Annals of internal medicine
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Review Meta Analysis
Implantable cardioverter defibrillators in primary and secondary prevention: a systematic review of randomized, controlled trials.
Sudden cardiac death is common in persons with cardiovascular disease. ⋯ Implantable cardioverter defibrillators prevent sudden cardiac death regardless of baseline risk. However, their impact on total mortality is sensitive to baseline risk for arrhythmic death. Decisions about resource allocation for ICDs depend on accurate stratification of patients according to risk.
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To evaluate the mini-clinical evaluation exercise (mini-CEX), which assesses the clinical skills of residents. ⋯ The measurement characteristics of the mini-CEX are similar to those of other performance assessments, such as standardized patients. Unlike these assessments, the difficulty of the examination will vary with the patients that a resident encounters. This effect is mitigated to a degree by the examiners, who slightly overcompensate for patient difficulty, and by the fact that each resident interacts with several patients. Furthermore, the mini-CEX has higher fidelity than these formats, permits evaluation based on a much broader set of clinical settings and patient problems, and is administered on site.
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Ventilator-associated pneumonia is a common cause of morbidity in critically ill patients. Interventions beneficial to the prevention of ventilator-associated pneumonia would therefore have a significant impact on the care of these patients. ⋯ After evaluation of potential benefits and risks, the authors recommend considering several specific interventions to reduce the incidence of ventilator-associated pneumonia: semi-recumbent positioning in all eligible patients, sucralfate rather than H2-antagonists in patients at low to moderate risk for gastrointestinal tract bleeding, and aspiration of subglottic secretions and oscillating beds in select patient populations. Selective digestive tract decontamination is not recommended because routine use may increase antimicrobial resistance.
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Despite the advances in supportive care and the availability of potent antimicrobial agents, mortality from sepsis, a leading cause of death in intensive care units, has not improved. Over the last decade, clinical trials with numerous adjunctive therapies, including antiendotoxin antibodies and inhibitors of the inflammatory response, have yielded disappointing results. Recently, treatment with recombinant human activated protein C reduced mortality 6% compared with controls. ⋯ Given the likelihood that sepsis represents an excessive innate immune response to microbial products, vigorous attempts must be made to develop rapid assays that reflect the level of innate immune activation. Such assays could be used to identify patients who would benefit from therapy and to monitor their response so that overtreatment does not completely abrogate host defense mechanisms and render these patients susceptible to fatal infection. It is now time to test a new therapeutic paradigm based on an improved understanding of the pathophysiology of the septic process and the recognition that we may have reached the limits of adjunctive monotherapy.
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Alzheimer disease is a complex neurodegenerative dementing illness. It has become a major public health problem because of its increasing prevalence, long duration, high cost of care, and lack of disease-modifying therapy. Over the past few years, however, remarkable advances have taken place in understanding both the genetic and molecular biology associated with the intracellular processing of amyloid and tau and the changes leading to the pathologic formation of extracellular amyloid plaques and the intraneuronal aggregation of hyperphosphorylated tau into neurofibrillary tangles. ⋯ Currently available cholinesterase inhibition therapy targets the cognitive symptoms. However, the goal of new therapies under development is halting the pathologic cascade and potentially reversing the course of the disease. If these new therapies are successful, they will represent a remarkable medical advance for patients and the families who care for them.