Maternal hypotension may result from bolus dosing of anesthesia for parturient patients. When comparing systolic and diastolic blood pressure and mean arterial pressure readings, the authors found that the incidence of hypotension was lower in subjects receiving anesthesia via continuous epidural infusion (CEI) instead of traditional CEI plus bolus administration (5 [20%] vs 15 [60%]; P=.009). Of these subjects, intervention for hemodynamic instability was required in 1 CEI-only subject and 7 control subjects. Sensory block reached the T10 dermatomal level in 54.4 minutes for CEI-only subjects and 38.0 minutes for control subjects (P=.04), though self-reported pain levels and maternal and fetal pulse rates remained similar in both study groups. Adjuvant analgesic treatment was used more frequently for CEI-only subjects (72% vs 32%, P=.01) without adverse effect. The authors conclude that CEI alone reduces the incidence of maternal hypotension by 67% and is safer than traditional CEI plus bolus dosing for routine labor and delivery.
The authors describe their evaluation of a 76-year-old man as a result of pleural-based densities identified on a chest x-ray film. The patient had a medical history that included Hodgkin disease, mild aortic stenosis, hypertension, sudden weight loss, and long-term tobacco use, but no known exposure to asbestos. Diffuse malignant mesothelioma is not only the most common primary tumor involving the pleura, it also poses a great challenge for diagnosis and treatment. This report of case describes a rare subtype of mesothelioma.
Many adverse drug reactions (ADRs) can be linked to single-nucleotide polymorphisms in genes that control drug disposition. These natural variations can dramatically alter the synthesis of proteins as they metabolize and respond to introduced pharmacologic agents. The authors report a case in which a standard dose of methotrexate, an antimetabolite, resulted in life-threatening mucositis, neutropenia, and thrombocytopenia in a 61-year-old woman. The emerging field of pharmacogenetics, which explores the contribution of genetic differences to drug response, has provided insight into the origin of many ADRs. These considerations are particularly important when drugs with narrow therapeutic indices or those typically administered at or near their maximum tolerated doses are prescribed.
During the past 20 years, the American Osteopathic Association (AOA) has responded to imbalances in the number of graduating osteopathic medical students and the availability of osteopathic medical residency positions through regular policy change, most recently through ongoing revisions to Resolution 42 (A/2000), Approval of ACGME (Accreditation Council on Graduate Medical Education) Training as an AOA-Approved Internship. This controversial resolution provides a mechanism for osteopathic medical trainees to pursue more plentiful opportunities in ACGME-accredited training in lieu of the required AOA-approved internship. The author conducted a review of the literature and analyzed the AOA's database of Resolution 42 petitions. Of the 937 applications filed, 80% have been approved. The majority of special circumstances described were "location because of family concerns" (60.5%), followed by specialty choice (16.9%). Two thirds of Resolution 42 applicants were in family medicine and internal medicine residency programs. The author encourages the renewed engagement of the osteopathic medical profession with this AOA policy as it continues to shape the future of osteopathic medicine in the United States.
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