Mayo Clinic Health System

Adverse drug events continue to be the single most frequent source of healthcare mishaps, continually placing patients at risk of injury. This is not unexpected, given that drug treatment is the most common medical intervention and medication use is a highly complex, multidisciplinary, and largely manual process. Assessing the actual safety of drug use has been historically difficult, mainly because traditional methods such as chart audits and voluntary reporting of data have been shown to be expensive, insensitive, and largely ineffective for detecting mistakes in drug administration and drug related adverse clinical events (ADEs). Computerized methods for detecting ADEs, employing sentinel words or "triggers" in a patient's medical record, are effective but expensive and require customized software linkage to pharmacy databases. This paper describes the use of the "trigger tool", a relatively low cost and "low tech" modification of the automated technique. The adapted technique appears to increase the rate of ADE detection approximately 50-fold over traditional reporting methodologies.

795,000 strokes occurring annually in the United States, 87% are classified as ischemic strokes [1].Aging is the most robust non-modifiable risk factor for incident stroke, which doubles every 10 years after age 55 years.Approximately three-quarters of all strokes occur in persons aged ≥65 years.As the number of people aged ≥ 65 years is projected to grow, the number of incident strokes in older adults is expected to rise, presenting major challenges for clinicians and policy makers in the foreseeable future.Aging and cerebral vasculature.The complex network of the adult brain vasculature measures approximately 370 miles, receives about 20% of total cardiac output, and exchanges 20% of total blood glucose and oxygen.With aging, both cerebral microand macro-circulations undergo structural and functional alterations.Age-related microcirculatory changes are presumably mediated by endothelial dys-function and impaired cerebral autoregulation and neurovascular coupling.Whereas endothelial dysfunc-tion promotes neuro-inflammation, impaired cerebral autoregulation may lead to microvascular injury, and impaired neurovascular coupling fosters a decline in cortical function, all potential targets for future therapeutic interventions.Aging, in otherwise healthy individuals, is associated with numerous noticeable changes in human intracranial and extracranial cerebral arteries that predict the risk of future stroke.Aging and silent cerebrovascular disease.Silent cerebrovascular disease represents structural abnormalities, presumed vascular etiology, on neuroimaging not supported by clinically recognized stroke symptoms.The prevalence of silent cerebrovascular disease increases with advancing age and is recognizable as the following parenchymal lesions: 1) Silent infarcts (silent strokes), prevalence 6% and 28%, exceeds symptomatic stroke by a ratio of 10:1, 2) white matter hyperintensity or hypodensity on neuroimaging represent microvascular disease occurring in 20% to 94% older adults, and 3) cerebral microbleeds indicate silent intracerebral hemorrhages in 38% of general population aged >80 years.These conditions are age dependent and forecast increased risk of future symptomatic strokes (Figure 1).Aging and stroke risk factors.A worldwide population-based study identified 10 risk factors that collectively account for 88% of the risk of stroke in all Aging and ischemic stroke

Importance: After percutaneous coronary intervention (PCI), patients with CYP2C19*2 or *3 loss-of-function (LOF) variants treated with clopidogrel have increased risk of ischemic events. Whether genotype-guided selection of oral P2Y12 inhibitor therapy improves ischemic outcomes is unknown. Objective: To determine the effect of a genotype-guided oral P2Y12 inhibitor strategy on ischemic outcomes in CYP2C19 LOF carriers after PCI. Design, Setting, and Participants: Open-label randomized clinical trial of 5302 patients undergoing PCI for acute coronary syndromes (ACS) or stable coronary artery disease (CAD). Patients were enrolled at 40 centers in the US, Canada, South Korea, and Mexico from May 2013 through October 2018; final date of follow-up was October 2019. Interventions: Patients randomized to the genotype-guided group (n = 2652) underwent point-of-care genotyping. CYP2C19 LOF carriers were prescribed ticagrelor and noncarriers clopidogrel. Patients randomized to the conventional group (n = 2650) were prescribed clopidogrel and underwent genotyping after 12 months. Main Outcomes and Measures: The primary end point was a composite of cardiovascular death, myocardial infarction, stroke, stent thrombosis, and severe recurrent ischemia at 12 months. A secondary end point was major or minor bleeding at 12 months. The primary analysis was in patients with CYP2C19 LOF variants, and secondary analysis included all randomized patients. The trial had 85% power to detect a minimum hazard ratio of 0.50. Results: Among 5302 patients randomized (median age, 62 years; 25% women), 82% had ACS and 18% had stable CAD; 94% completed the trial. Of 1849 with CYP2C19 LOF variants, 764 of 903 (85%) assigned to genotype-guided therapy received ticagrelor, and 932 of 946 (99%) assigned to conventional therapy received clopidogrel. The primary end point occurred in 35 of 903 CYP2C19 LOF carriers (4.0%) in the genotype-guided therapy group and 54 of 946 (5.9%) in the conventional therapy group at 12 months (hazard ratio [HR], 0.66 [95% CI, 0.43-1.02]; P = .06). None of the 11 prespecified secondary end points showed significant differences, including major or minor bleeding in CYP2C19 LOF carriers in the genotype-guided group (1.9%) vs the conventional therapy group (1.6%) at 12 months (HR, 1.22 [95% CI, 0.60-2.51]; P = .58). Among all randomized patients, the primary end point occurred in 113 of 2641 (4.4%) in the genotype-guided group and 135 of 2635 (5.3%) in the conventional group (HR, 0.84 [95% CI, 0.65-1.07]; P = .16). Conclusions and Relevance: Among CYP2C19 LOF carriers with ACS and stable CAD undergoing PCI, genotype-guided selection of an oral P2Y12 inhibitor, compared with conventional clopidogrel therapy without point-of-care genotyping, resulted in no statistically significant difference in a composite end point of cardiovascular death, myocardial infarction, stroke, stent thrombosis, and severe recurrent ischemia based on the prespecified analysis plan and the treatment effect that the study was powered to detect at 12 months. Trial Registration: ClinicalTrials.gov Identifier: NCT01742117.

The American Society of Anesthesiologists (ASA) physical status classification system was developed to offer clinicians a simple categorization of a patient's physiological status to help predict operative risk. The ASAPS originated in 1941 and has seen some revisions since that time.

The growing recognition of harm as an unwelcome and frequently unrecognized byproduct of health care has initiated focused efforts to create highly reliable organizations for safe healthcare delivery. While debate continues over the exact magnitude of harm, there is a general acceptance of the need to improve our ability to deliver care in a safer manner. A major barrier to progress in safety has been the ability to effectively measure harm consistently and thus develop effective and targeted strategies to prevent its occurrence. This has resulted in a shift from initiatives focused exclusively on analysis of errors to those targeting events linked to harm. There is a growing recognition of a distinction between errors and adverse events as they often represent unique concepts fostering different strategies for improvement of safety. Conventional approaches to identifying and quantifying harm such as individual chart audits, incident reports, or voluntary administrative reporting have often been less successful in improving the detection of adverse events. As a result, a new method of measuring harm--the trigger tool--has been developed. It is easily customized and can be readily taught, enabling consistent and accurate measurement of harm. The history, application, and impact of the trigger tool concept in identifying and quantifying harm are discussed.

BACKGROUND: Sepsis is a major risk factor for the development of thrombocytopenia, but few studies have specifically evaluated prognostic importance of thrombocytopenia in patients with sepsis. We investigated the incidence, risk factors, and prognostic importance of thrombocytopenia in adult patients admitted to the intensive care unit (ICU) with sepsis. METHODS: A retrospective analysis of patients admitted with severe sepsis/septic shock from December 2007 to January 2009 to a 24-bed medical ICU was done. RESULTS: A total of 304 patients were included in the study. The patients' mean (±SD) age was 68.8 (±15.8) years. The majority (93.7%) had septic shock, and pneumonia was the most common infection (38.8%). Thrombocytopenia developed in 145 patients (47.6%): 77 (25.3%) at ICU admission and 68 (22.3%) during their hospital course. The median (IQR) duration of thrombocytopenia was 4.4 (1.9-6.9) days. Patients who developed thrombocytopenia had more episodes of major bleeding (14.4% vs. 3.7%, P < 0.01) and received more transfusions. Patients with thrombocytopenia had a higher incidence of acute kidney injury (44.1% vs. 29.5%, P < 0.01), prolonged vasopressor support (median (IQR): 37 (17-76) vs. 23 (13-46) h, P < 0.01), and longer ICU stay (median (IQR): 3.1 (1.6-7.8) vs. 2.1 (1.2-4.4) days, P < 0.01). The 28-day mortality was similar between patients with and without thrombocytopenia (32.4% vs. 24.5%, P = 0.12). However, while 15 of 86 patients (17.4%) who resolved their thrombocytopenia died, 32 of 59 patients (54.2%) whose thrombocytopenia did not resolve died (P < 0.01). The association between non-resolution of thrombocytopenia and mortality remained significant after adjusting for age, APACHE III score and compliance with a sepsis resuscitation bundle (P < 0.01). CONCLUSIONS: Thrombocytopenia is common in patients who are admitted to the ICU with severe sepsis and septic shock. Patients with thrombocytopenia had more episodes of major bleeding, increased incidence of acute kidney injury, and prolonged ICU stay. Non-resolution of thrombocytopenia, but not thrombocytopenia itself, was associated with increased 28-day mortality.

Considering an increase in the life expectancy leading to a rise in the elderly population, it is important to recognize the changes that occur along the process of aging. Gastrointestinal (GI) changes in the elderly are common, and despite some GI disorders being more prevalent in the elderly, there is no GI disease that is limited to this age group. While some changes associated with aging GI system are physiologic, others are pathological and particularly more prevalent among those above age 65 years. This article reviews the most important GI disorders in the elderly that clinicians encounter on a daily basis. We highlight age-related changes of the oral cavity, esophagus, stomach, small and large bowels, and the clinical implications of these changes. We review epidemiology and pathophysiology of common diseases, especially as they relate to clinical manifestation in elderly. Details regarding management of specific disease are discussed in detail if they significantly differ from the management for younger groups or if they are associated with significant challenges due to side effects or polypharmacy. Cancers of GI tract are not included in the scope of this article.

BACKGROUND: Ehrlichiosis is a clinically important, emerging zoonosis. Only Ehrlichia chaffeensis and E. ewingii have been thought to cause ehrlichiosis in humans in the United States. Patients with suspected ehrlichiosis routinely undergo testing to ensure proper diagnosis and to ascertain the cause. METHODS: We used molecular methods, culturing, and serologic testing to diagnose and ascertain the cause of cases of ehrlichiosis. RESULTS: On testing, four cases of ehrlichiosis in Minnesota or Wisconsin were found not to be from E. chaffeensis or E. ewingii and instead to be caused by a newly discovered ehrlichia species. All patients had fever, malaise, headache, and lymphopenia; three had thrombocytopenia; and two had elevated liver-enzyme levels. All recovered after receiving doxycycline treatment. At least 17 of 697 Ixodes scapularis ticks collected in Minnesota or Wisconsin were positive for the same ehrlichia species on polymerase-chain-reaction testing. Genetic analyses revealed that this new ehrlichia species is closely related to E. muris. CONCLUSIONS: We report a new ehrlichia species in Minnesota and Wisconsin and provide supportive clinical, epidemiologic, culture, DNA-sequence, and vector data. Physicians need to be aware of this newly discovered close relative of E. muris to ensure appropriate testing, treatment, and regional surveillance. (Funded by the National Institutes of Health and the Centers for Disease Control and Prevention.).

IMPORTANCE: Hereditary factors play a key role in the risk of developing several cancers. Identification of a germline predisposition can have important implications for treatment decisions, risk-reducing interventions, cancer screening, and germline testing. OBJECTIVE: To examine the prevalence of pathogenic germline variants (PGVs) in patients with cancer using a universal testing approach compared with targeted testing based on clinical guidelines and the uptake of cascade family variant testing (FVT). DESIGN, SETTING, AND PARTICIPANTS: This prospective, multicenter cohort study assessed germline genetic alterations among patients with solid tumor cancer receiving care at Mayo Clinic cancer centers and a community practice between April 1, 2018, and March 31, 2020. Patients were not selected based on cancer type, disease stage, family history of cancer, ethnicity, or age. EXPOSURES: Germline sequencing using a greater than 80-gene next-generation sequencing platform. MAIN OUTCOMES AND MEASURES: Proportion of PGVs detected with a universal strategy compared with a guideline-directed approach and uptake of cascade FVT in families. RESULTS: A total of 2984 patients (mean [SD] age, 61.4 [12.2] years; 1582 [53.0%] male) were studied. Pathogenic germline variants were found in 397 patients (13.3%), including 282 moderate- and high-penetrance cancer susceptibility genes. Variants of uncertain significance were found in 1415 patients (47.4%). A total of 192 patients (6.4%) had incremental clinically actionable findings that would not have been detected by phenotype or family history-based testing criteria. Of those with a high-penetrance PGV, 42 patients (28.2%) had modifications in their treatment based on the finding. Only younger age of diagnosis was associated with presence of PGV. Only 70 patients (17.6%) with PGVs had family members undergoing no-cost cascade FVT. CONCLUSIONS AND RELEVANCE: This prospective, multicenter cohort study found that universal multigene panel testing among patients with solid tumor cancer was associated with an increased detection of heritable variants over the predicted yield of targeted testing based on guidelines. Nearly 30% of patients with high-penetrance variants had modifications in their treatment. Uptake of cascade FVT was low despite being offered at no cost.

BACKGROUND: The objective of this study was to determine the incidence and outcome of perioperative cardiac arrest (CA) in children younger than 18 yr undergoing anesthesia for noncardiac and cardiac procedures at a tertiary care center. METHODS: After institutional review board approval (Mayo Clinic, Rochester, Minnesota), all patients younger than 18 yr who had perioperative CA between November 1, 1988, and June 30, 2005, were identified. Perioperative CA was defined as a need for cardiopulmonary resuscitation or death during anesthesia care. A cardiac procedure was defined as a surgical procedure involving the heart or great vessels requiring an incision. RESULTS: A total of 92,881 anesthetics were administered during the study period, of which 4,242 (5%) were for the repair of congenital heart malformations. The incidence of perioperative CA during noncardiac procedures was 2.9 per 10,000, and the incidence during cardiac procedures was 127 per 10,000. The incidence of perioperative CA attributable to anesthesia was 0.65 per 10,000 anesthetics, representing 7.5% of the 80 perioperative CAs. Both CA incidence and mortality were highest among neonates (0-30 days of life) undergoing cardiac procedures (incidence: 435 per 10,000; mortality: 389 per 10,000). Regardless of procedure type, most patients who experienced perioperative CA (88%) had congenital heart disease. CONCLUSION: The majority of perioperative CAs were caused by factors not attributed to anesthesia, in distinction to some recent reports. The incidence of perioperative CA is many-fold higher in children undergoing cardiac procedures, suggesting that definition of case mix is necessary to accurately interpret epidemiologic studies of perioperative CA in children.

Treatment for individuals suffering from migraines and pain due to an inflammation or impingement of a nerve range from noninvasive methods such as massage, physical therapy, and medications to invasive methods such as epidural steroid injections and surgery. Each method of treatment has an associated level of risk. While minor to moderate complications from such procedures do occur, deaths are very rare. We report the first cited case of a death associated with the pain management procedure called nerve root block, also referred to as a transforaminal epidural steroid injection. We present the medical history and autopsy findings of a 44-year-old white female who died of massive cerebral edema secondary to the dissection of the left vertebral artery and subsequent thrombosis due to the perforation of that artery by a 25-gauge spinal needle during a C-7 nerve root block.

BACKGROUND: The goal of this project was to study the frequency and natural history of perioperative lower extremity neuropathies. METHODS: A prospective evaluation of lower extremity neuropathies in 991 adult patients undergoing general anesthetics and surgical procedures while positioned in lithotomy was performed. Patients were assessed with use of a standard questionnaire and neurologic examination before surgery, daily during hospital stay in the first week after surgery, and by phone if discharged before 1 postoperative week. Patients in whom lower extremity neuropathies developed were observed for 6 months. RESULTS: Lower extremity neuropathies developed in 15 patients (1.5%; 95% confidence interval, 0.8-2.5%). Unilateral or bilateral nerves were affected in patients as follows: obturator (five patients), lateral femoral cutaneous (four patients), sciatic (three patients), and peroneal (three patients). Paresthesia occurred in 14 of 15 patients, and 4 patients had burning or aching pain. No patient had weakness. Symptoms were noted within 4 h of completion of the anesthetic in all 15 patients. These symptoms resolved within 6 months in 14 of 15 patients. Prolonged positioning in a lithotomy position, especially for more than 2 h, was a major risk factor for this complication (P = 0.006). CONCLUSIONS: In this surgical population, lower extremity neuropathies were infrequent complications that were noted very soon after surgery and anesthesia. None resulted in prolonged disability. The longer patients were positioned in lithotomy positions, the greater the chance of development of a neuropathy. These findings suggest that a reduction of duration of time in lithotomy positions may reduce the risk of lower extremity neuropathies.

BACKGROUND: The incidence of distal biceps tendon ruptures was studied more than 10 years ago in a small patient cohort. Recent diagnostic advancements have improved the ability to detect this rare injury. HYPOTHESIS: The incidence of distal biceps tendon ruptures will be significantly greater than previously reported. STUDY DESIGN: Descriptive epidemiologic study. METHODS: A query of the PearlDiver Technologies national database containing public and private insurance patients was used to estimate the national incidence of distal biceps tendon ruptures in the United States. A retrospective chart review of our local population identified demographic groups and risk factors that increased likelihood of injury. RESULTS: The estimated national incidence of distal biceps tendon rupture was 2.55 per 100,000 patient-years. The local incidence was 5.35 per 100,000 patient-years. The mean and median ages of patients in our regional cohort were 46.3 and 46 years, respectively. Males composed the majority of the injured population (national 95%, regional 96%). Smoking and elevated body mass index were found to be associated with increased likelihood of injury, while diabetes mellitus showed no association. CONCLUSION: The incidence of distal biceps tendon ruptures in this study was higher than previously reported.

Real-time RT-PCR is considered the gold standard confirmatory test for coronavirus disease 2019 (COVID-19). However, many scientists disagree, and it is essential to understand that several factors and variables can cause a false-negative test. In this context, cycle threshold (Ct) values are being utilized to diagnose or predict SARS-CoV-2 infection. This practice has a significant clinical utility as Ct values can be correlated with the viral load. In addition, Ct values have a strong correlation with multiple haematological and biochemical markers. However, it is essential to consider that Ct values might be affected by pre-analytic, analytic, and post-analytical variables such as collection technique, specimen type, sampling time, viral kinetics, transport and storage conditions, nucleic acid extraction, viral RNA load, primer designing, real-time PCR efficiency, and Ct value determination method. Therefore, understanding the interpretation of Ct values and other influential factors could play a crucial role in interpreting viral load and disease severity. In several clinical studies consisting of small or large sample sizes, several discrepancies exist regarding a significant positive correlation between the Ct value and disease severity in COVID-19. In this context, a revised review of the literature has been conducted to fill the knowledge gaps regarding the correlations between Ct values and severity/fatality rates of patients with COVID-19. Various databases such as PubMed, Science Direct, Medline, Scopus, and Google Scholar were searched up to April 2021 by using keywords including "RT-PCR or viral load", "SARS-CoV-2 and RT-PCR", "Ct value and viral load", "Ct value or COVID-19". Research articles were extracted and selected independently by the authors and included in the present review based on their relevance to the study. The current narrative review explores the correlation of Ct values with mortality, disease progression, severity, and infectivity. We also discuss the factors that can affect these values, such as collection technique, type of swab, sampling method, etc.

All aspects of medical education were affected by the COVID-19 pandemic. Several challenges were experienced by trainees and programs alike, including economic repercussions of the pandemic; social distancing affecting the delivery of medical education, testing, and interviewing; the surge of patients affecting redeployment of personnel and potential compromises in core training; and the overall impact on the wellness and mental health of trainees and educators. The ability of medical teams and researchers to peer review, conduct clinical research, and keep up with literature was similarly challenged by the rapid growth in peer-reviewed and preprint literature. This article reviews these challenges and shares strategies that institutions, educators, and learners adopted, adapted, and developed to provide quality education during these unprecedented times.

BACKGROUND: Anesthetics administered to immature brains may cause histopathological changes and long-term behavioral abnormalities. The association between perinatal exposure to anesthetics during Cesarean delivery (CD) and development of learning disabilities (LD) was determined in a population-based birth cohort. METHODS: The educational and medical records of all children born to mothers residing in five townships of Olmsted County, Minnesota from 1976-1982 and remaining in the community at age 5 were reviewed to identify those with LDs. Cox proportional hazards regression was used to compare rates of LD between children delivered vaginally and via CD (with general or regional anesthesia). RESULTS: Of the 5,320 children in this cohort, 497 were delivered via CD (under general anesthesia n = 193, and regional anesthesia n = 304). The incidence of LD depended on mode of delivery (P = 0.050, adjusted for sex, birth weight, gestational age, exposure to anesthesia before age 4 yr, and maternal education). LD risk was similar in children delivered by vagina or CD with general anesthesia, but was reduced in children receiving CD with regional anesthesia (hazard ratio = 0.64, 95% confidence interval 0.44 to 0.92; P = 0.017 for comparison of CD under regional anesthesia compared to vaginal delivery). CONCLUSION: Children exposed to general or regional anesthesia during CD are not more likely to develop LD compared to children delivered vaginally, suggesting that brief perinatal exposure to anesthetic drugs does not adversely affect long-term neurodevelopmental outcomes. The risk of LD may be lower in children delivered by CD whose mothers received regional anesthesia.

Leadership is one of the most complex and multidimensional phenomena. It has been studied extensively over the years and has taken on greater importance than ever before in today’s fast-paced and increasingly globalised world. Nonetheless, leadership continues to generate captivating and confusing debate due to the complexity of the subject. Bennis notes that ‘leadership is the most studied and least understood topic of any in the social sciences’ and ‘never have so many laboured so long to say so little’.1 Researchers have proposed many different definitions and theories of leadership. Stogdill defines it as ‘an influencing process aimed at goal achievement’, focusing on leadership as a process directed at influencing a specific group of people to meet a stated objective.2 Kouzes and Posner similarly believe that ‘leadership is the art of mobilising others to want to struggle for the shared aspirations’3 and Maxwell states that leadership is simply influence.4 Yet there is no one definition or particular leadership approach that is considered universal and efforts continue in trying to identify what makes an effective leader. Effective leadership is recognised as key to the success of any organisation. In fact, there has been a shift towards acknowledging the importance of human capital and organisational management.5 6 But what is the difference between leadership and management? Leaders are generally viewed as visionaries and strategist whereas managers monitor and control performance, maintaining order and stability in an organisation.7 8 Some researchers argue that leaders and managers have distinct roles and responsibilities while others assert that leadership and management are complementary and it would be difficult to separate them in practice.7 The present paper traces the historical evolution of the main leadership theories and reviews the progress that has been made over the years. It explores four …

Supplementing with creatine is very popular amongst athletes and exercising individuals for improving muscle mass, performance and recovery. Accumulating evidence also suggests that creatine supplementation produces a variety of beneficial effects in older and patient populations. Furthermore, evidence-based research shows that creatine supplementation is relatively well tolerated, especially at recommended dosages (i.e. 3-5 g/day or 0.1 g/kg of body mass/day). Although there are over 500 peer-refereed publications involving creatine supplementation, it is somewhat surprising that questions regarding the efficacy and safety of creatine still remain. These include, but are not limited to: 1. Does creatine lead to water retention? 2. Is creatine an anabolic steroid? 3. Does creatine cause kidney damage/renal dysfunction? 4. Does creatine cause hair loss / baldness? 5. Does creatine lead to dehydration and muscle cramping? 6. Is creatine harmful for children and adolescents? 7. Does creatine increase fat mass? 8. Is a creatine 'loading-phase' required? 9. Is creatine beneficial for older adults? 10. Is creatine only useful for resistance / power type activities? 11. Is creatine only effective for males? 12. Are other forms of creatine similar or superior to monohydrate and is creatine stable in solutions/beverages? To answer these questions, an internationally renowned team of research experts was formed to perform an evidence-based scientific evaluation of the literature regarding creatine supplementation.

Contrary to common perception, modern palliative care (PC) is applicable to all people with an incurable disease, not only cancer. PC is appropriate at every stage of disease progression, when PC needs emerge. These needs can be of physical, emotional, social, or spiritual nature. This document encourages the use of validated assessment tools to recognize such needs and ascertain efficacy of management. PC interventions should be provided alongside cardiologic management. Treating breathlessness is more effective, when cardiologic management is supported by PC interventions. Treating other symptoms like pain or depression requires predominantly PC interventions. Advance Care Planning aims to ensure that the future treatment and care the person receives is concordant with their personal values and goals, even after losing decision-making capacity. It should include also disease specific aspects, such as modification of implantable device activity at the end of life. The Whole Person Care concept describes the inseparability of the physical, emotional, and spiritual dimensions of the human being. Addressing psychological and spiritual needs, together with medical treatment, maintains personal integrity and promotes emotional healing. Most PC concerns can be addressed by the usual care team, supported by a PC specialist if needed. During dying, the persons' needs may change dynamically and intensive PC is often required. Following the death of a person, bereavement services benefit loved ones. The authors conclude that the inclusion of PC within the regular clinical framework for people with heart failure results in a substantial improvement in quality of life as well as comfort and dignity whilst dying.

The accuracy of magnetic resonance imaging of the hip was prospectively evaluated in 19 military subjects engaged in endurance training. These patients had hip pain, negative radiographs, and radionuclide bone scans consistent with femoral neck stress fracture. Twenty-two hips were identified as positive for femoral neck stress fracture by bone scan. Each patient under went magnetic resonance imaging and 6-week fol low-up plain radiographs of the hips. Magnetic reso nance imaging studies differentiated femoral neck stress fractures from a synovial pit, iliopsoas muscle tear, iliopsoas tendinitis, obturator externus tendinitis, avascular necrosis of the femoral head, and a unicam eral bone cyst. The follow-up radiographs were used to verify the diagnosis of stress fracture. The radiographs showed healing callus in patients with stress fractures. Patients with diagnoses other than stress fractures had no changes on follow-up radiographs. Magnetic reso nance imaging studies were as sensitive and much more specific than bone scan in determining the cause of hip pain. Radionuclide bone scan had an accuracy of 68% for femoral neck stress fractures with 32% false-positive results; MRI was 100% accurate. Mag netic resonance imaging proved to be superior to ra dionuclide bone scanning in providing an early and accurate diagnostic tool that aided in the differential diagnosis of hip pain in the young endurance athlete.