Arch Intern Med
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To determine whether a relationship exists between the use of do-not-resuscitate (DNR) orders in the intensive care unit and the age of the patient after controlling for the severity of illness. ⋯ Older patients (> or = 75 years old) are significantly more likely than younger patients to have DNR orders written even after the severity of illness is controlled as a confounding variable. This association suggests age discrimination and becomes stronger as patient age increases.
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Randomized Controlled Trial Clinical Trial
Ketorolac vs chlorpromazine in the treatment of acute migraine without aura. A prospective, randomized, double-blind trial.
Many treatments for acute migraine exist. Chlorpromazine is effective but has serious side effects. Ketorolac has only rare side effects. ⋯ Using 60 mg of intramuscular ketorolac tromethamine is as effective as 25 mg of intravenous chlorpromazine hydrochloride in the treatment of acute migraine headache. Patients who do not respond to one of these medications may respond to the other.
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Prehospital cardiac care, first established in Belfast, Northern Ireland, in 1966, may be called revolutionary in that it was a radical break from existing practices. The Belfast program "moved" the coronary care unit into the community by treating the early complications of acute myocardial infarcation. The program staffed a mobile coronary care unit with a physician and nurse and demonstrated that patients with out-of-hospital sudden cardiac arrest could be resuscitated. ⋯ Prehospital cardiac care has evolved significantly in the past 3 decades. Some notable developments include the tiered response system, training of the general public in cardiopulmonary resuscitation, low-energy defibrillators, automatic external defibrillators, and 12-lead electrocardiographic telemetry. The basic lesson of prehospital cardiac care is that the timely provision of cardiopulmonary resuscitation and defibrillation saves lives.
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Cardiac rehabilitation programs represent opportunities to educate patients with cardiac disease about living wills and durable powers of attorney for health care. The extent of advance directive education that is currently provided in cardiac rehabilitation programs, however, is unknown. ⋯ Cardiac rehabilitation programs are potentially valuable but not widely used sites for educating patients with cardiac disease about advance directives.
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Patients presenting with stroke or transient cerebral ischemic episodes often undergo transesophageal echocardiography (TEE) as part of their initial evaluation. Previous studies have demonstrated that TEE is superior to transthoracic echocardiography for the detection of potential cardiac sources of embolism. In our institution, this scenario now represents the most frequent reason for requesting TEE. For the most part, these TEE examinations are ordered by a neurologist, and transthoracic echocardiography is not performed beforehand. ⋯ It may not be cost-effective to perform TEE as a routine diagnostic procedure in patients presenting with cerebral ischemic events. Most patients with atrial fibrillation are candidates for empiric warfarin sodium therapy, and patients in sinus rhythm usually have findings for which there is no recommended therapy or for which only aspirin is indicated.