Importance Although the YEARS algorithm is a safe and efficient way to rule out acute pulmonary embolism (PE), robust evidence on its accuracy in patients with cancer is lacking, and current guidelines suggest proceeding directly to computed tomographic pulmonary angiography (CTPA). Objective To compare the safety and efficiency of the YEARS algorithm with CTPA only to rule out acute PE in patients with active cancer. Design, Setting, and Participants The Hydra study was an open-label, randomized, investigator-initiated, noninferiority trial with blinded central outcome adjudication conducted from August 22, 2019, to August 21, 2025, the date of final follow-up. Patients with active cancer and suspected acute PE were recruited from emergency departments or medical units in 21 hospitals in the Netherlands, Italy, Switzerland, Belgium, France, and Spain. Interventions Patients were randomly assigned in a 1:1 ratio to receive diagnostic management by the YEARS algorithm (n = 352)—consisting of assessing YEARS items, D-dimer levels, and performing risk-dependent CTPA—or by CTPA only (n = 346). Main Outcomes and Measures The primary outcome was centrally adjudicated symptomatic venous thromboembolism or (possible) PE-related death within 90 days after ruling out PE at baseline, assessed in a per-protocol noninferiority analysis with a 2.6% margin for the upper bound of a 1-sided 99.9% CI. The key secondary outcome was the proportion of negative CTPA results at baseline, assessed in a superiority analysis. Results A total of 698 patients were randomized (median age, 65 years [IQR, 56-72 years], 422 female [60%]), and 104 patients (15%) had PE diagnosed at baseline. One patient was lost to follow-up. Of those in whom PE was considered excluded, 5 of 282 patients (1.8%) in the per-protocol YEARS group vs 15 of 273 patients (5.5%) in the per-protocol CTPA-only group had a primary outcome (absolute risk difference, −3.7%; 99.9% CI, −8.8% to 1.4%; P = 3.4 × 10 −5 for noninferiority). In the intention-to-diagnosis analysis, the absolute risk difference between the YEARS algorithm and CTPA only was −2.6% (99.9% CI, −7.5% to 2.4%; P = 5.9 × 10 −4 for noninferiority). Diagnostic management of PE was carried out for 77 of 352 patients (22%) in the YEARS group without CTPA. No difference in the proportion of negative CTPA ( P = .93) was observed between the groups. Conclusions and Relevance In patients with cancer and suspected PE, a diagnostic strategy using the YEARS diagnostic algorithm was as safe as using CTPA only, thus, obviating the need to perform CTPA in 22% of patients. Trial Registration ccmo.nl Identifier: NL-OMON52383
Importance:Formulary exclusions and drug utilization management, including prior authorization and step therapy, reduce drug spending but may limit timely treatment access. Objective:To estimate formulary-based rejections and subsequent dispensing of initial attempts to fill single-source branded drug prescriptions. Design, Setting, and Population:Retrospective, national, all-payer cohort study using IQVIA Formulary Impact Analyzer, which represents anonymized, patient-level, adjudicated US outpatient pharmacy claims, from January 2018 through September 2024. The study focused on 1.17 million individuals attempting to fill 2 million single-source branded drug prescriptions for the first time. Exposure:Attempt to fill a single-source branded drug prescription for the first time. Main Outcomes and Measures:The primary outcomes were (1) rejection for formulary exclusion or utilization management (prior authorization or step therapy) of an initial prescription fill attempt and (2) failure of dispensing of the rejected molecule or another member of the same therapeutic class within 90 days of the initially attempted fill. Results:Among more than 2 million initial fill attempts (commercial insurance, 0.84 million; stand-alone Medicare prescription drug plan, 0.40 million; Medicare Advantage prescription drug plan, 0.39 million; Medicaid fee-for-service, 0.21 million; Medicaid managed care, 0.10 million; health insurance marketplace [exchange] plan, 0.06 million), 68.0% were paid on the initial fill attempt, while the remainder were rejected for formulary exclusion (14.8%) or rejected due to requiring prior authorization or step therapy, ie, utilization management (17.2%). Formulary-based rejections increased 67.4% over the time frame examined, from 24.3% (2018) to 40.7% (2024), and rejections were most common among exchange (48.7%) and Medicaid managed care (49.8%) compared with Medicare prescription drug plans (24.0%) and Medicare Advantage prescription drug plans (19.8%). Of the 32% of attempts that were initially rejected, 38.6% ultimately resulted in the rejected molecule being filled within 90 days and nearly half (48.4%) resulted in no medication fill in the same therapeutic class within that time frame. Treatment initiation was delayed an average of 12.2 days (SD, 17.8 days) after initial rejection among those ultimately receiving the same molecule or a therapeutic substitute. Conclusions and Relevance:Among this large, diverse sample of individuals in the United States, formulary rejections were frequent and often resulted in delayed or absent treatment, highlighting trade-offs between cost and access to medicines.
SummaryA brief account is given of experiments with safflower oil in Australia. Under practical conditions, the drying power of safflower oil equals that of linseed oil. The non‐yellowing properties of the former render it superior to the latter as a vehicle in coatings for interior decoration and in stoving enamels. In the heat polymerization of safflower oil, temperatures 10° to 15°C. higher than those normally employed for linseed oil are recommended. During three years of outdoor exposure trials, paints based on safflower oil have performed at least as well as similar paints from linseed oil. The commercial production of the oil by solvent extraction presents no difficulty. Decortication prior to extraction is not necessary. The resulting oil has a very good colour and is free from “foots.” On alkali refining, losses are very small. Notwithstanding the high hull content of the meal, it has proved valuable as a stock fodder.
Paroxysmal (PNH) is an acquired clonal hematopoietic stem cell disorder characterized by corpuscular hemolytic anemia, bone marrow failure and frequent thrombotic events.
Our website uses cookies to enhance your experience. By continuing to use our site, or clicking "Continue," you are agreeing to our Cookie Policy | Continue JAMA Internal Medicine HomeNew OnlineCurrent IssueFor Authors Podcast Publications JAMA JAMA Network Open JAMA Cardiology JAMA Dermatology JAMA Health Forum JAMA Internal Medicine JAMA Neurology JAMA Oncology JAMA Ophthalmology JAMA Otolaryngology–Head & Neck Surgery JAMA Pediatrics JAMA Psychiatry JAMA Surgery Archives of Neurology & Psychiatry (1919-1959) JN Learning / CMESubscribeJobsInstitutions / LibrariansReprints & Permissions Terms of Use | Privacy Policy | Accessibility Statement 2023 American Medical Association. All Rights Reserved Search All JAMA JAMA Network Open JAMA Cardiology JAMA Dermatology JAMA Forum Archive JAMA Health Forum JAMA Internal Medicine JAMA Neurology JAMA Oncology JAMA Ophthalmology JAMA Otolaryngology–Head & Neck Surgery JAMA Pediatrics JAMA Psychiatry JAMA Surgery Archives of Neurology & Psychiatry Input Search Term Sign In Individual Sign In Sign inCreate an Account Access through your institution Sign In Purchase Options: Buy this article Rent this article Subscribe to the JAMA Internal Medicine journal
President ......................... Michael Schoenberger 1170 President-Elect .................... James D. Robertson 117 1 First Vice-President ..................... Neal R. Goins 117 1 Second Vice-President ........... ..Bria n H. Russell 117 1 Vice-President ................................... Oz Yilmaz 1171 Secretary-Treasurer.. ............... Don E. Robinson 1172 Editor ......................................... Bob A. Hardage 1178
Our website uses cookies to enhance your experience. By continuing to use our site, or clicking "Continue," you are agreeing to our Cookie Policy | Continue JAMA Internal Medicine HomeNew OnlineCurrent IssueFor Authors Podcast Publications JAMA JAMA Network Open JAMA Cardiology JAMA Dermatology JAMA Health Forum JAMA Internal Medicine JAMA Neurology JAMA Oncology JAMA Ophthalmology JAMA Otolaryngology–Head & Neck Surgery JAMA Pediatrics JAMA Psychiatry JAMA Surgery Archives of Neurology & Psychiatry (1919-1959) JN Learning / CMESubscribeJobsInstitutions / LibrariansReprints & Permissions Terms of Use | Privacy Policy | Accessibility Statement 2023 American Medical Association. All Rights Reserved Search All JAMA JAMA Network Open JAMA Cardiology JAMA Dermatology JAMA Forum Archive JAMA Health Forum JAMA Internal Medicine JAMA Neurology JAMA Oncology JAMA Ophthalmology JAMA Otolaryngology–Head & Neck Surgery JAMA Pediatrics JAMA Psychiatry JAMA Surgery Archives of Neurology & Psychiatry Input Search Term Sign In Individual Sign In Sign inCreate an Account Access through your institution Sign In Purchase Options: Buy this article Rent this article Subscribe to the JAMA Internal Medicine journal
ONE in vivo effect of growth hormone secreted by the anterior pituitary gland is to oppose the action of insulin in promoting the utilization of glucose in muscle (see ref. 1 for earlier references), an effect which is almost certainly of physiological significance2,3. Nevertheless, no satisfactorily reproducible effect of growth hormone in vitro on carbohydrate metabolism has been described. Rather surprisingly Park et al.4 observed that the addition of growth hormone in vitro to diaphragm from the hypophysectomized rat stimulates the uptake of glucose, that is, growth hormone exerts an insulin-like action in this system. This observation has been confirmed5 but is not reproducible with diaphragm from intact rats (see ref. 6 for further references). The amount of growth hormone added to diaphragm in vitro in these experiments was 1 µg/ml. or more.
DIAPER RASH PREVENTION: • Change the baby’s diaper frequently. Change diapers soiled with stool as soon as possible. Wet diapers should be changed if soaked or every 2-4 hours during the day. • Be careful with your wipes. Many baby wipes have soaps and fragrances that can be irritating to the skin, especially during the first few weeks of life. Use hypoallergenic/fragrance-free wipes. If your baby already has a rash or is a newborn, consider using baby washcloths. These can be easily made ahead of time by putting them in an old wipe container and pouring a mixture of roughly 2 cups water with 1 tablespoon baby oil over a full container of cloth wipes. • When possible, allow the baby’s bottom to be open to air. This will help “dry out” the rash by reducing moisture. When wearing a diaper or plastic pants, loosen the legs so that air can circulate to the skin or allow the baby to be naked from the waist down (you may want the baby on a waterproof pad).
developing countries. It has been proposed that this is the result of improved hygiene and sanitation, which have led to reduced exposure to enteric infections and immaturity of the immune system. In a recent systematic review of population based studies, incidence varied from 0.6 to more than 20 people per 100 000 person years in Europe and North America, compared with 0.1 to 6.3 per 100 000 person years in Asia and the Middle East. Overall, incidence appeared to be on the rise worldwide. Peak incidence occurred in the second to fourth decade of life, although a modest rise was also seen in later life. Prevalence was estimated at 5-500 people per 100 000 worldwide. No consistent difference was seen between the sexes. Smoking protects against developing ulcerative colitis. Risk is eight times higher in first degree relatives of people with the disorder compared with first degree relatives of healthy controls, although this is not completely explained by known genetic risk factors.
Progress in implementing the World Federation for Medical Education Edinburgh Recommendations in all three phases of education--undergraduate, postgraduate and continuing--is dependent upon recognition of the need to manage dissatisfaction with the present, to have appropriate visions for the future, to have a management strategy for implementing change and to be cost-effective. The extent to which progress can be anticipated is reflected in the formula: Change = (Dissatisfaction x Vision x Process) > Cost We have to aim for a curriculum that will be more convenient, relevant, individualized to the need of each student or trainee, diagnostic--emphasizing self-assessment, interesting--taking account of motivation of students and doctors, systematic or planned and allowing for speculation and a consideration of the grey areas or uncertainties of medicine as well as the certainties.
A case of paroxysmal nocturnal hemoglobinuria (PNH) is presented in which MR imaging and CT findings were characteristic. The signal intensity of renal cortex was lower than that of medulla on both T1- and T2-weighted imaging. On CT without contrast enhancement the attenuation of renal cortex was higher than that of renal medulla. These findings at MR imaging and CT were the results of a deposition of hemosiderin in the cells of proximal convoluted tubules, and were helpful for diagnosis of PNH.
