Descripción del proyecto
Annals of Internal Medicine - recientes
Brown RT, Diaz-Ramirez L, Boscardin W, et al.
Background:Difficulties with daily functioning are common in middle-aged adults. However, little is known about the epidemiology or clinical course of these problems, including the extent to which they share common features with functional impairment in older adults.
Objective:To determine the epidemiology and clinical course of functional impairment and decline in middle age.
Setting:The Health and Retirement Study.
Participants:6874 community-dwelling adults aged 50 to 56 years who did not have functional impairment at enrollment.
Measurements:Impairment in activities of daily living (ADLs), defined as self-reported difficulty performing 1 or more ADLs, assessed every 2 years for a maximum follow-up of 20 years, and impairment in instrumental ADLs (IADLs), defined similarly. Data were analyzed by using multistate models that estimate probabilities of different outcomes.
Results:Impairment in ADLs developed in 22% of participants aged 50 to 64 years, in whom further functional transitions were common. Two years after the initial impairment, 4% (95% CI, 3% to 5%) of participants had died, 9% (CI, 8% to 11%) had further ADL decline, 50% (CI, 48% to 52%) had persistent impairment, and 37% (CI, 35% to 39%) had recovered independence. In the 10 years after the initial impairment, 16% (CI, 14% to 18%) had 1 or more episodes of functional decline and 28% (CI, 26% to 30%) recovered from their initial impairment and remained independent throughout this period. The pattern of findings was similar for IADLs.
Limitation:Functional status was self-reported.
Conclusion:Functional impairment and decline are common in middle age, as are transitions from impairment to independence and back again. Because functional decline in older adults has similar features, current interventions used for prevention in older adults may hold promise for those in middle age.
Primary Funding Source:National Institute on Aging and National Center for Advancing Translational Sciences through the University of California, San Francisco, Clinical and Translational Sciences Institute.
Identifying Trends in Undiagnosed Diabetes in U.S. Adults by Using a Confirmatory Definition A Cross-sectional Study5/12/2017
Selvin E, Wang D, Lee AK, et al.
Background:A common belief is that one quarter to one third of all diabetes cases remain undiagnosed. However, such prevalence estimates may be overstated by epidemiologic studies that do not use confirmatory testing, as recommended by clinical diagnostic criteria.
Objective:To provide national estimates of undiagnosed diabetes by using a confirmatory testing strategy, in line with clinical practice guidelines.
Setting:National Health and Nutrition Examination Survey results from 1988 to 1994 and 1999 to 2014.
Participants:U.S. adults aged 20 years and older.
Measurements:Confirmed undiagnosed diabetes was defined as elevated levels of fasting glucose (≥7.0 mmol/L [≥126 mg/dL]) and hemoglobin A1c (≥6.5%) in persons without diagnosed diabetes.
Results:The prevalence of total (diagnosed plus confirmed undiagnosed) diabetes increased from 5.5% (9.7 million adults) in 1988 to 1994 to 10.8% (25.5 million adults) in 2011 to 2014. Confirmed undiagnosed diabetes increased during the past 2 decades (from 0.89% in 1988 to 1994 to 1.2% in 2011 to 2014) but has decreased over time as a proportion of total diabetes cases. In 1988 to 1994, the percentage of total diabetes cases that were undiagnosed was 16.3%; by 2011 to 2014, this estimate had decreased to 10.9%. Undiagnosed diabetes was more common in overweight or obese adults, older adults, racial/ethnic minorities (including Asian Americans), and persons lacking health insurance or access to health care.
Conclusion:Establishing the burden of undiagnosed diabetes is critical to monitoring public health efforts related to screening and diagnosis. When a confirmatory definition is used, undiagnosed diabetes is a relatively small fraction of the total diabetes population; most U.S. adults with diabetes (about 90%) have received a diagnosis of the condition.
Primary Funding Source:National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases and National Heart, Lung, and Blood Institute.
46-Year Trends in Systemic Lupus Erythematosus Mortality in the United States, 1968 to 2013 A Nationwide Population-Based Study5/12/2017
Yen EY, Shaheen M, Woo JP, et al.
Background:No large population-based studies have been done on systemic lupus erythematosus (SLE) mortality trends in the United States.
Objective:To identify secular trends and population characteristics associated with SLE mortality.
Design:Population-based study using a national mortality database and census data.
Participants:All U.S. residents, 1968 through 2013.
Measurements:Joinpoint trend analysis of annual age-standardized mortality rates (ASMRs) for SLE and non-SLE causes by sex, race/ethnicity, and geographic region; multiple logistic regression analysis to determine independent associations of demographic variables and period with SLE mortality.
Results:There were 50 249 SLE deaths and 100 851 288 non-SLE deaths from 1968 through 2013. Over this period, the SLE ASMR decreased less than the non-SLE ASMR, with a 34.6% cumulative increase in the ratio of the former to the latter. The non-SLE ASMR decreased every year starting in 1968, whereas the SLE ASMR decreased between 1968 and 1975, increased between 1975 and 1999, and decreased thereafter. Similar patterns were seen in both sexes, among black persons, and in the South. However, statistically significant increases in the SLE ASMR did not occur among white persons over the 46-year period. Females, black persons, and residents of the South had higher SLE ASMRs and larger cumulative increases in the ratio of the SLE to the non-SLE ASMR (31.4%, 62.5%, and 58.6%, respectively) than males, other racial/ethnic groups, and residents of other regions, respectively. Multiple logistic regression showed independent associations of sex, race, and region with SLE mortality risk and revealed significant racial/ethnic differences in associations of SLE mortality with sex and region.
Limitations:Underreporting of SLE on death certificates may have resulted in underestimates of SLE ASMRs. Accuracy of coding on death certificates is difficult to ascertain.
Conclusion:Rates of SLE mortality have decreased since 1968 but remain high relative to non-SLE mortality, and significant sex, racial, and regional disparities persist.
Primary Funding Source:None.
Should This Patient Receive Aspirin? Grand Rounds Discussion From Beth Israel Deaconess Medical Center5/12/2017
Burns RB, Graham K, Sawhney MS, et al.
Aspirin exerts antiplatelet effects through irreversible inhibition of cyclooxygenase-1, whereas its anticancer effects may be due to inhibition of cyclooxygenase-2 and other pathways. In 2009, the U.S. Preventive Services Task Force endorsed aspirin for primary prevention of cardiovascular disease. However, aspirin's role in cancer prevention is still emerging, and no groups currently recommend its use for this purpose. To help physicians balance the benefits and harms of aspirin in primary disease prevention, the Task Force issued a guideline titled, “Aspirin Use for the Primary Prevention of Cardiovascular Disease and Colorectal Cancer” in 2016. In the evidence review conducted for the guideline, cardiovascular disease mortality and colorectal cancer mortality were significantly reduced among persons taking aspirin. However, there was no difference in nonfatal stroke, cardiovascular disease mortality, or all-cause mortality, nor in total cancer mortality, among those taking aspirin. Aspirin users were found to be at increased risk for major gastrointestinal bleeding. In this Beyond the Guidelines, the guideline is reviewed and 2 experts discuss how they would apply it to a 57-year-old man considering starting aspirin for primary prevention. Our experts review the data on which the guideline is based, discuss how they would balance the benefits and harms of aspirin therapy, and explain how they would incorporate shared decision making into clinical practice.
Hepatitis B Vaccination, Screening, and Linkage to Care: Best Practice Advice From the American College of Physicians and the Centers for Disease Control and Prevention5/12/2017
Abara WE, Qaseem A, Schillie S, et al.
Background:Vaccination, screening, and linkage to care can reduce the burden of chronic hepatitis B virus (HBV) infection. However, recommendations vary among organizations, and their implementation has been suboptimal. The American College of Physicians' High Value Care Task Force and the Centers for Disease Control and Prevention developed this article to present best practice statements for hepatitis B vaccination, screening, and linkage to care.
Methods:A narrative literature review of clinical guidelines, systematic reviews, randomized trials, and intervention studies on hepatitis B vaccination, screening, and linkage to care published between January 2005 and June 2017 was conducted.
Best Practice Advice 1:Clinicians should vaccinate against hepatitis B virus (HBV) in all unvaccinated adults (including pregnant women) at risk for infection due to sexual, percutaneous, or mucosal exposure; health care and public safety workers at risk for blood exposure; adults with chronic liver disease, end-stage renal disease (including hemodialysis patients), or HIV infection; travelers to HBV-endemic regions; and adults seeking protection from HBV infection.
Best Practice Advice 2:Clinicians should screen (hepatitis B surface antigen, antibody to hepatitis B core antigen, and antibody to hepatitis B surface antigen) for HBV in high-risk persons, including persons born in countries with 2% or higher HBV prevalence, men who have sex with men, persons who inject drugs, HIV-positive persons, household and sexual contacts of HBV-infected persons, persons requiring immunosuppressive therapy, persons with end-stage renal disease (including hemodialysis patients), blood and tissue donors, persons infected with hepatitis C virus, persons with elevated alanine aminotransferase levels (≥19 IU/L for women and ≥30 IU/L for men), incarcerated persons, pregnant women, and infants born to HBV-infected mothers.
Best Practice Advice 3:Clinicians should provide or refer all patients identified with HBV (HBsAg-positive) for posttest counseling and hepatitis B–directed care.
Lok AS, Chung RT, Vargas HE, et al.
Emerging data show that direct-acting antivirals (DAAs) improve clinical outcomes in hepatitis C virus (HCV). This commentary discusses these benefits in light of a recent systematic review suggesting that evidence is insufficient to confirm or reject an effect of DAA therapy on HCV-related illness.
Terwiesch C, Asch DA, Volpp KG.
Technologies enabling remote monitoring and transmission of patients' data hold promise for improved care. The authors caution, however, that these developments might increase the burden on physicians if the flow of additional information is not thoughtfully channeled in a manner that decreases rather than increases the need for physician–patient interactions.
Huerta TR, McAlearney A, Rizer M.
Although a great deal of information has been published about Web-based portals for outpatients, little is known about the use of this technology among inpatients. In this article, the authors describe their experience with patients admitted to 2 academic hospitals who were provided with electronic tablets to enable them to access their medical records, care plans, care team rosters, and other information through a Web-based portal.
Paules CI, Eisinger RW, Marston HD, et al.
Presidential administrations face any number of unexpected crises during their tenure, and global pandemics are among the most challenging. As of January 2017, one of the authors had served under 5 presidents as the director of the National Institute of Allergy and Infectious Diseases at the National Institutes of Health. During each administration, the government faced unexpected pandemics, ranging from the HIV/AIDS pandemic, which began during the Reagan administration, to the recent Zika outbreak in the Americas, which started during the Obama administration. These experiences underscored the need to optimize preparation for and response to these threats whenever and wherever they emerge. This article recounts selected outbreaks occurring during this period and highlights lessons that were learned that can be applied to the infectious disease threats that will inevitably be faced in the current presidential administration and beyond.
Brown and colleagues used longitudinal data from a large, nationally representative sample of nondisabled persons aged 50 to 56 years who were interviewed every 2 years for up to 20 years to describe the cumulative rates of disability by the age of 64 years. The editorialist discusses the findings, which suggest that disability may be as complex in middle age as it is in late life.
Talluri R, Ranadive R, Rao JK, et al.
The advent of large, information-rich data sets partnered with advanced computation has made it increasingly possible to inject life into data through interactive visualization. Brown and colleagues' study of midlife health trajectories includes the type of complex data that begs interactive exploration. The editorialists introduce an interactive graphic that enables readers to delve into the data reported by these investigators.
In their study assessing the population burden of unrecognized diabetes, Selvin and colleagues used a definition that aligns more closely with clinical practice recommendations than that frequently used in epidemiologic studies. Here, the editorialist discusses the implications of this study.
Taichman DB, Bauchner H, Drazen JM, et al.
Editors from Annals of Internal Medicine, JAMA (Journal of the American Medical Association), New England Journal of Medicine, and PLOS Medicine offer a shortlist of what health care professionals can do to fight the threat that firearms present to health in the United States.
When I was called out of a morbidity and mortality conference to receive the fateful imaging results, my life expectancy collapsed from decades to months and I entered a surreal dystopia from which I've never fully emerged.
No longer able to hide from the dual realities that dementia has struck my family and that it begets suffering, I see now that denial has been a stubborn undercurrent in my life.
Murphy DR, Schneider MJ, Bise CG, et al.
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