Arch Intern Med
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No large controlled studies to date have examined the hepatic safety of parenteral ketorolac, which is used to treat acutely ill hospitalized patients who may be at greatest risk of liver injury. ⋯ This study failed to find evidence of a hepatotoxic effect of parenteral ketorolac use in the hospital setting and provides strong evidence against the existence of a clinically meaningful association between exposure to parenteral ketorolac in the hospital setting and liver injury.
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In treating venous thromboembolic disorders, patient outcomes appear to correlate with heparin levels. Due to pharmacokinetic and pharmacodynamic variations, a relationship between heparin dose and level cannot be reliably predicted in individual patients. Some patients have low heparin levels despite therapeutic activated partial thromboplastin times (aPTTs), which may increase their risk for recurrent thromboembolism. Patients with high heparin requirements appear to have fewer bleeding episodes with heparin level-guided therapy. The aPTT does not reliably correlate with heparin blood concentrations or antithrombotic effects. Consequently, heparin therapy monitored with heparin levels may be more effective and safer. ⋯ The aPTT does not appear to be a useful surrogate for heparin levels. These findings suggest that the current recommendations on the use of heparin levels should be expanded.
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There is a significant direct relationship between steady-state intravenous heparin dose requirements and total body weight. Less is known about whether sex, age, clinical diagnosis, and the thromboplastin used to measure the activated partial thromboplastin time (aPTT) affect heparin dose requirements. ⋯ Steady-state heparin dose requirements were significantly different in patients with DVT compared with patients with CAD, suggesting that different dosing nomograms are needed for each condition. For patients with DVT, the accuracy of the initial heparin dose estimate may be improved by considering the patient's age and weight.
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Practice Guideline Guideline
The sixth report of the Joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure.
Racial and ethnic minority populations are growing segments of our society. The prevalence of hypertension in these populations differs across groups, and control rates are not as good as in the general population. Clinicians should be aware of these management challenges, taking social and cultural factors into account. ⋯ ACE inhibitors have additional renoprotective effects over other antihypertensive agents. Patients with diabetes should be treated to a therapy blood pressure goal of below 130/85 mm Hg. Hypertension may coexist with various other conditions and may be induced by various pressor agents.
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Physicians often use their relationships with patients to promote specific therapeutic goals. Because of their personal histories, values, and biases, patients may react to physicians in ways that inhibit or enhance the relationship. The feelings that are aroused may induce physicians to become overly distant, engendering patient and physician dissatisfaction, or to become overly involved emotionally, which can have serious psychological and clinical consequences. ⋯ The nature and origin of personal boundaries are described. Boundary transgressions on the part of the patient are discussed, and the means of preventing transgressions by both patients and physicians through medical education, the process of self-awareness, and an exploration of family-of-origin issues are proposed. Through attention to communication with patients, the physician can maintain an empathetic yet objective relationship with the patient.