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, Tamara G. Fong, Tammy T. Hshieh, Sharon K. Inouye
Published: 26 September 2017
Journal: JAMA
JAMA, Volume 318, pp 1161-1174; https://doi.org/10.1001/jama.2017.12067

Abstract:
Delirium is defined as an acute disorder of attention and cognition. It is a common, serious, and often fatal condition among older patients. Although often underrecognized, delirium has serious adverse effects on the individual’s function and quality of life, as well as broad societal effect with substantial health care costs. To summarize the current state of the art in diagnosis and treatment of delirium and to highlight critical areas for future research to advance the field. We searched Ovid MEDLINE, Embase, and the Cochrane Library for the past 6 years, from January 1, 2011 until March 16, 2017 using a combination of controlled vocabulary and keyword terms. Since delirium is more prevalent in older adults, the focus was on studies in elderly populations; studies based solely in the intensive care unit (ICU) and non-English-language articles were excluded. Of 127 articles included, 25 were clinical trials, 42 cohort studies, 5 systematic reviews and meta-analyses, and 55 were other categories. A total of 11 616 patients were represented in the treatment studies. Advances in diagnosis have included the development of brief screening tools with high sensitivity and specificity, such as the 3-Minute Diagnostic Assessment, 4 A’s test, and proxy-based measures such as the Family Confusion Assessment Method. Measures of severity, such as the Confusion Assessment Method-Severity Score, can aid in monitoring response to treatment, risk stratification, and assessing prognosis. Nonpharmacologic approaches focused on risk factors such as immobility, functional decline, visual or hearing impairment, dehydration, and sleep deprivation are effective for delirium prevention and also are recommended for delirium treatment. Current recommendations for pharmacologic treatment of delirium, based on recent reviews of the evidence, recommend reserving use of antipsychotics and other sedating medications for treatment of severe agitation that poses risk to patient or staff safety or threatens interruption of essential medical therapies. Advances in diagnosis can improve recognition and risk stratification of delirium. Prevention of delirium using nonpharmacologic approaches is documented to be effective, while pharmacologic prevention and treatment of delirium remains controversial.
Published: 26 September 2017
Journal: JAMA
JAMA, Volume 318, pp 1100-1100; https://doi.org/10.1001/jama.2017.13441

Abstract:
The vast majority of US adolescent contact lens wearers slip up on safety measures known to protect against potentially blinding eye infections, according to a recent CDC report. Even so, their track record on some of those measures is better than that of adult lens wearers. According to the analysis of data from an online survey, an estimated 3.6 million youths aged 12 to 17 years wore contact lenses in 2016. About 85% said they’ve disregarded at least 1 of several recommended contact lens hygiene practices. The most common breaches were not visiting an eye doctor annually, sleeping or swimming while wearing their lenses, and waiting too long to replace lenses or lens cases.
, Paul Lichtenstein, , Christina Hultman, Henrik Larsson, Abraham Reichenberg
Published: 26 September 2017
Journal: JAMA
JAMA, Volume 318, pp 1182-1184; https://doi.org/10.1001/jama.2017.12141

Abstract:
Studies have found that autism spectrum disorder (ASD) aggregates in families, and twin studies estimate the proportion of the phenotype variance due to genetic factors (heritability) to be about 90%.1
, Vilma Irazola, Katherine T. Mills, Rosana Poggio, Andrea Beratarrechea, Jacquelyn Dolan, Chung-Shiuan Chen, Luz Gibbons, Marie Krousel-Wood, Lydia A. Bazzano, et al.
Published: 19 September 2017
Journal: JAMA
JAMA, Volume 318, pp 1016-1025; https://doi.org/10.1001/jama.2017.11358

Abstract:
Quiz Ref ID Hypertension is a leading global modifiable risk factor for cardiovascular disease and premature death.1,2 Despite extensive knowledge of hypertension prevention and treatment, the global prevalence of hypertension is high and increasing, while the proportion of controlled hypertension is low, especially in low- and middle-income countries.3 It was estimated that 31.1% of the world’s adults had hypertension in 2010, and 75% of those with hypertension lived in low- and middle-income countries. Of those, only 7.7% of patients with hypertension had their blood pressure (BP) controlled to less than 140/90 mm Hg.3 Therefore, developing and implementing effective, affordable, and sustainable programs for hypertension control is a public health priority in low- and middle-income countries.
Published: 19 September 2017
Journal: JAMA
JAMA, Volume 318, pp 979-981; https://doi.org/10.1001/jama.2016.13311

Abstract:
In low- and middle-income countries, few adults with hypertension have adequate blood pressure (BP) control. A randomized clinical trial by He and colleagues in
Published: 19 September 2017
Journal: JAMA
JAMA, Volume 318, pp 983-984; https://doi.org/10.1001/jama.2016.13312

Abstract:
The JAMA Network is a consortium of peer-reviewed print and online medical publications that includes JAMA® and 11 other specialty Network journals.JAMA does no
, , Robert O. Bonow, Neil M. Bressler, Mary L. (Nora) Disis, Stephan Heckers, S. Andrew Josephson, Melina R. Kibbe, , , et al.
Published: 14 November 2017
Journal: JAMA
JAMA, Volume 318, pp 1763-1764; https://doi.org/10.1001/jama.2017.16446

Kenneth D. Mandl,
Published: 21 November 2017
Journal: JAMA
JAMA, Volume 318, pp 1859-1860; https://doi.org/10.1001/jama.2017.15028

Abstract:
Physicians are still taught to diagnose patients according to the 19th-century Oslerian blueprint. A physician takes a history, performs an examination, and matches each patient to the traditional taxonomy of medical conditions. Symptoms, signs, family history, and laboratory reports are interpreted in light of clinical experience and scholarly interpretation of the medical literature. However, diagnosis is evolving from art to data-driven science, whereby large populations contextualize each individual’s medical condition. Advances in artificial intelligence now bring insight from population-level data to individual care; a recent study sponsored by and including researchers from Google used data sets with more than 11 000 retinal fundus images to develop a deep learning algorithm that outperformed clinicians for detecting diabetic retinopathy.1
, Joan M. Teno, Jason Roy, Glen Kabumoto, Vincent Mor
Published: 2 July 2003
Journal: JAMA
JAMA, Volume 290, pp 73-80; https://doi.org/10.1001/jama.290.1.73

Abstract:
A growing proportion of the approximately 4 million older US adults with Alzheimer disease or other dementias are now surviving to the advanced stages of their illness. Eating and swallowing problems typically develop during the terminal stages of dementias. Whether to initiate feeding tube use or to focus on comfort is one of the most challenging dilemmas facing families, clinicians, and institutions caring for these patients.1,2
Published: 26 September 2017
Journal: JAMA
JAMA, Volume 318, pp 1100-1100; https://doi.org/10.1001/jama.2017.13443

Abstract:
The number of epilepsy cases in the United States has reached an all-time high, according to CDC researchers reporting in the Morbidity and Mortality Weekly Report. Their analysis is the first time epilepsy estimates have been available for every state. Data from sources including the 2015 National Health Interview Survey for adults and the 2011-2012 National Survey of Children’s Health show that in 2015 about 1.2% of the US population—3 million adults and 470 000 children—had the neurological disorder. Previous estimates indicated that 2.3 million adults had epilepsy in 2010 and 450 000 had the condition in 2007. The recently released study indicated that the increased number of cases is the result of population growth.
Vito Marco V.M. Ranieri, Daniel D. Brodie,
Published: 26 September 2017
Journal: JAMA
JAMA, Volume 318, pp 1105-1106; https://doi.org/10.1001/jama.2017.10108

Abstract:
Mechanical ventilation, renal replacement therapy, and artificial liver detoxification circuits are among the systems designed to support or replace organs compromised by trauma, sepsis, or acute respiratory, kidney, or liver failure. Among these systems, extracorporeal membrane oxygenation (ECMO) has recently generated increasing expectations despite results from early clinical trials in adults that suggested ECMO use should be restricted to only those patients determined by specialized clinicians to have a very high risk of mortality.
Peter B. Bach, Sergio A. Giralt,
Published: 21 November 2017
Journal: JAMA
JAMA, Volume 318, pp 1861-1862; https://doi.org/10.1001/jama.2017.15218

Abstract:
Approval of the drug tisagenlecleucel (Kymriah; Novartis) by the US Food and Drug Administration (FDA) for the treatment of pediatric and young adult acute lymphoblastic leukemia (ALL) in August 2017 was a landmark in oncology. The science underlying chimeric antigen receptor T cells (CAR-T) heralds a new era of treatment, and the list price of $475 000 for the new drug (delivered as a one-time infusion) definitively shattered oncology drug pricing norms.1
, , , Jon Bishop, Natalie Ives, , Richard Gray, for the Stroke Oxygen Study Investigators and the Stroke OxygenStudy Collaborative Group
Published: 26 September 2017
Journal: JAMA
JAMA, Volume 318, pp 1125-1135; https://doi.org/10.1001/jama.2017.11463

Abstract:
Importance Hypoxia is common in the first few days after acute stroke, is frequently intermittent, and is often undetected. Oxygen supplementation could prevent hypoxia and secondary neurological deterioration and thus has the potential to improve recovery. Objective To assess whether routine prophylactic low-dose oxygen therapy was more effective than control oxygen administration in reducing death and disability at 90 days, and if so, whether oxygen given at night only, when hypoxia is most frequent, and oxygen administration is least likely to interfere with rehabilitation, was more effective than continuous supplementation. Design, Setting, and Participants In this single-blind randomized clinical trial, 8003 adults with acute stroke were enrolled from 136 participating centers in the United Kingdom within 24 hours of hospital admission if they had no clear indications for or contraindications to oxygen treatment (first patient enrolled April 24, 2008; last follow-up January 27, 2015). Interventions Participants were randomized 1:1:1 to continuous oxygen for 72 hours (n = 2668), nocturnal oxygen (21:00 to 07:00 hours) for 3 nights (n = 2667), or control (oxygen only if clinically indicated; n = 2668). Oxygen was given via nasal tubes at 3 L/min if baseline oxygen saturation was 93% or less and at 2 L/min if oxygen saturation was greater than 93%. Main Outcomes and Measures The primary outcome was reported using the modified Rankin Scale score (disability range, 0 [no symptoms] to 6 [death]; minimum clinically important difference, 1 point), assessed at 90 days by postal questionnaire (participant aware, assessor blinded). The modified Rankin Scale score was analyzed by ordinal logistic regression, which yields a common odds ratio (OR) for a change from one disability level to the next better (lower) level; OR greater than 1.00 indicates improvement. Results A total of 8003 patients (4398 (55%) men; mean [SD] age, 72 [13] years; median National Institutes of Health Stroke Scale score, 5; mean baseline oxygen saturation, 96.6%) were enrolled. The primary outcome was available for 7677 (96%) participants. The unadjusted OR for a better outcome (calculated via ordinal logistic regression) was 0.97 (95% CI, 0.89 to 1.05;P = .47) for oxygen vs control, and the OR was 1.03 (95% CI, 0.93 to 1.13;P = .61) for continuous vs nocturnal oxygen. No subgroup could be identified that benefited from oxygen. At least 1 serious adverse event occurred in 348 (13.0%) participants in the continuous oxygen group, 294 (11.0%) in the nocturnal group, and 322 (12.1%) in the control group. No significant harms were identified. Conclusions and Relevance Among nonhypoxic patients with acute stroke, the prophylactic use of low-dose oxygen supplementation did not reduce death or disability at 3 months. These findings do not support low-dose oxygen in this setting. Trial Registration ISRCTN Identifier:ISRCTN52416964
, Sean E. McCabe, James T. Eckner, John E. Schulenberg
Published: 26 September 2017
Journal: JAMA
JAMA, Volume 318, pp 1180-1182; https://doi.org/10.1001/jama.2017.9087

Abstract:
Little is known about the prevalence and correlates of concussions among US adolescents. A regional study of Canadian adolescents found that approximately 20% had sustained a concussion.1,2 Providing a national baseline of concussion prevalence and correlates is necessary to target and monitor prevention efforts to reduce these types of injuries during this important developmental period.
Comment
William J Maloney, David S Jevsevar, Kevin G Shea
Published: 26 September 2017
Journal: JAMA
JAMA, Volume 318, pp 1184-1185; https://doi.org/10.1001/jama.2017.11335

Comment
Jon D Emery
Published: 26 September 2017
Journal: JAMA
JAMA, Volume 318, pp 1110-1112; https://doi.org/10.1001/jama.2017.11465

Abstract:
Warfarin is the most widely prescribed anticoagulant worldwide and is a significant cause of emergency department visits and hospitalizations. Warfarin has a na
Comment
Pim A. J. Luijsterburg, Pieter K. Bos, Sita M. A. Bierma-Zeinstra
Published: 26 September 2017
Journal: JAMA
JAMA, Volume 318, pp 1184-1184; https://doi.org/10.1001/jama.2017.11331

Abstract:
To the Editor Dr McAlindon and colleagues investigated the long-term effects on cartilage of intra-articular corticosteroid injections in the knee every 3 months for 2 years in people with knee osteoarthritis.1 With respect to the clinical outcome, we agree with the authors that the usual short-term benefits after the injections probably were missed.
Carol Snyder Halberstadt
Published: 26 September 2017
Journal: JAMA
Wei Liu, Jia-Wei Liu, Dong-Lai Ma
Published: 19 September 2017
Journal: JAMA
JAMA, Volume 318, pp 1059-1060; https://doi.org/10.1001/jama.2017.13023

, Angela Radulescu, , Matthew Root, , Anthony A. Killeen, James S. Hodges, Shu-Ling Fan, Angela Ferguson, Uttam Garg, et al.
Published: 26 September 2017
Journal: JAMA
JAMA, Volume 318, pp 1150-1160; https://doi.org/10.1001/jama.2017.13705

Abstract:
Inaccuracy of laboratory medicine diagnostic tests may be associated with ingestion of over-the-counter vitamin and herbal supplements.1,2 One such example is interference associated with biotin. Biotin (vitamin B7), a water-soluble vitamin found in meat, fish, eggs, and dairy,3 serves as a catalyst for carboxylase enzymes important in macronutrient metabolism.4 Biotin supplements, especially very large doses (eg, 10-15 mg/d, or 333-fold greater than the dietary recommendation of 30 µg/d)5 have become popular for presumptive health benefits such as stimulating hair growth and treating certain medical conditions including biotinidase deficiency, diabetes, lipid disorders, and diabetic peripheral neuropathy.6-9 Ingestion of up to 300 mg/d may be beneficial for multiple sclerosis.10,11 Taking high-doses of biotin may result in inaccurate laboratory results because biotin is commonly used, in the form of biotinylated antibodies or analogues, as a critical component in immunoassays. These assays exploit the strong, stable, and specific binding between biotin and streptavidin to amplify the assay sensitivity for detecting low analyte levels.12,13 Excessive biotin in a blood sample can compete with biotinylated components in the assay, potentially falsely decreasing results in sandwich immunoassays or falsely increasing results in competitive immunoassays (eFigures 1 and 2 in the Supplement).14
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