Arch Intern Med
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Noninvasive instruments such as plasma D-dimer measurement (DD) and lower-limb compression ultrasonography (US) are being increasingly advocated to reduce the number of necessary angiograms in patients having suspected pulmonary embolism (PE) and a nondiagnostic lung scan. We therefore designed a decision analysis model (1) to evaluate the cost-effectiveness of combining these noninvasive diagnostic aids with lung scan and angiography in the diagnosis of PE and (2) to determine the optimal sequence and combination of tests taking into account the clinical probability of PE. ⋯ The DD test and US are cost-effective in the diagnostic workup of PE, whether performed after or before lung scan, thus allowing centers devoid of lung scanning and/or angiography facilities to screen patients with suspected PE and avoid costly referrals. In patients with a low clinical probability, a low-probability lung scan, and a normal US, treatment may be withheld without resorting to angiography.
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Physicians often use their relationships with patients to promote specific therapeutic goals. Because of their personal histories, values, and biases, patients may react to physicians in ways that inhibit or enhance the relationship. The feelings that are aroused may induce physicians to become overly distant, engendering patient and physician dissatisfaction, or to become overly involved emotionally, which can have serious psychological and clinical consequences. ⋯ The nature and origin of personal boundaries are described. Boundary transgressions on the part of the patient are discussed, and the means of preventing transgressions by both patients and physicians through medical education, the process of self-awareness, and an exploration of family-of-origin issues are proposed. Through attention to communication with patients, the physician can maintain an empathetic yet objective relationship with the patient.
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Randomized Controlled Trial Comparative Study Clinical Trial
A comparison between emergency diagnostic and treatment unit and inpatient care in the management of acute asthma.
Emergency diagnostic and treatment units (EDTUs) may provide an alternative to hospitalization for patients with reversible diseases, such as asthma, who fail to adequately respond to emergency department therapy. ⋯ Treatment of selected patients with asthma in an EDTU results in the safe discharge of most such patients. This study suggests that quality gains and cost-effective measures can be achieved by the use of such units.
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While prior studies show that combat veterans with posttraumatic stress disorder (PTSD) report more physical symptoms than veterans without PTSD, the link between PTSD and somatic complaints in Persian Gulf War veterans (PGWVs) is yet to be evaluated. ⋯ Physicians examining PGWVs should be alert to the possibility of PTSD in this group and that those with PTSD are more likely to report physical symptoms that may overlap with those in Persian Gulf syndrome. Consequently, mental health screening is essential, since for those veterans with PTSD diagnosis of other coexisting conditions may be confounded and early effective treatment of their PTSD may be delayed. Also, given the increased reporting of certain symptoms by those with PTSD, those seeking the cause of Persian Gulf syndrome should control for PTSD when determining the symptom cluster that may constitute this condition.
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A 31-year-old man ingested an unknown amount of mandrake plant purchased at a local health food store and came to the emergency department with severe nausea and vomiting. He was hospitalized overnight but recovered uneventfully without obvious adverse systemic effects. ⋯ Other users of herbal substances and authors of the medical literature have also confused these 2 versions of mandrake. Given the growing popularity of alternative therapies, physicians should understand the distinction between these substances and should be aware of the medical effects of other commonly used herbal remedies.