Arch Intern Med
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Case Reports
Risk of alloimmunization and delayed hemolytic transfusion reactions in patients with sickle cell disease.
Blood transfusion is an integral part of the supportive care of patients with sickle cell diseases. The hazards of red blood cell alloimmunization and delayed hemolytic transfusion reactions (DHTRs) complicate the treatment of patients with sickle cell diseases, particularly since such reactions may be misinterpreted as a pain crisis, and, as a result, specific transfusion serologic studies may not be performed. The frequency of alloimmunization in this population has been the subject of several reports; however, the frequency of DHTRs is unknown. ⋯ Red blood cell alloimmunization was seen in 22 (30%) of 73 of the patients. The calculated risk of alloimmunization was 3.1% per unit of blood. These observations suggest that alloimmunization and clinically apparent DHTRs occur more frequently in patients with sickle cell diseases and support pretransfusion testing for at least Rh and Kell red blood cell antigens in patients who are at high risk of such events (patients who have formed an alloantibody or who are being enrolled in a transfusion program).
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The "do not resuscitate" (DNR) order has wide-ranging ethical, legal, and economic implications. We reviewed the course of 244 patients who died during two three-month periods, in 1982 and 1986. We found that 68% of patients who died had a DNR order written, including 94% with malignancy and half of patients with cardiovascular disease. ⋯ No patient was transferred to the critical care units after a DNR order had been written. The prevalence of DNR orders written for patients dying of cardiovascular disease increased from 27% to 64% over the four years. We conclude, from study of deaths in this representative community hospital, that an explicit DNR order is now the rule rather than the exception, but decisions are made late and involve family far more than the patient.
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Factors related to risk of perioperative pulmonary complications include site of incision, obstructive lung disease, prolonged anesthesia time, smoking history with productive cough, and obesity. Hypercapnia is a consistent indicator of high risk. There is no difference between spinal and general anesthesia with regard to risk of pulmonary complications. ⋯ Newer methods of assessing cardiopulmonary reserve may prove useful in identifying which patients with one or more of these risk factors are suitable operative candidates. Prevention of postoperative complications in chronic obstructive pulmonary disease patients should begin in the preoperative period with discontinuation of smoking at least eight weeks before surgery and vigorous pulmonary toilet in the 48 to 72 hours before surgery. Prophylactic lung expansion maneuvers can be effective in decreasing the incidence of postoperative atelectasis in high-risk patients undergoing high-risk operations.
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When patients are examined for possible cobalamin deficiency, great stress is often placed on the presence or absence of macrocytosis and anemia and on how low the serum cobalamin level is. The present study, however, shows that only 45 (64%) of 70 consecutively diagnosed patients with pernicious anemia, the most common cause of cobalamin deficiency, had very low cobalamin levels (less than 74 pmol/L [or less than 100 ng/L]). Anemia was absent in 13 (19%) of the patients, and macrocytosis was absent in 23 (33%) of the patients; such absence was particularly common when cobalamin levels were only slightly or moderately low (74 to 184 pmol/L). ⋯ These observations indicate that macrocytosis and anemia, two classic features of pernicious anemia, may be overstressed in our diagnostic approach. All subnormal serum cobalamin results are best viewed as pathological until proved otherwise. Emphasis on only very low cobalamin levels risks delaying the diagnosis of pernicious anemia in a substantial proportion of cases, particularly in those without anemia or macrocytosis.
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There is a growing effort to formalize ethics teaching for medical residents. Currently, this effort is overemphasizing a single approach--the clinical ethics consultation or ethics case conference--at the expense of several other important options. While the clinical ethics approach has many benefits, it also has harmful side effects when it is made the single method for residency ethics teaching: it constricts ethics teaching within too narrow a view of medical ethics, and it forfeits an opportunity for ethics to challenge some problematic features of residency education itself.