Arch Intern Med
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An accurate diagnosis of pulmonary embolism is essential to prevent excessive morbidity and mortality from lack of therapy or inappropriate anticoagulation. Clinical signs and symptoms are reported to be nonspecific, although published studies do not allow calculation of true specificity. Since certain clinical characteristics or groups of findings may be sensitive enough for pulmonary embolism, the diagnosis is unlikely in their absence. ⋯ Scans with less extensive perfusion abnormalities or matching ventilation defects do not reliably exclude pulmonary embolism. Pulmonary angiography is the most definitive procedure for diagnosing pulmonary embolism. Digital subtraction pulmonary angiography and radiolabeled platelet scanning are promising but require more extensive validation before routine use.
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Case Reports
Treatment of thrombotic thrombocytopenic purpura. Plasmapheresis, plasma transfusion, and vincristine.
In four patients with thrombotic thrombocytopenic purpura (TTP), the administration of plasma exchange and vincristine sulfate was associated with reversal of clinical and hematologic evidence of disease. Plasmapheresis with fresh frozen plasma replacement appears effective in acutely improving neurologic and hematologic abnormalities of patients with TTP and provides time for vincristine to become effective and induce lasting remissions. One patient with early relapse responded to a second short course of vincristine without other therapy. These data suggest that these treatment modalities should be considered as the initial treatment of TTP.
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Lowering systemic blood pressure (BP) in patients with acute cerebral infarction may produce clinical deterioration. Because of impaired cerebral autoregulation and the spontaneous fluctuations in BP following stroke, antihypertensive medication should be avoided in patients with acute cerebral infarction unless vital organs such as the heart or kidney are compromised, the diastolic BP rises to 130 mm Hg or greater, or the patient has hypertensive encephalopathy. Brief remarks about BP control in intracerebral hematoma and subarachnoid hemorrhage are also included.
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The major task of medicine with the geriatric population is to assist with the promotion of a vigorous quality of life and maintenance of function. The key to functioning is cognitive capacity. ⋯ Deficits in attitude, skill, and knowledge all contribute to this failure. It must be addressed in medical education, both in medical school and in postgraduate medical education.