The American journal of medicine
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The do-not-resuscitate order, introduced nearly a half century ago, continues to raise questions and controversy among health care providers and patients. In today's society, the expectation and availability of medical interventions, including at the end of life, have rendered the do-not-resuscitate order particularly relevant. ⋯ Specific strategies can improve the quality of code status conversations and enhance end-of-life care planning. In this article, we review the history, epidemiology, and determinants of do-not-resuscitate orders, as well as frequently encountered questions and recommended strategies for discussing this important topic with patients.
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Psoriasis is a common chronic inflammatory disease that is associated with serious comorbidities, including psoriatic arthritis, reduced quality of life, depression, malignancy, and cardiovascular comorbidities. Patients with psoriasis have been shown to have an increased incidence of metabolic syndrome and cardiovascular disease compared with the general population. ⋯ Understanding the interrelationship between these conditions is important for the management of psoriasis and the associated comorbidities. This review will focus on the range of comorbidities associated with psoriasis, with emphasis on cardiometabolic conditions and the aim of encouraging primary care physicians to screen psoriatic patients for cardiometabolic disorders and risk factors.
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Because of the firm refusal of transfusion of blood and blood components by Jehovah's Witnesses, the management of Jehovah's Witness patients with severe bleeding is often complicated by medical, ethical, and legal concerns. Because of a rapidly growing and worldwide membership, physicians working in hospitals should be prepared to manage these patients. Appropriate management of a Jehovah's Witness patient with severe bleeding entails understanding of the legal and ethical issues involved, and meticulous medical management, including treatment of hypovolemic shock, local hemostatic interventions, and administration of prohemostatic agents, when appropriate. In addition, high-dose recombinant erythropoietin in combination with supplemental iron may enhance the speed of hemoglobin synthesis.
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Fibromyalgia is the diagnosis given to individuals with chronic widespread musculoskeletal pain for which no alternative cause, such as tissue inflammation or damage, can be identified. Fibromyalgia is now believed to be, at least in part, a disorder of central pain processing that produces heightened responses to painful stimuli (hyperalgesia) and painful responses to nonpainful stimuli (allodynia). Aberrations in central pain processing may also be partly responsible for symptoms experienced in several chronic pain disorders that coaggregate with fibromyalgia, which is itself a product of genetic and environmental factors. ⋯ In some cases, psychological and behavioral factors are also in play. Although the overlapping symptomatology between fibromyalgia and related disorders may present diagnostic challenges, proper examination and observation can help clinicians make an accurate diagnosis. In recent years, the vastly improved understanding of the mechanism underlying fibromyalgia and the related spectrum of diseases has fostered rapid advances in the therapy of these chronic pain disorders by both pharmacologic and nonpharmacologic interventions.
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The presentation of fibromyalgia is heterogeneous, and the treatment approach should be individualized for each patient, depending on the severity of the patient's pain, the presence of other symptoms or comorbidities, and the degree of functional impairment. The management of fibromyalgia includes the identification and treatment of all pain sources that may be present in addition to fibromyalgia, such as peripheral pain generators (e.g., comorbid osteoarthritis or neuropathic pain) or visceral pain (e.g., comorbid irritable bowel syndrome). ⋯ In most cases, the management of fibromyalgia involves both pharmacologic and nonpharmacologic treatments. This report provides an in-depth review of randomized, controlled trials for pharmacologic and nonpharmacologic approaches to fibromyalgia therapy.