Journal of the American Medical Association最新文献_第8页

Axial Spondyloarthritis: A Review.

Journal of the American Medical Association Pub Date : 2024-12-04 DOI: 10.1001/jama.2024.20917

Mohamad Bittar, Atul Deodhar

{"title":"Axial Spondyloarthritis: A Review.","authors":"Mohamad Bittar, Atul Deodhar","doi":"10.1001/jama.2024.20917","DOIUrl":"https://doi.org/10.1001/jama.2024.20917","url":null,"abstract":"Importance: Axial spondyloarthritis is an immune-mediated inflammatory condition involving the sacroiliac joints, spine, and peripheral joints. It affects approximately 1% of adults in the US and is associated with impaired physical function and reduced quality of life.Observations: Inflammatory chronic back pain characterized by gradual onset starting before age 45 years, prolonged morning stiffness, improvement with exercise, and lack of improvement with rest is the most common symptom of axial spondyloarthritis and affects more than 80% of patients. Patients with axial spondyloarthritis may also have inflammatory arthritis in large peripheral joints (most commonly knees) in an oligoarticular, asymmetric fashion; inflammation at tendon insertions (enthesitis); inflammatory eye disease (uveitis); psoriasis; and inflammatory bowel disease. The pathogenesis of axial spondyloarthritis may involve genetic predisposition, gut microbial dysbiosis, and entheseal trauma, with immune cell infiltration of the sacroiliac joints and entheseal insertion areas in the spine. There are currently no diagnostic criteria for axial spondyloarthritis. The diagnosis, often delayed 6 to 8 years after symptom onset, is based on history (ie, inflammatory back pain [sensitivity, 74%-81%; specificity, 25%-44%]), laboratory findings (human leukocyte antigen B27-positive [sensitivity, 50%; specificity, 90%] and elevated C-reactive protein level [sensitivity, 35%; specificity, 91%]), and imaging findings consisting of sacroiliitis on plain radiography (sensitivity, 66%; specificity, 68%) or magnetic resonance imaging (sensitivity, 78%; specificity, 88%). First-line treatments are physical therapy and nonsteroidal anti-inflammatory drugs (NSAIDs). However, less than 25% of patients achieve complete symptom control with NSAIDs. Approximately 75% of patients require biologic drugs (tumor necrosis factor inhibitors [anti-TNF agents], interleukin 17 inhibitors [anti-IL-17 agents]) or targeted synthetic disease-modifying antirheumatic agents (Janus kinase [JAK] inhibitors) to reduce symptoms, prevent structural damage, and improve quality of life. Clinical trials reported that anti-TNF agents significantly improved ASAS20 (measure of pain, function, and inflammation) in 58% to 64% of patients compared with 19% to 38% for placebo. Similar outcomes were attained with anti-IL-17 agents (48%-61%, vs 18%-29% with placebo) and JAK inhibitors (52%-56%, vs 26%-29% with placebo). Anti-TNF agents, anti-IL-17 agents, and JAK inhibitors have been associated with reduced radiographic progression of axial spondyloarthritis.Conclusions: Axial spondyloarthritis predominantly affects the sacroiliac joints and spine but is also associated with extraskeletal manifestations such as uveitis, psoriasis, and inflammatory bowel disease. Physical therapy and NSAIDs are first-line treatments, but most patients require therapy with biologic","PeriodicalId":17196,"journal":{"name":"Journal of the American Medical Association","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-12-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142770083","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

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Firearm Policy in the Hospital Setting.

Journal of the American Medical Association Pub Date : 2024-12-04 DOI: 10.1001/jama.2024.22548

Dermot Cox

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Firearm Policy in the Hospital Setting-Reply.

Journal of the American Medical Association Pub Date : 2024-12-04 DOI: 10.1001/jama.2024.22551

Joshua B Romero, Richard S Saver, Joseph Blocher

引用次数: 0

Associations of Internal Medicine Residency Ratings and Certification Examination Scores With Patient Outcomes-Reply. 内科住院医生评分和认证考试成绩与患者预后的关系--回复。

Journal of the American Medical Association Pub Date : 2024-12-03 DOI: 10.1001/jama.2024.19945

Bradley M Gray, Bruce E Landon

引用次数: 0

Kidney Transplant Outcomes From Donors Who Received Dialysis. 接受过透析的捐献者的肾移植结果。

Journal of the American Medical Association Pub Date : 2024-12-03 DOI: 10.1001/jama.2024.19705

Rogério da Hora Passos, Rafaella Maria da Cunha Lyrio, Giselle Guerra

引用次数: 0

Frequency of Screening and Spontaneous Breathing Trial Techniques: A Randomized Clinical Trial. 筛查频率和自主呼吸试验技术：随机临床试验

Journal of the American Medical Association Pub Date : 2024-12-03 DOI: 10.1001/jama.2024.20631

Karen E A Burns, Jessica Wong, Leena Rizvi, Myriam Lafreniere-Roula, Kevin Thorpe, John W Devlin, Deborah J Cook, Andrew Seely, Peter M Dodek, Maged Tanios, Thomas Piraino, Audrey Gouskos, Kenneth C Kiedrowski, Phyllis Kay, Susan Mitchell, George W Merner, Michael Mayette, Frederick D'Aragon, Francois Lamontagne, Bram Rochwerg, Alexis Turgeon, Ying Tung Sia, Emmanuel Charbonney, Pierre Aslanian, Gerard J Criner, Robert C Hyzy, Jeremy R Beitler, Elias Baedorf Kassis, Demetrios James Kutsogiannis, Maureen O Meade, Janice Liebler, Santhi Iyer-Kumar, Jennifer Tsang, Robert Cirone, Carl Shanholtz, Nicholas S Hill

{"title":"Frequency of Screening and Spontaneous Breathing Trial Techniques: A Randomized Clinical Trial.","authors":"Karen E A Burns, Jessica Wong, Leena Rizvi, Myriam Lafreniere-Roula, Kevin Thorpe, John W Devlin, Deborah J Cook, Andrew Seely, Peter M Dodek, Maged Tanios, Thomas Piraino, Audrey Gouskos, Kenneth C Kiedrowski, Phyllis Kay, Susan Mitchell, George W Merner, Michael Mayette, Frederick D'Aragon, Francois Lamontagne, Bram Rochwerg, Alexis Turgeon, Ying Tung Sia, Emmanuel Charbonney, Pierre Aslanian, Gerard J Criner, Robert C Hyzy, Jeremy R Beitler, Elias Baedorf Kassis, Demetrios James Kutsogiannis, Maureen O Meade, Janice Liebler, Santhi Iyer-Kumar, Jennifer Tsang, Robert Cirone, Carl Shanholtz, Nicholas S Hill","doi":"10.1001/jama.2024.20631","DOIUrl":"10.1001/jama.2024.20631","url":null,"abstract":"Importance: The optimal screening frequency and spontaneous breathing trial (SBT) technique to liberate adults from ventilators are unknown.Objective: To compare the effects of screening frequency (once-daily screening vs more frequent screening) and SBT technique (pressure-supported SBT with a pressure support level that was >0-≤8 cm H2O and a positive end-expiratory pressure [PEEP] level that was >0-≤5 cm H2O vs T-piece SBT) on the time to successful extubation.Design, setting, and participants: Randomized clinical trial with a 2 × 2 factorial design including critically ill adults who were receiving invasive mechanical ventilation for at least 24 hours, who were capable of initiating spontaneous breaths or triggering ventilators, and who were receiving a fractional concentration of inspired oxygen that was 70% or less and a PEEP level of 12 cm H2O or less. Recruitment was between January 2018 and February 2022 at 23 intensive care units in North America; last follow-up occurred October 18, 2022.Interventions: Participants were enrolled early to enable protocolized screening (more frequent vs once daily) to identify the earliest that patients met criteria to undergo pressure-supported or T-piece SBT lasting 30 to 120 minutes.Main outcome and measures: Time to successful extubation (time when unsupported, spontaneous breathing began and was sustained for ≥48 hours after extubation).Results: Of 797 patients (198 in the once-daily screening and pressure-supported SBT group, 204 in once-daily screening and T-piece SBT, 195 in more frequent screening and pressure-supported SBT, and 200 in more frequent screening and T-piece SBT), the mean age was 62.4 (SD, 18.4) years and 472 (59.2%) were men. There were no statistically significant differences by screening frequency (hazard ratio [HR], 0.88 [95% CI, 0.76-1.03]; P = .12) or by SBT technique (HR, 1.06 [95% CI, 0.91-1.23]; P = .45). The median time to successful extubation was 2.0 days (95% CI, 1.7-2.7) for once-daily screening and pressure-supported SBT, 3.1 days (95% CI, 2.7-4.8) for once-daily screening and T-piece SBT, 3.9 days (95% CI, 2.9-4.7) for more frequent screening and pressure-supported SBT, and 2.9 days (95% CI, 2.0-3.1) for more frequent screening and T-piece SBT. An unexpected interaction between screening frequency and SBT technique required pairwise contrasts that revealed more frequent screening (vs once-daily screening) and pressure-supported SBT increased the time to successful extubation (HR, 0.70 [95% CI, 0.50-0.96]; P = .02). Once-daily screening and pressure-supported SBT (vs T-piece SBT) did not reduce the time to successful extubation (HR, 1.30 [95% CI, 0.98-1.70]; P = .08).Conclusions and relevance: Among critically ill adults who received invasive mechanical ventilation for more than 24 hours, screening frequenc","PeriodicalId":17196,"journal":{"name":"Journal of the American Medical Association","volume":" ","pages":"1808-1821"},"PeriodicalIF":0.0,"publicationDate":"2024-12-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11581551/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142391480","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 0

Kidney Transplant Outcomes From Donors Who Received Dialysis. 接受过透析的捐献者的肾移植结果。

Journal of the American Medical Association Pub Date : 2024-12-03 DOI: 10.1001/jama.2024.19702

Chengliang Yang, Scott J Tebbutt

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a fall. a fall.

Journal of the American Medical Association Pub Date : 2024-12-03 DOI: 10.1001/jama.2024.15337

James M Wilkins

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Associations of Internal Medicine Residency Ratings and Certification Examination Scores With Patient Outcomes. 内科住院医师评级和认证考试成绩与患者预后的关系。

Journal of the American Medical Association Pub Date : 2024-12-03 DOI: 10.1001/jama.2024.19942

James L Rudolph, Luci K Leykum

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Peptic Ulcer Disease: A Review. 消化性溃疡病：综述。

Journal of the American Medical Association Pub Date : 2024-12-03 DOI: 10.1001/jama.2024.19094

Nimish Vakil

{"title":"Peptic Ulcer Disease: A Review.","authors":"Nimish Vakil","doi":"10.1001/jama.2024.19094","DOIUrl":"10.1001/jama.2024.19094","url":null,"abstract":"Importance: In the US, peptic ulcer disease affects 1% of the population and approximately 54 000 patients are admitted to the hospital annually for bleeding peptic ulcers.Observations: Approximately 10% of patients presenting with upper abdominal pain in a primary care setting have a peptic ulcer as the cause of their symptoms. The principal causes of peptic ulcer disease are Helicobacter pylori infection, which affects approximately 42% of patients with peptic ulcer disease, and aspirin or nonsteroidal anti-inflammatory drug (NSAID) use, which are etiologic factors in approximately 36% of people with peptic ulcer disease. Complications of peptic ulcer include bleeding (73% of patients), perforation (9% of patients), and pyloric obstruction (3% of patients). Annually, 10 000 people die of peptic ulcer disease in the US. Endoscopy definitively diagnoses peptic ulcer disease. Acid blockers, such as omeprazole, can heal peptic ulcers in approximately 80% to 100% of patients within 4 weeks, but gastric ulcers larger than 2 cm may require 8 weeks of treatment. Eradication of H pylori decreases peptic ulcer recurrence rates from approximately 50% to 60% to 0% to 2%. Discontinuing NSAIDs heals 95% of ulcers identified on endoscopy and reduces recurrence from 40% to 9%. When discontinuing an NSAID is not desirable, changing the NSAID (eg, from ketorolac to ibuprofen), adding a proton pump inhibitor such as omeprazole or lansoprazole, and eradicating H pylori with treatment such as bismuth, metronidazole, and tetracycline combined with omeprazole can reduce recurrence rates.Conclusions and relevance: Peptic ulcer disease is associated with increased hospitalization rates and mortality. Acid blocking with proton pump inhibitors, such as omeprazole or lansoprazole, is the primary treatment. Recurrence of ulcers can be prevented by eradicating H pylori if present and discontinuing aspirin or NSAIDs if applicable.","PeriodicalId":17196,"journal":{"name":"Journal of the American Medical Association","volume":" ","pages":"1832-1842"},"PeriodicalIF":0.0,"publicationDate":"2024-12-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142502794","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 0