Clinical cornerstone
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Death and dying are profound events that bring into focus important ethical and medical questions for all patients, whatever their cultural background. For ethnic minority groups and their families, specific issues or barriers may arise related to culturally appropriate health care practices, cultural or religious differences, diverse health beliefs, and access to services for care and support during end-of-life conditions. National policy and local initiatives in both the United States and the United Kingdom support the development of services that address the care of ethnic minorities. This article examines end-of-life care for ethnic minority groups.
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Clinical cornerstone · Jan 2003
Review Randomized Controlled Trial Clinical TrialInsulin therapy for the critically ill patient.
The risk of mortality or significant morbidity is high among critically ill patients who are treated in the intensive care unit (ICU) for > 5 days. These patients are susceptible to sepsis, excessive inflammation, critical illness polyneuropathy, and multiple organ failure, the latter often being the cause of death. Most intensive care patients, even those who did not previously suffer from diabetes, are hyperglycemic, which is presumed to reflect an adaptive development of insulin resistance. ⋯ Logistic regression analysis indicated that control of BG levels, rather than insulin administration itself, likely explains the observed clinical benefits. Use of insulin infusion to maintain normoglycemia using a titration algorithm, at least in populations similar to those in the Leuven study, improves outcome. Further data are needed to establish the applicability of this strategy to other patient groups, such as those in a medical ICU and in general hospital care.
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Clinical cornerstone · Jan 2002
ReviewDiseases of the rectum and anus: a clinical approach to common disorders.
Diseases of the rectum and anus are common, and the prevalence in the general population is probably much higher than that seen in clinical practice since most patients with symptoms referable to the anorectum do not seek medical attention. The examination and diagnosis of certain anorectal disorders can be challenging, and the physical examination of the anorectum is often inadequately performed in clinical practice. This article reviews the important features of the anorectal examination and the diagnosis and treatment of benign anorectal disorders such as hemorrhoids, fissures, fistulas, solitary rectal ulcer syndrome, fecal incontinence, and pruritus ani. Approaches to staging and managing malignant neoplasms of the anus and rectum are outlined.
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Clinical cornerstone · Jan 2001
Review Comparative StudyComparative aspects of triptans in treating migraine.
Triptans, beginning with sumatriptan, have revolutionized the treatment of migraine. New triptans in several formulations will soon become available in the United States. Although the similarities of these 5-hydroxytryptamine (5-HT) 1B/1D receptor agonists outweigh their differences, important differences in pharmacokinetics and clinical responses do exist. ⋯ Naratriptan and frovatriptan, with their slow onset, high tolerability, and long half-lives, may have a role in aborting prolonged migraine attacks and in headache prevention. Eletriptan at higher doses (80 mg) has a response rate approaching that of rizatriptan but may be limited by potential side effects. The many triptans available offer the opportunity to individualize migraine treatment, depending on the patient's attack characteristics, tolerance, and preferences.
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Despite a decade of progress, migraine headache remains prevalent, disabling, underdiagnosed, and undertreated in the United States. Migraine affects approximately 12% of the population, and the economic burden in terms of annual cost of labor lost to migraine disability is between $5.6 and $17.2 billion. The threshold for migraine may be genetically determined, although recent genetic and neurophysiologic studies point to migraine as possibly a channelopathy. ⋯ Head pain and associated symptoms of migraine can be explained by activation of the trigeminal vascular system. Evidence has also been accumulated that suggests the release of nitric oxide is an important trigger mechanism. Introduction of the triptans has dramatically advanced acute migraine pharmacotherapy, and preventive therapy has greatly improved; however, public health initiatives may be needed to further advance diagnosis and treatment of this common and disabling disorder.