asthma Education Program (NAEP). ⋯ This is the first documentation of multiple problems in conforming with the standards of care delineated by the NAEP as they relate to the outpatient management of inner-city patients with moderate to severe asthma in the United States. In this population of patients with asthma, management was characterized by underutilization of anti-inflammatory therapy, inability to use inhalation devices properly, inadequate communication between patient and physician of an action plan to be utilized in the event of an acute exacerbation and inadequate physician intervention during the acute stages of the exacerbation. There was also overutilization of inhaled beta-agonists during exacerbations. It is imperative that these aspects of management, for which the NAEP has set standards of care, are addressed as part of the effort to reduce asthma morbidity in the urban United States.
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We sought to describe sarcoidosis mortality in the United States from 1979 through 1991. ⋯ Reported mortality due to sarcoidosis varies by region, sex, and race. We cannot determine whether these differences are related to characteristics of the disease, or problems in death certification and coding.