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Both physicians and surrogates do little pted CPR varied significantly with geographic location better than random chance when predicting the patient’s 23 purchase 50 mcg flonase fast delivery,24 and with diagnosis; CPR rates were more than threefold wishes about CPR. Discussion with patients about greater for patients with congestive heart failure than preferences should ideally occur in advance of significant 30 other diagnoses. Orders to not attempt resuscitation decline in cognitive status, although psychiatric or (DNR) are more common for patients with more neurologic illness should not preclude a discussion with functional compromise and with increased age and vary by diagnosis, gender, race, and location. In one geriatric practice, Alternative approaches that are possible to manage expected events a discussion of probability of survival reduced by ap- The good and bad effects likely from each alternative proximately 50% the number of elderly patients who 302 S. Goodlin stated that they wished CPR attempted for a cardiac family more easily accept decreased intake of food and arrest. Requests for excellent patient and family guides may help with weigh- physician-assisted suicide center around patient fears of ing the burdens and benefits of artificial nutrition and decline in function, suffocation, pain, suffering, and the hydration and other treatments. Allowing patients to refuse food discomfort46 that may outweigh any benefits of improved and water in concert with pharmacologic treatment of hydration and nutritional status. In patients with any symptom distress has been proposed as an alterna- progressive dementia, families can anticipate the loss of tive to active physician aid in dying. Decisions about tube feeding and Planning and Providing Care other interventions can be made in advance, in the context of the goals of care (comfort and safety versus The physician’s willingness to listen to a patient’s or maximal possible life prolongation). When a decision is family member’s concerns and to discuss plans for care made not to employ artificial nutrition and hydration, may be critical to satisfaction with their care. Aspiration should be accepted as a con- medical events in the course of the illness, social and care- sequence of late-stage dementia, with or without feeding. An interdisciplinary team—either estab- caregivers can be coached in appropriate techniques lished or virtual (brought "together" via telephone or (such as sitting up at 90°, tipping the chin forward), as other communication for the specific patient)—can best there is not evidence that tube feeding reduces the risk address these varied issues based upon the explicit goals of aspiration.

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Question 10 Has this test been placed in the context of other potential tests in the diagnostic sequence for the condition? In general buy flonase 50 mcg with amex, we treat high blood pressure sim ply on the basis of the blood pressure reading alone (although we tend to rely on a series of readings rather than a single value). Com pare this with the sequence we use to diagnose stenosis ("hardening") of the coronary arteries. First, we select patients with a typical history of effort angina (chest pain on exercise). N ext, we usually do a resting ECG , an exercise ECG , and, in som e cases, a radionuclide scan of the heart to look for areas short of oxygen. M ost patients only com e to a coronary angiogram (the definitive investigation for coronary artery stenosis) after they have produced an abnorm al result on these prelim inary tests. If you took 100 people off the street and sent them straight for a coronary angiogram , the test m ight display very different positive and negative predictive values (and even different sensitivity and specificity) than it did in the sicker population on which it was originally validated. This m eans that the various aspects of validity of the coronary angiogram as a diagnostic test are virtually m eaningless unless these figures are expressed in term s of what they contribute to the overall diagnostic work up. In such circum stances, it can be preferable to express the test result not as "norm al" or "abnorm al" but in term s of the actual chances of a patient having the target disorder if the test result reaches a particular level. Take, for exam ple, the use of the prostate specific antigen (PSA) test to screen for prostate cancer. Each table would use a different definition of an abnorm al PSA result to classify patients as "norm al" or "abnorm al". From these tables, we could generate different likelihood ratios associated with a PSA level above each different cutoff point. Then, when faced with a PSA result in the "grey zone", we would at least be able to say "This test has not proved that the patient has prostate cancer, but it has increased [or decreased] the odds of that diagnosis by a factor of x". In other words, there is no value for PSA that gives a particularly high likelihood ratio in cancer detection. As Sackett and colleagues explain at great length in their textbook,5 the likelihood ratio can be used directly in ruling a particular diagnosis in or out. For exam ple, if a person enters m y consulting room with no sym ptom s at all, I know that they have a 5% chance of having iron deficiency anaem ia, since I know that one person in 20 has this condition (in the language of diagnostic tests, this m eans that the pretest probability of anaem ia, equivalent to the prevalence of the condition, is 0.

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This technique buy flonase 50mcg with amex, which is not founded on any theoretical basis at all, which has been subjected to no clinical testing, illustrates a con- scious effort to confound charlatanesque practices with the placebo effect — with injectable treatments as one more "plus" over traditional homeopathic practice. Urine Therapy Among those therapies that fall halfway between practical jokes and reality, urine therapy heads the list, and it has the merit of a long history. The Ebers papyrus (an Egyptian medical document written on papyrus) mentions, among other supposed prescriptions for curing eye inflammations, a composition incorporating as varied and odorous in- gredients as fly and pelican droppings, human urine, and lizard’s, chil- dren’s, gazelle’s and even more often crocodile’s excrement. The mud of the Nile, swamp muck, mud and a certain type of earth referred to as "BTJ" are also mentioned as remedies in other Egyptian medical papy- ruses. Egyptian ophthalmologists also mixed excrements (dried and pulverized) with honey — if at all possible, fermented honey. This mixture was used as the basis for baths and ointments against tra- choma and chronic inflammations that withstood any other remedy. Urine was also employed for eye baths, while mud and earth were used to make plasters. In 1948, Benjamin Duggar discovered aureomycin (a fungus, like penicillin, that is effective against some viruses). According to Duggar’s research, aureomycin, whose antibiotic functions he revealed, could be found in the earth at the edges of cemeteries. Duggar and his team analyzed this earth and found that it contained molds that had the property of destroying pathogenic microbes and bacteria. Continuing his research, Duggar, who held the plant physiology chair at the University of W isconsin, showed that urine and feces also had antibiotic properties. This fact is known empirically, and novels for young people often mention cases of the explorer who "disinfects" his wounds with his own urine.

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A 1998 randomized controlled trial evaluated the physician consultants utility of a single home visit after discharge from acute Support for other team members hospital care by a nurse and a pharmacist to patients at Participation 50mcg flonase with visa, as needed, in home care/family conferences high risk of readmission to optimize compliance and Reassessments of care plan, outcomes of care 11 Evaluation of quality of care identify clinical deterioration. Six-month results in the Documentation in appropriate medical records intervention group found fewer unplanned hospital Provision for 24-h on-call coverage by a physician readmissions, fewer out-of-hospital deaths, fewer total Source: Adapted from the Amerian Medical Association, with deaths, and fewer emergency department visits. An earlier prospective randomized study of that 36,350 house calls were made to 11,917 patients. Patients readmissions, better quality of life scores, and lower costs 13 who received house calls were noted to be very sick and in the intervention group. These recent trials stand in contrast to older studies that In an accompanying editorial, Campion reviewed the failed to demonstrate the benefits of multiple interven- disadvantages of house calls: they are time consuming, tions provided to unselected populations of community- inefficient, and poorly reimbursed, and there are con- residing elderly. A 1986 critical review of 12 experimental 17 cerns about safety and lack of equipment. The ad- or quasi-experimental studies of home care concluded vantages include patient convenience, support, and that there was no evidence of a consistent effect on reassurance, and the availability of assessment informa- mortality, hospitalization, physical/functional status, 14 tion. Similarly, a 1987 review of cantly more likely to receive a CT scan or a cardiac 16 waiver-financed demonstration projects, including catheterization than a home visit. Most subjects, apparently, were not actually at internists and family physicians found similar results, with high risk of nursing home care. Subsequently, Weissert physicians noting that, although house calls were impor- and Hedrick suggested that targeting might improve out- 19 tant, reimbursement was poor. Physicians in Home Care Home Care Recipients The role of physicians in home care may include author- ization of services, communication with providers, Homebound patients are community-dwelling individu- patients, and families, or even actual home visits. In the percent had Mini Mental State Examination (MMSE) absence of this help, they would be at high risk of insti- scores suggestive of cognitive impairment (23%, under tutionalization. One-third reported visual (36%) and older than 50 receive help with at least one of the hearing (33%) deficits. Many could not independently ADLS—bathing, dressing, eating, toileting, continence, bathe (53%), ambulate in their own homes (55%), use transferring, and ambulating—or instrumental activities the toilet (25%), or eat (20%). Only 31% were free of of daily living (IADLs)—management of finances, use of functional impairments; 50% had two or more functional the telephone, organizing transportation, meal planning deficiencies. Of people receiving home health ser- more likely to be depressed, live alone, or have two or vices in 1996, 72% were aged 65 or older, 67% were more ADL deficiencies.