Arch Intern Med
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Review Case Reports
Hypoglycemic coma in anorexia nervosa. Case report and review of the literature.
Clinically significant hypoglycemia is an unusual complication of anorexia nervosa. We describe a 44-year-old woman with a 5-year history of anorexia nervosa who presented with hypoglycemic coma and eventually experienced sudden death. ⋯ Nine previously reported cases of severe hypoglycemia in anorexia nervosa are reviewed (six of the patients involved also died). The presence of severe hypoglycemia in anorexia nervosa implies a grave prognosis and mandates aggressive medical and nutritional therapy to improve the chance of survival.
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Central to the nature of the physician-patient relationship is how fully patients are informed about their disease and prognosis and how active a role they take in deciding treatment; the "autonomy" and "paternalistic" models represent current poles of physician behavior. While informed consent has become ubiquitous in medical practice, it is not clear to what extent the value of patient autonomy has entered into everyday medical decisions. ⋯ We found that most patients wanted guidance from their physicians and most physicians did not view the patient as autonomous. The more traditional parentalistic model continues to influence the physician-patient relationship, at least for this technical endeavor.
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Comparative Study
Reliability and validity of an objective structured clinical examination for assessing the clinical performance of residents.
Clinical performance of residents should be assessed as reliably and validly as possible. This study investigated the reliability and validity of an objective structured clinical examination (OSCE) for assessing clinical performance of internal medicine residents. Residents were required to take a 17-patient OSCE in their first and second year. ⋯ American Board of Internal Medicine certifying examination scores were consistently positively correlated only with diagnosis. This 17-case OSCE is a feasible method for obtaining moderately reliable, valid data not available from other sources about the clinical performance of residents. More cases should be added to increase its reliability.
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Comparative Study
The search for an optimized treatment of hypoglycemia. Carbohydrates in tablets, solutin, or gel for the correction of insulin reactions.
Recommendations for the treatment of insulin reactions are based more on habit than data. We investigated the efficacy in correcting blood glucose levels and alleviating clinical symptoms of hypoglycemia of seven orally administered carbohydrates--glucose in solution, tablets, and gel; sucrose in solution and tablets; a hydrolized polysaccharide solution; and orange juice--each of which provided 15 g of carbohydrate. Forty-one type I diabetic patients recently treated with insulin agreed to submit to artificially induced hypoglycemia by an intravenous injection of insulin. ⋯ We conclude that in moderately severe hypoglycemia, ingestion of 15 g of carbohydrate in the form of glucose or sucrose tablets or as a solution provides an effective therapy; both sugars seem equivalent. Even if sucrose lumps are better recommended in terms of cost and availability, they may not be recommendable in terms of palatability. Glucose gel or orange juice cannot be recommended, at least in light of our experimental procedure and at the dosage used therein.
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We investigated attitudes toward resuscitation by interviewing 97 competent patients classified as do not resuscitate, 60 physicians, 80 family members, and 84 nurses. In addition, 58 family members of incompetent do not resuscitate patients were interviewed. Interview patients were generally elderly, female widows with a diagnosis of malignancy. ⋯ Sixty-four patients (66%) did not think discussing resuscitation was cruel and insensitive. Eighteen physicians (30%) said they were uncomfortable discussing resuscitation with patients. We recommend introducing the topic of resuscitation early in the patient-physician relationship before diminished competency occurs.