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23andMe, the Food and Drug Administration, and the Future of Genetic Testing

from ArchInte - 01 Apr 14

On November 22, 2013, the US Food and Drug Administration (FDA) effectively halted health-related direct-to-consumer genetic testing in the United States by sending a warning letter to 23andMe, the leading company in the field, directing it to stop providing such testing. The FDA acted as the era of widespread, clinical use of DNA sequencing rapidly approaches. The agency’s action will contribute to changes in which genetic tests are offered to patients and how testing is provided.



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Surgical Aortic Valve Replacement vs Transcatheter Aortic Valve Replacement A Consumer’s Perspective Regarding Data Education and Transparency of Hospitals

from ArchInte - 01 Apr 14

When my grandfather had symptomatic severe aortic valve stenosis diagnosed and was evaluated as “intermediate/serious risk” for surgery, he became eligible to join a 50-50 randomized transcatheter aortic valve replacement (TAVR) trial or to choose conventional surgical aortic valve replacement (SAVR). The techniques were presented as equally acceptable options. The hospital staff physicians explained the significant advantage of not undergoing the rigors of open heart surgery.



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How Should Top-Five Lists Be Developed? What Is the Next Step?

from ArchInte - 01 Apr 14

Readers might wonder why the editors of JAMA Internal Medicine decided to publish “A Top-Five List for Emergency Medicine.” Some of our readers might practice emergency medicine (EM), and many provide “urgent” care. However, we decided to publish this article for another reason.



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National Hospice Survey Results For-Profit Status, Community Engagement, and Service

from ArchInte - 01 Apr 14

ImportanceThe impact of the substantial growth in for-profit hospices in the United States on quality and hospice access has been intensely debated, yet little is known about how for-profit and nonprofit hospices differ in activities beyond service delivery.ObjectiveTo determine the association between hospice ownership and (1) provision of community benefits, (2) setting and timing of the hospice population served, and (3) community outreach.Design, Setting, and ParticipantsCross-sectional surv



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A Top-Five List for Emergency Medicine A Pilot Project to Improve the Value of Emergency Care

from ArchInte - 01 Apr 14

ImportanceThe mean cost of medical care in the United States is growing at an unsustainable rate; from 2003 through 2011, the cost for an emergency department (ED) visit rose 240%, from $560 to $1354. The diagnostic tests, treatments, and hospitalizations that emergency clinicians order result in significant costs.ObjectiveTo create a “top-five” list of tests, treatments, and disposition decisions that are of little value, are amenable to standardization, and are actionable by emergency medicine



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Added Sugar Intake and Cardiovascular Diseases Mortality Among US Adults

from ArchInte - 01 Apr 14

ImportanceEpidemiologic studies have suggested that higher intake of added sugar is associated with cardiovascular disease (CVD) risk factors. Few prospective studies have examined the association of added sugar intake with CVD mortality.ObjectiveTo examine time trends of added sugar consumption as percentage of daily calories in the United States and investigate the association of this consumption with CVD mortality.Design, Setting, and ParticipantsNational Health and Nutrition Examination Surv



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Intervention to Promote Physician Well-being, Job Satisfaction, and Professionalism A Randomized Clinical Trial

from ArchInte - 01 Apr 14

ImportanceDespite the documented prevalence and clinical ramifications of physician distress, few rigorous studies have tested interventions to address the problem.ObjectiveTo test the hypothesis that an intervention involving a facilitated physician small-group curriculum would result in improvement in well-being.Design, Setting, and ParticipantsRandomized clinical trial of 74 practicing physicians in the Department of Medicine at the Mayo Clinic in Rochester, Minnesota, conducted between Septe



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Patient-Centered Community Health Worker Intervention to Improve Posthospital Outcomes A Randomized Clinical Trial

from ArchInte - 01 Apr 14

ImportanceSocioeconomic and behavioral factors can negatively influence posthospital outcomes among patients of low socioeconomic status (SES). Traditional hospital personnel often lack the time, skills, and community linkages required to address these factors.ObjectiveTo determine whether a tailored community health worker (CHW) intervention would improve posthospital outcomes among low-SES patients.Design, Setting, and ParticipantsA 2-armed, single-blind, randomized clinical trial was conducte



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Hospital Variation in the Use of Noninvasive Cardiac Imaging and Its Association With Downstream Testing, Interventions, and Outcomes

from ArchInte - 01 Apr 14

ImportanceCurrent guidelines allow substantial discretion in use of noninvasive cardiac imaging for patients without acute myocardial infarction (AMI) who are being evaluated for ischemia. Imaging use may affect downstream testing and outcomes.ObjectiveTo characterize hospital variation in use of noninvasive cardiac imaging and the association of imaging use with downstream testing, interventions, and outcomes.Design, Setting, and ParticipantsCross-sectional study of hospitals using 2010 adminis



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Effect of Health Insurance and Facility Quality Improvement on Blood Pressure in Adults With Hypertension in Nigeria A Population-Based Study

from ArchInte - 01 Apr 14

ImportanceHypertension is a major public health problem in sub-Saharan Africa, but the lack of affordable treatment and the poor quality of health care compromise antihypertensive treatment coverage and outcomes.ObjectiveTo report the effect of a community-based health insurance (CBHI) program on blood pressure in adults with hypertension in rural Nigeria.Design, Setting, and ParticipantsWe compared changes in outcomes from baseline (2009) between the CBHI program area and a control area in 2011



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Histamine-2 Receptor Antagonists vs Proton Pump Inhibitors on Gastrointestinal Tract Hemorrhage and Infectious Complications in the Intensive Care Unit

from ArchInte - 01 Apr 14

ImportanceHistamine-2 receptor antagonists (H2RAs) and proton pump inhibitors (PPIs) are commonly used to prevent gastrointestinal tract (GI) hemorrhage in critically ill patients. The stronger acid suppression of PPIs may reduce the rate of bleeding but enhance infectious complications, specifically pneumonia and Clostridium difficile infection (CDI).ObjectiveTo evaluate the occurrence and risk factors for GI hemorrhage, pneumonia, and CDI in critically ill patients.Design, Setting, and Partici



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Vegetarian Diets and Blood Pressure A Meta-analysis

from ArchInte - 01 Apr 14

ImportancePrevious studies have suggested an association between vegetarian diets and lower blood pressure (BP), but the relationship is not well established.ObjectiveTo conduct a systematic review and meta-analysis of controlled clinical trials and observational studies that have examined the association between vegetarian diets and BP.Data SourcesMEDLINE and Web of Science were searched for articles published in English from 1946 to October 2013 and from 1900 to November 2013, respectively.Stu



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Antihypertensive Medications and Serious Fall Injuries in a Nationally Representative Sample of Older Adults

from ArchInte - 01 Apr 14

ImportanceThe effect of serious injuries, such as hip fracture and head injury, on mortality and function is comparable to that of cardiovascular events. Concerns have been raised about the risk of fall injuries in older adults taking antihypertensive medications. The low risk of fall injuries reported in clinical trials of healthy older adults may not reflect the risk in older adults with multiple chronic conditions.ObjectiveTo determine whether antihypertensive medication use was associated wi



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Increased Risk of Acute Cardiovascular Events After Partner Bereavement A Matched Cohort Study

from ArchInte - 01 Apr 14

ImportanceThe period immediately after bereavement has been reported as a time of increased risk of cardiovascular events. However, this risk has not been well quantified, and few large population studies have examined partner bereavement.ObjectiveTo compare the rate of cardiovascular events between older individuals whose partner dies with those of a matched control group of individuals whose partner was still alive on the same day.Design, Setting, and ParticipantsMatched cohort study using a U



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Outbreak of Bacteremia Due to Burkholderia contaminans Linked to Intravenous Fentanyl From an Institutional Compounding Pharmacy

from ArchInte - 01 Apr 14

ImportanceMany health care facilities compound medications on site to fulfill local demands when customized formulations are needed, national supply is critically low, or costs for manufactured pharmaceuticals are excessive. Small, institutional compounding facilities may perform the same high-risk procedures as large distributors of compounded medications.ObjectivesTo investigate an outbreak related to contamination of compounded sterile preparations and to determine processes to prevent future



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A Consumer’s Pursuit of Health Care Outcomes Daunting Even With a Guardian Angel!

from ArchInte - 01 Apr 14

Every patient should have a guardian angel to help navigate our health care system. Yet even with a guardian angel, the challenges encountered in deciding various treatment options can prove daunting. Frankel poignantly illustrates these challenges as he describes his journey through various sources of health care information to find the best treatment for his grandfather’s aortic stenosis. Among the resources he searched, with some frustration, were hospital websites, the Society of Thoracic Su



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The Changing Face of the Hospice Industry What Really Matters?

from ArchInte - 01 Apr 14

In recent years, the tremendous growth in the number of for-profit hospices has received increasing scrutiny in both the lay press and medical journals. Academicians, reporters, and government regulators have raised concerns about for-profit hospices’ aggressive marketing practices, narrower scope of services offered, and enrollment of a case mix of patients with longer lengths of stay and higher profits. Although there is no direct evidence that the quality of care provided to patients differs



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New Unsweetened Truths About Sugar

from ArchInte - 01 Apr 14

We are in the midst of a paradigm shift in research on the health effects of sugar, one fueled by extremely high rates of added sugar overconsumption in the American public. By “added sugar overconsumption,” we refer to a total daily consumption of sugars added to products during manufacturing (ie, not naturally occurring sugars, as in fresh fruit) in excess of dietary limits recommended by expert panels. Past concerns revolved around obesity and dental caries as the main health hazards. Overcon



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Physician Well-being Addressing Downstream Effects, but Looking Upstream

from ArchInte - 01 Apr 14

In this issue of JAMA Internal Medicine, West et al report results of a randomized clinical trial of an intervention to improve physicians’ psychological well-being. The intervention—a series of small-group discussions—showed success in 2 indicators of distress. But the results also constitute a warning about the growing demoralization of physicians.



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Social Determinants of Health From Bench to Bedside

from ArchInte - 01 Apr 14

Poverty is misery. It saps nutrients, because the poor may trade sustenance for cheap calories to stave off hunger. It precludes restorative sleep, given the demands of staying alive in the elements of the streets, the noisy crowded quarters, or the grueling hours of a second job. Poverty challenges the most basic levels of safety, security, hygiene, mental health, and the overall well-being of the lives of the almost 50 million Americans and billions worldwide in its grasp.



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The Patient With Chest Pain Low Risk, High Stakes

from ArchInte - 01 Apr 14

The etiology of chest pain is serious in only a distinct minority of the multitude of patients who visit the emergency department (ED) with this symptom each year, but the consequences of missing acute coronary syndrome or other life-threatening conditions can include grave clinical sequelae and major liability. Thus, the dilemma of low risk but high stakes in this patient population continues to spur efforts to optimally serve both groups by rapid identification of those requiring urgent treatm



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Unintended Consequences of Therapy in the Intensive Care Unit

from ArchInte - 01 Apr 14

Gastric acidity suppression is recommended for critically ill patients, with strong clinical evidence for efficacy, particularly in mechanically ventilated patients. Acid-suppressive agents such as proton pump inhibitors (PPIs) and histamine-2 receptor antagonists (H2RA) are thought to decrease the risk of acute gastrointestinal tract (GI) hemorrhage from stress-induced ulcers. However, the suppression of gastric acidity has been shown in several observational studies to lead to higher rates of



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Treating Hypertension in the Elderly Should the Risk of Falls Be Part of the Equation?

from ArchInte - 01 Apr 14

Hypertension affects two-thirds of persons 60 years or older. Treatment of hypertension has clear cardiovascular benefits in younger adults, but, as is true for most classes of medications, it is less clear whether these benefits extend to the growing elderly population. Medications used to treat hypertension are often prescribed for the remaining years of a patient’s life, increasing the risk of adverse effects and financial strain. Clinicians must balance the uncertain cardiovascular benefits



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Risks of Compounded Drugs

from ArchInte - 01 Apr 14

A nurse notices “floaters” in an infusion bag of magnesium sulfate, initiating a chain of discoveries that causes a single hospital to recall 12?000 units of 44 types of products sourced from the same compounding pharmacy. In this issue, Boyce et al describe how this drug quality problem, which was eventually identified as fungal contamination, led to the readmission of 545 potentially exposed patients and cost the hospital system 15?000 hours of personnel time and nearly $900?000. The case illu


 

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