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Highlights

from JAMA - 01 Oct 14



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Evidence-Based Practice Is Not Synonymous With Delivery of Uniform Health Care

from JAMA - 01 Oct 14

Current clinical practice is characterized by substantial variation in delivery of health care for the same conditions. In turn, clinical variation is considered one of the major drivers of ever-increasing health care costs contributing to the estimated 30% of inappropriate or wasteful health care. Perhaps as a natural response to this unsatisfactory situation, a widespread and influential school of thought has emerged contending that greater uniformity of clinical practice is desirable. Advocat



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The Connection Between Evidence-Based Medicine and Shared Decision Making

from JAMA - 01 Oct 14

This Viewpoint considers the interdependence of evidence-based medicine and shared decision making.



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Why Should High-Income Countries Help Combat Ebola?

from JAMA - 01 Oct 14

This Viewpoint outlines the reasons why high-income countries have a duty to help combat Ebola disease in affected countries.



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Evaluating Novel Therapies During the Ebola Epidemic

from JAMA - 01 Oct 14

This Viewpoint considers the ethical and scientific dilemmas that arise in evaluating the use of experimental therapies in an epidemic.



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Graduation Gift

from JAMA - 01 Oct 14

I graduated medical school on a Sunday. On Monday, with the newly earned letters MD adorning the end of my name, I accompanied two friends to their doctor’s appointment at the institution where I trained. These friends happened to have graduated from a neighboring medical school just two days earlier, so as three new 20-some-year-old physicians entered an outpatient appointment, we humored one another by addressing each other only as “Doctor.” I was there primarily for moral support (and to help



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Managing Posthospital Care Transitions for Older Adults Challenges and Opportunities

from JAMA - 01 Oct 14

In this issue of JAMA, Dhalla and colleagues report findings from a randomized trial comparing the effect of usual care vs a “virtual ward” model of posthospital care management for older adults on reducing the primary end point of 30-day hospital readmissions. The virtual ward focused on care coordination by telephone or e-mail contact as well as clinic or home visits for several weeks following hospital discharge. With Medicare hospital reimbursement increasingly tied to 30-day readmission rat



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Effect of a Postdischarge Virtual Ward on Readmission or Death for High-Risk Patients A Randomized Clinical Trial

from JAMA - 01 Oct 14

ImportanceHospital readmissions are common and costly, and no single intervention or bundle of interventions has reliably reduced readmissions. Virtual wards, which use elements of hospital care in the community, have the potential to reduce readmissions, but have not yet been rigorously evaluated.ObjectiveTo determine whether a virtual ward—a model of care that uses some of the systems of a hospital ward to provide interprofessional care for community-dwelling patients—can reduce the risk of re



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Acupuncture for Chronic Knee Pain A Randomized Clinical Trial

from JAMA - 01 Oct 14

ImportanceThere is debate about benefits of acupuncture for knee pain.ObjectiveTo determine the efficacy of laser and needle acupuncture for chronic knee pain.Design, Setting, and ParticipantsZelen-design clinical trial (randomization occurred before informed consent), in Victoria, Australia (February 2010-December 2012). Community volunteers (282 patients aged =50 years with chronic knee pain) were treated by family physician acupuncturists.InterventionsNo acupuncture (control group, n?=?71) an



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Survival and Long-term Outcomes Following Bioprosthetic vs Mechanical Aortic Valve Replacement in Patients Aged 50 to 69 Years

from JAMA - 01 Oct 14

ImportanceThe choice between bioprosthetic and mechanical aortic valve replacement in younger patients is controversial because long-term survival and major morbidity are poorly characterized.ObjectiveTo quantify survival and major morbidity in patients aged 50 to 69 years undergoing aortic valve replacement.Design, Setting, and ParticipantsRetrospective cohort analysis of 4253 patients aged 50 to 69 years who underwent primary isolated aortic valve replacement using bioprosthetic vs mechanical



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Clinical Management of Staphylococcus aureus Bacteremia A Review

from JAMA - 01 Oct 14

ImportanceSeveral management strategies may improve outcomes in patients with Staphylococcus aureus bacteremia.ObjectivesTo review evidence of management strategies for S aureus bacteremia to determine whether transesophageal echocardiography is necessary in all adult cases and what is the optimal antibiotic therapy for methicillin-resistant S aureus (MRSA) bacteremia.Evidence ReviewA PubMed search from inception through May 2014 was performed to identify studies addressing the role of transesop



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Minimal Clinically Important Difference Defining What Really Matters to Patients

from JAMA - 01 Oct 14

When assessing the clinical utility of therapies intended to improve subjective outcomes, the amount of improvement that is important to patients must be determined. The smallest benefit of value to patients is called the minimal clinically important difference (MCID). The MCID is a patient-centered concept, capturing both the magnitude of the improvement and also the value patients place on the change. Using patient-centered MCIDs is important for studies involving patient-reported outcomes, fo



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Preventing Early Readmissions

from JAMA - 01 Oct 14

JAMA Internal MedicinePreventing 30-Day Hospital Readmissions: A Systematic Review and Meta-analysis of Randomized TrialsAaron L. Leppin, MD; Michael R. Gionfriddo, PharmD; Maya Kessler, MD; Juan Pablo Brito, MBBS; Frances S. Mair, MD; Katie Gallacher, MBChB; Zhen Wang, PhD; Patricia J. Erwin, MLS; Tanya Sylvester, BS; Kasey Boehmer, BA; Henry H. Ting, MD, MBA; M. Hassan Murad, MD; Nathan D. Shippee, PhD; Victor M. Montori, MDImportance Reducing early (Objective To synthesize the evidence of t



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Medical Professional Liability Claims Related to Esophageal Cancer Screening

from JAMA - 01 Oct 14

Endoscopic screening for esophageal adenocarcinoma has been recommended for patients with chronic symptoms of gastroesophageal reflux disease, but only if they have additional risk factors. Surveys of gastroenterologists indicate that concern about litigation for missing a cancer may drive endoscopy use in patients at low risk for esophageal adenocarcinoma. However, the perception of medical professional liability may not accurately reflect the true incidence of liability claims.



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Medications for Alcohol Use Disorders

from JAMA - 01 Oct 14

To the Editor The review by Dr Jonas and colleagues of the efficacy of medications to treat alcohol use disorders concluded that “well-controlled trials of disulfiram did not show overall reductions in alcohol consumption.” Although the conclusion may be true for the studies included in the review, double-blind randomized clinical trials are not the correct design to test the efficacy of a medication that works because patients know they are taking it and that it will make them sick if they drin



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Medications for Alcohol Use Disorders

from JAMA - 01 Oct 14

To the Editor The meta-analysis by Dr Jonas and colleagues of medical treatments for alcohol use disorders and the accompanying Editorial left me with a sense of scientific unease. Meta-analyses appear to offer solace in large clinical samples culled from many studies but really provide only approximate data when no definitive answers exist.



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Medications for Alcohol Use Disorders

from JAMA - 01 Oct 14

To the Editor A systematic review and meta-analysis highlighted the current pharmacotherapy for outpatients affected by alcohol use disorders. However, regarding off-label drugs, some issues need more discussion, particularly those regarding nalmefene use.



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Medications for Alcohol Use Disorders—Reply

from JAMA - 01 Oct 14

In Reply We agree with Dr Saitz that disulfiram may benefit some patients but not that the trials cited adequately establish disulfiram efficacy. These trials were designed to evaluate closely monitored programs that included disulfiram and additional counseling, social support, coaching, or a combination of these. At best, they might allow a conclusion that the programs work for patients interested in taking disulfiram who adhere to the medication. None of these trials disentangle whether benef



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Azithromycin for Elderly Patients With Pneumonia

from JAMA - 01 Oct 14

To the Editor Dr Mortensen and colleagues conducted a retrospective cohort study that evaluated the risk of death with azithromycin use in elderly patients with pneumonia in comparison with other guideline-recommended antibiotics. Azithromycin use was associated with a statistically significant decrease in mortality at 10, 30, and 90 days. However, prior studies in elderly populations have shown an increase in mortality from any cause associated with current use of azithromycin, defined as withi



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Medications for Alcohol Use Disorder—Reply

from JAMA - 01 Oct 14

In Reply We agree with Dr Beresford that patient-centered care with shared decision making is not a new concept in medicine. However, patient-centered care is not currently the routine approach to management of alcohol use disorders in medical settings. Instead, referral to specialty treatment is often recommended for patients diagnosed with alcohol use disorders.



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Azithromycin for Elderly Patients With Pneumonia—Reply

from JAMA - 01 Oct 14

In Reply Regarding the concern of Dr Bin Abdulhak and colleagues about examining shorter periods than 10 days after admission, we consider follow-up durations longer than 5 days to be more clinically relevant and important. Although there may be an increased risk of arrhythmias earlier due to the use of azithromycin, we doubt that clinicians or patients would then avoid this medication when there is a clinically significant survival advantage at 90 days.



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Rates of Cholesterol Screening of Youth

from JAMA - 01 Oct 14

To the Editor The recent analysis by Mr Vinci and colleagues provides insights into the rates of cholesterol screening of youth in the United States, accounting for key demographic and geographic covariates. Even though these data are of value, there are deficits in the analysis and findings, meriting further examination.



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Rates of Cholesterol Screening of Youth—Reply

from JAMA - 01 Oct 14

In Reply Dr Gregory and colleagues raise the concern that because our analysis used only health maintenance visits, we may have underestimated a substantial proportion of cholesterol testing. In fact, we consciously excluded subspecialist, urgent care, or other visits because we suspected those visits had a higher chance of including testing performed in follow-up of a known cholesterol disorder or to look for adverse events from medications that can affect lipid levels.



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Calls Increase for Tighter Control of e-Cigarettes

from JAMA - 01 Oct 14

The World Health Organization (WHO) and the American Heart Association (AHA) have joined the chorus of groups calling for tighter regulation of e-cigarettes, which have grown into a $3 billion global industry.



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CDC Tracking Enterovirus D-68 Outbreak Causing Severe Respiratory Illness in Children in the Midwest

from JAMA - 01 Oct 14

Clinicians should be on the alert for severe respiratory illness in children that might be caused by infection with a rarely seen virus, enterovirus D-68 (EV-D68), according to federal health officials. This advice, from the US Centers for Disease Control and Prevention (CDC), was prompted by clusters of severe respiratory illness in children in Missouri and Illinois that emerged in August.


 

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