JAMA : the journal of the American Medical Association
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Aldosterone antagonist therapy for heart failure and reduced ejection fraction has been highly efficacious in randomized trials. However, questions remain regarding the effectiveness and safety of the therapy in clinical practice. ⋯ Initiation of aldosterone antagonist therapy at hospital discharge was not independently associated with improved mortality or cardiovascular readmission but was associated with improved heart failure readmission among eligible older patients with heart failure and reduced ejection fraction. There was a significant increase in the risk of readmission with hyperkalemia, predominantly within 30 days after discharge.
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Heart failure with preserved ejection fraction (HFPEF) may be as common and as lethal as heart failure with reduced ejection fraction (HFREF). Three randomized trials of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (ie, renin-angiotensin system [RAS] antagonists) did not reach primary end points but may have had selection bias or been underpowered. ⋯ Among patients with heart failure and preserved ejection fraction, the use of RAS antagonists was associated with lower all-cause mortality.
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Case Reports
Management of gout: a 57-year-old man with a history of podagra, hyperuricemia, and mild renal insufficiency.
Gout is an ancient disease. Despite significant advances in the understanding of its risk factors, etiology, pathogenesis, prevention, and treatment, millions of people with gout experience repeated attacks of acute arthritis and other complications. The incidence of gout is increasing, most likely reflecting increasing rates of obesity and other lifestyle factors, including diet. ⋯ Using the case of Mr R, a 57-year-old man with a history of podagra, hyperuricemia, and mild renal insufficiency, the diagnosis and treatment of gout are discussed. For those with moderate to severe gout, urate-lowering treatment can eliminate acute attacks of arthritis and prevent complications. In the near future, it is likely that new risk factors for gout will be identified and new ways of preventing and managing this common disease will become available.
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In 2010, California experienced its largest pertussis epidemic in more than 60 years; a substantial burden of disease was noted in the 7- to 10-year-old age group despite high diphtheria, tetanus, and acellular pertussis vaccine (DTaP) coverage, indicating the possibility of waning protection. ⋯ Among children in 15 California counties, children with pertussis, compared with controls, had lower odds of having received the 5-dose DTaP series; as time since last DTaP dose increased, the odds increased, which is consistent with a progressive decrease in estimated vaccine effectiveness each year after the final dose of pertussis vaccine.