Arch Intern Med
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Patients with recent-onset atrial fibrillation often undergo routine thyroid function screening to rule out thyroid disease as a cause of atrial fibrillation. ⋯ An abnormal TSH level is common in patients with recent-onset atrial fibrillation. However, clinical thyroid disease is uncommon. Routine TSH screening of patients who have atrial fibrillation has a low yield and may be better applied to those patients at higher risk of having undiagnosed clinical thyroid disease.
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Most Americans die in the acute care hospital, where aggressive, life-prolonging interventions are readily performed. Although patients with incurable illness might prefer palliative care, perceived differences in prognosis by physicians may influence the type of care provided. Patients with advanced cancer and advanced dementia represent 2 extremes in the use of hospice services and may also be treated differently in the acute care hospital. We tested this hypothesis and quantitated the use of nonpalliative interventions in hospitalized, incurably ill patients. ⋯ Incurably ill patients often receive nonpalliative interventions at the end of life. Patients with cancer receive more diagnostic tests, but patients with dementia receive more enteral tube feeding. Patients commonly receive systemic antibiotics, often empirically. Cardiopulmonary resuscitation is equally applied, but is out of proportion to expected survival.
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Open-access endoscopy allows nongastroenterologist physicians the opportunity to directly schedule elective common endoscopic procedures for their patients without having them first examined in the gastrointestinal clinic. There are few data as to whether nongastroenterologist physicians in the United States schedule patients for appropriate indications. ⋯ Primary care physicians were significantly more likely to schedule patients for open-access EGD and colonoscopy for appropriate indications than were non-primary care physicians. The frequency of inappropriate indications for colonoscopy referrals was greater than for EGD. The reasons for the differences among primary care physicians, surgeons, and internal medicine subspecialists require further exploration.
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Multicenter Study
A multi-institutional study of care given to patients dying in hospitals. Ethical and practice implications.
Relatively little attention has been paid to how physicians care for dying patients once an initial decision to forgo life-sustaining treatment is made. ⋯ The majority of patients dying at these institutions did so after decisions to limit treatment, but few patients were able to participate in these decisions. Forgoing life-sustaining treatment generally occurred in a sequential manner over several days; the rationale for this stepwise retreat is not, however, clinically or ethically obvious.
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Bronchodilator delivery by metered dose inhaler (MDI) to treat airflow obstruction is considered to be less expensive and as effective as nebulized therapy. ⋯ Bronchodilator delivery by WN is commonly prescribed for hospitalized patients despite evidence for equivalency of effect using MDI and in the absence of substitution protocols. Previous studies have estimated a far greater cost differential based on unrealistic labor estimates. We found that supervision of patients using MDIs minimized the differential cost between WN and MDI therapy and that cost savings are maximal in patients who can self-administer MDI therapy. Methodologically sound economic evaluations can better identify true cost savings and variables that need further study.