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The CLOTS (Clots in Legs Or sTockings after Stroke) Trial Collaboration

This large randomized trial sought to determine whether thigh-length or below-knee stockings better reduce risk for deep venous thrombosis (DVT) in patients with stroke. Patients with acute stroke had ultrasonography 7 to 10 days after hospitalization and then 15 to 20 days later. Proximal DVT on ultrasonography was more common in patients who received below-knee stockings than in those assigned to thigh-length stockings. The occurrence of skin breaks did not differ statistically between the groups. These data suggest that when using compression stockings to prevent DVT in patients after stroke, thigh-length stockings are preferable to below-knee stockings.

Topics: cerebrovascular accident, ischemic stroke, hospitals, knee region, thigh, thrombosis, deep venous, prophylaxis, ...
  
Alexander K. Smith, MD, MS, MPH; Irena Stijacic Cenzer, MA; Sara J. Knight, PhD; Kathleen A. Puntillo, RN, DNSc; Eric Widera, MD; Brie A. Williams, MD; W. John Boscardin, PhD; and Kenneth E. Covinsky, MD, MPH

A nationally representative sample of noninstitutionalized adults or their proxies reported on the experience of pain in the 2 years before death. The prevalence of moderate or severe pain was highest in the last 4 months before death. The prevalence of pain was similar across categories of terminal illness but was substantially greater for patients with comorbid arthritis. The researchers conclude that attention to pain and its management is warranted for all patients with serious conditions who may be nearing death, especially those who also have arthritis.

Topics: pain
  
Kelli D. Allen, PhD; Eugene Z. Oddone, MD, MHSc; Cynthia J. Coffman, PhD; Santanu K. Datta, PhD; Karen A. Juntilla, MEd; Jennifer H. Lindquist, MStat; Tessa A. Walker, MPH; Morris Weinberger, PhD; and Hayden B. Bosworth, PhD

Patients with osteoarthritis benefit from a healthy lifestyle, but it is challenging to support such engagement. This randomized trial assigned primary care patients with hip or knee osteoarthritis to telephone-based support of osteoarthritis self-management (intervention) or traditional health education materials or usual care (controls). After 12 months, the telephone-based program produced moderate improvements in pain compared with the control groups, but there were no statistically or clinically significant differences in function or care utilization.

Topics: osteoarthritis, telephone, self-management, pain
  
William D. Leslie, MD, MSc; Suzanne Morin, MD, MSc; and Lisa M. Lix, PhD

Beginning in 2006, absolute fracture risk, not just T-score, has been reported with bone mineral density testing results in Manitoba, Canada. In this before-and-after study, prescriptions for osteoporosis drugs were found to be reduced after introduction of the new reporting system. The reductions were primarily in people at low and intermediate risk for fracture. Standardized reporting of absolute fracture risk seemed to lead to appropriate reductions in use of osteoporosis drugs in people at lower risk for fractures.

Topics: osteoporosis, fracture
  

Patients with metastatic melanoma have a poor prognosis and limited treatment options. A mutated signal transduction molecule, v-raf murine sarcoma viral oncogene homolog B1 (BRAF), has been identified in about one half of analyzed patients with metastatic melanoma. This article provides an overview of treatment options for metastatic melanoma, describes the pathophysiology underlying the development of therapies based on inhibition of BRAF, and summarizes findings of phase 1 and phase 2 studies of BRAF inhibitor therapy. At a minimum, BRAF inhibitors seem to be valuable as palliative therapy for metastatic melanoma.

Topics: melanoma, metastatic melanoma, braf gene, narrative review, mutation
  
Pasquale Santangeli, MD; Luigi Di Biase, MD; Antonio Dello Russo, MD; Michela Casella, MD; Stefano Bartoletti, MD; Pietro Santarelli, MD; Gemma Pelargonio, MD; and Andrea Natale, MD

To determine the effectiveness of implantable cardioverter-defibrillators (ICDs) versus medical therapy for primary prevention of sudden cardiac death in younger and older patients with severe left ventricular dysfunction, this review summarized 5 trials that enrolled 5783 patients. The primary analysis excluded the 2 trials that enrolled patients early after acute myocardial infarction and found that prophylactic ICD therapy reduced mortality in younger patients. A smaller, statistically nonsignificant survival benefit was found in older patients.

Topics: implantable defibrillators, elderly, ventricular dysfunction, left, mortality, sudden cardiac death
  
Paul E. Stang, PhD; Patrick B. Ryan, MEng; Judith A. Racoosin, MD, MPH; J. Marc Overhage, MD, PhD; Abraham G. Hartzema, PharmD, MSPH, PhD; Christian Reich, MD, PhD; Emily Welebob, RN, MS; Thomas Scarnecchia, MS; and Janet Woodcock, MD

Congress mandated the U.S. Food and Drug Administration to develop a system for using automated health care data to identify risks of marketed drugs and other medical products. The Observational Medical Outcomes Partnership is a public–private partnership that responds to this mandate. This article describes the governance structure, data-access model, methods-testing approach, and technology development of this effort and the work that has been initiated.

Topics: watchful waiting, surveillance, safety, silver, surveillance, medical, united states food and drug ...
  
Cyrus K. Yamin, BS; Asaf Bitton, MD, MPH; and David W. Bates, MD, MSc
Includes: Audio/Video

Electronic cigarettes (e-cigarettes) aerosolize nicotine and produce a vapor that emulates that of cigarettes but purportedly has fewer traditional toxins than secondhand smoke. Physicians should be aware of the popularity, questionable efficacy claims, and safety concerns of e-cigarettes so that they may counsel patients against use and advocate for research to inform an evidence-based regulatory approach.

Topics: internet, cigarettes
  

In this issue, the CLOTS Trial Collaboration presents findings from CLOTS Trial 2, which compared thigh-length stockings with below-knee stockings in 3014 patients with acute stroke and found fewer cases of venous thromboembolism with thigh-length stockings than with below-knee stockings. This editorial notes that CLOTS Trial 1 found that thigh-length stockings were ineffective in preventing the combined outcome of asymptomatic, ultrasonography-detected, and symptomatic proximal DVT and discusses this puzzling discrepancy between CLOTS Trials 1 and 2.

Topics: cerebrovascular accident, ischemic stroke, stockings, compression, venous thromboembolism
  

In this issue, Smith and colleagues used data from the Health and Retirement Study to examine pain in the last 2 years of life. The editorialists highlight these findings, place them in the context of previous research, and discuss their clinical implications. Although we know much about the prevalence and effects of pain among older adults, we know considerably less about pain as patients near death.

Topics: pain
  
Stanley Shi-Dan Liu, MD

After flailing my way through a tough general wards service as a fresh and wide-eyed intern in July, I couldn't wait to do it again with half the workload. The only dream I wanted to fulfill was that of getting some sleep on a call night, a rare indulgence I had learned months ago not to expect.

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J. David Baxter, MD

What is the difference between air and water? One costs more and takes more sustained effort to deliver, but both are medical interventions with risks and benefits. When death is upon us, why do we easily withdraw or withhold one but struggle with withholding or terminating another?

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Saika Kumiko, PhD; Saito Hiroshi, MD, PhD; Ohuchi Noriaki, MD, PhD; and Sobue Tomotaka, MD, PhD, MPH
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Heidi D. Nelson, MD, MPH; and Benjamin K. Chan, MS
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Kapil Gupta, MD, MPH; and Bechien Wu, MD, MPH
Topics: pancreatitis, acute
  
Topics: pain, terminally ill
  
Topics: hip joint, telephone, pain management, arthritis of knee
  
Topics: osteoporosis, fracture
  
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