Arch Intern Med
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The incidence of esophageal adenocarcinoma has been rising rapidly over the past few decades. The major risk factors predisposing to the development of adenocarcinoma are long-standing gastroesophageal reflux disease and Barrett esophagus, but other factors may be involved as cancer can occur in their absence. ⋯ As neither medical nor surgical therapies have been proven to prevent adenocarcinoma, endoscopic screening of patients with chronic reflux and endoscopic surveillance of patients diagnosed with Barrett esophagus are usually performed in an effort to detect adenocarcinomas at earlier stages. The evidence supporting strategies in the management of patients with gastroesophageal reflux and Barrett esophagus is presented.
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The management of nursing home (NH) residents' pain requires adequate nursing assessment and clinician knowledge of pain therapies. However, the timely communication of pain from residents to nurses and from nurses to clinicians is equally necessary. Using a 4-step model (nursing assessment of pain, notification of clinicians regarding pain assessment, clinicians' assessment of pain and intervention), and nursing reassessment following an intervention, we describe the timing with which each of these steps occur. ⋯ There is considerable variability in how frequently nurses and clinicians assess pain, when clinicians are notified about pain, and how frequently nurses reassess pain. Studies are needed to determine optimal timing in the communication process of pain to allow better pain management outcomes and quality of care for NH residents.
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Despite abundant epidemiologic evidence, the role of elevated serum uric acid level as a cardiovascular risk factor is controversial. We assessed the predictive value of serum uric acid levels for cardiovascular and overall mortality. ⋯ Serum uric acid levels are a strong predictor of cardiovascular disease mortality in healthy middle-aged men, independent of variables commonly associated with gout or the metabolic syndrome. Serum uric acid measurement is an easily available and inexpensive risk marker, but whether its relationship to cardiovascular events is circumstantial or causal remains to be answered.
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Care plans for patients with do-not-resuscitate (DNR) orders often fail to define limits other than cardiopulmonary resuscitation and fail to address other patient care needs. We studied the explicitness and comprehensiveness of care plans for patients with DNR orders and what factors were associated with this aspect of the quality of their care. ⋯ Documented consent conversations and care plans for patients with DNR orders are less than ideal. Care plans differ in quality by diagnosis, institution, and whether or not a consent conversation is documented. These observations might help to guide interventions that aim to improve the care of patients with DNR orders.
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Advance directives have not fulfilled their promise of facilitating decisions about end-of-life care for incompetent patients. Many legal requirements and restrictions concerning advance directives are counterproductive. Requirements for witnessing or notarizing advance directives make it difficult for patients to complete a written directive during a physician visit. ⋯ Procedures for written advance directives should be simplified. Patients should be able to designate health care proxies through oral statements to physicians. These reforms will encourage discussions between patients and physicians about advance directives and may lead to more informed decisions near the end of life.