The Ochsner journal
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The Ochsner journal · Jan 2015
ReviewClinical Comparative Effectiveness Research Through the Lens of Healthcare Decisionmakers.
Healthcare expenditures in the United States exceed the healthcare expenditures of other countries, yet relatively unfavorable health outcomes persist. Despite the emergence of numerous evidence-based interventions, wide variations in clinical care have caused disparities in quality of care and cost. Comparative effectiveness and cost effectiveness research may better guide healthcare decisionmakers in determining which interventions work best, for which populations, under which conditions, and at what cost. ⋯ Learning health systems and practice-based research networks provide the infrastructure for advancing CER methods, generating local solutions to high-quality cost-effective care, and transitioning research into implementation and dissemination science-all of which will ultimately guide health policy on clinical care, payment for care, and population health.
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The Ochsner journal · Jan 2014
ReviewEffect of opiates, anesthetic techniques, and other perioperative factors on surgical cancer patients.
Opioid pharmacotherapy is often used to treat cancer pain. However, morphine and other opioid-like substance use in patients with cancer may have significant adverse consequences, including the suppression of both innate and acquired immune responses. Although studies have examined the possibility that regional anesthesia attenuates the immunosuppressive response of surgery, the effects of morphine and other opioid-related substances on tumor progression remain unknown. ⋯ Immune responses from all components of the immune system, including both the humoral and cell-mediated components, appear to be suppressed by anesthetics and analgesics. The clinical anesthesiologist should consider these factors in the application of technique, especially in cancer surgery.
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The Ochsner journal · Jan 2014
ReviewAcute hypertension: a systematic review and appraisal of guidelines.
Few clinical practice guidelines provide management recommendations for acute hypertensive episodes except in the context of specific conditions such as pregnancy and stroke. ⋯ NHLBI and ESH/ESC guidelines are high quality and provide similar recommendations for management of asymptomatic acute hypertensive episodes and hypertensive emergencies. Additional research is needed to inform clinical practice guidelines for this common condition.
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The Ochsner journal · Jan 2014
ReviewPrimary palliative care for the general internist: integrating goals of care discussions into the outpatient setting.
Primary palliative care consists of the palliative care competencies required of all primary care clinicians. Included in these competencies is the ability to assist patients and their families in establishing appropriate goals of care. Goals of care help patients and their families understand the patient's illness and its trajectory and facilitate medical care decisions consistent with the patient's values and goals. General internists and family medicine physicians in primary care are central to getting patients to articulate their goals of care and to have these documented in the medical record. ⋯ General internists and family medicine practitioners in primary care are central to eliciting patients' goals of care and achieving optimal end-of-life outcomes for their patients.
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Acute kidney injury (AKI) is frequently encountered in the nephrology practice. Serum creatinine, with its many shortcomings, is still the main biomarker used to detect AKI. ⋯ Despite major advances in AKI research, serum creatinine remains the major biomarker for the detection of AKI. The following interventions have shown to be beneficial: IV fluids for contrast-induced AKI; diuretics for acute decompensated heart failure/cardiorenal syndrome; and combination therapy with midodrine, octreotide, and albumin for hepatorenal syndrome. Fluid resuscitation in a patient with AKI should be used with caution because too liberal use of fluids can be associated with increased mortality. AKI appears to be related to increased rates of subsequent chronic kidney disease, and patients with AKI should therefore be monitored closely. Recent studies on renal replacement therapy have neither revealed an optimal timing for initiation of dialysis nor a clear advantage for a specific dialysis modality.