Arch Intern Med
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Comparative Study
Performing procedures on the newly deceased for teaching purposes: what if we were to ask?
Performance of procedures on the recently dead for physician training is controversial. It has been suggested that permission be obtained. We investigated whether patients and family members would grant such permission or if even this request might anger the recently bereaved. ⋯ Asking for permission to perform procedures on the recently deceased for physician training purposes may often anger the bereaved. The emotional response to the consent request may be culturally determined. Increased willingness of individuals to permit the use of their bodies in the immediate postmortem period suggests that a preauthorization program similar to organ donor cards might be acceptable, successful, and ethical.
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We evaluated whether a highly sensitive D-dimer test is clinically useful and safe for ruling out pulmonary embolism (PE) in patients with a high clinical probability and whether adopting different cutoff values according to the clinical probability category might increase the proportion of patients in whom PE is ruled out. ⋯ The safety of D-dimer testing in patients with a high clinical probability of PE is not established, and testing results are rarely negative in such patients. Increasing the enzyme-linked immunosorbent assay D-dimer cutoff value only marginally increased the test's usefulness.
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Randomized Controlled Trial Clinical Trial
High rates of advance care planning in New York City's elderly population.
Previous studies have demonstrated low rates of advance care planning (ACP), particularly among nonwhite populations, raising questions about the generalizability of this decision-making process. ⋯ African American, Hispanic, and white community-dwelling, older adults had similarly high rates of advance directive completion. The primary predictors of advance directive completion involved modifiable factors such as established primary care physicians, personal experience with mechanical ventilation, knowledge about the process of ACP, and physicians' willingness to effectively initiate such discussions. Some of the racial/ethnic differences in desire for collective family-based decision making that were observed in this study have implications for the evolution of ACP policy that respects and operationalizes these preferences.
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Long-term management of chronic pain with opioids may be stable over time or may be complicated by problematic dose increases, drug dependencies, and toxic effects. To determine clinical contexts in which stability or problems may occur, we examined the pharmacologic and clinical correlates of long-term prescriptions of oxycodone/acetaminophen, a commonly prescribed short-acting opioid formulation. ⋯ In veteran patients who received long-term oxycodone/acetaminophen prescriptions, mean daily doses were typically modest and stable, likely reflecting a selection of patients with successful, long-term management. Among patients without cancer, however, associations of higher oxycodone/acetaminophen doses with benzodiazepine prescriptions, psychogenic pain, alcohol abuse, and HIV/AIDS may portend opioid prescription management problems.
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Review Meta Analysis
A systematic review and meta-analysis of studies comparing readmission rates and mortality rates in patients with heart failure.
Heart failure is the leading cause of hospitalization and readmission in many hospitals worldwide. We performed a meta-analysis to evaluate the effectiveness of multidisciplinary heart failure management programs on hospital admission rates. ⋯ This systematic review suggests that specific heart failure-targeted interventions significantly decrease hospital readmissions but do not affect mortality rates.