South Dakota medicine : the journal of the South Dakota State Medical Association
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Numerous studies have confirmed the importance of advance care planning. Despite the benefits of directed end-of-life discussions, a variety of barriers including discomfort with the topic, physician ideology, lack of time and reimbursement, delaying discussions, and lack of training impede physicians from facilitating these crucial conversations with their patients. This study aims to understand physicians' perceptions to additional barriers to advance care planning with patients and their families. ⋯ Complex challenges in communication impede the delivery of successful end-of-life experiences for patients and their families. With improvements in the practices of advance care planning, many of these challenges can be removed - enabling individuals to remain in control as they near the end of their lives and preventing unnecessary pain and suffering on behalf of the patient and family.
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Health care spending in the U.S. totaled $3 trillion in 2014 and continues to increase rapidly. Minimizing waste through clinical guidelines is a promising strategy to reduce spending without compromising patient care. In 2011, clinical guidelines recommended against the use of chest X-ray (CXR) for diagnosis of community-acquired pneumonia (CAP) in pediatric ambulatory settings. However, use of CXR has not changed post-guideline. Thus, understanding the drivers of CXR utilization prior to guideline implementation could improve guideline adherence. ⋯ The research demonstrates a strong correlation between socioeconomic status of the pediatric patient and use of chest radiograph for CAP in the ED setting prior to 2011 guideline publication. Further research to determine the reason for this correlation could give rise to focused efforts to successfully encourage adherence to clinical practice guidelines.
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There are so far only a few reported cases of acute fulminant hepatic failure resulting from acute cardiomyopathy. This is a rare occurrence, especially in patients that do not exhibit any signs and symptoms of acute cardiac decompensation. We report a case of fulminant liver failure with nondiagnostic work up for the common causes of liver failure. ⋯ Echocardiogram revealed dilated left atrium and ventricle, severe mitral regurgitation, severe tricuspid regurgitation, grade 4 diastolic dysfunction, diffuse hypokinesis of left ventricle, and severely and newly reduced systolic function with an ejection fraction of 10 percent (decreased from 25 percent on last ECHO 18 months prior). Liver biopsy demonstrated marked centrilobular hepatocyte necrosis and dropout accompanied by congestion, some areas of bridging necrosis and focal confluent necrosis which was suggestive of severe congestive hepatopathy. With initiation of heart failure medications, liver function improved significantly.
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A patient's transition from hospitalization to discharge may represent an additional opportunity for antibiotic stewardship. ⋯ Our results align with the only previously published study of oral antibiotics prescribed at hospital discharge, both in the duration of inpatient and outpatient therapy and in the fact that about 60 percent of the treatment duration occurred after discharge. However, the median total antibiotic duration of 10 days is longer than that recommended by national and institutional guidelines for some of the most common infections in hospitalized patients.
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In this case report, we describe an unusual episode of bilateral submassive pulmonary embolism (PE) caused by a popliteal vein aneurysm (PVA). The development of PE stems from many risk factors including obesity (BMI³ 30 kg/m2), hypertension, cigarette smoking (greater than 25 cigarettes per day), increasing age, surgery, immobility, malignancy, and inherited thrombophilia. A PVA is a rare but significant cause of PE. ⋯ The definitive management of a PVA is surgical repair. Some studies suggest recurrent PE in as high as 80 percent of patients on oral anticoagulation alone. Therefore, an IVC filter is often placed to prevent further thrombi progression until definitive surgical treatment of the aneurysm has been performed.