Arch Intern Med
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Randomized Controlled Trial Multicenter Study Clinical Trial
Toleration of high doses of angiotensin-converting enzyme inhibitors in patients with chronic heart failure: results from the ATLAS trial. The Assessment of Treatment with Lisinopril and Survival.
Treatment with angiotensin-converting enzyme (ACE) inhibitors reduces mortality and morbidity in patients with chronic heart failure (CHF), but most affected patients are not receiving these agents or are being treated with doses lower than those found to be efficacious in trials, primarily because of concerns about the safety and tolerability of these agents, especially at the recommended doses. The present study examines the safety and tolerability of high- compared with low-dose lisinopril in CHF. ⋯ These findings demonstrate that ACE inhibitor therapy in most patients with CHF can be successfully titrated to and maintained at high doses, and that more aggressive use of these agents is warranted.
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Radiological studies are an important component of ambulatory medical costs, and guidelines often focus on their appropriate use. However, little is known about the correlates of the use of those services, particularly the influence of patients' preferences on physicians' utilization decisions. ⋯ Patients' perceived need for radiological studies was significantly associated with use of those services for outpatients with respiratory problems and low back pain. These findings suggest that patients communicate their wishes to physicians, either directly or indirectly, regarding services they think are necessary. Differences in physicians' adherence to guidelines regarding radiology utilization may in part reflect variations in patients' perceived need for those services. Efforts to educate patients about when radiological studies are medically indicated may be an important complement to practice guidelines or other utilization-related financial incentives.
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Randomized Controlled Trial Clinical Trial
Is it worth treating fever in intensive care unit patients? Preliminary results from a randomized trial of the effect of external cooling.
Antipyresis is a common clinical practice in intensive care, although it is unknown if fever is harmful, beneficial, or a negligible adverse effect of infection and inflammation. ⋯ These results suggest that the systematic suppression of fever may not be useful in patients without severe cranial trauma or significant hypoxemia. Letting fever take its natural course does not seem to harm patients with systemic inflammatory response syndrome or influence the discomfort level and may save costs.
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Anaphylaxis is a severe, life-threatening allergic reaction that affects both children and adults in the United States. However, data regarding the incidence and prevalence of anaphylaxis and the number of deaths caused by it are limited. ⋯ The occurrence of anaphylaxis in the US is not as rare as is generally believed. On the basis of our figures, the problem of anaphylaxis may, in fact, affect 1.21% to 15.04% of the US population.
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Patients with infections are usually discharged from the hospital with antibiotics when afebrile and clinically improved. ⋯ The infectious diseases hospitalist discharged patients from the hospital earlier than the IM hospitalists by more efficient use of antibiotics. The earlier discharge did not adversely affect outcomes.