Articles: adult.
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A 9-year-old girl accidentally injected her right thumb with an adult dose of epinephrine through an auto-injector syringe, delivering 0.3 mg of 1:1000 epinephrine. This injection caused immediate ischemic changes in the digit. ⋯ This report compares the management of a pediatric case to that of all reported adult cases of accidental subcutaneous epinephrine injections. This case suggests a pattern of infiltration with low-dose phentolamine that may be the most effective form of treatment for this condition in a patient of any age.
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Recent prospective controlled trials of induced moderate hypothermia (32-34 degrees C) for relatively short periods (24-48 h) in patients with severe head injury have suggested improvement in intracranial pressure control and outcome. It is possible that increased benefit might be achieved if hypothermia was maintained for more periods longer than 48 h, but there is little in the literature on the effects of prolonged moderate hypothermia in adults with severe head injury. We used moderate induced hypothermia (30-33 degrees C) in 43 patients with severe head injury for prolonged periods (mean 8 days, range 2-19 days). ⋯ Moderate hypothermia may be induced for more prolonged periods, and is a relatively safe and feasible therapeutic option in the treatment of selected patients with severe traumatic brain injury. Thus, further prospective controlled trials using induced hypothermia for longer periods than 48 h are warranted.
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Objective. Over the past two decades, with the increasing use of spinal instrumentation to treat deformity, surgical restoration has become more frequent. A complication of surgical reconstruction for adult scoliosis, the iatrogenic flat back syndrome, has been described. ⋯ Given the unpredictability of spinal osteotomy to address this pain, a possible alternative treatment strategy is presented. This involves the use of selective pharmaceutical therapy and spinal cord stimulation. Based on the response of this patient to spinal cord stimulation, it is a possible that a component of this persistent pain is neuropathic, despite the fact that preoperative imaging studies failed to disclose a significant compressive lesion.
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J. Acquir. Immune Defic. Syndr. Hum. Retrovirol. · Dec 1998
A prospective study of community-acquired bloodstream infections among febrile adults admitted to Mulago Hospital in Kampala, Uganda.
Septicemia is a frequent cause of death in HIV-infected adults in developing countries. Additional prospective studies are needed to determine the etiology of bloodstream infections (BSI) in febrile HIV-infected adults and guide initial evaluation and treatment in this setting. We assessed the prevalence and etiology of community-acquired BSI among 299 consecutive febrile adult medical admissions to Mulago Hospital, Kampala, Uganda, over a 4-month period in 1997. ⋯ Bacteremia and disseminated tuberculosis are frequent causes of morbidity in febrile HIV-infected Ugandan adults. Initial empiric antibiotic coverage in this setting should be targeted toward the pneumococcus and gram-negative enteric bacilli, especially nontyphi Salmonella species. All patients presenting with chronic cough should be evaluated for tuberculosis.
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J Ment Health Policy Econ · Dec 1998
The role of mental health service research in promoting effective treatment for adults with schizophrenia*
Significant gaps exist between scientific knowledge about the efficacy of treatments for mental disorders and the availability of efficacious treatments in routine practice. Mental health service research can help bridge this gap between basic clinical research and the usual care afforded adults with mental disorders. AIMS: To illustrate this potential, data on the efficacy of treatment for schizophrenia are reviewed. ⋯ Major deficiencies in treatment that were identified include inappropriate dosing with antipsychotic agents, underutilization of adjunctive antidepressant therapy, very low rates of prescription of psychosocial interventions and lack of continuity between inpatient and outpatient settings. DISCUSSION: These findings raise serious concerns about access to care and the appropriateness and quality of care that is offered. IMPLICATIONS: This knowledge about what treatments work for schizophrenia and the patterns of current care suggest the following major questions be addressed by mental health services research: What is the nature of care currently being offered adults with mental disorders? To what degree does this care measure up to scientifically derived quality of care and treatment standards? What is the effectiveness of new technologies under usual practice conditions? For which patients are they cost-effective and under what conditions? How should financial incentives be structured within systems of care to promote the most cost-effective use of new technologies? How should service systems themselves be organized to promote appropriate access and utilization? What educational, organizational and financing interventions promote adoption of effective interventions? Do we have valid methods for assessing quality of care? What strategies (interventions) are effective at improving the quality of care? In addition, we need to develop strategies that transfer mental health services research technologies into practice. These include: (i) development of outcome measures that meet scientific standards and that are practical for general application in service systems to facilitate "outcome management"; (ii) development of quality of care assessment methodologies that are practical and scientifically sound and (iii) cost-effectiveness methodologies. Mental health services research can facilitate the translation of knowledge developed from basic clinical research into more effective systems of care. The tools used by health services research to this end include examination of patterns of usual care in relation to scientifically established standards of efficacious care, interventions to improve the effectiveness of care and examination of the impacts of the organization and financing of services on outcomes and costs. In short, mental health service research holds high on its agenda the translation of basic and clinical research into practice. All of us must face the challenges posed by our rapidly changing mental health care system, changes driven not only by managed care and cost containment, but by exciting new developments in the treatment of mental disorders. We take on these challenges as researchers, clinicians, administrators, patients, families and taxpayers. Here I seek to provide a perspective on what we know about the treatment of adults with mental disorders and to discuss the implications of this knowledge for the work of mental health service research. Each of us has a particular window on this scene; mine is primarily that of a clinical mental health services researcher who studies schizophrenia. I will briefly summarize current knowledge about the efficacy of treatments for schizophrenia and the services research questions that this knowledge raises in its translation to clinical practice. The lessons from this examination readily generalize to the treatment of other adult mental disorders.