QJM : monthly journal of the Association of Physicians
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Review
A communication model for encouraging optimal care at the end of life for hospitalized patients.
Multiple studies have demonstrated that treatment at or near the end of life is rarely optimal. Unwanted death-prolonging treatments are frequently provided and open communication about death and dying is often lacking. ⋯ The five steps are founded upon the recognition that trials of life-sustaining treatments are also, by definition, trials of palliative care. A narrative review of currently available qualitative and quantitative research is used to support the recommendations.
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Case Reports
Uncovering the basis of a severe degree of acidemia in a patient with diabetic ketoacidosis.
In this teaching exercise, the goal is to demonstrate how an application of principles of physiology can reveal the basis for a severe degree of acidaemia (pH 6.81, bicarbonate <3 mmol/l (P(HCO(3))), PCO(2) 8 mmHg), why it was tolerated for a long period of time, and the issues for its therapy in an 8-year-old female with diabetic ketoacidosis. The relatively low value for the anion gap in plasma (19 mEq/l) suggested that its cause was both a direct and an indirect loss of NaHCO(3). ⋯ He was also able to explain why there was a 16-h delay before there was a rise in the P(HCO(3)) once therapy began. The missing links in this interesting story, including a possible basis for the hypokalaemia, emerge during the discussion between the medical team and Professor McCance.
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Studies addressing the effect of nesiritide on renal function in patients hospitalized for decompensated heart failure (HF) are limited, with conflicting results. ⋯ We failed to detect any significant risk of WRF in patients treated with nesiritide compared to conventional therapy in patients with decompensated HF during index hospitalization. Larger randomized, placebo-controlled trials are required to further elucidate the effect of nesiritide on renal function in these patients.
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Review Comparative Study
Drug-induced QT prolongation and torsades de pointes: evaluation of a QT nomogram.
Although QT prolongation is associated with increased risk of torsade de pointes (TdP), the precise relationship is not well defined. ⋯ The QT nomogram is a clinically relevant risk assessment tool that accurately predicts arrhythmogenic risk for drug-induced QT prolongation. Further prospective evaluation of the nomogram is needed.
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Atrial fibrillation (AF) is associated with an increased stroke risk that may be reduced by therapeutic anticoagulation. However, anticoagulation is associated with an increased risk of bleeding that in some patients may outweigh the benefits in reducing the risk of stroke. We systematically reviewed the literature for risk factors of anticoagulation-related bleeding complications in patients with AF, as part of the formulation of recently published national guidelines for the management of AF. ⋯ The presence of diabetes mellitus, controlled hypertension and gender were not identified as significant risk factors. Some of the risk factors for anticoagulation-related bleeding are also indications for the use of anticoagulants in AF patients. There is a need for further research in this area to help physicians to balance the risks and benefits of anticoagulation in AF patients.