Arch Intern Med
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Since the passage of the Patient Self-Determination Act in 1991, there has been interest in urging patients to execute advance directives (ADs) for medical care. There are not much data, however, as to what the ADs that patients execute actually specify. I have investigated the percentage of inpatients and outpatients who are admitted to a community hospital who have executed ADs, and I have tabulated what preferences are actually expressed in the ADs that are in hospital records. ⋯ The overwhelming desire expressed by the patients in the ADs was not to have their lives prolonged if their medical condition were such that treatment would merely delay death. Only a minuscule number of patients, less than 0.7%, wanted everything done to prolong life regardless of the chance for improvement or the cost. Because such a small percentage of patients have ADs, it is recommended that each hospital appoint a committee on ADs to do everything possible to encourage patients to execute an AD. A second mission of this committee would be to do everything possible to encourage physicians to pay close attention to their patients' wishes for medical care at the end of life.
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To examine the effects of the Kobe, Japan, earthquake, a life-threatening event, on stress and glycemic control in diabetic patients. ⋯ These results suggest an association between chronic, life-threatening stress and the worsening of metabolic control in patients with diabetes mellitus.
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Guidelines developed by the Centers for Disease Control and Prevention, Atlanta, Ga, recommend that peripheral intravenous catheters be changed every 3 days. However, routine replacement of central venous catheters is no longer supported in their latest update. ⋯ The hazard for catheter-related complications--phlebitis, catheter-related infections, and mechanical complications--did not increase during prolonged catheterization. The recommendation for routine replacement of peripheral intravenous catheters should be reevaluated considering the additional cost and discomfort to the patient.
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Uncertainties remain about the contribution of methicillin resistance to morbidity and mortality associated with bacteremia caused by Staphylococcus aureus. ⋯ Methicillin resistance in patients with S aureus bacteremia had no significant impact on patient outcome as measured by in-hospital mortality after adjustment was made for major confounders.
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Nonsteroidal anti-inflammatory drugs (NSAIDs) cause substantial morbidity and mortality from upper gastrointestinal tract disease. Ketorolac tromethamine has been singled out as an NSAID with a distinct gastrotoxicity profile. Calcium channel blockers, a class of antihypertensive drugs, have also been found to increase the risk of gastrointestinal tract bleeding. ⋯ The excess risk of major upper gastrointestinal tract complications associated with outpatient use of ketorolac suggests an unfavorable risk-benefit assessment compared with other NSAIDs. More data are required to reduce the uncertainty about the apparent small increased risk of upper gastrointestinal tract bleeding in patients using calcium channel blockers.