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Highlights

from JAMA - 23 Apr 14



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How Neurologists Can Choose (Even More) Wisely Prioritizing Waste Reduction Targets and Identifying Gaps in Knowledge

from JAMA - 23 Apr 14

Health care accounts for a large, and escalating, proportion of the gross domestic product, yet the overall value of many of these expenditures is unclear. The Institute of Medicine estimates that $750 billion could be saved annually by reducing health care inefficiencies, including $210 billion by eliminating unnecessary services. A recent attempt to reduce these unnecessary services, the Choosing Wisely campaign aims to stimulate a conversation between physicians and patients about the necessi



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Global Opportunities and Challenges for Clinical Neuroscience

from JAMA - 23 Apr 14

Clinical neuroscience faces 2 challenges: (1) an increasing number of persons worldwide with neurodegenerative and neurovascular disorders and the increased expenditures necessary for their care; and (2) patients with rare neurologic diseases who also deserve and demand attention. Demographic changes and the “epidemiologic transition” (from infections to chronic diseases) have converged, causing an unprecedented global burden of disabling neurologic disorders: in 2010, approximately 35 million p



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Neurology at a Crossroads Opportunities and Challenges

from JAMA - 23 Apr 14

Neurology was once derided as a field known for the diagnostic skills of its practitioners but also for its inability to offer effective treatments for a majority of patients. Today, neurologists have an increasing number of available therapeutic options, many of which substantially improve physical well-being and quality of life. Rapid and transformative advances in understanding the underlying neurobiology of the diseases neurologists treat and in development of increasingly targeted and effec



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Decisions

from JAMA - 23 Apr 14



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tPA for Stroke Important Progress in Achieving Faster Treatment

from JAMA - 23 Apr 14

Intravenous tissue plasminogen activator (tPA) remains the only level 1A treatment for acute ischemic stroke. The results of several prospective randomized trials comparing tPA with standard treatment and pooled analyses confirm the relationship of treatment success with time from symptom onset to initiation of treatment. However, despite 2 decades of efforts to streamline systems of care including formation of designated stroke centers, placement of CT scanners in emergency departments (EDs), i



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Acetazolamide for Pseudotumor Cerebri Evidence From the NORDIC Trial

from JAMA - 23 Apr 14

After sulfanilamide was introduced as an antibiotic it was found to inhibit carbonic anhydrase, but too weakly to be a useful diuretic for patients with congestive heart failure. In search of a more potent compound, Roblin and Clapp synthetized 20 heterocyclic sulfonamides and discovered C4H6N4O3S2, an agent with 2000 times the inhibitory activity of sulfanilamide. Named acetazolamide, it was soon tested for its ability to lower intracranial pressure. Maren and colleagues administered the drug t



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Advancing Neurotherapeutics in the 21st Century

from JAMA - 23 Apr 14

Neurology is emerging rapidly as a clinical discipline with new and effective therapies for major neurological disorders. This theme issue of JAMA, devoted to neurology, includes 5 original research investigations that provide new data on neurotherapeutic advances and 3 Viewpoints that discuss how therapeutic momentum in neurology must be focused and implemented in the future to ensure progress and effectiveness and to improve health outcomes.



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Effect of the Use of Ambulance-Based Thrombolysis on Time to Thrombolysis in Acute Ischemic Stroke A Randomized Clinical Trial

from JAMA - 23 Apr 14

ImportanceTime to thrombolysis is crucial for outcome in acute ischemic stroke.ObjectiveTo determine if starting thrombolysis in a specialized ambulance reduces delays.Design, Setting, and ParticipantsIn the Prehospital Acute Neurological Treatment and Optimization of Medical care in Stroke Study (PHANTOM-S), conducted in Berlin, Germany, we randomly assigned weeks with and without availability of the Stroke Emergency Mobile (STEMO) from May 1, 2011, to January 31, 2013. Berlin has an establishe



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Door-to-Needle Times for Tissue Plasminogen Activator Administration and Clinical Outcomes in Acute Ischemic Stroke Before and After a Quality Improvement Initiative

from JAMA - 23 Apr 14

ImportanceThe benefits of intravenous tissue plasminogen activator (tPA) in patients with acute ischemic stroke (AIS) are time dependent and guidelines recommend a door-to-needle (DTN) time of 60 minutes or less. However, studies have found that less than 30% of US patients are treated within this time window. Target: Stroke was designed as a national quality improvement initiative to improve DTN times for tPA administration in patients with AIS.ObjectivesTo evaluate DTN times for tPA administra



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Effect of Acetazolamide on Visual Function in Patients With Idiopathic Intracranial Hypertension and Mild Visual Loss The Idiopathic Intracranial Hypertension Treatment Trial

from JAMA - 23 Apr 14

ImportanceAcetazolamide is commonly used to treat idiopathic intracranial hypertension (IIH), but there is insufficient information to establish an evidence base for its use.ObjectiveTo determine whether acetazolamide is beneficial in improving vision when added to a low-sodium weight reduction diet in patients with IIH and mild visual loss.Design, Setting, and ParticipantsMulticenter, randomized, double-masked, placebo-controlled study of acetazolamide in 165 participants with IIH and mild visu



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Lorazepam vs Diazepam for Pediatric Status Epilepticus A Randomized Clinical Trial

from JAMA - 23 Apr 14

ImportanceBenzodiazepines are considered first-line therapy for pediatric status epilepticus. Some studies suggest that lorazepam may be more effective or safer than diazepam, but lorazepam is not Food and Drug Administration approved for this indication.ObjectiveTo test the hypothesis that lorazepam has better efficacy and safety than diazepam for treating pediatric status epilepticus.Design, Setting, and ParticipantsThis double-blind, randomized clinical trial was conducted from March 1, 2008,



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Outcome After Conservative Management or Intervention for Unruptured Brain Arteriovenous Malformations

from JAMA - 23 Apr 14

ImportanceWhether conservative management is superior to interventional treatment for unruptured brain arteriovenous malformations (bAVMs) is uncertain because of the shortage of long-term comparative data.ObjectiveTo compare the long-term outcomes of conservative management vs intervention for unruptured bAVM.Design, Setting, and PopulationPopulation-based inception cohort study of 204 residents of Scotland aged 16 years or older who were first diagnosed as having an unruptured bAVM during 1999



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Pharmacological Treatment of Parkinson Disease A Review

from JAMA - 23 Apr 14

ImportanceParkinson disease is the second most common neurodegenerative disease worldwide. Although no available therapies alter the underlying neurodegenerative process, symptomatic therapies can improve patient quality of life.ObjectiveTo provide an evidence-based review of the initial pharmacological management of the classic motor symptoms of Parkinson disease; describe management of medication-related motor complications (such as motor fluctuations and dyskinesia), and other medication adve



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Serum Brain-Derived Neurotrophic Factor and the Risk for Dementia

from JAMA - 23 Apr 14

JAMA NeurologySerum Brain-Derived Neurotrophic Factor and the Risk for Dementia: The Framingham Heart StudyGalit Weinstein, PhD; Alexa S. Beiser, PhD; Seung Hoan Choi, MS; Sarah R. Preis, ScD, MPH; Tai C. Chen, PhD; Demetrios Vorgas, MSc; Rhoda Au, PhD; Aleksandra Pikula, MD; Philip A. Wolf, MD; Anita L. DeStefano, PhD; Ramachandran S. Vasan, MD; Sudha Seshadri, MDImportance In animal studies, brain-derived neurotrophic factor (BDNF) has been shown to impact neuronal survival and function and i



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Deep Brain Stimulation for Parkinson’s Disease With Early Motor Complications

from JAMA - 23 Apr 14

Deep brain stimulation is FDA-approved and has been used for years to treat patients with advanced Parkinson’s disease (PD) who have severe levodopa-induced motor complications. New evidence from a controlled trial suggests that it may also be effective for patients with PD and early motor complications.



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Testing the Presumption of Consent to Emergency Treatment for Acute Ischemic Stroke

from JAMA - 23 Apr 14

In life-threatening emergencies involving incapacitated patients without surrogates, clinicians may intervene without obtaining informed consent, applying the presumption that reasonable people would consent to treatment in such circumstances. Whether this rationale applies to the treatment of acute ischemic stroke with intravenous thrombolysis is controversial because this intervention improves functional outcomes but is not life preserving.



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Financial Relationships Between Medical Communication Companies and Industry

from JAMA - 23 Apr 14

To the Editor I believe Dr Rothman and colleagues misrepresented the Accreditation Council for Continuing Medical Education (ACCME) system and the rules safeguarding continuing medical education (CME) from industry influence. The authors asserted that the organizations in their report are all ACCME accredited and that the organizations also provide marketing services to industry, including “prelaunch and branding campaigns.” I do not believe these assertions are true, for the following reasons.



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Financial Relationships Between Medical Communication Companies and Industry

from JAMA - 23 Apr 14

To the Editor The article by Dr Rothman and colleagues contained 2 inaccuracies in Table 4 related to our group, Research to Practice (RTP). The table indicates that RTP has a parent company. Research to Practice has no parent company, affiliates, or any related entities.



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Financial Relationships Between Medical Communication Companies and Industry—Reply

from JAMA - 23 Apr 14

In Reply We believe Dr Kopelow misrepresents our methods and analysis. We explored the financial relationships between the pharmaceutical industry and MCCs, whose primary business is disseminating information about disease prevention and management. Our article does not focus on the ACCME. It is mentioned once and Kopelow misstates the sentence: “The authors asserted that the organizations in their report are all ACCME accredited.” We wrote that the top 18 MCC industry grant recipients (not all



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Strategies to Overcome Medication Nonadherence

from JAMA - 23 Apr 14

To the Editor The suggestions by Dr Zullig and colleagues for improving medication adherence are laudable, but we believe their list of barriers to nonadherence overlooks 2 fundamental features of human behavior, inattention and inertia, while overemphasizing the need for engagement.



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Strategies to Overcome Medication Nonadherence—Reply

from JAMA - 23 Apr 14

In Reply As stated in our Viewpoint, the problem of medication nonadherence is often multifactorial, and there is no universal formula that will resolve adherence issues for every patient in every situation. The key is to identify characteristics and situations making patients vulnerable for medication nonadherence and subsequently provide a personalized program to address specific needs in the mode and time that will be most effective to motivate adherence.



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Incorrect Author Affiliation

from JAMA - 23 Apr 14

In the Original Investigation entitled “Age-Adjusted D-Dimer Cutoff Levels to Rule Out Pulmonary Embolism: The ADJUST-PE Study” published in the March 19, 2014, issue of JAMA (2014;311[11]:1117-1124. doi:10.1001/jama.2014.2135), an author’s institutional information was incorrect. Dr Le Gal is affiliated with Ottawa Health Research Institute, Ottawa, Ontario, Canada and Centre d’Investigations Cliniques, Université de Brest, Brest, France. This article was corrected online.



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Incorrect Language

from JAMA - 23 Apr 14

In the Editorial entitled “Medical Communication Companies and Continuing Medical Education: Clouding the Sunshine?” published in the December 18, 2013, issue of JAMA (2013;310[23]2507-2508. doi:10.1001/JAMA.2013.281640), there was incorrect language. In the fifth paragraph from the end, the sentence that begins “Nevertheless” should have read “Nevertheless, close to half of medical school CME revenue in 2012 was commercial, ranging from 50%, if advertising and exhibits are counted as commercia



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Researchers Test Strategies to Prevent Alzheimer Disease

from JAMA - 23 Apr 14

A decade of disappointing clinical trial results for Alzheimer disease (AD)-modifying therapies in people suggests that treatment should be targeted at earlier stages in the disease—even before overt symptoms arise.


 

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