The American journal of medicine
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During the last 15 years, there has been a dramatic decline in the incidence of bleeding from stress-related mucosal damage. This decrease probably relates to an increased understanding of those mechanisms responsible for the pathogenesis of stress-related mucosal damage and the application of this knowledge to prophylaxis and treatment. ⋯ The nearly routine use of prophylactic antacid and/or histamine (H2)-receptor antagonist therapy to adequately buffer intragastric acidity is another factor that has minimized the development of stress-related damage. As continued understanding of the mechanisms responsible for stress damage is obtained and therapy applied appropriately, this disease should become a disorder of only historical interest in years to come.
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Randomized Controlled Trial Comparative Study Clinical Trial
A randomized trial of dexamethasone and acetazolamide for acute mountain sickness prophylaxis.
Forty-seven climbers participated in a double-blind, randomized trial comparing acetazolamide 250 mg, dexamethasone 4 mg, and placebo every eight hours as prophylaxis for acute mountain sickness during rapid, active ascent of Mount Rainier (elevation 4,392 m). Forty-two subjects (89.4 percent) achieved the summit in an average of 34.5 hours after leaving sea level. At the summit or high point attained above base camp, the group taking dexamethasone reported less headache, tiredness, dizziness, nausea, clumsiness, and a greater sense of feeling refreshed (p less than or equal to 0.05). ⋯ These drug side effects probably obscured the previously established prophylactic effects of acetazolamide for acute mountain sickness. Separate analysis of an acetazolamide subgroup that did not experience side effects at low elevations revealed a prophylactic effect of acetazolamide similar in magnitude to the dexamethasone effect but lacking the euphoric effects of dexamethasone. This study demonstrates that prophylaxis with dexamethasone can reduce the symptoms associated with acute mountain sickness during active ascent and that acetazolamide can cause side effects that may limit its effectiveness as prophylaxis against the disease.
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Visual and auditory neurotoxicity was previously documented in 42 of 89 patients with transfusion-dependent anemia who were receiving iron chelation therapy with daily subcutaneous deferoxamine. Twenty-two patients in the affected group had abnormal audiograms with deficits mostly in the high frequency range of 4,000 to 8,000 Hz and in the hearing threshold levels of 30 to 100 decibels. When deferoxamine therapy was discontinued and serial studies were performed, audiograms in seven cases reverted to normal or near normal within two to three weeks, and nine of 13 patients with symptoms became asymptomatic. ⋯ Moderate abnormalities require a reduction of deferoxamine to 25 mg/kg per dose with careful monitoring. In those with symptoms of hearing loss, the drug should be stopped for four weeks, and when the audiogram is stable or improved, therapy should be restarted at 10 to 25 mg/kg per dose. Serial audiograms should be performed every six months in those without problems and more frequently in young patients with normal serum ferritin values and in those with auditory dysfunction.
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Patients, as the recipients of medical care, have a unique and crucial perspective from which to judge the performance of physicians. In this study, 27 interns (postgraduate year 1 residents) were evaluated by a sample of 212 medical inpatients at two university-affiliated hospitals using a previously validated questionnaire constructed from patients' comments. Patients were generally very satisfied with the performance of their interns and valued traditional clinical skills and interpersonal skills equally. ⋯ Encouraging mutuality by the interns was not often done and was not believed to be particularly important by patients. Older patients and whites were more satisfied with their interns, whereas college-educated, employed, and male patients were less satisfied. Implications of the findings for understanding and teaching about the physician-patient relationship are discussed.
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Fifty-one diabetic patients with osteomyelitis of the foot were studied to determine potential prognostic factors and the role of antimicrobial therapy. Most of the patients were elderly, with diminished pulses, a sensory neuropathy, and a polymicrobial infection. Twenty-seven patients had a good outcome, defined as clinical resolution at the time of the last follow-up examination, without the need for amputation. ⋯ Fifteen patients had a below-knee amputation, and nine had a toe amputation. The absence of necrosis and/or gangrene, the presence of swelling, and the use of antimicrobial therapy active against the isolated pathogens for at least four weeks intravenously, or combined intravenously and orally for 10 weeks, predicted a good outcome. Diabetic foot osteomyelitis, in the absence of extensive necrosis or gangrene, usually responds to antimicrobial therapy without the need for an ablative surgical procedure.