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JAMA Internal Medicine - más leídos

Hospital Resource Use and Outcomes of Hospitalists vs PCPs vs Generalists
1/12/2017
Stevens JP, Nyweide DJ, Maresh S, et al.
ver resumen
This cohort study uses Medicare claims data to examine differences in health care resource use and outcomes among hospitalized Medicare beneficiaries cared for by hospitalists, their own primary care physicians, or other generalists.

Noninvasive Cardiac Testing vs Clinical Evaluation Alone
14/11/2017
Reinhardt SW, Lin C, Novak E, et al.
ver resumen
This secondary analysis of data from a randomized clinical trial examines differences in outcomes with clinical evaluation and noninvasive testing vs clinical evaluation alone.

Acute Chest Pain in the Emergency Department
14/11/2017
Curfman G.
ver resumen
In 2014, a total of 6 887 000 patients came to US emergency departments (EDs) because of symptoms of chest pain, representing 5% of all ED visits. While some of them have clinical evidence of acute coronary syndromes (ACS), many others have no ischemic changes on the electrocardiogram (ECG) and normal cardiac troponin levels. Uncertainty surrounds proper treatment of these low- to intermediate-risk patients.

Warfarin Use and Lower Cancer Incidence Among Older Patients
1/12/2017
Haaland GS, Falk RS, Straume O, et al.
ver resumen
This population-based cohort study uses the Norwegian national registries to determine the association between warfarin use and cancer incidence among persons aged 52 to 82 years.

Impact of Influenza Vaccination on Seasonal Mortality in the US Elderly Population
14/2/2005
Simonsen L, Reichert TA, Viboud C, et al.
ver resumen
Background
Observational studies report that influenza vaccination reduces winter mortality risk from any cause by 50% among the elderly. Influenza vaccination coverage among elderly persons (≥65 years) in the United States increased from between 15% and 20% before 1980 to 65% in 2001. Unexpectedly, estimates of influenza-related mortality in this age group also increased during this period. We tried to reconcile these conflicting findings by adjusting excess mortality estimates for aging and increased circulation of influenza A(H3N2) viruses.
Methods
We used a cyclical regression model to generate seasonal estimates of national influenza-related mortality (excess mortality) among the elderly in both pneumonia and influenza and all-cause deaths for the 33 seasons from 1968 to 2001. We stratified the data by 5-year age group and separated seasons dominated by A(H3N2) viruses from other seasons.
Results
For people aged 65 to 74 years, excess mortality rates in A(H3N2)-dominated seasons fell between 1968 and the early 1980s but remained approximately constant thereafter. For persons 85 years or older, the mortality rate remained flat throughout. Excess mortality in A(H1N1) and B seasons did not change. All-cause excess mortality for persons 65 years or older never exceeded 10% of all winter deaths.
Conclusions
We attribute the decline in influenza-related mortality among people aged 65 to 74 years in the decade after the 1968 pandemic to the acquisition of immunity to the emerging A(H3N2) virus. We could not correlate increasing vaccination coverage after 1980 with declining mortality rates in any age group. Because fewer than 10% of all winter deaths were attributable to influenza in any season, we conclude that observational studies substantially overestimate vaccination benefit.

Meditation for Psychological Stress and Well-being
1/3/2014
Goyal M, Singh S, Sibinga ES, et al.
ver resumen
Goyal et al determine the efficacy of meditation programs in improving stress-related outcomes in diverse adult clinical populations. See the Invited Commentary by [IIC130096].

A Brief Measure for Assessing Generalized Anxiety Disorder The GAD-7
22/5/2006
Spitzer RL, Kroenke K, Williams JW, et al.
ver resumen
Background
Generalized anxiety disorder (GAD) is one of the most common mental disorders; however, there is no brief clinical measure for assessing GAD. The objective of this study was to develop a brief self-report scale to identify probable cases of GAD and evaluate its reliability and validity.
Methods
A criterion-standard study was performed in 15 primary care clinics in the United States from November 2004 through June 2005. Of a total of 2740 adult patients completing a study questionnaire, 965 patients had a telephone interview with a mental health professional within 1 week. For criterion and construct validity, GAD self-report scale diagnoses were compared with independent diagnoses made by mental health professionals; functional status measures; disability days; and health care use.
Results
A 7-item anxiety scale (GAD-7) had good reliability, as well as criterion, construct, factorial, and procedural validity. A cut point was identified that optimized sensitivity (89%) and specificity (82%). Increasing scores on the scale were strongly associated with multiple domains of functional impairment (all 6 Medical Outcomes Study Short-Form General Health Survey scales and disability days). Although GAD and depression symptoms frequently co-occurred, factor analysis confirmed them as distinct dimensions. Moreover, GAD and depression symptoms had differing but independent effects on functional impairment and disability. There was good agreement between self-report and interviewer-administered versions of the scale.
Conclusion
The GAD-7 is a valid and efficient tool for screening for GAD and assessing its severity in clinical practice and research.

Overlapping Surgery and Risk for Complications Following Hip Surgery
4/12/2017
Ravi B, Pincus D, Wasserstein D, et al.
ver resumen
This cohort study determines if overlapping surgery is associated with greater risk for complications following surgical treatment for hip fracture and arthritis.

Medical Cannabis Laws and Opioid Mortality
1/10/2014
Bachhuber MA, Saloner B, Cunningham CO, et al.
ver resumen
Bachhuber et al determine the association between the presence of state medical cannabis laws and opioid analgesic overdose mortality in a time series analysis. See also the Invited Commentary by Hayes and Brown.

Health Care Database Use for Supplemental Medication Indications
20/11/2017
Fralick M, Kesselheim AS, Avorn J, et al.
ver resumen
This study examines whether longitudinal data from a health care database can support the results of a randomized clinical trial that led to a supplemental indication of telmisartan.

Sugar Intake and Cardiovascular Diseases Mortality
1/4/2014
Yang Q, Zhang Z, Gregg EW, et al.
ver resumen
Yang et al examine time trends of added sugar consumption as percentage of daily calories in the United States and investigate the association of this consumption with cardiovascular disease mortality. See the Invited Commentary by [IIC130095].

Association Between Marijuana Use and Cognitive Function in Middle Age
1/3/2016
Auer R, Vittinghoff E, Yaffe K, et al.
ver resumen
This study uses data from the Coronary Artery Risk Development in Young Adults (CARDIA) study to examine the association between cumulative lifetime exposure to marijuana and cognitive performance in middle age.

Strong Anticholinergics and Incident Dementia
1/3/2015
Gray SL, Anderson ML, Dublin S, et al.
ver resumen
This prospective population-based cohort study reports an increased risk for dementia with increased total standard daily doses of anticholinergics. See the Invited Commentary by Campbell and Boustani.

Burnout and Satisfaction With Work-Life Balance Among US Physicians Relative to the General US Population
8/10/2012
Shanafelt TD, Boone S, Tan L, et al.
ver resumen
Shanafelt and colleagues evaluated rates of burnout among US physicians, differences by specialty, and comparisons of physicians with US workers in other fields. Burnout was measured using validated instruments, and satisfaction with work-life balance was explored. See the editorial by O’Malley.

Costs and Benefits of Hospital Care by Primary Physicians
1/12/2017
Willett LL, Landefeld C.
ver resumen
In 1948, LIFE magazine published the “Country Doctor” (http://time.com/3456085/w-eugene-smiths-landmark-photo-essay-country-doctor/), the photographic essay by W. Eugene Smith that established the iconic American physician as one who provides comprehensive care for his or her patients wherever they were, whenever they were needed. In Kremmling, Colorado, Dr Ernest Ceriani cared for people at home, in the office, and in the hospital, sometimes carrying them bodily from one place to another. Since 1948, times have changed, and comprehensive care with continuity in the relationship of a patient with “my doctor” has decreased, especially during inpatient hospital care. In 1996, Wachter and Goldman heralded the emerging role of hospitalists, and the proportion of general medicine inpatient services attributed to hospitalists has increased rapidly, from 9% in 1995 to 37% in 2006 and 58% in 2013.

Unanticipated Outcomes: A Medical Memoir—A Book Review
20/11/2017
Prasad V.
ver resumen
Unanticipated Outcomes: A Medical Memoir is the story of Jerome P. Kassirer, MD, MPH, who was born at the height of the Great Depression, grew up in a “two story-rat infested wooden house”(p16) in Buffalo, New York, and, in 1991, became the sixth Editor in Chief of the New England Journal of Medicine (NEJM). Kassirer’s memoir takes us through the life of a legendary figure in modern medicine, a man who, above all else, embodied what it meant to be, and, what it still means to be, a professional. At a time when we increasingly read about disillusionment and burnout among physicians, the high costs of drugs and care, and the corrupting influences of money on medicine, Kassirer’s book reminds us why we became doctors. His life lessons are timeless.

Consumer Behaviors Among Individuals Enrolled in High-Deductible Health Plans
27/11/2017
Kullgren JT, Cliff EQ, Krenz C, et al.
ver resumen
This survey study examines the consumer behaviors among individuals enrolled in high-deductible health plans in the United States.

Association of Blood Pressure Lowering With Mortality and CVD
13/11/2017
Brunström M, Carlberg B.
ver resumen
This systematic review and meta-analysis assesses the association of treatment to lower blood pressure with death and cardiovascular disease at different blood pressure levels in randomized clinical trials.

Marijuana, Secondhand Smoke, and Social Acceptability
20/11/2017
Glantz SA, Halpern-Felsher B, Springer ML.
ver resumen
On April 20, 2017, at 4:20 in the afternoon, 15 000 people in San Francisco’s Golden Gate Park lit marijuana joints during the annual “420 Day.” In cannabis culture, April 20 has become an international countercultural holiday; people gather to celebrate and consume cannabis, typically around 4:20 pm.

Effects of Evening vs Morning Levothyroxine Intake A Randomized Double-blind Crossover Trial
13/12/2010
Bolk N, Visser TJ, Nijman J, et al.
ver resumen
Background
Levothyroxine sodium is widely prescribed to treat primary hypothyroidism. There is consensus that levothyroxine should be taken in the morning on an empty stomach. A pilot study showed that levothyroxine intake at bedtime significantly decreased thyrotropin levels and increased free thyroxine and total triiodothyronine levels. To date, no large randomized trial investigating the best time of levothyroxine intake, including quality-of-life evaluation, has been performed.
Methods
To ascertain if levothyroxine intake at bedtime instead of in the morning improves thyroid hormone levels, a randomized double-blind crossover trial was performed between April 1, 2007, and November 30, 2008, among 105 consecutive patients with primary hypothyroidism at Maasstad Hospital Rotterdam in the Netherlands. Patients were instructed during 6 months to take 1 capsule in the morning and 1 capsule at bedtime (one containing levothyroxine and the other a placebo), with a switch after 3 months. Primary outcome measures were thyroid hormone levels; secondary outcome measures were creatinine and lipid levels, body mass index, heart rate, and quality of life.
Results
Ninety patients completed the trial and were available for analysis. Compared with morning intake, direct treatment effects when levothyroxine was taken at bedtime were a decrease in thyrotropin level of 1.25 mIU/L (95% confidence interval [CI], 0.60-1.89 mIU/L; P < .001), an increase in free thyroxine level of 0.07 ng/dL (0.02-0.13 ng/dL; P = .01), and an increase in total triiodothyronine level of 6.5 ng/dL (0.9-12.1 ng/dL; P = .02) (to convert thyrotropin level to micrograms per liter, multiply by 1.0; free thyroxine level to picomoles per liter, multiply by 12.871; and total triiodothyronine level to nanomoles per liter, multiply by 0.0154). Secondary outcomes, including quality-of-life questionnaires (36-Item Short Form Health Survey, Hospital Anxiety and Depression Scale, 20-Item Multidimensional Fatigue Inventory, and a symptoms questionnaire), showed no significant changes between morning vs bedtime intake of levothyroxine.
Conclusions
Levothyroxine taken at bedtime significantly improved thyroid hormone levels. Quality-of-life variables and plasma lipid levels showed no significant changes with bedtime vs morning intake. Clinicians should consider prescribing levothyroxine intake at bedtime.
Trial Registration
isrctn.org Identifier: ISRCTN17436693 (NTR959).







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