Archives of family medicine
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To assess the prevalence of advance directives among nursing home residents before and after passage of the Patient Self-Determination Act (PSDA) and to identify factors associated with advance directive completion. ⋯ Nearly 35% of the residents in the post PSDA cohort had an advance directive documented in the medical record. Most residents with advance directives had completed them more than 6 months before the nursing home admission. The major effect of the PSDA for nursing homes has been to enhance the documentation of existing advance directives. Little evidence exists that providing advance directive information at the time of nursing home admission has enhanced the completion of an advance directive after admission.
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Randomized Controlled Trial Clinical Trial
Multiple-attack efficacy and tolerability of sumatriptan nasal spray in the treatment of migraine.
Sumatriptan hemisulfate nasal spray may provide a useful therapeutic option for patients with migraine who find injectable medications inconvenient or uncomfortable and for patients whose migraine-associated nausea and vomiting preclude the use of oral medication. This study was the first US trial to evaluate the effects of sumatriptan nasal spray administered for multiple migraine attacks. ⋯ Sumatriptan hemisulfate nasal spray (5, 10, or 20 mg) is effective and well tolerated in the treatment of multiple migraine attacks. The 20-mg dose was associated with the highest efficacy rates across the greatest number of parameters.
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We reviewed the approach to preoperative cardiac risk assessment, incorporating new information regarding the pathophysiologic features of perioperative myocardial ischemia and recent clinical trials. Relevant articles were identified from a MEDLINE search, followed by bibliography review of the articles identified. The multifactorial risk indexes are valuable in stratifying risks among unselected patients undergoing noncardiac surgery, but they underestimate the risks in selected groups, particularly patients with peripheral vascular disease. ⋯ A thorough, targeted history and physical examination supplemented with judicious laboratory studies are usually sufficient to assess a patient's risk for upcoming noncardiac surgery. The clinical history should identify risk factors that predict cardiac complications, and special attention should be given to those risk factors that can be modified before surgery. New developments in perioperative medicine will likely lead to postoperative interventions to reduce silent myocardial ischemia and clinical complications.
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To determine the association between "difficult" patient status and personality disorder. ⋯ Unrecognized personality disorder can make difficult provider-patient relationships more likely. Dependent personality disorder may be especially difficult. Improved physician awareness of personality disorders may lead to more effective understanding and treatment of some difficult patients.
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To gain an understanding of the prevalence, utilization patterns, and practice implications of the use of Native American healers together with the use of physicians, we conducted semistructured interviews at an urban Indian Health Service clinic in Milwaukee, Wisc, of a convenience sample of 150 patients at least 18 years old. The mean age of patients was 40 years, and the sex distribution was 68.7% women and 31.3% men. Thirty tribal affiliations were represented, the largest groups being Ojibwa (20.7%), Oneida (20.0%), Chippewa (11.3%), and Menominee (8.0%). ⋯ The patients rate their healer's advice higher than their physician's advice 61.4% of the time. Only 14.8% of the patients seeing healers tell their physician about their use. We conclude that physicians should be aware that their Native American patients may be using alternative forms of treatment, and they should open a respectful and culturally sensitive dialogue about this use with their patients.