Cleveland Clinic journal of medicine
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Our understanding of the pathophysiology and treatment of sepsis has advanced over the last decade, and evidence-based protocols have improved its outcomes. Here, we review its management in the first hours and afterward, including topics of ongoing study and debate.
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Frailty has important implications for the care needs of older adults and how those needs are met. By recognizing frailty and measuring it objectively, clinicians can better engage patients and their loved ones in difficult discussions about treatment plans and prognosis, and ultimately deliver better palliative care.
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Blood pressure that remains above target levels despite drug therapy is an increasingly common problem. The evaluation of resistant hypertension includes confirming blood pressure measurements with an automated device that works without the clinician present and with 24-hour ambulatory monitoring; assessing for target-organ damage; and determining if kidney disease is present or if the hypertension is secondary to another condition. The goal of management should be to optimize drug therapy by using different classes of appropriate drugs.
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The focus of palliative care is to alleviate pain and suffering for patients, potentially while they concurrently pursue life-prolonging or curative therapy. The potential breadth of palliative care is recognized by the Medicare program, but the Medicare hospice benefit is narrowly defined and limited to care that is focused on comfort and not on cure. ⋯ Two home health-based programs have reported improved patient satisfaction, better utilization of services, and significant cost savings with palliative care. Moving the focus of care from the hospital to the home and community can be achieved with integrated care and can be facilitated by changes in government policy.
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With length of hospital stay for heart failure patients steadily decreasing, the home has become an increasingly important venue of care. Contemporary research suggests that postacute, home-based care of patients with chronic heart failure may yield outcomes similar to those of clinic-based outpatient care. ⋯ In 2010, a group at Cleveland Clinic launched the "Heart Care at Home" program in order to minimize the risks that patients experience both when being transitioned to home and when being cared for at home. This program joins a handful of transitional care programs that have been discussed in the medical literature.