Annals of internal medicine
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To review the pathophysiology of gastrointestinal motility disorders during pregnancy, their clinical manifestations, and their management. ⋯ Given the large number of pregnancies each year complicated by gastrointestinal motility disorders, many physicians (including internists and gastroenterologists) must manage these problems. Knowledge of the underlying physiologic alterations in gastrointestinal motility during pregnancy and of safe treatment options is essential to the care of the pregnant patient.
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For many older persons, hospitalization results in functional decline despite cure or repair of the condition for which they were admitted. Hospitalization can result in complications unrelated to the problem that caused admission or to its specific treatment for reasons that are explainable and avoidable. Usual aging is often associated with functional change, such as a decline in muscle strength and aerobic capacity; vasomotor instability; reduced bone density; diminished pulmonary ventilation; altered sensory continence, appetite, and thirst; and a tendency toward urinary incontinence. ⋯ Any of these factors may thrust vulnerable older persons into a state of irreversible functional decline. The factors that contribute to a cascade to dependency are identifiable and can be avoided by modification of the usual acute hospital environment by deemphasizing bed rest, removing the hazard of the high hospital bed with rails, and actively facilitating ambulation and socialization. The relationships among physicians, nurses, and other health professionals must reflect the importance of interdisciplinary care and the implementation of shared objectives.
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Review Case Reports
Management of the severely anemic patient who refuses transfusion: lessons learned during the care of a Jehovah's Witness.
To present the case of a Jehovah's Witness with severe anemia and to review the religious philosophy of such patients, the ethical and medicolegal aspects of their care, and the therapeutic options available to clinicians. ⋯ A clear understanding of the philosophy of the Jehovah's Witnesses regarding blood transfusion and of the medicolegal and ethical aspects of their care is essential to clinicians who care for such patients. One must also be aware of the many alternative therapeutic options that can maximize oxygen delivery and minimize oxygen consumption. The insights gained from this review are applicable to any severely anemic patient who refuses blood transfusion.
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To review the current role of transesophageal echocardiography in the evaluation of stroke. ⋯ Transesophageal echocardiography is most helpful in patients with stroke who are less than 45 years of age and in those without clinical evidence of heart disease. The indications for its use in the evaluation of stroke remain controversial. Further studies are needed using transesophageal echocardiography in patients with stroke and in control groups, not only to determine the natural history of transesophageal, echocardiographically detected abnormalities but also to evaluate treatment options.
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To review available information on cough and angioneurotic edema associated with angiotensin-converting enzyme (ACE) inhibitors. ⋯ Cough occurs in 5% to 20% of patients treated with ACE inhibitors, recurring with reintroduction of the same or another ACE inhibitor. It is more common in women. The mechanism may involve accumulation of prostaglandins, kinins (such as bradykinin), or substance P (neurotransmitter present in respiratory tract C-fibers); both bradykinin and substance P are degraded by ACE. A 4-day trial of withdrawal of the ACE inhibitor or temporary substitution of another class of antihypertensive agent inexpensively and easily ascertains if the ACE inhibitor caused the cough. Change to another ACE inhibitor or additive therapy with nonsteroidal anti-inflammatory drugs is not recommended. Prompt recognition of ACE inhibitor-related cough can prevent unnecessary diagnostic testing and treatment. Angioedema occurs in 0.1% to 0.2% of patients receiving ACE inhibitors. The onset usually occurs within hours or, at most, 1 week after starting therapy. The mechanism may involve autoantibodies, bradykinin, or complement-system components. Treatment involves first protecting the airway, followed by epinephrine, antihistamines, and corticosteroids if needed. Therapy is then resumed with an alternate class of antihypertensive agent.