revistasmedicasafyc

Lancet 2013; doi:10.1016/S0140-6736(13)61127-7A team of researchers from Thailand and the US has shown for the first time that tenofovir can help prevent HIV in injecting drug users. Daily...

JAMA2013;309:2480-8Adults with acute ischaemic stroke need thrombolysis within 4.5 hours, but even within that time frame those treated sooner do significantly better than those treated later,...

N Engl J Med2013; doi:10.1056/NEJMoa1303006bmj;346/jun18_8/f3846/FIG1F1fig1When methotrexate fails to control rheumatoid arthritis, patients can add other disease modifying drugs or opt for more...

N Engl J Med2013;368:2286-93A new trial challenges a widespread treatment for infants with bronchiolitis. Inhalations of racemic adrenaline worked no better than inhalations of saline in infants...

Lancet2013; doi:10.1016/S0140-6736(13)61205-2Women attending fracture clinics report a high prevalence of domestic violence. In the latest survey from clinics on three continents, one in six women...

Ann Intern Med2013;158:869-76Evidence is growing of an important drug interaction between widely used statins and antibiotics. Clarithromycin and erythromycin inhibit the cytochrome P450 isoenzyme...

To the Editor: The article by Dr Johnson and colleagues demonstrated an increase in the advanced breast cancer incidence in women younger than 40 years. As illustrated in Figure 3 of the article, this increasing incidence has occurred across the 4 largest US racial/ethnic populations; however, the magnitude of the increase has not been the same across groups. The largest increases were observed for black women, followed by white women (APCs of 3.48 and 2.67, respectively).

Although passage of the Patient Protection and Affordable Care Act in 2010 promised to extend or guarantee health insurance for the vast majority of children in the United States, the law specifically excludes certain immigrant children. Some public health advocacy groups want the discrepancy rectified in the immigration reform legislation now being considered in Congress.

New insights into the causes, incidence, and clinical outcome of moderate to severe cases of diarrheal disease in infants and young children have emerged from a large prospective case-control study in sub-Saharan Africa and south Asia, report an international team of researchers (Kotloff KL et. Lancet. doi: 10.1016/S0140-6736[13]60844-2 [published online May 14, 2013]).

Teaching Kenyan women to collect their own genital specimens to be used in testing for human papillomavirus (HPV)—the primary risk factor for cervical cancer—shows promise in the detection of this malignancy and could help lower the high rate of cervical cancer in eastern Africa, which is thought to result from a lack of screening programs (Ting J et al. Sexually Transmitted Diseases. doi: 10.1097/OLQ.0b013e31828e5a91 [published online April 23, 2013]).

Randomized clinical trials suggest the benefit of intravenous tissue-type plasminogen activator (tPA) in acute ischemic stroke is time dependent. However, modest sample sizes have limited characterization of the extent to which onset to treatment (OTT) time influences outcome; and the generalizability of findings to clinical practice is uncertain. To evaluate the degree to which OTT time is associated with outcome among patients with acute ischemic stroke treated with intraveneous tPA. Data were analyzed from 58 353 patients with acute ischemic stroke treated with tPA within 4.5 hours of symptom onset in 1395 hospitals participating in the Get With The Guidelines-Stroke Program, April 2003 to March 2012. Relationship between OTT time and in-hospital mortality, symptomatic intracranial hemorrhage, ambulatory status at discharge, and discharge destination. Among the 58 353 tPA-treated patients, median age was 72 years, 50.3% were women, median OTT time was 144 minutes (interquartile range, 115-170), 9.3% (5404) had OTT time of 0 to 90 minutes, 77.2% (45 029) had OTT time of 91 to 180 minutes, and 13.6% (7920) had OTT time of 181 to 270 minutes. Median pretreatment National Institutes of Health Stroke Scale documented in 87.7% of patients was 11 (interquartile range, 6-17). Patient factors most strongly associated with shorter OTT included greater stroke severity (odds ratio [OR], 2.8; 95% CI, 2.5-3.1 per 5-point increase), arrival by ambulance (OR, 5.9; 95% CI, 4.5-7.3), and arrival during regular hours (OR, 4.6; 95% CI, 3.8-5.4). Overall, there were 5142 (8.8%) in-hospital deaths, 2873 (4.9%) patients had intracranial hemorrhage, 19 491 (33.4%) patients achieved independent ambulation at hospital discharge, and 22 541 (38.6%) patients were discharged to home. Faster OTT, in 15-minute increments, was associated with reduced in-hospital mortality (OR, 0.96; 95% CI, 0.95-0.98; P < .001), reduced symptomatic intracranial hemorrhage (OR, 0.96; 95% CI, 0.95-0.98; P < .001), increased achievement of independent ambulation at discharge (OR, 1.04; 95% CI, 1.03-1.05; P < .001), and increased discharge to home (OR, 1.03; 95% CI, 1.02-1.04; P < .001). In a registry representing US clinical practice, earlier thrombolytic treatment was associated with reduced mortality and symptomatic intracranial hemorrhage, and higher rates of independent ambulation at discharge and discharge to home following acute ischemic stroke. These findings support intensive efforts to accelerate hospital presentation and thrombolytic treatment in patients with stroke.

Type 1 diabetes (T1D) occurs in individuals with a genetic predisposition to the disease, predominantly from a human leukocyte antigen (HLA)-related immunogenotype that accounts for approximately 60% of the genetic influence. In these individuals who are genetically at risk, an environmental trigger is thought to initiate an immune response targeting the insulin-secreting pancreatic islet β cells. The initial immune response also may engender secondary and tertiary immune responses that contribute to the impairment of β-cell function and destruction of β cells. The rate of development of T1D varies, probably related to non-HLA genetic factors and additional environmental factors beyond the triggering exposure.

June 19, 2013

In front the golden coast of the gulf, the blue sea breaking on a small beach. . . . In the background the blue silhouettes of the Maures and the Esterel—there is enough material to work on for the rest of my days. Happiness—that is what I have just discovered.” (Ferretti-Bocquillon M, Distel A, Leighton J, Stein SA. Signac, 1863-1935. New York, NY: Metropolitan Museum of Art/Yale University Press; 2001:172.) Well-heeled tourists visiting St Tropez today may echo the glowing review of Neo-Impressionist painter Paul Signac (1863-1935) at his 1892 arrival in the area. Signac was enchanted with the Mediterranean mise en scène, highlighted in his glittering renderings of this region of southern France.

In Reply: Mr Teater suggests that legislation, even without effective enforcement, will modify driver behavior and that enforcement practices will eventually catch up with the laws. Prior research has demonstrated that active enforcement is important to reduce unsafe driving behavior. Seat belt law experience has revealed that belt use increases shortly after the law implementation but decreases without active and sustained enforcement. Similarly, roadside observational studies have demonstrated either no change in driver handheld phone use following legislative bans or only transient effects that fade over the long-term without active enforcement.

June 21, 1913

In this issue of JAMA, the JAMA Clinical Evidence Synopsis by Krogsbøll et al summarizes a systematic review of 9 randomized trials of a general health check. A general health check is defined as health care motivated by the need to assess general health and prevent future illness rather than to attend to symptoms. Screening tests are performed and counseling may occur during a general health check. The Cochrane systematic review on which this Clinical Evidence Synopsis is based concluded that a general health check was not associated with an increase or decrease in total mortality.

Wayne Katon, MD, professor of psychiatry at the University of Washington in Seattle, has worked to develop and test models for integrating mental health care into primary care practice for the past 30 years. For much of that time, dissemination of the model moved slowly, but this process has been rapidly accelerated by health reform and growing recognition of the benefits of integrated care.

The outbreak of invasive fungal infections among patients who received injections of contaminated methylprednisolone acetate from the New England Compounding Center continues.

In Reply: Drs Hou and Huo suggest that we should correct for missing data on receptor status in the SEER database. Using the method cited by Hou and Huo, we calculated that for 25- to 39-year-old women diagnosed with distant stage breast cancer during 1992-2009, the APC after correcting for missing values was 3.85 (95% CI, 1.61 to 6.15; P = .002) for ER+PR+ disease and 3.32 (95% CI, 0.81 to 5.90; P = .01) for ER+PR− disease. The APCs for ER−PR+ and ER−PR− were −6.24 (95% CI, −10.53 to −1.74; P = .01) and 2.01 (95% CI, 0.44 to 3.60; P = .02), respectively. Thus, we again find that the incidence of ER+PR+, ER+PR−, and ER−PR− disease in young women is increasing. The ER−PR+ receptor status was initially nonsignificant but decreased with significance after the correction. We agree that divergent trends exist between the different receptor subtypes, but ER−PR− disease is increasing as are both subtypes of ER+ disease.