Articles: patients.
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Multicenter Study Comparative Study
Characteristics of patient visits to nurse practitioners and physician assistants in hospital outpatient departments.
Many authors have described differences between nurse practitioners and physician assistants. Most studies have compared physician with nonphysician providers' practice. Few studies have compared nurse practitioners and physician assistants, and none has used a national data base. ⋯ Results of multivariate logistic regression suggest that nurse practitioners were the most likely nonphysician provider for outpatients receiving more health promotion and counseling (therapeutic) services and for those needing women's and children's services. Outpatients in rural areas predicted visits to physician assistants. As more nonphysician providers enter the work force, the results of this research may assist with understanding the utilization of nurse practitioners and physician assistants in primary care.
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Recent advances in the application of regional anesthesia to the care of patients undergoing shoulder surgery are discussed. New techniques for the management of postoperative pain are highlighted, with an emphasis on interscalene patient-controlled analgesia and suprascapular block. ⋯ Intraoperative hypotension and bradycardia caused by activation of the Bezold-Jarisch reflex is considered. The ongoing debate regarding the use of paresthesia versus nerve-stimulator techniques is examined.
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Biplane methods of determining left ventricular volumes are inaccurate in the presence of aneurysmal distortions. Multiplane transesophageal echocardiography, which provides multiple, unobstructed cross-sectional views of the heart from a single, stable position, has the potential for more accurate determinations of volumes of irregular cavity forms than the biplane methods. The aim of the study was to determine the feasibility of three-dimensional measurements of ventricular volumes in patients with normal and aneurysmatic left ventricles by using multiplane transesophageal echocardiography. ⋯ In 12 observations (4 normal and 8 aneurysmal) from the ten patients with indwelling pulmonary artery catheters, correlation between stroke volumes determined from thermodilution cardiac output measurements and those derived from multiplane transesophageal echocardiographic images was high (r = 0.91, SEE = 6 ml). The results indicate that three-dimensional measurements of volumes of irregular and distorted left ventricles are feasible with multiplane transesophageal echocardiography. This method may be more accurate than biplane methods, especially in the presence of left ventricular aneurysms.
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J Stroke Cerebrovasc Dis · Sep 1998
Reduced stroke risk in patients with compromised cerebral blood flow reactivity treated with superficial temporal artery to distal middle cerebral artery bypass surgery.
Extracranial-to-intracranial (EC-IC) bypass surgery for the prevention of stroke in patients with symptomatic carotid artery occlusion has nearly ended after a randomized trial showed no benefit of the procedure. Although an EC-IC bypass might benefit patients with compromised cerebrovascular hemodynamics, the randomized trial did not differentiate patients with hemodynamic from embolic etiologies. However, subsequent investigators have identified a subgroup of patients at increased stroke risk from hemodynamic compromise. ⋯ STA-MCA bypass surgery can restore cerebrovascular reserve in high-risk patients with symptomatic internal carotid artery occlusion. This was achieved with minimal perioperative complications, resulting in a subsequent reduction of stroke frequency. We suggest that the efficacy of STA-MCA bypass surgery for symptomatic carotid occlusion be re-examined prospectively using hemodynamic selection criteria.
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Neuropathic pain syndromes may be treated by intervention at the sympathetic nervous system. The pain in these syndromes is therefore called sympathetically maintained pain (SMP). Typical disorders with a SMP component are complex regional pain syndromes (reflex sympathetic dystrophy and causalgia), traumatic neuralgias and herpes zoster. ⋯ Open questions are how the efferent sympathetic nervous system is capable of influencing pain sensation and which mechanisms underly the autonomic dysregulation often observed in these syndromes.(1) Somatic afferents that project through the sympathetic trunk do not exist. Therefore, a pure sympathetic block does not block afferent information arising from the affected extremity. What alternatives are possible? Under pathophysiological conditions a functional interaction of efferent sympathetic fibers and afferent nociceptive fibers could be demonstrated in patients and animal studies. The intensity of this coupling varies considerably between individual patients and is not necessary for the diagnosis of the disorder. (2) Sympathetically maintained pain and signs of autonomic dysfunction are independent clinical and pathophysiological phenomena without any causal relation. However, it is possible to treat both the SMP and the autonomic dysfunction with sympathetic blocks.