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Bringing High-Value Care to the Inpatient Teaching Service

from ArchInte - 01 Jul 14

High-value care is a strategic priority of major academic and medical organizations. One of the greatest challenges training programs face is fostering practice patterns in young physicians that avoid tests and treatments of dubious value.



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The Role of Testing for BRCA1 and BRCA2 Mutations in Cancer Prevention

from ArchInte - 01 Jul 14

In May 2013, Angelina Jolie, the actress and director, announced in an op-ed in the New York Times that she carried a BRCA1 mutation and had had a preventive double mastectomy. Jolie’s message was striking—by identifying a mutation in a cancer susceptibility gene, one of the most famous actresses of our generation dramatically reduced her risk of dying from cancer.



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Expanding the Roles of Medical Assistants Who Does What in Primary Care?

from ArchInte - 01 Jul 14

Adult primary care in the United States faces a dilemma. Many patients report poor access to their primary care clinician. Yet the growing demand for primary care leads to high levels of clinician burnout. A commonly voiced solution is to increase the numbers of adult primary care clinicians—physicians, nurse practitioners, and physician assistants. However, most workforce projections find that there will not be enough clinicians to meet the increasing demand. At the same time, many primary care



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Choosing a Screening Method for Cervical Cancer Papanicolaou Testing Alone or With Human Papillomavirus Testing

from ArchInte - 01 Jul 14

Screening for cervical cancer with the Papanicolaou (Pap) test has been remarkably successful at reducing the morbidity and mortality rates associated with this disease. The discovery that human papillomavirus (HPV) has an essential role in cervical carcinogenesis led to the development of molecular tests to measure the presence of HPV types associated with cancer. In 2012, screening guidelines were updated to incorporate HPV testing. According to these guidelines, women 21 to 29 years old shoul



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Can the New Cervical Cancer Screening and Management Guidelines Be Simplified?

from ArchInte - 01 Jul 14

Effective cervical cancer prevention relies on frequent screening and appropriate management of abnormal test results to prevent cells with precancerous changes from progressing to cancer. Historically, guidelines were simple and clear: screen annually with Papanicolaou (Pap) tests, evaluate abnormal results with colposcopy and diagnostic biopsy, treat most abnormal results by means of either excision (loop excision) or ablation (cryosurgery), and then resume annual Pap testing. This approach wa



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Allopurinol Overuse in Asymptomatic Hyperuricemia A Teachable Moment

from ArchInte - 01 Jul 14

Screening for plasma uric acid is widespread in many countries including Italy. This is based on the assumption that alongside gout, hyperuricemia may be associated with and contribute to several cardiovascular, renal, and metabolic disorders, although evidence of the clinical utility of such routine screening is still scant.



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Approach to Overuse of Herbal and Dietary Supplements A Teachable Moment

from ArchInte - 01 Jul 14

Herbal and dietary supplement use is prevalent. Medication reconciliation should include a careful review of herbal and dietary supplements, including medical and nonmedical harms and benefits. The use of shared decision-making is recommended to integrate these findings into a patient-centered treatment plan.




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The Diagnostic and Healing Qualities of Story Goals of Care

from ArchInte - 01 Jul 14

Recently, I was asked to see a woman in her 80s for a goals-of-care discussion in a cardiovascular intensive care unit. She had experienced a myocardial infarction and had been offered coronary artery bypass grafting. In addition to her coronary artery disease, she had chronic kidney disease and type 2 diabetes mellitus. The consulting cardiovascular surgeon had quoted her a 20% perioperative risk of death. She was unsure how to proceed. As a palliative care consultant, I would help guide her fo



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Different Time Trends of Caloric and Fat Intake Between Statin Users and Nonusers Among US Adults Gluttony in the Time of Statins?

from ArchInte - 01 Jul 14

ImportanceBoth dietary modification and use of statins can lower blood cholesterol. The increase in caloric intake among the general population is reported to have plateaued in the last decade, but no study has examined the relationship between the time trends of caloric intake and statin use.ObjectiveTo examine the difference in the temporal trends of caloric and fat intake between statin users and nonusers among US adults.Design, Setting, and ParticipantsA repeated cross-sectional study in a n



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Physical Activity and Sedentary Behaviors Associated With Risk of Progression From Gestational Diabetes Mellitus to Type 2 Diabetes Mellitus A Prospective Cohort Study

from ArchInte - 01 Jul 14

ImportanceWomen with a history of gestational diabetes mellitus (GDM) are at substantially increased risk of type 2 diabetes mellitus (T2DM). The identification of important modifiable factors could help prevent T2DM in this high-risk population.ObjectiveTo examine the role of physical activity and television watching and other sedentary behaviors, and changes in these behaviors in the progression from GDM to T2DM.Design, Setting, and ParticipantsProspective cohort study of 4554 women from the N



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Low-Dose Estradiol and the Serotonin-Norepinephrine Reuptake Inhibitor Venlafaxine for Vasomotor Symptoms A Randomized Clinical Trial

from ArchInte - 01 Jul 14

ImportanceEstrogen therapy is the gold standard treatment for hot flashes and night sweats, but some women are unable or unwilling to use it because of associated risks. The serotonin-norepinephrine reuptake inhibitor venlafaxine hydrochloride is used widely as a nonhormonal treatment. While the clinical impression is that serotonin-norepinephrine reuptake inhibitors are less effective than estrogen, these medications have not been simultaneously evaluated in one clinical trial to date.Objective



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Measuring Low-Value Care in Medicare

from ArchInte - 01 Jul 14

ImportanceDespite the importance of identifying and reducing wasteful health care use, few direct measures of overuse have been developed. Direct measures are appealing because they identify specific services to limit and can characterize low-value care even among the most efficient providers.ObjectivesTo develop claims-based measures of low-value services, examine service use (and associated spending) detected by these measures in Medicare, and determine whether patterns of use are related acro



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Resveratrol Levels and All-Cause Mortality in Older Community-Dwelling Adults

from ArchInte - 01 Jul 14

ImportanceResveratrol, a polyphenol found in grapes, red wine, chocolate, and certain berries and roots, is considered to have antioxidant, anti-inflammatory, and anticancer effects in humans and is related to longevity in some lower organisms.ObjectiveTo determine whether resveratrol levels achieved with diet are associated with inflammation, cancer, cardiovascular disease, and mortality in humans.DesignProspective cohort study, the Invecchiare in Chianti (InCHIANTI) Study (“Aging in the Chiant



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Stability of End-of-Life Preferences A Systematic Review of the Evidence

from ArchInte - 01 Jul 14

ImportancePolicies and practices that promote advance care planning and advance directive completion implicitly assume that patients’ choices for end-of-life (EOL) care are stable over time, even with changes in health status.ObjectiveTo systematically evaluate the evidence on the stability of EOL preferences over time and with changes in health status.Evidence ReviewWe searched for longitudinal studies of patients’ preferences for EOL care in PubMed, EMBASE, and using citation review. Studies r



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Preventing 30-Day Hospital Readmissions A Systematic Review and Meta-analysis of Randomized Trials

from ArchInte - 01 Jul 14

ImportanceReducing early (ObjectiveTo synthesize the evidence of the efficacy of interventions to reduce early hospital readmissions and identify intervention features—including their impact on treatment burden and on patients’ capacity to enact postdischarge self-care—that might explain their varying effects.Data SourcesWe searched PubMed, Ovid MEDLINE, Ovid EMBASE, EBSCO CINAHL, and Scopus (1990 until April 1, 2013), contacted experts, and reviewed bibliographies.Study SelectionRandomized tria



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Diagnostic Performance of Random Urine Samples Using Albumin Concentration vs Ratio of Albumin to Creatinine for Microalbuminuria Screening in Patients With Diabetes Mellitus A Systematic Review and M

from ArchInte - 01 Jul 14

ImportanceA random urine sample measuring the albumin concentration (UAC) without simultaneously measuring the urinary creatinine is less expensive than measuring the ratio of albumin to creatinine (ACR), but comparisons of their diagnostic performance for microalbuminuria screening among patients with diabetes mellitus (DM) have not been undertaken in previous meta-analyses.ObjectiveTo compare the diagnostic performance of the UAC vs the ACR in random urine samples for microalbuminuria screenin



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National Trends in US Hospital Admissions for Hyperglycemia and Hypoglycemia Among Medicare Beneficiaries, 1999 to 2011

from ArchInte - 01 Jul 14

ImportanceThe increasing intensity of diabetes mellitus management over the past decade may have resulted in lower rates of hyperglycemic emergencies but higher rates of hospital admissions for hypoglycemia among older adults. Trends in these hospitalizations and subsequent outcomes are not known.ObjectiveTo characterize changes in hyperglycemia and hypoglycemia hospitalization rates and subsequent mortality and readmission rates among older adults in the United States over a 12-year period, and



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Fracture Prediction After Discontinuation of 4 to 5 Years of Alendronate Therapy The FLEX Study

from ArchInte - 01 Jul 14

ImportanceDiscontinuation of bisphosphonate therapy after 3 to 5 years is increasingly considered, but methods to monitor fracture risk after discontinuation have not been established.ObjectiveTo test methods of predicting fracture risk among women who have discontinued alendronate therapy after 4 to 5 years.Design, Setting, and ParticipantsThe prospective Fracture Intervention Trial Long-term Extension (FLEX) study randomized postmenopausal women aged 61 to 86 years previously treated with 4 to



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Invasive Group A Streptococcus Infections Associated With Liposuction Surgery at Outpatient Facilities Not Subject to State or Federal Regulation

from ArchInte - 01 Jul 14

ImportanceLiposuction is one of the most common cosmetic surgery procedures in the United States. Tumescent liposuction, in which crystalloid fluids, lidocaine, and epinephrine are infused subcutaneously before cannula-assisted aspiration of fat, can be performed without intravenous or general anesthesia, often at outpatient facilities. However, some of these facilities are not subject to state or federal regulation and may not adhere to appropriate infection control practices.ObjectiveTo descri



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A Comparison of Live Counseling With a Web-Based Lifestyle and Medication Intervention to Reduce Coronary Heart Disease Risk A Randomized Clinical Trial

from ArchInte - 01 Jul 14

ImportanceMost primary care clinicians lack the skills and resources to offer effective lifestyle and medication (L&M) counseling to reduce coronary heart disease (CHD) risk. Thus, effective and feasible CHD prevention programs are needed for typical practice settings.ObjectiveTo assess the effectiveness, acceptability, and cost-effectiveness of a combined L&M intervention to reduce CHD risk offered in counselor-delivered and web-based formats.Design, Setting, and ParticipantsA comparative effec



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Impact of an Intensive Care Unit Telemedicine Program on Patient Outcomes in an Integrated Health Care System

from ArchInte - 01 Jul 14

ImportanceIntensive care unit (ICU) telemedicine (TM) programs have been promoted as improving access to intensive care specialists and ultimately improving patient outcomes, but data on effectiveness are limited and conflicting.ObjectiveTo examine the impact of ICU TM on mortality rates and length of stay (LOS) in an integrated health care system.Design, Setting, and ParticipantsObservational pre-post study of patients treated in 8 “intervention” ICUs (7 hospitals within the US Department of Ve



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A Call to Increase Physical Activity Among Women of Reproductive Age Is It Possible?

from ArchInte - 01 Jul 14

Gestational diabetes (GDM) is an increasingly common pregnancy complication. Women with GDM are at extremely high risk of developing diabetes, especially in the first 5 years after delivery. In their article on the Nurses’ Health Study (NHS) II in this issue of JAMA Internal Medicine, Bao et al found that following a GDM pregnancy, increasing physical activity levels were associated with a reduced risk of progression from GDM to diabetes. This finding highlights the importance of developing effe



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What Should Be the Goal of Advance Care Planning?

from ArchInte - 01 Jul 14

The systematic review by Auriemma et al provides a valuable synthesis of the evidence on stability of end-of-life (EOL) treatment preferences. Among 24 longitudinal studies included in quantitative analysis, they found that in most (17 of 24), more than 70% of patients’ preferences for EOL care were stable over periods ranging from weeks to years. The results suggest a greater degree of preference stability among inpatients and seriously ill outpatients than among older adults without serious il


 

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