JAMA internal medicine
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JAMA internal medicine · May 2015
ReviewEffect of Vitamin D Supplementation on Blood Pressure: A Systematic Review and Meta-analysis Incorporating Individual Patient Data.
Low levels of vitamin D are associated with elevated blood pressure (BP) and future cardiovascular events. Whether vitamin D supplementation reduces BP and which patient characteristics predict a response remain unclear. ⋯ Vitamin D supplementation is ineffective as an agent for lowering BP and thus should not be used as an antihypertensive agent.
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JAMA internal medicine · May 2015
Reducing inappropriate polypharmacy: the process of deprescribing.
Inappropriate polypharmacy, especially in older people, imposes a substantial burden of adverse drug events, ill health, disability, hospitalization, and even death. The single most important predictor of inappropriate prescribing and risk of adverse drug events in older patients is the number of prescribed drugs. ⋯ A deprescribing protocol is proposed comprising 5 steps: (1) ascertain all drugs the patient is currently taking and the reasons for each one; (2) consider overall risk of drug-induced harm in individual patients in determining the required intensity of deprescribing intervention; (3) assess each drug in regard to its current or future benefit potential compared with current or future harm or burden potential; (4) prioritize drugs for discontinuation that have the lowest benefit-harm ratio and lowest likelihood of adverse withdrawal reactions or disease rebound syndromes; and (5) implement a discontinuation regimen and monitor patients closely for improvement in outcomes or onset of adverse effects. Whereas patient and prescriber barriers to deprescribing exist, resources and strategies are available that facilitate deliberate yet judicious deprescribing and deserve wider application.
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JAMA internal medicine · May 2015
Effect of published scientific evidence on glycemic control in adult intensive care units.
Little is known about the deadoption of ineffective or harmful clinical practices. A large clinical trial (the Normoglycemia in Intensive Care Evaluation and Survival Using Glucose Algorithm Regulation [NICE-SUGAR] trial) demonstrated that strict blood glucose control (tight glycemic control) in patients admitted to adult intensive care units (ICUs) should be deadopted; however, it is unknown whether deadoption occurred and how it compared with the initial adoption. ⋯ Among patients admitted to adult ICUs in the United States, there was a slow steady adoption of tight glycemic control following publication of a clinical trial that suggested benefit, with little to no deadoption following a subsequent trial that demonstrated harm. There is an urgent need to understand and promote the deadoption of ineffective clinical practices.
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JAMA internal medicine · May 2015
Perioperative cardiovascular care for patients undergoing noncardiac surgical intervention.
The field of perioperative medicine has garnered legitimacy during the past 3 decades. Adverse cardiovascular events in the perioperative period account for significant morbidity and mortality. Although testing patients preoperatively to detect ischemia and identify those who may benefit from modifications in care is a tempting strategy, risk assessment should account for posterior probability. ⋯ There has been enthusiasm for medical therapies that may reduce the risk of adverse cardiovascular events in the perioperative period. Current guidelines encourage the perioperative use of β-blockade in patients already receiving such therapy and caution against initiating such therapy on the day of the surgical procedure. Reduction of morbidity and mortality in the perioperative period relies on an understanding of the myriad physiological perturbations in this period and thoughtful selection of patients for further testing and treatment.
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JAMA internal medicine · May 2015
Randomized Controlled Trial Multicenter StudyPrimary Results of the Patient-Centered Disease Management (PCDM) for Heart Failure Study: A Randomized Clinical Trial.
Heart failure (HF) has a major effect on patients' health status, including their symptom burden, functional status, and health-related quality of life. ⋯ This multisite randomized trial of a multifaceted HF PCDM intervention did not demonstrate improved patient health status compared with usual care.