Arch Intern Med
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We examined the incidence of complete heart block (CHB) as a complication of pulmonary artery catheterization with balloon-tipped, flow-directed catheters in patients with left bundle-branch block (LBBB). The study group included 47 consecutive critically ill patients with LBBB in the medical intensive care and coronary care units, who underwent a total of 82 pulmonary artery catheterizations. Twenty-six patients had an acute myocardial infarction, 34 patients had severe congestive heart failure (Killip class III or class IV), and 15 patients died during their hospitalization. ⋯ Although it is unlikely, we could not rule out the possibility that the CHB was related to the presence of the pulmonary artery catheter. We conclude that the incidence of CHB complicating pulmonary artery catheterization with balloon-tipped, flow-directed catheters in critically ill patients with old or indeterminate-aged LBBB is extremely low. Therefore, we do not recommend the routine placement of a temporary transvenous pacemaker in all patients with LBBB prior to pulmonary artery catheterization.
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Comparative Study
Pernicious anemia in Latin Americans is not a disease of the elderly.
Pernicious anemia is widely regarded as a disease of the elderly. However, it is expressed differently in black women, among the most striking differences being their younger age at presentation of the disease compared with whites. ⋯ Only 21% of Latin-American patients were 70 years of age or older, compared with 49% of whites. It is apparent that pernicious anemia is indeed predominantly a disease of the elderly in whites but that this is not the case in other racial groups.
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Chronic atrial fibrillation without valvular disease has been associated with increased stroke incidence. The impact of atrial fibrillation on the risk of stroke with increasing age was examined in 5184 men and women in the Framingham Heart Study. ⋯ The proportion of strokes associated with this arrhythmia was 14.7%, 68 of the total 462 initial strokes, increasing steadily with age from 6.7% for ages 50 to 59 years to 36.2% for ages 80 to 89 years. In contrast to the impact of cardiac failure, coronary heart disease, and hypertension, which declined with age, atrial fibrillation was a significant contributor to stroke at all ages.
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Three cases of subarachnoid hemorrhage (SAH) due to ruptured developmental (berry) aneurysm are reported. Two patients presented with cardiac arrest and were successfully resuscitated, but the diagnosis of SAH was delayed and this most likely influenced poor final outcome. ⋯ The possible mechanisms responsible for SAH-triggered cardiac arrhythmia and/or respiratory arrest are discussed. Absence of previous cardiac history, persistent headache, focal neurologic findings (especially papilledema or subhyaloid hemorrhages) should warn the clinician of the possibility of SAH and warrant further neurologic investigation.
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There are substantial problems with the clinical training provided to medical students and with the assessment procedure used by medical schools to ensure that students have acquired the clinical skills necessary for graduate medical education. These skills are not evaluated carefully nor systematically at any point in training or licensure. This article describes the use of standardized patients to help resolve some of these shortcomings. ⋯ They are effective teachers of interviewing and physical examination skills. They can help to provide a controlled exposure to common ambulatory and difficult patient communication situations. Initial studies indicate the promise of this approach for ensuring the competence of medical school graduates.