The Permanente journal
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The Emergency Department (ED) is the place where people most frequently seek urgent care. For patients living with chronic disease or malignancy who may be in a crisis, this visit may be pivotal in determining the patients' trajectory. There is a large movement in education of emergency medicine physicians, hospitalists, and intensivists from acute aggressive interventions to patient-goal assessment, recognizing last stages of life and prioritizing symptom management. ⋯ This article will summarize the following: identification of patients who may need palliation, discussing prognosis, eliciting goals of care and directives, symptom management in the ED, and making plans for further care. These efforts have been shown to improve outcomes and to decrease length of stay and cost. The focus of this article is relieving "patient" symptoms and family distress, honoring the patient's goals of care, and assisting in transition to a noncurative approach and placement where this may be accomplished.
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The Permanente journal · Jan 2014
Eluding meaninglessness: a note to self in regard to Camus, critical care, and the absurd.
Here I present a medical narrative, as a catharsis, regarding Albert Camus’s The Myth of Sisyphus in an attempt to elude meaninglessness in my difficult everyday practice of critical care medicine. It is well documented that physicians who practice critical care medicine are subject to burnout. The sense of despair that occasionally overwhelms me prompted my rereading of Camus’s classic text and caused me to recount his arguments that life is meaningless unless one is willing to take a leap of faith to the divine or, alternately, to commit suicide. This set up the examination of his third alternative, acceptance of a life without prima facie evidence of purpose and meaning, a view that may truly have some bearing on my professional life in the intensive care unit.
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The Permanente journal · Jan 2014
Prediabetes and lifestyle modification: time to prevent a preventable disease.
More than 100 million Americans have prediabetes or diabetes. Prediabetes is a condition in which individuals have blood glucose levels higher than normal but not high enough to be classified as diabetes. People with prediabetes have an increased risk of Type 2 diabetes. ⋯ To prevent 1 case of diabetes during a 3-year period, 6.9 persons would have to participate in the lifestyle intervention program. In addition, recent data suggest that the difference in direct and indirect costs to care for a patient with prediabetes vs a patient with diabetes may be as much as $7000 per year. Investment in a diabetes prevention program now may have a substantial return on investment in the future and help prevent a preventable disease.
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Intestinal microbiota play an important role in health and disease. The gut-liver axis provides for an interaction between bacterial components like lipopolysaccharide and hepatic receptors (Toll-like receptors). ⋯ Administration of health-promoting microbial strains may help ameliorate these harmful interactions and hepatic disorders. This review focuses on changes in gut microbiota in the context of liver disease and possible roles of probiotics, prebiotics, and synbiotics in liver disease.
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The Permanente journal · Jan 2013
ReviewTelepsychiatry in correctional facilities: using technology to improve access and decrease costs of mental health care in underserved populations.
It is unclear if telepsychiatry, a subset of telemedicine, increases access to mental health care for inmates in correctional facilities or decreases costs for clinicians or facility administrators. The purpose of this investigation was to determine how utilization of telepsychiatry affected access to care and costs of providing mental health care in correctional facilities. ⋯ Increasing access to mental health care for this underserved group through telepsychiatry may improve living conditions and safety inside correctional facilities. Providers, facilities, and state and federal governments can expect increased savings with utilization of telepsychiatry.