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This Week in JAMA
June 11, 2008

This Week in JAMA

JAMA. 2008;299(22):2599. doi:10.1001/jama.299.22.2599

Children with attention-deficit/hyperactivity disorder (ADHD) are often treated effectively with stimulant medications. However, some parents prefer alternative therapies. In a randomized, double-blind, placebo-controlled, 8-week trial, Weber and colleagues Article investigated the efficacy and safety of Hypericum perforatum (St John's wort; 300 mg 3 times daily) for the treatment of children and adolescents with ADHD. The authors report that H perforatum was no better than placebo in reducing the severity of ADHD symptoms, and the frequency of adverse events was similar in both groups. In an editorial, Chan Article discusses patients' increasing use of complementary and alternative therapies and comments on efforts to improve the quality of research assessing the efficacy and safety of these therapies.

Circadian rhythm disturbances have been associated with cognitive decline and mood, behavioral, and sleep disturbances that affect many elderly persons with dementia. In a randomized trial of residents of elder care facilities in the Netherlands, Riemersma-van der Lek and colleagues investigated whether bright light and melatonin—known circadian system synchronizers—might ameliorate these symptoms of dementia. Care facilities were randomly assigned to either daily bright light or dim light, and study participants were randomly assigned to an evening dose of melatonin or placebo. The authors found that whole-day bright light was associated with modest improvements in cognitive and noncognitive symptoms of dementia. Melatonin was associated with improvements in sleep onset and duration but was associated with adverse effects on mood unless administered in conjunction with bright light.

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Electrical dyssynchrony, defined as a QRS duration of 120 milliseconds (ms) or greater, is associated with increased mortality in outpatients with heart failure. To assess the predictive value of the QRS duration in patients hospitalized for heart failure, Wang and colleagues retrospectively analyzed data from the Efficacy of Vasopressin Antagonism in Heart Failure Outcome Study with Tolvaptan (EVEREST) trial. The authors report that during a median follow-up of 9.9 months, all-cause mortality and a composite of cardiovascular death or rehospitalization for heart failure were higher in patients whose QRS duration at enrollment in EVEREST was prolonged (≥ 120 ms) compared with patients with a normal QRS duration (< 120 ms) at enrollment.

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Mr L was a 56-year-old businessman who was diagnosed with stage IV lung cancer with brain and bone metastases. He was treated with brain and spinal radiation and 3 courses of systemic chemotherapy and lived for 14 months after diagnosis. Palliative intrathecal chemotherapy was administered until 6 days before his death. Harrington and Smith discuss the appropriate use of chemotherapy at the end of life and the importance of effective coordination of oncology and palliative care.

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“Should I mar the identity of this complex person with such a rich life and legacy by reducing her to a medical diagnosis at the end—when, really, it was just genug?” From “Genug Syndrome.”

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Aging in America is explored in articles on how the US health care system is ill prepared to deliver geriatric care to an aging population Article, on projections that emergency departments may be strained by increasing numbers of visits by older adults Article, and on programs that are tackling the challenge of bringing physician-based care to homebound seniors Article.

Complexities of the physician workforce equation
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Biofilms and chronic infections
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Join Wendie Berg, MD, PhD, June 18 from 2 to 3 PM eastern time to discuss screening women at high risk of breast cancer with mammography plus ultrasound vs mammography alone. To register, go to http://www.ihi.org/AuthorintheRoom.

How would you manage a 70-year-old man with severe coronary and peripheral artery disease who presents with acute-onset slurred speech and left facial droop? Go to www.jama.com, read the case, and submit your response, which may be selected for online publication. Submission deadline is June 25.

For your patients: Information about cancer chemotherapy.

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