Polskie Archiwum Medycyny Wewnętrznej
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Pol. Arch. Med. Wewn. · Oct 2009
Glycemic profile and effectiveness and safety of insulin therapy in septic patients: is the blood glucose level sufficient?
Hyperglycemia in sepsis is managed by intensive insulin therapy, which can cause hypoglycemia. ⋯ Patients who died experienced more episodes of hyperglycemia, spontaneous hypoglycemia and greater variation in the daily glycemia level. Daily glycemia variation is more reliable than a mean glycemic level in evaluating glucose homeostasis in septic patients. Few episodes of severe insulin-induced hypoglycemia occurred while using the nurse-controlled insulin therapy protocol.
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Pol. Arch. Med. Wewn. · Sep 2009
ReviewThe Terri Schiavo saga: ethical and legal aspects and implications for clinicians.
On March 31, 2005, Terri Schiavo (born December 3, 1963) died -- the final complication of a cardiac arrest on February 25, 1990. Her death was preceded by the withdrawal of artificially administered hydration and nutrition through a feeding tube. Prior to her death, Terri's saga was the focus of intense medical, ethical, and legal debates in the United States (US) and elsewhere. ⋯ Much of the confusion revolved around a number of ethical and legal questions including: Is it ethically and legally permissible to withhold or withdraw life-sustaining treatments from patients who do not want the treatments? Is withholding or withdrawing life-sustaining treatments the same as physician-assisted suicide or euthanasia? Is artificially administered hydration and nutrition a medical treatment or mandatory care akin to bathing? What were Terri's values, preferences, and goals regarding life-sustaining treatments? In this article, the medical, ethical, and legal data related to the case and the aforementioned ethical and legal questions raised by it are reviewed. Finally, the clinical implications of the saga, such as the need for clinicians to be more proactive in educating patients about their rights related to making health care decisions, end-of-life care options, and advance care planning (e.g., completing an advance directive) are discussed. Notably, given that the Schiavo saga occurred in the US, this article is written from a US perspective.
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Pol. Arch. Med. Wewn. · Sep 2009
Comparative StudyAdditional spirometry criteria predict postoperative complications after coronary artery bypass grafting (CABG) independently of concomitant chronic obstructive pulmonary disease: when is off-pump CABG more beneficial?
Concomitant chronic obstructive pulmonary disease (COPD) is associated with an increased rate of post-coronary artery bypass grafting (CABG) complications. The ratio of forced expiratory volume in 1 second to forced vital capacity (FEV1/FVC) <70%, proposed by the Global Initiative for Chronic Obstructive Lung Disease as a criterion for the diagnosis of COPD, is criticized for not considering physiological, age-related changes in lung function. ⋯ FEV1
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Pol. Arch. Med. Wewn. · Sep 2009
2009 evidence-based clinical practice guidelines for diagnosing a first episode of lower extremities deep vein thrombosis in ambulatory outpatients.
The GRADE working group has recently suggested a rigorous framework for clinical practice guidelines (CPG) addressing diagnostic tests and test strategies based on the impact of alternative approaches on patient-important outcomes. The framework mandates explicit evidence summaries, ratings of the quality of evidence, and specifying recommendations as strong or weak. ⋯ We provide three groups of recommendations for clinicians practicing in settings with access to different types of D-dimer tests -- highly sensitive, moderately sensitive, and no availability of D-dimer. We consider the use of clinical prediction rules in guiding the diagnostic process, the potential for negative D-dimer or venous ultrasound (US) to rule out disease, and the role of follow-up testing (US following positive D-dimer result, D-dimer following negative US, and serial US) depending on the probability of DVT at the start of diagnostic process. We recommend the following: that clinicians without access to a highly or moderately sensitive D-dimer test rely on US to guide DVT diagnosis; that those with access use the highly sensitive D-dimer to determine, in patients with low or moderate probability of DVT (by the Wells rule) whether US is needed; that in patients with low pre-test probability (pre-TP) and a negative D-dimer (either highly or moderately sensitive) they follow patients without further testing; that in patients with high pre-test probability they perform a compression ultrasound without D-dimer testing.
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Pol. Arch. Med. Wewn. · Jul 2009
Review2009 Clinical Guidelines from the American Pain Society and the American Academy of Pain Medicine on the use of chronic opioid therapy in chronic noncancer pain: what are the key messages for clinical practice?
Safe and effective chronic opioid therapy (COT) for chronic noncancer pain requires clinical skills and knowledge in both the principles of opioid prescribing and in the assessment and management of risks associated with opioid abuse, addiction, and diversion. The American Pain Society and the American Academy of Pain Medicine commissioned a systematic review of the evidence on COT for chronic noncancer pain and convened a multidisciplinary expert panel to review the evidence and formulate recommendations based on the best available evidence. This article summarizes key clinical messages from this guideline regarding patient selection and risk stratification, informed consent and opioid management plans, initiation and titration of COT, use of methadone, monitoring of patients, use of opioids in high-risk patients, assessment of aberrant drug-related behaviors, dose escalations and high-dose opioid therapy, opioid rotation, indications for discontinuation of therapy, prevention and management of opioid-related adverse effects, driving and work safety, identifying a medical home and when to obtain consultation, and management of breakthrough pain.