tbuckley/cabot-search huggingface dataset:
The Meat You Eat
Journal: JAMA (1942)

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 HomeNew OnlineCurrent IssueFor Authors Podcasts Clinical Reviews Editors' Summary Medical News Author Interviews More 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 journal
Picture Quiz: Distinctive skin signs
Authors: Menelaos Philippou, Katie Clifford, Steven Derbyshire
Journal: BMJ (2007)

A 48 year old man presented to the accident and emergency department with syncope and was admitted for further investigation. He had the signs shown in figures 1 and 2, which are well recognised clinical features of an inherited disorder.



Photo of patient's back





Close up of patient's back





The condition neurofibromatosis encompasses at least two distinct diseases, neurofibromatosis type 1 (von Recklinghausen's neurofibromatosis) and neurofibromatosis type 2. The patient was diagnosed with neurofibromatosis type 2 on clinical grounds; his syncopal episode was incidental and unrelated.

Neurofibromatosis type 1 was first described by RW Smith in 1849 and later in 1892 by Friedreich D von Recklinghausen. It is now recognised as the most …
Impact of Consensus Molecular Subtype on Survival in Patients With Metastatic Colorectal Cancer: Results From CALGB/SWOG 80405 (Alliance)
Authors: Heinz-Josef Lenz, Fang-Shu Ou, Alan P. Venook, Howard S. Hochster, Donna Niedzwiecki, Richard M. Goldberg, Robert J. Mayer, Monica M. Bertagnolli, Charles D. Blanke, Tyler Zemla, Xueping Qu, Pratyaksha Wirapati, Sabine Tejpar, Federico Innocenti, Omar Kabbarah
Journal: Journal of Clinical Oncology (2019)

To determine the predictive and prognostic value of the consensus molecular subtypes (CMSs) of colorectal cancer (CRC) that represent a merging of gene expression-based features largely in primary tumors from six independent classification systems and provide a framework for capturing the intrinsic heterogeneity of CRC in patients enrolled in CALGB/SWOG 80405.
Arterial Stiffness in the Heart Disease of CKD
Authors: Luca Zanoli, Paolo Lentini, Marie Briet, Pietro Castellino, Andrew A. House, Gerard M. London, Lorenzo Malatino, Peter A. McCullough, Dimitri P. Mikhailidis, Pierre Boutouyrie
Journal: Journal of the American Society of Nephrology (2019)

CKD frequently leads to chronic cardiac dysfunction. This complex relationship has been termed as cardiorenal syndrome type 4 or cardio-renal link. Despite numerous studies and reviews focused on the pathophysiology and therapy of this syndrome, the role of arterial stiffness has been frequently overlooked. In this regard, several pathogenic factors, including uremic toxins ( i.e. , uric acid, phosphates, endothelin-1, advanced glycation end-products, and asymmetric dimethylarginine), can be involved. Their effect on the arterial wall, direct or mediated by chronic inflammation and oxidative stress, results in arterial stiffening and decreased vascular compliance. The increase in aortic stiffness results in increased cardiac workload and reduced coronary artery perfusion pressure that, in turn, may lead to microvascular cardiac ischemia. Conversely, reduced arterial stiffness has been associated with increased survival. Several approaches can be considered to reduce vascular stiffness and improve vascular function in patients with CKD. This review primarily discusses current understanding of the mechanisms concerning uremic toxins, arterial stiffening, and impaired cardiac function, and the therapeutic options to reduce arterial stiffness in patients with CKD.
Acute abdomen in an infant
Authors: Olivia R K Kingston, Fernando Isaza
Journal: BMJ (2008)

A 10 month old boy was brought into the accident and emergency department with a six hour history of vomiting and irritability that began after his first feed of the day. The vomiting was stained green. During this period the child opened his bowels once and passed a large amount of diarrhoea with no specific characteristics. He continued to have wet nappies throughout the morning. He was also noted to have crying episodes that lasted approximately 20 minutes and involved the child bending his legs over his trunk.

There was no history of fever, rashes, or preceding illness and he had not had a change in diet. The baby was breast fed until 9 months of age and had been weaned at five months. He had always been healthy and had normal development.

On examination he was apyrexial, his peripheries were warm, well perfused, and he was not in obvious distress. During the examination the child became acutely irritable. He began to cry, bending his legs on to his trunk. On palpation of his abdomen his right iliac fossa was empty and a mass was noticed in the right upper quadrant. He also passed a small amount of red stool containing mucus. Testes and femoral pulses were present. The child was sent for an urgent abdominal ultrasound examination.



Fig 1 
Transverse sonogram of the abdomen.





Fig 2 
Longitudinal sonogram …
Device-Based Neuromodulation for Resistant Hypertension Therapy
Authors: Thomas E. Lohmeier, John E. Hall
Journal: Circulation Research (2019)

Despite availability of effective drugs for hypertension therapy, significant numbers of hypertensive patients fail to achieve recommended blood pressure levels on ≥3 antihypertensive drugs of different classes. These individuals have a high prevalence of adverse cardiovascular events and are defined as having resistant hypertension (RHT) although nonadherence to prescribed antihypertensive medications is common in patients with apparent RHT. Furthermore, apparent and true RHT often display increased sympathetic activity. Based on these findings, technology was developed to treat RHT by suppressing sympathetic activity with electrical stimulation of the carotid baroreflex and catheter-based renal denervation (RDN). Over the last 15 years, experimental and clinical studies have provided better understanding of the physiological mechanisms that account for blood pressure lowering with baroreflex activation and RDN and, in so doing, have provided insight into which patients in this heterogeneous hypertensive population are most likely to respond favorably to these device-based therapies. Experimental studies have also played a role in modifying device technology after early clinical trials failed to meet key endpoints for safety and efficacy. At the same time, these studies have exposed potential differences between baroreflex activation and RDN and common challenges that will likely impact antihypertensive treatment and clinical outcomes in patients with RHT. In this review, we emphasize physiological studies that provide mechanistic insights into blood pressure lowering with baroreflex activation and RDN in the context of progression of clinical studies, which are now at a critical point in determining their fate in RHT management.
A pilot study to assess the tolerability and efficacy of RAD-001 (everolimus) with gefitinib in patients with recurrent glioblastoma multiforme (GBM)
Authors: T. D. Nguyen, A. B. Lassman, E. Lis, N. Rosen, D. R. Shaffer, H. I. Scher, L. M. Deangelis, L. E. Abrey
Journal: Journal of Clinical Oncology (2006)

1507 Background: The majority of GBMs overexpress EGFR and have PTEN loss leading to activation of AKT signaling. mTOR is a downstream target which is blocked by RAD-001. The addition of an mTOR inhibitor to EGFR blockade by gefitinib may augment downregulation of AKT. Methods: Nineteen patients with GBM were enrolled in a phase I/II protocol open to patients with either hormone refractory prostate cancer or recurrent GBM. Patients on enzyme inducing anti-epileptic drugs (EIAEDs) were excluded, but prior treatment with an EGFR inhibitor was allowed. All patients received gefitinib 250 mg daily. Two patients enrolled in a dose escalation arm received RAD-001 30 mg or 50 mg weekly; 17 patients received the maximum tolerated dose of RAD-001 70 mg weekly. Baseline and follow-up MRIs were reviewed by a neuro-radiologist. Primary endpoints were radiographic response and progression-free survival (PFS). Results: There were 11 men and 8 women with a median age of 53 years (range 22–72) and median KPS of 80 (range 70–100). Seventeen patients (89%) were treated at their second or greater recurrence. The most frequent grade 1 and 2 toxicities were thrombocytopenia, elevated ALT, rash, anemia, leukopenia, and diarrhea. Grade 3 lymphopenia occurred in 8 patients (42%); two patients (11%) had grade 4 seizures unrelated to the study drugs. Five patients (26%) had a partial radiographic response, including one treated at 3 rd recurrence, 2 treated at 4 th recurrence, and one who had progressed through prior gefitinib therapy. Two additional patients (11%) had disease stabilization for greater than 4 months. Median PFS was 2.6 months. Median overall survival has not been reached, with a median follow up of 5.4 months for surviving patients. Conclusions: The combination of RAD-001 and gefitinib demonstrated activity in 37% of patients with GBM (26% responded, 11% achieved stable disease). Most subjects were heavily pre-treated and expected to have resistant disease. Because disease control was not durable, alternate dosing, or treatment earlier in the course of disease should be considered in further studying this promising combination. [Table: see text]
10 minute consultation: Low back pain
Authors: Jo Samanta, Julia Kendall, Ash Samanta
Journal: BMJ (2003)

A 40 year old man presents with a two year history of chronic low back pain. For the past week he has had an exacerbation of his symptoms and intermittent pain radiating down his right leg.

Symptoms--Discuss the likely causes. Show him a diagram or model of the lumbar spine indicating the vertebrae, discs, and nerve roots. Explain that his leg pain is due to irritation of the nerve roots and that effective treatment should alleviate both his back pain and his leg pain.

Examination--Look for reduced …
Abstract P254: Willingness to Restart Statins: The Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study
Authors: Gabriel S Tajeu, Lisandro D Colantonio, Rikki M Tanner, Keri L Monda, Ricardo Dent, Michael E Farkouh, Benjamin Taylor, Robert S Rosenson, Monika M Safford, Paul Muntner
Journal: Circulation (2017)

Introduction: Many patients who discontinue statins due to side effects can restart treatment without the return of side effects. However, statin rechallenge is often met with resistance. Statins are associated with a larger absolute cardiovascular disease (CVD) risk reduction among high risk individuals, but it is unclear whether individuals with higher CVD risk are more willing to be rechallenged. Methods: Between 2014 and 2016, 12,604 participants in theREasons for Geographic and Racial Differences in Stroke study completed a study examination and a questionnaire about their experiences with statins. Of 6,947 participants who reported ever having taken a statin, this analysis included the 688 (9.9%) who reported having discontinued treatment due to side effects and who were not currently taking a statin. We asked participants whether they would be willing to restart a statin, and among those who answered no, we asked whether they were willing to restart at a lower dose or less frequently. Data from the study examination were used to define CVD risk factors and 10-year predicted CVD risk was calculated using the Pooled Cohort risk equations. Results: Participant mean age was 62.4 years, 29.6% were African American, and 66.4% were women. Overall, 26.0% (n=179) of participants were willing to be rechallenged with a statin (Table) . After adjustment for sociodemographic characteristics, older age, cigarette smoking, hypertension, diabetes, or history of CVD were not associated with an increased willingness to be rechallenged with a statin (Table) . Higher 10-year predicted CVD risk was also not associated with willingness to be rechallenged. Conclusions: Over a quarter of participants who discontinued statin treatment due to side effects were willing to be rechallenged. The presence of CVD risk factors and higher predicted CVD risk were not associated with increased willingness to be rechallenged with a statin.
Guidelines for Perioperative Care in Cardiac Surgery
Authors: Daniel T. Engelman, Walid Ben Ali, Judson B. Williams, Louis P. Perrault, V. Seenu Reddy, Rakesh C. Arora, Eric E. Roselli, Ali Khoynezhad, Marc Gerdisch, Jerrold H. Levy, Kevin Lobdell, Nick Fletcher, Matthias Kirsch, Gregg Nelson, Richard M. Engelman, Alexander J. Gregory, Edward M. Boyle
Journal: JAMA Surgery (2019)

Enhanced Recovery After Surgery (ERAS) evidence-based protocols for perioperative care can lead to improvements in clinical outcomes and cost savings. This article aims to present consensus recommendations for the optimal perioperative management of patients undergoing cardiac surgery. A review of meta-analyses, randomized clinical trials, large nonrandomized studies, and reviews was conducted for each protocol element. The quality of the evidence was graded and used to form consensus recommendations for each topic. Development of these recommendations was endorsed by the Enhanced Recovery After Surgery Society.
Oxytocin antagonism prevents pregnancy-associated aortic dissection in a mouse model of Marfan syndrome
Authors: Jennifer Pardo Habashi, Elena Gallo MacFarlane, Rustam Bagirzadeh, Caitlin Bowen, Nicholas Huso, Yichun Chen, Djahida Bedja, Tyler J. Creamer, Graham Rykiel, Maurice Manning, David Huso, Harry C. Dietz
Journal: Science Translational Medicine (2019)

Protection from pregnancy-associated aortic dissection is achieved by decreasing oxytocin-induced ERK signaling in a mouse model of Marfan syndrome.
Sounding: Chart of darkness
Authors: Séamus Phillips
Journal: BMJ (2000)

In our hospital all the house officers take their turn doing a week of night duty on emergency medical take. This usually leaves time for considered decision making about patients, something that is in short supply in the daytime.

We arrive at the emergency ward and immediately scan the board for arrivals, as if at some very small airport where planes only carry individuals. The nurses put big magnetic tags on the white board to indicate triage categories. The effect of this is that, …
How organisations contribute to improving the quality of healthcare
Authors: Naomi J Fulop, Angus I G Ramsay
Journal: BMJ (2019)

The contribution of healthcare organisations to improving quality is not fully understood or considered sufficiently Organisations can facilitate improvement by developing and implementing an organisation-wide strategy for improving quality Organisational leaders need to support system-wide staff engagement in improvement activity and, where necessary, challenge professional interests and resistance Leaders need to be outward facing, to learn from others, and to manage external influences.Strong clinical representation and challenge from independent voices are key components of effective leadership for improving quality Regulators can facilitate healthcare organisations' contribution by minimising regulatory overload and contradictory demands Placing healthcare organisations in their contextHealth systems operate at three inter-related levels: macro, meso, and micro (box 1).Research suggests that an organisation-through its leadership and processes-can bridge these levels to influence the quality of care delivered at the front line.
While there's moonlight and music
Authors: Alan Laverty
Journal: BMJ (2007)

Being a musical sort of a being and finding myself in a profession that encourages the abandonment of all extracurricular activities on entering medical school, I have discovered myself singing, humming, air guitaring, and/or drum soloing at work. Sometimes I'm aware of it and at other times fellow staff threaten to section me.



White Stripes and White Blood Cells



When in good form I tend to start the day with Chelsea Morning by Joni Mitchell or a Penguin …
Minerva: July 2001
Authors: T A Chave, R H Thomas, J E Osborne, R D R Camp, P McArthur, M Murison
Journal: BMJ (2001)

Sir Douglas Black, known for the 1980 “Black report” on equalities in health,makes the point that what one can do may depend on available resources.Watching a man give another man an intravenous injection in Bengal during the war, Sir Douglas asked what he was doing. “Giving him calcium” was the reply. Pursuing the matter further, Sir Douglas asked, “Why?” He received the conclusive answer: “Calcium is what I have got” (SK Goolamali. Twice Daily after Meals . London: Medi–Derm, 2001).

Using a protein “glue” and short, synthetic, single strands of DNA, scientists at the National Cancer Institute have invented a new system of molecular ``cutting and pasting for repairing intracellular DNA. Their method can apparently remove single base mutations and longer sections of rogue genetic material, and it should provide interesting new ways of studying the genomes of various organisms ( Proceedings of the National Academy of Sciences 2001;98:6742–6).

Unhappy doctors thinking about leaving the profession should reconsider. Work related stress is positively associated with high blood pressure, according to a retrospective …
Ophthalmology: The painful red eye
Authors: Sophia Pathai, Andrew McNaught
Journal: BMJ (2002)

A painful red eye can be the presenting problem for a large number of eye conditions, spanning a wide range of complaints from the fairly trivial to diseases that threaten sight. Although common, not all cases of red eye are attributable to conjunctivitis; take time to get a good history, and perform a thorough examination. You will then be able to judge the severity of the condition and the urgency and need for specialist referral.

Knowing when symptoms started and how quickly they have progressed is useful. Important symptoms to ask about when thinking of conditions affecting the anterior segment (the structures from the conjunctiva to the lens) include pain, photophobia, and reduced vision. When asking about photophobia, find out if light makes the eye feel painful or just uncomfortable. Reduced vision may be described as blurring; find out if this clears with blinking. Also ask about any discharge and stickiness of the eye. Try to elucidate the characteristics of the pain--is it a deep, boring pain that keeps the patient awake at night, or is just slightly uncomfortable?

Remember to ask patients if they have had similar symptoms before--patients with a recurrent anterior uveitis can often recognise the symptoms signalling an attack. Similarly, knowing any previous ophthalmic history is useful. For example, a patient may have had herpes zoster (shingles) affecting the eye in the past, which can lead to further ophthalmic complications. With a painful red eye, be sure to ask about any recent intraocular surgery such as cataract extraction or refractive corneal surgery.



Traumatic corneal abrasion - stained with fluorescein



Take note of the general medical history; consider the medical or surgical complaint that may have brought a patient to hospital, and also any background history such as rheumatoid arthritis. Ask about any new systemic symptoms such …
Better Model Transfers Require Knowledge of Mechanisms
Authors: Phil J. Bouchet, A.Townsend Peterson, Damaris Zurell, Carsten F. Dormann, David Schoeman, Rebecca E. Ross, Paul Snelgrove, Ana M.M. Sequeira, Mark J. Whittingham, Lifei Wang, Giovanni Rapacciuolo, Steffen Oppel, Camille Mellin, Valentina Lauria, Periyadan K. Krishnakumar, Alice R. Jones, Stefan Heinänen, Risto K. Heikkinen, Edward J. Gregr, Alan H. Fielding, M.Julian Caley, A.Márcia Barbosa, Andrew J. Bamford, Hector Lozano-Montes, Stephen Parnell, Seth Wenger, Katherine L. Yates
Journal: Trends in Ecology & Evolution (2019)
Cost-of-Care Conversations During Clinical Visits in Federally Qualified Health Centers
Authors: Douglas D. Bradham, Deliana Garcia, Alma Galván, Corey Erb
Journal: Annals of Internal Medicine (2019)

The Centers for Disease Control and Prevention estimates that 10% of the U.S. population delays or avoids health care because of cost concerns. It is unknown whether and how cost-of-care conversations occur in primary encounters, especially settings that provide care to vulnerable patients.To describe cost-of-care conversations with financially vulnerable (<400% federal poverty level) adult patients during clinical encounters.Five observers shadowed a convenience sample of patients during encounters and then interviewed patients and clinicians after the encounter.Federally Qualified Health Centers in Texas (n = 2) and Pennsylvania (n = 2).A convenience sample of 67 adult patients seeking chronic disease management or prenatal care from 9 clinicians (5 medical doctors, 2 physician assistants, and 2 nurse practitioners).Self-reported characteristics of patients, and frequency and characteristics of interviewer-observed cost-of-care conversations.Because of missing responses from patient and clinician interviews, data are reported for 67 consenting patients. During 46.3% of encounters, some discussion of costs of care was observed. Discussion of indirect costs (lost work time or transportation) was observed in only 2.9% of encounters. In only 11.9% of encounters did the physician discuss costs of care. When costs were discussed, the conversation was not organized and did not take place in conjunction with the discussion of the treatment plan.This exploratory work involved a small convenience sample, and generalizability to other settings is uncertain. Missing data prohibited meaningful analysis of patient and clinician interview data.In the 4 federally funded health centers studied, cost-of-care conversations occurred in a minority of clinical visits, discussions were unorganized, and indirect costs of care were rarely addressed. Whether more frequent discussion of the costs of care improves patient adherence and outcomes requires further study.Robert Wood Johnson Foundation.
Over-the-scope clip used to treat duodenal ulcer can cause damage to ulcer base and massive bleeding
Authors: Emilien Daire, Emmanuel Forte, Badis Mennassel, Charles-Eric Ber, Emilie Roy, Jérémie Jacques, Mathieu Pioche
Journal: Endoscopy (2019)

The efficacy of the over-the-scope clip (OTSC; Ovesco, Tübingen, Germany) to achieve primary hemostasis and prevent rebleeding has been demonstrated in the treatment of gastroduodenal ulcers [1]. Recent data have shown technical success and hemostasis rates of almost 100 % [1] [2] [3]. We present the case of technical failure of an OTSC used for a rebleeding duodenal ulcer, leading to massive bleeding when the clip was released ([Video 1]).