Annals of internal medicine
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Randomized Controlled Trial Multicenter Study Clinical Trial
Continuous intravenous epoprostenol for pulmonary hypertension due to the scleroderma spectrum of disease. A randomized, controlled trial.
Pulmonary hypertension is a progressive and often fatal complication of the scleroderma spectrum of disease for which no treatment has been proven effective in a randomized trial. ⋯ Continuous epoprostenol therapy improves exercise capacity and cardiopulmonary hemodynamics in patients with pulmonary hypertension due to the scleroderma spectrum of disease.
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Comprehensive palliative care, as exemplified by many state-of-the-art hospice programs, is the standard of care for the dying. Although palliative care is very effective, physicians, nurses, patients, families, and loved ones regularly face clinically, ethically, legally, and morally challenging decisions throughout the dying process. This is especially true when terminally ill patients are ready to die in the face of complex, difficult-to-treat suffering and request assistance from their health care providers. ⋯ The moral distinctions between these practices are critical to some but relatively inconsequential to others. This paper illustrates, through summaries of real clinical cases, how each of these practices might be used in response to patients in particular clinical circumstances, keeping in focus the patient's values as well as those of families, other loved ones, and health care providers. The challenge is to find the least harmful solution to the patient's problem without abandoning patients and their loved ones to unacceptable suffering or to acting in a more deleterious way on their own.
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To review the literature on prevention of intravascular catheter-related infections. ⋯ Simple interventions can reduce the risk for serious catheter-related infection. Adequately powered randomized trials are needed.
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Humans have only a limited ability to incorporate information in decision making. In certain situations, the mismatch between this limitation and the availability of extensive information contributes to the varying performance and high error rate of clinical decision makers. Variation in clinical practice is due in part to clinicians' poor compliance with guidelines and recommended therapies. ⋯ However, one of these reasonable approaches must be chosen and incorporated into the protocol to promote consistent clinical decisions. This reasoning is the basis of an explicit method of decision support that allows the rigorous evaluation of interventions, including use of the protocols themselves. Computerized protocols for mechanical ventilation and management of intravenous fluid and hemodynamic factors in patients with the acute respiratory distress syndrome provide case studies for this discussion.