Hospital practice (1995)
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Hospital practice (1995) · Aug 2011
ReviewSepsis: the inflammatory foundation of pathophysiology and therapy.
Sepsis, defined as an infection accompanied by inflammation, is a complex disease process wherein the body's response to a pathogen is amplified far beyond the initial site of infection. The process begins when pathogen-associated molecular patterns on the bacteria or other pathogens induce an inflammatory cascade in the host. In the United States, it is estimated that every minute a patient with severe sepsis or septic shock presents to an emergency department and that > 751 000 cases of severe sepsis occur annually, resulting in an estimated 215 000 deaths. ⋯ The clinical management of severe sepsis and septic shock has evolved dramatically over the past decade and these new therapeutic approaches have been built on a deeper understanding of the natural evolution of sepsis. This article examines the underlying pathophysiological mechanisms of sepsis to help explain the clinical signs and symptoms manifested by severe sepsis patients. It also examines the significance of current proposed treatment strategies, including early goal-directed therapy, from a pathophysiological and inflammatory perspective.
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Hospital practice (1995) · Aug 2011
ReviewVenous thromboembolism prophylaxis after hospital discharge: transition to preventive care.
Deep vein thrombosis and pulmonary embolism, the common clinical manifestations of venous thromboembolism (VTE), are among the most preventable complications of hospitalized patients. However, survey data repeatedly show poor rates of compliance with guideline-based preventive strategies. This has led the Centers for Medicare and Medicaid Services to deny reimbursement for hospital readmission for thromboembolic complications in patients undergoing total hip or knee arthroplasty. ⋯ Although there is clear consensus that most hospitalized patients should receive VTE prophylaxis, there is uncertainty about whether to continue VTE prophylaxis in the immediate post-hospital period or for an extended duration. The transition from inpatient to outpatient care is a key event in the coordination of continuity of care, but VTE-specific care transition guidance is limited. In this article, we review the evidence for both standard- and extended-duration VTE prophylaxis and discuss the difficulties in effectively maintaining VTE prophylaxis during the transition from inpatient to outpatient care.
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Hospital practice (1995) · Aug 2011
ReviewProtecting the heart from ischemia: an update on ischemic and pharmacologic conditioning.
The attempt to find treatments that will reduce myocardial cell death during periods of ischemia and subsequent reperfusion has spanned nearly 40 years. Although many therapies have shown promise in animal models, relatively few have been successful in clinical trials. Some of the most effective clinical therapies involve techniques designed to elicit the heart's own innate capacity to protect itself. ⋯ Several pharmacologic agents have the ability to mimic the effects of ischemic conditioning and can also reduce the amount of cell death during ischemia/reperfusion. This article provides the clinician with an overview of the different techniques of ischemic conditioning and how they can protect the myocardium from ischemia/reperfusion injury. Additionally, several pharmacologic agents that can protect the heart in a similar manner are discussed.
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Hospital practice (1995) · Aug 2011
Impact of dyspnea on medical utilization and affiliated costs in patients with acute coronary syndrome.
Current clinical practice guidelines recommend dual antiplatelet therapy with aspirin and clopidogrel or prasugrel for patients with acute coronary syndrome (ACS). Ticagrelor, an experimental antiplatelet therapy, has been shown to be associated with significantly higher rates of dyspnea than clopidogrel in clinical trials. Patients with ACS presenting with dyspnea require additional medical attention to rule out possible heart failure or other serious diagnoses. This study used real-world data to quantify the direct medical costs of dyspnea among patients with a history of ACS. ⋯ Dyspnea is a significant event associated with high medical resource utilization and hospital costs. Ticagrelor, an experimental antiplatelet agent not yet available on the market, has been shown to be associated with significantly higher rates of dyspnea than clopidogrel in clinical trials. Considering that the increased risk of dyspnea for ticagrelor is well documented, these costs may be important to health plan decision-makers when evaluating costs associated with each antiplatelet therapy.