JAMA internal medicine
-
JAMA internal medicine · Dec 2017
ReviewThe Practice and Implications of Finding Fluid During Point-of-Care Ultrasonography: A Review.
Point-of-care ultrasonography (POCUS) is an increasingly affordable and portable technology that is an important part of 21st-century medicine. When appropriately used, POCUS has the potential to expedite diagnosis and improve procedural success and safety. POCUS is now being adopted in medical education as early as the first year of medical school. While potentially powerful and versatile, POCUS is a user-dependent technology that has not been formalized or standardized yet within internal medicine residency training programs. Physicians and residency directors are trying to determine whether to incorporate POCUS, and if so, how. In this systematic review, basic concepts and applications of POCUS are examined, as are issues surrounding training and implementation. ⋯ POCUS can augment physical examination and procedural efficacy but requires appropriate education and program setup. As POCUS continues to spread, internal medicine physicians need to clarify how they intend to use this technology. Equipment is now increasingly accessible, but programs need to determine how to allocate time and resources to training, clinical use, and quality assurance. Programs that develop robust implementation processes that establish proper scope of practice and include quality assurance that use image archival and feedback can ensure POCUS will positively impact patient care across hospital systems.
-
JAMA internal medicine · Nov 2017
ReviewDeterminants of Market Exclusivity for Prescription Drugs in the United States.
The high prices of brand-name prescription drugs are a growing source of controversy in the United States. Manufacturers of brand-name drugs can command high prices because they are protected from generic competition by two types of government-granted monopoly rights. The first are patents on the drugs that generally define the basic period of brand-name-only sales. ⋯ We reviewed the peer-reviewed medical and health policy literature to identify studies that described the different types of patent protection and regulatory exclusivities that shield brand-name prescription drugs from competition and thus help to sustain high drug prices. We also identified potential policy reforms intended to modify exclusivity periods to address public health needs by balancing drug affordability and industry revenue. The goal of policy in this area should be to ensure that drug market exclusivity periods provide for fair return on investment but do not indefinitely block availability of lower-cost generic drugs.
-
JAMA internal medicine · Oct 2017
Review Meta AnalysisAssociation Between More Intensive vs Less Intensive Blood Pressure Lowering and Risk of Mortality in Chronic Kidney Disease Stages 3 to 5: A Systematic Review and Meta-analysis.
Trials in patients with hypertension have demonstrated that intensive blood pressure (BP) lowering reduces the risk of cardiovascular disease and all-cause mortality but may increase the risk of chronic kidney disease (CKD) incidence and progression. Whether intensive BP lowering is associated with a mortality benefit in patients with prevalent CKD remains unknown. ⋯ Randomization to more intensive BP control is associated with lower mortality risk among trial participants with hypertension and CKD. Further studies are required to define absolute BP targets for maximal benefit and minimal harm.
-
JAMA internal medicine · Feb 2017
Review Meta AnalysisControlled Interventions to Reduce Burnout in Physicians: A Systematic Review and Meta-analysis.
Burnout is prevalent in physicians and can have a negative influence on performance, career continuation, and patient care. Existing evidence does not allow clear recommendations for the management of burnout in physicians. ⋯ Evidence from this meta-analysis suggests that recent intervention programs for burnout in physicians were associated with small benefits that may be boosted by adoption of organization-directed approaches. This finding provides support for the view that burnout is a problem of the whole health care organization, rather than individuals.