Harefuah
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Grafts from living donors are a novel alternative to cadaveric organs for adult liver recipients. ⋯ Right lobe grafts prevented small-for-size syndrome. Although donor hepatectomy and recipient grafting are technically more demanding, right lobe grafting seems to involve fewer recipient complications and better outcome.
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Profound hypothermia (core temperature of less than 28 degrees C) is a life threatening state and a medical emergency associated with a high mortality rate. The prognosis depends on underlying diseases, advanced or very early age, the duration prior to treatment, the degree of hemodynamic deterioration, and especially, the methods of treatment, including active external or internal rewarming. This is a case study of an 80-year-old female patient with severe accidental hypothermia (core temperature 27 degrees C). ⋯ Respiratory and metabolic, sometimes lactic, acidosis, lethargy and coma, hypercoagulopathy, hyperosmolar state, acute pancreatitis and renal and hepatic failure are frequent complications of hypothermia. Underlying predisposing causes of hypothermia are diabetic ketoacidosis, cerebrovascular disease, mental retardation, hypothyroidism, pituitary and adrenal insufficiency, malnutrition, acute alcoholism, liver damage, hypoglycemia, sepsis, hypothalamic dysfunction, sepsis and polypharmacy, and especially, the use of sedative and narcotic drugs. Our case demonstrates once again that CPR once begun should continue until the successful rewarming because "no one is dead until warm and dead".
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Physicians participate in the legal process of appointing guardianship by writing medical certificates concerning guardianship. There are no instructions or clear-cut methods to examine how to determine a person's ability to handle his own affairs (estate and body), or to evaluate his ability to express his opinion concerning guardianship. There are, however, a number of ways to examine and analyze the subject. Our paper presents findings from 16 randomly collected medical certificates from diverse sources (13 different institutions, physicians from various specialties), for which the courts decision is known. We checked to see if the medical certificates relate to and fulfill basic medico-legal and clinical points referred to in the professional literature. ⋯ We found that full demographic details were recorded in only one certificate (6.2%), the identity of the solicitor of the certificate was mentioned in 3 cases (18.7%) and the source/s of information in 6 cases (37.5%). Results of complete cognitive/mental examination (mental status) were mentioned in 4 cases (25%), psychiatric diagnoses in 12 cases (75%), level of severity in 9 cases (56.2%), reference to a temporary phenomenon in one case, and evaluation of basic daily functioning in 2 cases (12.5%). None of the cases included more complex daily functioning evaluations (instrumental). Similarly, none of the certificates mentioned whether or not legal criteria were used to evaluate the subjects ability to handle his estate or body or his ability to express his opinion concerning guardianship. On the other hand, formal reference to the ability to handle affairs (in 7 cases [43.7%] distinction between estate and body) and to express an opinion concerning guardianship was noted in 15 cases (93.75%). The length of the medical certificate averaged 13.8 lines (standard deviation 10.1, range 4-41); 13 of the certificates were written in public forums with an average length of 9.9 lines (standard deviation 4.6, range 4-20 lines), as opposed to 31 lines (standard deviation 9.5, range 22-41) for the private sector. Our findings suggest that the medical certificates were lacking in clinical facets examined, especially the medico-legal aspects. Despite these shortcomings, the courts accepted the overwhelming majority of the documents (15/16, 93.7%), perhaps because most of the certificates included formal reference to specific legal questions raised in the court (ability to handle affairs, ability to express opinion concerning guardianship). In our opinion, these findings, if validated in larger groups and in more courts, require multi-system re-evaluation of the subject of writing medical certificates for legal guardianship of the elderly.
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Randomized Controlled Trial Multicenter Study Comparative Study Clinical Trial
[The benefit of combining spinal morphine and intravenous buprenorphine for perioperative pain].
Concurrent administration of opioids with different affinity produces synergistic antinociceptive effect in rats. We tested the perioperative antinociceptive effects of the simultaneous double blind administration of morphine, a pure agonist and buprenorphine, a partial agonist, in 30 patients undergoing hysterectomy under general anesthesia. Pre- and post-operatively regimens consisted of random patient assignment to intrathecal 0.3 mg morphine plus intravenous saline (group 1), intravenous 0.09 mg buprenorphine plus intrathecal saline (group 2) or intrathecal morphine 0.3 mg plus intravenous buprenorphine 0.09 mg (group 3). ⋯ Buprenorphine-induced analgesia in group 3 lasted significantly (P < 0.05) longer than in group 2. Side effects in groups 2 and 3 were by 44% and 42% fewer than in group 1, respectively, with no withdrawal symptoms. Thus, concomitant administration of intrathecal morphine and low dose intravenous buprenorphine produces better and longer pain relief than intravenous buprenorphine alone in women after hysterectomy.