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Journal Cover JAMA The Journal of the American Medical Association
   [789 followers]  Follow    
   Full-text available via subscription Subscription journal
     ISSN (Print) 0098-7484 - ISSN (Online) 1538-3598
     Published by American Medical Association Homepage  [11 journals]   [SJR: 4.843]   [H-I: 456]
  • Flexible Sigmoidoscopy for Colorectal Cancer Screening More Evidence,
           Persistent Ironies
    • Authors: Brett AS.
      Abstract: In this issue of JAMA, Holme and colleagues report results of a large randomized trial of colorectal cancer screening in Norway in which one-time flexible sigmoidoscopy was compared with no screening. In intention-to-screen analysis—which included all people invited for screening, regardless of their follow-through—relative reductions in colorectal cancer incidence and cancer-specific mortality were 20% and 27% in the sigmoidoscopy group, respectively, compared with the no-screening control group, during an average follow-up of about 11 years. In absolute terms, colorectal cancer death was averted in 1 person per 1000; cancer-specific mortality was roughly 4 per 1000 in the control group and 3 per 1000 in the sigmoidoscopy group. Colorectal cancer mortality curves did not diverge until the ninth year, suggesting that the benefit of screening might increase with longer follow-up. Additionally, because only two-thirds of people invited for screening actually participated, the population benefit would likely be higher with greater adherence. Half the sigmoidoscopy group also received one-time immunological fecal occult blood testing (FOBT), but this addition did not improve outcomes beyond sigmoidoscopy alone.
      PubDate: Wed, 13 Aug 2014 00:00:00 GMT
       
  • Hepatitis C
    • Authors: Sugerman D.
      PubDate: Wed, 13 Aug 2014 00:00:00 GMT
       
  • JAMA
    • PubDate: Wed, 13 Aug 2014 00:00:00 GMT
       
  • Heroin Use Leads to Anthrax
    • Abstract: Researchers in the United Kingdom warn that patients who inject illicit drugs and present with sepsis, soft-tissue infection, or multiorgan failure may have contracted a novel type of anthrax from contaminated heroin.
      PubDate: Wed, 13 Aug 2014 00:00:00 GMT
       
  • Watercress Is the Winner
    • Abstract: From mothers’ admonitions to Michelle Obama’s White House kitchen garden, messages to eat fruits and vegetables are ubiquitous. But which picks from the produce aisle pack the biggest nutritional punch'
      PubDate: Wed, 13 Aug 2014 00:00:00 GMT
       
  • Costly Cancer Care
    • Abstract: A new analysis has added to concerns that the high cost of cancer care and related productivity losses will risk financial ruin for increasing numbers of US families.
      PubDate: Wed, 13 Aug 2014 00:00:00 GMT
       
  • Malaria’s Toll in the Peace Corps
    • Abstract: About one-fourth of US Peace Corps volunteers serving in malaria-endemic regions of Africa don’t take the prescribed antimalarial medications that the agency requires, according to a recent survey.
      PubDate: Wed, 13 Aug 2014 00:00:00 GMT
       
  • The Aqueduct William Sartain
    • Authors: Smith JM.
      Abstract: A fancy for faraway places by William Sartain (1843-1924) was perhaps not a little unexpected, given his comfortable childhood in an upscale area of Philadelphia, surrounded by illustrious family. But although Sartain attained success as an engraver, his heart’s desire was to paint, and in pursuit of this siren call, he would one day find himself sipping fragrant coffee and donning a burnoose in exotic North Africa, the spice and local flavor of which he would chronicle with delight in his evocative paintings.
      PubDate: Wed, 13 Aug 2014 00:00:00 GMT
       
  • Fast
    • Authors: Masson V.
      Abstract: For a painful procedure you want fast.In truth, you always want fast—same-day appointmentshort wait in the waiting roomprompt attention in the exam roomon the spot test resultsclean diagnosisdefinitive treatment(preferably pills)and, of course, a quick cure
      PubDate: Wed, 13 Aug 2014 00:00:00 GMT
       
  • Viral Hepatitis—1975
    • Authors: Conrad M; Knodell R.
      Abstract: Viral hepatitis has been recognized as an illness since antiquity. However, it was not until World War II that it was realized that this disease was a commonplace entity. On the basis of epidemiologic data, it was believed that there were two distinct types of viral hepatitis: hepatitis A, or infectious hepatitis, contracted by oral exposure and with a short incubation period (15 to 45 days), and hepatitis B, or serum hepatitis, caused by parenteral exposure and with a long incubation period (50 to 180 days). Recent investigation has shown that (1) other infectious diseases may mimic viral hepatitis (cytomegalovirus, EB virus, toxoplasmosis, infectious mononucleosis), (2) hepatitis A and B may be transmitted by either the oral or the parenteral routes, and (3) there is at least one additional cause of viral hepatitis (hepatitis “C”'), which has an incubation period intermediate to those of hepatitis A and B. The development of immunologic methods for the identification of these diseases during the past decade has permitted these advances.… The following are highlights of recent investigations.
      PubDate: Wed, 13 Aug 2014 00:00:00 GMT
       
  • Meta-analysis as Evidence Building a Better Pyramid
    • Authors: Berlin JA; Golub RM.
      Abstract: In following the practice of evidence-based medicine, when faced with a question about prevention or treatment the clinician should seek out the best evidence that addresses the question. If quality of evidence is considered a pyramid, what category should be placed at the peak' One dogma argues that it is the best-conducted randomized clinical trial (RCT) comprising patients similar to those seen by the clinician, reasoning that a well-done RCT mimics pure experimental conditions better than any other study design, hence minimizing the likelihood of confounding. A counterargument is that the best evidence is a systematic review with meta-analysis, because this approach can integrate all of the relevant evidence and provide a more reliable answer than a single study, however well conducted.
      PubDate: Wed, 13 Aug 2014 00:00:00 GMT
       
  • Effect of Flexible Sigmoidoscopy Screening on Colorectal Cancer Incidence
           and Mortality A Randomized Clinical Trial
    • Authors: Holme Ø; Løberg M, Kalager M, et al.
      Abstract: ImportanceColorectal cancer is a major health burden. Screening is recommended in many countries.ObjectiveTo estimate the effectiveness of flexible sigmoidoscopy screening on colorectal cancer incidence and mortality in a population-based trial.Design, Setting, and ParticipantsRandomized clinical trial of 100 210 individuals aged 50 to 64 years, identified from the population of Oslo city and Telemark County, Norway. Screening was performed in 1999-2000 (55-64–year age group) and in 2001 (50-54–year age group), with follow-up ending December 31, 2011. Of those selected, 1415 were excluded due to prior colorectal cancer, emigration, or death, and 3 could not be traced in the population registry.InterventionsParticipants randomized to the screening group were invited to undergo screening. Within the screening group, participants were randomized 1:1 to receive once-only flexible sigmoidoscopy or combination of once-only flexible sigmoidoscopy and fecal occult blood testing (FOBT). Participants with positive screening test results (cancer, adenoma, polyp ≥10 mm, or positive FOBT) were offered colonoscopy. The control group received no intervention.Main Outcomes and MeasuresColorectal cancer incidence and mortality.ResultsA total of 98 792 participants were included in the intention-to-screen analyses, of whom 78 220 comprised the control group and 20 572 comprised the screening group (10 283 randomized to receive a flexible sigmoidoscopy and 10 289 to receive flexible sigmoidoscopy and FOBT). Adherence with screening was 63%. After a median of 10.9 years, 71 participants died of colorectal cancer in the screening group vs 330 in the control group (31.4 vs 43.1 deaths per 100 000 person-years; absolute rate difference, 11.7 [95% CI, 3.0-20.4]; hazard ratio [HR], 0.73 [95% CI, 0.56-0.94]). Colorectal cancer was diagnosed in 253 participants in the screening group vs 1086 in the control group (112.6 vs 141.0 cases per 100 000 person-years; absolute rate difference, 28.4 [95% CI, 12.1-44.7]; HR, 0.80 [95% CI, 0.70-0.92]). Colorectal cancer incidence was reduced in both the 50- to 54-year age group (HR, 0.68; 95% CI, 0.49-0.94) and the 55- to 64-year age group (HR, 0.83; 95% CI, 0.71-0.96). There was no difference between the flexible sigmoidoscopy only vs the flexible sigmoidoscopy and FOBT screening groups.Conclusions and RelevanceIn Norway, once-only flexible sigmoidoscopy screening or flexible sigmoidoscopy and FOBT reduced colorectal cancer incidence and mortality on a population level compared with no screening. Screening was effective both in the 50- to 54-year and the 55- to 64-year age groups.Trial Registrationclinicaltrials.gov Identifier: NCT00119912
      PubDate: Wed, 13 Aug 2014 00:00:00 GMT
       
  • E-Cigarettes, Vaping, and Youth
    • Authors: Gostin LO; Glasner AY.
      Abstract: The Family Smoking Prevention and Tobacco Control Act of 2009 empowered the US Food and Drug Administration (FDA) to regulate tobacco, the leading preventable cause of death. The agency, however, initially exercised authority only over specific tobacco products: cigarettes, cigarette tobacco, roll-your-own (loose tobacco), and smokeless tobacco. This decision left other forms of tobacco unregulated. Five years later, in April 2014, the FDA sought to close this regulatory gap by issuing proposed rules—referred to as “deeming”—to regulate electronic cigarettes, cigars, pipe tobacco, nicotine gels, waterpipe (hookah) tobacco, and orally ingested dissolvable tobacco products. The proposed rules represent a watershed moment in tobacco control but do not go far enough in regulating e-cigarettes, a product with uncertain benefits and potentially significant harms.
      PubDate: Wed, 13 Aug 2014 00:00:00 GMT
       
  • Patient Referrals A Linchpin for Increasing the Value of Care
    • Authors: Song Z; Sequist TD, Barnett ML.
      Abstract: The success of accountable care organizations (ACOs) under global payment may depend in part on a common yet poorly understood clinical decision: the patient referral in the outpatient setting. Fundamental to collaboration among physicians and other health care professionals, patient referrals have been largely ignored in the payment reform debate.
      PubDate: Wed, 13 Aug 2014 00:00:00 GMT
       
  • Use of Morcellation to Remove Fibroids Scrutinized at FDA Hearings
    • Authors: Hampton T.
      Abstract: A boxed warning about the risk of inadvertently disseminating cancerous tissue from an unsuspected malignancy during minimally invasive surgery to remove fibroids “would be useful but not enough to address the issue alone,” said the Obstetrics and Gynecology Devices Advisory Committee of the US Food and Drug Administration (FDA) at a meeting last month (http://1.usa.gov/WENsAI).
      PubDate: Wed, 13 Aug 2014 00:00:00 GMT
       
  • From JAMA’s Daily News Site
    • PubDate: Wed, 13 Aug 2014 00:00:00 GMT
       
  • House Passes Bill to Support Newborn Screening
    • Authors: Slomski A.
      Abstract: Efforts to screen newborns for at least 31 genetic and metabolic diseases gained another 5 years of funding when the House passed the Newborn Screening Saves Lives Reauthorization Act (HR 1281) on June 24. The Senate passed similar legislation in late January.
      PubDate: Wed, 13 Aug 2014 00:00:00 GMT
       
  • Lawmakers Call for Details on Trial Participants’ Sex and Race
    • Authors: Slomski A.
      Abstract: In a letter to the director of the National Institutes of Health (NIH), 27 House members called for ClinicalTrials.gov, an online repository of information on publicly and privately supported clinical trials, to enable users to search all trial results by sex, race, and other demographic data (http://1.usa.gov/1pgBYfl). Although NIH trials are mandated to include women and minorities as study participants, the requirement does not pertain to privately supported trials, which constitute the majority of the studies.
      PubDate: Wed, 13 Aug 2014 00:00:00 GMT
       
  • Lawmakers Respond to Hobby Lobby Ruling
    • Authors: Slomski A.
      Abstract: Democratic lawmakers in Congress quickly attempted to reverse the June 30 Supreme Court decision in Burwell v Hobby Lobby that allows closely held businesses to refuse to provide certain types of contraceptive coverage in their employee health plans based on religious objections. The Senate and House bills would have prohibited for-profit corporations from denying coverage for any specific benefits mandated under the Affordable Care Act, including contraception, by modifying the law that was the basis of the Supreme Court’s ruling in Burwell v Hobby Lobby. A 56 to 43 vote in the Senate on July 16 quashed the bill, however, and the companion legislation is unlikely to pass in the Republican-controlled House.
      PubDate: Wed, 13 Aug 2014 00:00:00 GMT
       
  • Verifying Eligibility for Insurance and Subsidies Problematic for
           Exchanges
    • Authors: Slomski A.
      Abstract: Federal and state health insurance exchanges were unable to verify the eligibility of many applicants for health coverage under the Affordable Care Act, stated a July 1 report to Congress by the Inspector General for the Department of Health and Human Services (http://1.usa.gov/1rfaZoq). The Centers for Medicare & Medicaid Services (CMS) operates the federal marketplace and oversees the health exchanges for 36 states. Because CMS’ eligibility system was not fully operational as of the first quarter of 2014, the federal marketplace couldn’t resolve 2.6 million of 2.9 million inconsistencies on applications for insurance and premium subsidies, according to the report.
      PubDate: Wed, 13 Aug 2014 00:00:00 GMT
       
  • Incorrect Units, Group Name, and Author Name
    • Abstract: In the Special Communication entitled “HIV Prevention in Clinical Care Settings: 2014 Recommendations of the International Antiviral Society–USA Panel” published in the July 23/30, 2014, issue of JAMA (2014;312[4]:390-409. doi:10.1001/jama.2014.7999), units were incorrectly reported. In the second and third paragraphs in “Section B: Prevention Measures Specific to HIV-Infected Individuals,” the units for CD4 cell counts reported as cells/mL should have been reported as cells/μL. Additionally, in the Author Contributions section, the name del Rio incorrectly appeared as “Del Rio.” Last, in the Funding/Support section, “International Antivirus Society–USA” should have read “International Antiviral Society–USA.” This article was corrected online.
      PubDate: Wed, 13 Aug 2014 00:00:00 GMT
       
  • Updated Information
    • Abstract: In the Viewpoint entitled “An HIV Cure: Feasibility, Discovery, and Implementation” published in the July 23/30, 2014, issue of JAMA (2014;312[4]:335-336. doi:10.1001/jama.2014.4754), important information became available after the Viewpoint went to press. In paragraph 7, sentence 4 onward has been updated to read “First, the infant referred to as the ‘Mississippi Baby,’ who was born to an HIV-infected mother who had received neither prenatal nor perinatal ART, began receiving full antiretroviral treatment at age 30 hours. It was later determined that the infant was infected, and ART was continued through age 18 months, at which point the child was lost to follow-up. At age 23 months the child was again seen in clinic and had no detectable virus in the blood, despite not taking ART for the previous 5 months, and had no HIV-specific antibodies. These results persisted for a total of 27 months without therapy. However, at age 46 months, the child experienced unequivocal viral rebound (consecutive plasma viral load measurements of 16 750 HIV RNA copies/mL and 10 564 copies/mL). Although a permanent cure was not achieved, the infant’s early treatment led to a markedly sustained virologic remission. In light of these new findings, researchers must now work to better understand what enabled the child to remain off treatment for more than 2 years without detectable virus or measurable immunologic response and what might be done to extend the period of sustained HIV remission in the absence of ART.” Additionally, one reference was updated, another added, and the references were renumbered accordingly. This article was corrected online.
      PubDate: Wed, 13 Aug 2014 00:00:00 GMT
       
  • AAP: Toxic Stress Threatens Kids’ Long-term Health
    • Authors: Kuehn BM.
      Abstract: Pediatricians have long had a window into the troubles facing young patients and their families. Now, emerging data on how early exposure to adversity can impair long-term health and development have led the American Academy of Pediatrics (AAP) and other thought leaders to call for more effective and aggressive intervention for children in distress.
      PubDate: Wed, 13 Aug 2014 00:00:00 GMT
       
  • NIH’s Undiagnosed Diseases Program Expands 6 New Sites Offer
           Potential Answers to More Patients
    • Authors: Kuehn BM.
      Abstract: Louise Benge, of Brodhead, Kentucky, enjoyed a normal, active childhood, including playing running games with friends, the 51-year-old woman explained at a National Institutes of Health (NIH) press briefing in July. Then in her teens, Benge developed crippling pain in her hands.
      PubDate: Wed, 13 Aug 2014 00:00:00 GMT
       
  • Risk and Benefits of Screening Mammography—Reply
    • Authors: Pace LE; Keating NL.
      Abstract: In Reply We agree with Dr Lannin that the evidence of the benefits of mammography in women at higher risk for breast cancer is limited. None of the randomized trials of mammography screening specifically assessed if the mortality benefits of mammography differed for higher-risk groups, such as women with a family history of breast cancer or women with dense breasts, compared with women at lower risk. However, these trials did allow assessment of the modifying effect of age, one of the most important risk factors for breast cancer. Results from meta-analyses suggest that the relative risk reduction is greater for 60- to 70-year-old women than for younger women, as shown in Table 1 of the article.
      PubDate: Wed, 13 Aug 2014 00:00:00 GMT
       
  • Transparency in the Delivery of Mental Health Care
    • Authors: Ritter JT.
      Abstract: To the Editor At the end of their article, Dr Kahn and colleagues concluded, “It’s time to offer fully transparent care to our patients with mental illness.” I assume the authors were referring to adult patients. That being said, working with children and families adds to the complexity in many ways that Kahn and colleagues may not have considered.
      PubDate: Wed, 13 Aug 2014 00:00:00 GMT
       
  • Transparency in the Delivery of Mental Health Care—Reply
    • Authors: Walker J; Kahn MW, Delbanco T.
      Abstract: In Reply Dr Ritter raises difficult questions. Adults are increasingly reviewing clinicians’ notes, and we expect that adolescents and younger children, raised with ever-evolving social media, will be interested in what is being written about them in medical records. Even though some clinicians are beginning to offer adults access to their mental health notes, we are not familiar with institutions doing so for young people.
      PubDate: Wed, 13 Aug 2014 00:00:00 GMT
       
  • Hospital Alarms and Patient Safety
    • Authors: Barach P; Arora VM.
      Abstract: To the Editor Drs Chopra and McMahon highlighted several valid points about the need to redesign patient alarms. However, the authors overlooked the most important reason to redesign the hospital acoustic environment of care—to improve patient safety and well-being.
      PubDate: Wed, 13 Aug 2014 00:00:00 GMT
       
  • Hospital Alarms and Patient Safety—Reply
    • Authors: Chopra V; McMahon LF, Jr.
      Abstract: In Reply In response to our recent Viewpoint, Drs Barach and Arora state that we overlooked the most important reason to redesign the hospital acoustic environment of care. Barach and Arora cite several articles supporting the assertion that hospital noise is associated with adverse patient satisfaction and clinical well-being.
      PubDate: Wed, 13 Aug 2014 00:00:00 GMT
       
  • Incorrect Phrase in Sentence
    • Abstract: In the Letter to the Editor entitled “Housing Mobility and Adolescent Mental Health” published in the July 9, 2014, issue of JAMA (2014;312[2]:190. doi:10.1001/jama.2014.6468), an incorrect phrase was substituted for a word in a sentence. In the second paragraph, the last sentence should have read “It would be of interest to know how the Moving to Opportunity voucher and control boys with PTSD differed with respect to the settings, types,3 chronicity, and severity of the precipitating stressors and PTSD symptoms; whether PTSD cases clustered in boys who relocated to high-poverty neighborhoods after voucher-facilitated moves4; and whether any effect modification by age at randomization is detectable.” This article was corrected online.
      PubDate: Wed, 13 Aug 2014 00:00:00 GMT
       
  • Serum Ammonia Level for the Evaluation of Hepatic Encephalopathy
    • Authors: Ge PS; Runyon BA.
      PubDate: Wed, 13 Aug 2014 00:00:00 GMT
       
  • Time to Cardioversion for Acute Atrial Fibrillation and Thromboembolic
           Complications
    • Authors: Nuotio I; Hartikainen JK, Grönberg T, et al.
      Abstract: In 1995, practice guidelines recommended a limit of 48 hours after the onset of atrial fibrillation (AF) for cardioversion without anticoagulation. Whether the risk of thromboembolic complications is increased when cardioversion without anticoagulation is performed in less than 48 hours is unknown.
      PubDate: Wed, 13 Aug 2014 00:00:00 GMT
       
  • Risk and Benefits of Screening Mammography
    • Authors: Lannin DR.
      Abstract: To the Editor One of the major conclusions of the recent article by Drs Pace and Keating was that “The net benefit of screening depends greatly on baseline breast cancer risk, which should be incorporated into screening decisions.” This seems logical, but I do not believe there is evidence that it is true.
      PubDate: Wed, 13 Aug 2014 00:00:00 GMT
       
  • Youth Experimentation With e-Cigarettes Another Interpretation of the Data
    • Authors: Niaura RS; Glynn TJ, Abrams DB.
      Abstract: JAMA PediatricsElectronic Cigarettes and Conventional Cigarette Use Among US Adolescents: A Cross-sectional StudyLauren M. Dutra, ScD; Stanton A. Glantz, PhDImportance Electronic cigarette (e-cigarette) use is increasing rapidly among adolescents, and e-cigarettes are currently unregulated.Objective To examine e-cigarette use and conventional cigarette smoking.Design, Setting, and Participants Cross-sectional analyses of survey data from a representative sample of US middle and high school students in 2011 (n = 17 353) and 2012 (n = 22 529) who completed the 2011 and 2012 National Youth Tobacco Survey.Exposures Ever and current e-cigarette use.Main Outcomes and Measures Experimentation with, ever, and current smoking, and smoking abstinence.Results Among cigarette experimenters (≥1 puff), ever e-cigarette use was associated with higher odds of ever smoking cigarettes (≥100 cigarettes; odds ratio [OR] = 6.31; 95% CI, 5.39-7.39) and current cigarette smoking (OR = 5.96; 95% CI, 5.67-6.27). Current e-cigarette use was positively associated with ever smoking cigarettes (OR = 7.42; 95% CI, 5.63-9.79) and current cigarette smoking (OR = 7.88; 95% CI, 6.01-10.32). In 2011, current cigarette smokers who had ever used e-cigarettes were more likely to intend to quit smoking within the next year (OR = 1.53; 95% CI, 1.03-2.28). Among experimenters with conventional cigarettes, ever use of e-cigarettes was associated with lower 30-day (OR = 0.24; 95% CI, 0.21-0.28), 6-month (OR = 0.24; 95% CI, 0.21-0.28), and 1-year (OR = 0.25; 95% CI, 0.21-0.30) abstinence from cigarettes. Current e-cigarette use was also associated with lower 30-day (OR = 0.11; 95% CI, 0.08-0.15), 6-month (OR = 0.11; 95% CI, 0.08-0.15), and 1-year (OR = 0.12; 95% CI, 0.07-0.18) abstinence. Among ever smokers of cigarettes (≥100 cigarettes), ever e-cigarette use was negatively associated with 30-day (OR = 0.61; 95% CI, 0.42-0.89), 6-month (OR = 0.53; 95% CI, 0.33-0.83), and 1-year (OR = 0.32; 95% CI, 0.18-0.56) abstinence from conventional cigarettes. Current e-cigarette use was also negatively associated with 30-day (OR = 0.35; 95% CI, 0.18-0.69), 6-month (OR = 0.30; 95% CI, 0.13-0.68), and 1-year (OR = 0.34; 95% CI, 0.13-0.87) abstinence.Conclusions and Relevance Use of e-cigarettes was associated with higher odds of ever or current cigarette smoking, higher odds of established smoking, higher odds of planning to quit smoking among current smokers, and, among experimenters, lower odds of abstinence from conventional cigarettes. Use of e-cigarettes does not discourage, and may encourage, conventional cigarette use among US adolescents.JAMA Pediatr. doi:10.1001/jamapediatrics.2013.5488.
      PubDate: Wed, 13 Aug 2014 00:00:00 GMT
       
  • Treatment of Hepatitis C A Systematic Review
    • Authors: Kohli A; Shaffer A, Sherman A, et al.
      Abstract: ImportanceHepatitis C virus (HCV) infects more than 185 million individuals worldwide. Twenty percent of patients chronically infected with HCV progress to cirrhosis. New, simpler therapeutics using direct-acting antivirals that target various stages of the HCV life cycle are in development to eradicate HCV without concomitant interferon.ObjectivesTo summarize published evidence on safety, efficacy (measured by a sustained virologic response [SVR], which is the treatment goal of undetectable plasma HCV RNA 12 or 24 weeks after therapy completion), and tolerability of current US Food and Drug Administration–approved interferon-based regimens and oral interferon-free regimens used for treating HCV infection and coinfection with human immunodeficiency virus (HIV) and HCV; to provide treatment recommendations for specialists and generalists based on published evidence.Evidence ReviewA literature search of Web of Science, Scopus, Embase, Agricola, Cochrane Library, Cinahl Plus, ClinicalTrials.gov, Conference Papers Index, Gideon, PsycINFO, Google Scholar, and Oaister was conducted from January 1, 2009, to May 30, 2014. Publications describing phase 2, 3, and 4 studies evaluating the treatment of HCV were included. Forty-one studies involving 19 063 adult patients were included. Strength of clinical data and subsequent HCV treatment recommendations were graded according to the Oxford Centre for Evidence-Based Medicine.FindingsPatients infected with HCV genotype 1 represent 60% to 75% of HCV infections in the United States. Hepatitis C virus genotype 1 is more difficult to cure than genotype 2 or genotype 3. Patients with HCV genotype 1 should receive treatment with sofosbuvir + pegylated interferon + ribavirin because of the shorter duration of therapy and high rates of SVR (89%-90%). Simeprevir + pegylated interferon + ribavirin is an alternative for patients with HCV genotype 1 (SVR, 79%-86%). Patients with HCV genotypes 2 and 3, representing 20% to 29% of US HCV infections, should receive therapy with sofosbuvir + ribavirin alone (SVR for genotype 2, 12 weeks’ duration: 82%-93%; SVR for genotype 3, 24 weeks’ duration, 80%-95%). Patients with HIV-HCV coinfection and patients with compensated cirrhosis (ie, cirrhosis but preserved synthetic liver function) should receive the same treatment as HCV-monoinfected patients.Conclusions and RelevanceNew, short-duration, simpler therapies result in high SVR rates for HCV-infected patients. In conjunction with increased screening for HCV as suggested by recent Centers for Disease Control and Prevention guidelines, availability of new therapies may lead to the treatment of many more people with chronic HCV infection.
      PubDate: Wed, 13 Aug 2014 00:00:00 GMT
       
  • Perioperative Atrial Fibrillation and the Long-term Risk of Ischemic
           Stroke
    • Authors: Gialdini G; Nearing K, Bhave PD, et al.
      Abstract: ImportanceClinically apparent atrial fibrillation increases the risk of ischemic stroke. In contrast, perioperative atrial fibrillation may be viewed as a transient response to physiological stress, and the long-term risk of stroke after perioperative atrial fibrillation is unclear.ObjectiveTo examine the association between perioperative atrial fibrillation and the long-term risk of stroke.Design, Setting, and ParticipantsRetrospective cohort study using administrative claims data on patients hospitalized for surgery (as defined by surgical diagnosis related group codes), and discharged alive and free of documented cerebrovascular disease or preexisting atrial fibrillation from nonfederal California acute care hospitals between 2007 and 2011. Patients undergoing cardiac vs other types of surgery were analyzed separately.Main Outcomes and MeasuresPreviously validated diagnosis codes were used to identify ischemic strokes after discharge from the index hospitalization for surgery. The primary predictor variable was atrial fibrillation newly diagnosed during the index hospitalization, as defined by previously validated present-on-admission codes. Patients were censored at postdischarge emergency department encounters or hospitalizations with a recorded diagnosis of atrial fibrillation.ResultsOf 1 729 360 eligible patients, 24 711 (1.43%; 95% CI, 1.41%-1.45%) had new-onset perioperative atrial fibrillation during the index hospitalization and 13 952 (0.81%; 95% CI, 0.79%-0.82%) experienced a stroke after discharge. At 1 year after hospitalization for cardiac surgery, cumulative rates of stroke were 0.99% (95% CI, 0.81%-1.20%) in those with perioperative atrial fibrillation and 0.83% (95% CI, 0.76%-0.91%) in those without atrial fibrillation. At 1 year after noncardiac surgery, cumulative rates of stroke were 1.47% (95% CI, 1.24%-1.75%) in those with perioperative atrial fibrillation and 0.36% (95% CI, 0.35%-0.37%) in those without atrial fibrillation. In a Cox proportional hazards analysis accounting for potential confounders, perioperative atrial fibrillation was associated with subsequent stroke both after cardiac surgery (hazard ratio, 1.3; 95% CI, 1.1-1.6) and noncardiac surgery (hazard ratio, 2.0; 95% CI, 1.7-2.3). The association was significantly stronger for perioperative atrial fibrillation after noncardiac vs cardiac surgery (P 
      PubDate: Wed, 13 Aug 2014 00:00:00 GMT
       
  • Association Between Analytic Strategy and Estimates of Treatment Outcomes
           in Meta-analyses
    • Authors: Dechartres A; Altman DG, Trinquart L, et al.
      Abstract: ImportanceA persistent dilemma when performing meta-analyses is whether all available trials should be included in the meta-analysis.ObjectivesTo compare treatment outcomes estimated by meta-analysis of all trials and several alternative analytic strategies: single most precise trial (ie, trial with the narrowest confidence interval), meta-analysis restricted to the 25% largest trials, limit meta-analysis (a meta-analysis model adjusted for small-study effect), and meta-analysis restricted to trials at low overall risk of bias.Data SourcesOne hundred sixty-three meta-analyses published between 2008 and 2010 in high-impact-factor journals and between 2011 and 2013 in the Cochrane Database of Systematic Reviews: 92 (705 randomized clinical trials [RCTs]) with subjective outcomes and 71 (535 RCTs) with objective outcomes.Data SynthesisFor each meta-analysis, the difference in treatment outcomes between meta-analysis of all trials and each alternative strategy, expressed as a ratio of odds ratios (ROR), was assessed considering the dependency between strategies. A difference greater than 30% was considered substantial. RORs were combined by random-effects meta-analysis models to obtain an average difference across the sample. An ROR greater than 1 indicates larger treatment outcomes with meta-analysis of all trials. Subjective and objective outcomes were analyzed separately.ResultsTreatment outcomes were larger in the meta-analysis of all trials than in the single most precise trial (combined ROR, 1.13 [95% CI, 1.07-1.19]) for subjective outcomes and 1.03 (95% CI, 1.01-1.05) for objective outcomes). The difference in treatment outcomes between these strategies was substantial in 47 of 92 (51%) meta-analyses of subjective outcomes (meta-analysis of all trials showing larger outcomes in 40/47) and in 28 of 71 (39%) meta-analyses of objective outcomes (meta-analysis of all trials showing larger outcomes in 21/28). The combined ROR for subjective and objective outcomes was, respectively, 1.08 (95% CI, 1.04-1.13) and 1.03 (95% CI, 1.00-1.06) when comparing meta-analysis of all trials and meta-analysis of the 25% largest trials, 1.17 (95% CI, 1.11-1.22) and 1.13 (95% CI, 0.82-1.55) when comparing meta-analysis of all trials and limit meta-analysis, and 0.94 (95% CI, 0.86-1.04) and 1.03 (95% CI, 1.00-1.06) when comparing meta-analysis of all trials and meta-analysis restricted to trials at low risk of bias.Conclusions and RelevanceEstimation of treatment outcomes in meta-analyses differs depending on the strategy used. This instability in findings can result in major alterations in the conclusions derived from the analysis and underlines the need for systematic sensitivity analyses.
      PubDate: Wed, 13 Aug 2014 00:00:00 GMT
       
  • If These Walls Could Talk
    • Authors: Manning KD.
      Abstract: I saw you when you stood there fumbling with the parking meter. You were nervous—very nervous. I could tell by the way you kept looking over your shoulder. I knew it was all because of what you’d heard people saying about me—which is weird considering we grew up right next to each other. Then again, even though you’d technically known of me for most of your life, your point of reference was primarily built on news clips and idle chatter from your carpool group every time you passed me on Interstate 85. Yes, I know.
      PubDate: Wed, 13 Aug 2014 00:00:00 GMT
       
  • Highlights
    • PubDate: Wed, 13 Aug 2014 00:00:00 GMT
       
  • New Expensive Treatments for Hepatitis C Infection
    • Authors: Brennan T; Shrank W.
      Abstract: Treatment of infection with hepatitis C virus (HCV) has changed substantially in the last 3 years, with new therapies now reaching cure rates (defined by sustained virologic response) higher than 95%. As little as 3 years ago, treatment involved an arduous course of pegylated interferon and ribavirin, which caused serious adverse effects in more than 80% of patients; less than 50% of patients could finish the treatment course. Because HCV infection can be indolent, with slowly developing liver injury in the form of scarring and fibrosis, many patients were so-called warehoused by their physicians, followed up closely while waiting for more promising treatments.
      PubDate: Wed, 13 Aug 2014 00:00:00 GMT
       
 
 
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