Missouri medicine
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The treatment of sepsis and septic shock is an important clinical problem. While effective antibiotic intervention and strong supportive care have improved survival, mortality remains at unacceptable levels. ⋯ The available evidence would support the conclusion that microbial mediators can function synergistically in the induction of host inflammation, providing a potential explanation that anti-endotoxin and anti-inflammatory agents have not been particularly successful in clinical trials to treat septic shock. The identification of specific recognition molecules on the surface of inflammatory mediator cells responsible for initiation of signal transduction, as well as the elucidation of the specific molecular pathways leading to gene expression, provide new opportunities for the development of effective intervention strategies for treatment of septic shock.
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We studied the effectiveness of single and repetitive transcranial electrical stimulation to activate motor tracts under partial neuromuscular blockade and total intravenous anesthesia. During spinal surgery, in 10 patients, the latency and amplitude of the evoked abductor pollicis brevis muscle response after cortical stimulation was calculated and compared. The number of responses evoked by the double (pair) pulse stimulation was significantly higher (p = 0.0191) than single pulse stimulation. ⋯ An increase of interstimulus interval from 1-3 msec did not significantly increase the motor response with the double pulse or repetitive stimulations. Varying the number of electrical pulses per train stimulation from 3-9 did not significantly change latency (P > 0.05) or amplitude (P > 0.05) of the motor response. The findings suggest that use of repetitive stimulation of the motor cortex is an effective method to activate motor pathway during spinal surgery.
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Three-fourths of those who die in America are 65 or older. In all but the cases where death is sudden and unexpected, decisions frequently must be made about whether to limit treatment. In this paper, we provide a framework and specific tools that may help physicians in talking to older patients and their family members about end-of-life care. ⋯ Defining goals of care. 4. Implementing a management plan consistent with those goals. The paper concludes with special considerations about four common experiences of dying as an older person: chronic diseases with acute exacerbations (e.g. congestive heart failure or chronic obstructive lung disease), cancer, end stage dementia, and unexpected catastrophic decline.
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Cultural origins influence the way patients and health care providers think about care and treatment at the end-of-life. With increasing ethnic diversity there is greater chance that clinical encounters will occur between individuals of different backgrounds, therefore there is greater risk of misunderstanding. Health care providers should be mindful of cultural differences when informing patients, discussing advance care planning, responding to requests for assistance in dying, and responding to requests for limiting treatment.
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Finding health in folklore, herbs and supplements: the good, the bad & the ugly. Part II-- The ugly.
The dark 'bad' side of herbal and supplement use is not only in their direct adverse effects or toxicity, but in their potential for interactions with a variety of agents commonly used by mainstream practitioners. In the next issue, Part III--The Ugly--will focus on the distorted image of these hazardous herbal drifters.