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Elena Losina, PhD; Rochelle P. Walensky, MD, MPH; William M. Reichmann, MA; Holly L. Holt, BA; Hanna Gerlovin, BA; Daniel H. Solomon, MD, MPH; Joanne M. Jordan, MD, MPH; David J. Hunter, MD, PhD; Lisa G. Suter, MD; Alexander M. Weinstein, BA; A. David Paltiel, PhD; and Jeffrey N. Katz, MD, MSc

Obesity and knee osteoarthritis are common comorbid conditions. This modeling study, based on data from several national sources, showed substantial losses for middle-aged and older Americans, particularly black and Hispanic women, in quality-adjusted life-years owing to knee osteoarthritis and obesity. The model estimated that reversing obesity prevalence to levels seen 10 years ago would avert hundreds of thousands of cases of coronary heart disease, diabetes, and knee replacements and would improve life expectancy.

Topics: obesity, osteoarthritis, knee
  
Karen S. Kmetik, PhD; Michael F. O'Toole, MD; Heidi Bossley, MSN, MBA; Carmen A. Brutico, MD, MBA; Gary Fischer, MD; Sherry L. Grund, RN; Bridget M. Gulotta, MSN, MBA; Mark Hennessey, MBA; Stasia Kahn, MD; Karen M. Murphy, RN, PhD; Ted Pacheco, MD; L. Greg Pawlson, MD, MPH; John Schaeffer, MD; Patricia A. Schwamberger, RHIA; Sarah H. Scholle, MPH, DrPh; and Gregory Wozniak, PhD

Electronic health records (EHRs) can facilitate quality improvement efforts, but quality reports generated from EHRs must accurately reflect valid exceptions to recommended care. This study examined EHR-based quality reports for 47 075 outpatients with coronary artery disease seen during 2006 and 2007 in 5 medical practices that used EHRs. Automated systems reported that 3.5% of patients had an exception to a recommended drug, and researchers confirmed 92.6% of those exceptions during manual review. These data suggest that automatically reported exceptions to recommended care occur infrequently and are usually valid.

Topics: coronary arteriosclerosis, outpatients, quality indicators, electronic medical records
  
Amy S. Kelley, MD, MSHS; Susan L. Ettner, PhD; R. Sean Morrison, MD; Qingling Du, MS; Neil S. Wenger, MD, MPH; and Catherine A. Sarkisian, MD, MSHS

Medical expenses in the final months of life are high and vary by region. Understanding patient factors that contribute to intensity of care may allow for interventions aimed at reducing inappropriate variations in care and costs. While accounting for regional factors, this study examined the relationship of intensity of care among patients during the last 6 months of life with patient-level factors. Higher expenditures were associated with decline in functional status, black or Hispanic ethnicity, certain chronic conditions (including diabetes), and lack of nearby family support.

Topics: medicare, idiopathic pulmonary fibrosis, functional status, hospitals, terminally ill, beds, chronic disease, ...
  
William L. Baker, PharmD; Jennifer A. Colby, PharmD; Vanita Tongbram, MBBS, MPH; Ripple Talati, PharmD; Isaac E. Silverman, MD; C. Michael White, PharmD; Jeffrey Kluger, MD; and Craig I. Coleman, PharmD

This review evaluates the evidence related to neurothrombectomy devices in the treatment of acute ischemic stroke. Among 87 articles that met eligibility criteria were 62 case reports or series and no randomized trials or head-to-head comparisons. Reported rates of successful recanalization and harms varied. Predictors of harm included older age, history of stroke, and higher baseline stroke severity scores. Although currently available neurothrombectomy devices are intriguing treatment options for acute ischemic stroke, high-quality evidence is lacking.

Topics: acute cerebrovascular accidents, ischemic stroke
  
Holly Janes, PhD; Margaret S. Pepe, PhD; Patrick M. Bossuyt, PhD; and William E. Barlow, PhD

Methods for choosing treatment selection markers are inadequate because they give misleading measures of performance that do not answer key clinical questions. These investigators propose that marker-by-treatment predictiveness curves are a more useful aid to answering certain clinically relevant questions. They also propose that randomized therapeutic clinical trials in which entry criteria and treatment regimens are not restricted by the marker should be the basis for constructing the curves and evaluating and comparing markers.

Topics: chemotherapy regimen, adjuvant chemotherapy, tamoxifen, women, breast cancer, cancer research, inference, academic ...
  
Amir Qaseem, MD, PhD, MHA; Linda L. Humphrey, MD, MPH; Roger Chou, MD; Vincenza Snow, MD; Paul Shekelle, MD, PhD, for the Clinical Guidelines Committee of the American College of Physicians

This American College of Physicians (ACP) guideline addresses the effectiveness of intensive insulin therapy (IIT) in improving outcomes in hospitalized patients with or without diabetes mellitus. The ACP recommends not using IIT to strictly control or to normalize blood glucose in hospitalized patients. If insulin therapy is used in intensive care unit settings, the ACP recommends a target blood glucose level of 7.8 to 11.1 mmol/L (140 to 200 mg/dL).

Topics: insulin, glucose control, american college of physicians, inpatient, blood glucose, clinical practice ...
  
Devan Kansagara, MD, MCR; Rongwei Fu, PhD; Michele Freeman, MPH; Fawn Wolf, MD; and Mark Helfand, MD, MPH

This systematic review presents the evidence that informs the associated ACP clinical guideline and evaluates the benefits and harms of IIT in hospitalized patients. No consistent evidence demonstrates that IIT targeted to strict glycemic control compared with less strict glycemic control improves health outcomes in hospitalized patients, and IIT was associated with an increased risk for severe hypoglycemia.

Topics: hypoglycemia, blood glucose, insulin, intensive care unit, inpatient
  

In this issue, Kelley and colleagues report that the intensity of end-of-life care is associated with several patient-level as well as regional factors. The editorialists discuss how the study extends what we know and highlights the challenges of identifying the “right” intensity of care for individual patients.

Topics: end-of-life care
  

In this issue, Baker and colleagues review evidence for using neurothrombectomy devices to treat patients with acute ischemic stroke. The editorialist discusses challenges to the conduct of randomized trials of stroke therapies, the need to establish the clinical benefit of neurothrombectomy devices over established therapies before comparing different devices, and the importance of understanding which patients are likely to benefit from neurothrombectomy.

Topics: acute cerebrovascular accidents
  
Colleen Christmas, MD

One of my very favorite patients died last night. I know doctors are not supposed to have favorites, but everyone does. It's not all that dissimilar from being a parent. “I love you both equally, but for different reasons.”

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Ali Salavati, MD, MPH; Farid Radmanesh, MD, MPH; and Shadi A. Esfahani, MD, MPH
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Kenneth F. Schulz, PhD, MBA; Douglas G. Altman, DSc; and David Moher, PhD
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Timothy J. Franxman, MD; Moutaz Al-Nabhan, MD; Rodrigo S. Cavallazzi, MD; and Aaron J. Speak, PharmD
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Daniel Bosch
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Elisabeth Hyde
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Felicia M.T. Lewis, MD
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Topics: oxygen, dyspnea, palliative care
  
Topics: thrombosis, leg, fondaparinux, venous thromboembolism
  
Topics: asthma, beclomethasone, tiotropium
  
Topics: glucocorticoids, mineralocorticoids, tendinopathy
  
Topics: nitroglycerin, activities of daily living, pain
  
Topics: carotid stenosis, cerebrovascular accident, ischemic stroke
  
Topics: transient ischemic attack, cerebrovascular accident, ischemic stroke, vitamin b complex
  
Topics: hypertension, blood pressure, pharmacist
  
Topics: colchicine, postpericardiotomy syndrome, cardiac surgery procedures
  
Topics: progestins, estrogen, postmenopause, breast cancer, invasive
  
Topics: delirium, inpatient
  
Topics: hypoglycemia, diabetes mellitus, type 2, treatment outcome
  
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