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Palo Alto, CA, United States

An advance health care directive, also known as living will, personal directive, advance directive, or advance decision, is a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity. In the U.S. it has a legal status in itself, whereas in some countries it is legally persuasive without being a legal document.A living will is one form of advance directive, leaving instructions for treatment. Another form is a specific type of power of attorney or health care proxy, in which the person authorizes someone to make decisions on their behalf when they are incapacitated. People are often encouraged to complete both documents to provide comprehensive guidance regarding their care. An example of combination documents includes the Five Wishes in the United States. The term living will is also the commonly recognised vernacular in many countries, especially the U.K. Wikipedia.

Kalb T.H.,ADVANCE Medical
Critical Care Clinics | Year: 2015

This article explores the hypothesis that a telemedicine intensive care unit (Tele-ICU) platform is uniquely suited to facilitate quality performance improvement (PI). This article addresses some substantial hurdles to overcome that may limit the effectiveness of a Tele-ICU platform to achieve PI objectives. Lastly, this article describes the author's experience with a PI project to improve ventilator management conducted via a Tele-ICU hub interacting with 11 geographically dispersed ICUs. Using this example to illustrate the concepts, the author hopes to shed some light on the successes and lessons learned so as to generate best-practice guidelines for Tele-ICU-directed PI initiatives. © 2015 Elsevier Inc.

Tuso P.,Physician Leader for Total Health in Southern California. | Stoll S.R.,Physician for Coordinated Health in Bethlehem | Li W.W.,ADVANCE Medical
The Permanente journal | Year: 2015

A plant-based diet is increasingly becoming recognized as a healthier alternative to a diet laden with meat. Atherosclerosis associated with high dietary intake of meat, fat, and carbohydrates remains the leading cause of mortality in the US. This condition results from progressive damage to the endothelial cells lining the vascular system, including the heart, leading to endothelial dysfunction. In addition to genetic factors associated with endothelial dysfunction, many dietary and other lifestyle factors, such as tobacco use, high meat and fat intake, and oxidative stress, are implicated in atherogenesis. Polyphenols derived from dietary plant intake have protective effects on vascular endothelial cells, possibly as antioxidants that prevent the oxidation of low-density lipoprotein. Recently, metabolites of L-carnitine, such as trimethylamine-N-oxide, that result from ingestion of red meat have been identified as a potential predictive marker of coronary artery disease (CAD). Metabolism of L-carnitine by the intestinal microbiome is associated with atherosclerosis in omnivores but not in vegetarians, supporting CAD benefits of a plant-based diet. Trimethylamine-N-oxide may cause atherosclerosis via macrophage activation. We suggest that a shift toward a plant-based diet may confer protective effects against atherosclerotic CAD by increasing endothelial protective factors in the circulation while reducing factors that are injurious to endothelial cells. The relative ratio of protective factors to injurious endothelial exposure may be a novel approach to assessing an objective dietary benefit from a plant-based diet. This review provides a mechanistic perspective of the evidence for protection by a plant-based diet against atherosclerotic CAD.

ADVANCE Medical | Date: 2010-09-03

Methods and apparatuses for treating a root canal in a tooth or hard and/or soft tissue within a tooth and surrounding tissues by pulsing a laser light into a reservoir, preferably after introducing liquid fluid into the reservoir, so as to disintegrate, separate, or otherwise neutralize pulp, plaque, calculus, and/or bacteria within and adjacent the fluid reservoir without elevating the temperature of any of the dentin, tooth, bones, gums, other soft tissues, other hard tissues, and any other adjacent tissue more than about 5 C.

Kesavan R.,ADVANCE Medical | Narayan S.K.,Jawaharlal Institute of Postgraduate Medical Education & Research | Adithan C.,ADVANCE Medical
European Journal of Clinical Pharmacology | Year: 2010

Objective Cytochrome P450 2C9 and 2C19 (CYP2C9 and CYP2C19, respectively) genetic polymorphisms play an important role in phenytoin (PHT) metabolism. We have evaluated whether these genetic polymorphisms have an effect on PHT-induced neurological toxicity in Tamilian (ethnic group native to southern India) patients with epilepsy. Methods We studied 292 Tamilian patients who were taking PHT for the treatment of various epileptic seizures. PHT toxicity was defined on the basis of neurological signs of toxicity and further sub-classified into mild, moderate, and severe toxicity based on clinical severity. Genomic DNA was extracted from peripheral leukocytes and genotyped for CYP2C9*2, *3 and CYP2C19*2, *3 by PCRrestriction fragment length polymorphism analysis. Results Of the 292 patients in the patient cohort, 58 were clinically diagnosed to have PHT toxicity. When risk ratios were calculated for each mutant CYP2C9 genotype separately, the adjusted odds ratio for CYP2C9*1/*3 was found to be 15.3 (95% confidence interval 5.8-40.3, P<0.0001) for the cases compared to controls. When the four single nucleotide polymorphisms of CYP2C9 and CYP2C19 were analyzed using a haplotype approach, significant difference in the distribution of the C-C-G-G haplotype was observed between the cases and controls. Conclusion Our results show that CYP2C9 genetic polymorphisms (particularly the *3 allele) were associated with high risk of epileptic patients developing PHT-induced neurological toxicity.

Greer J.A.,Harvard University | Jackson V.A.,Harvard University | Meier D.E.,ADVANCE Medical | Temel J.S.,Harvard University
CA Cancer Journal for Clinicians | Year: 2013

Answer questions and earn CME/CNE Scientific advances in novel cancer therapeutics have led to remarkable changes in oncology practice and longer lives for patients diagnosed with incurable malignancies. However, the myriad options for treatment have established a culture of cancer care that has not been matched with a similar availability of efficacious supportive care interventions aimed at relieving debilitating symptoms due to progressive disease and treatment side effects. Accumulating data show that the introduction of palliative care services at the time of diagnosis of advanced cancer leads to meaningful improvement in the experiences of patients and family caregivers by emphasizing symptom management, quality of life, and treatment planning. In this review article, the rationale and evidence base for this model of early palliative care services integrated into standard oncology care are presented. In addition, the implications and limitations of the existing data to 1) elucidate the mechanisms by which early palliative care benefits patients and families; 2) guide the dissemination and application of this model in outpatient settings; and 3) inform health care policy regarding the delivery of high-quality, cost-effective, and comprehensive cancer care are discussed. Copyright © 2013 American Cancer Society, Inc.

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