Early warning system scores perform well for prediction of cardiac arrest and death within 48 hours, although the impact on health outcomes and resource utilization remains uncertain, owing to methodological limitations. Efforts to assess performance and effectiveness more rigorously will be needed as early warning system use becomes more widespread.

Background: Medications to reduce risk for primary breast cancer are recommended for women at increased risk; however, use is low. Purpose:To update evidence about the effectiveness and adverse effects of medications to reduce breast cancer risk, patient use of such medications, and methods for identifying women at increased risk for breast cancer.Data Sources: MEDLINE and Cochrane databases (through 5 December 2012), Scopus, Web of Science, clinical trial registries, and reference lists.Study Selection: English-language randomized trials of medication effectiveness and adverse effects, observational studies of adverse effects and patient use, and diagnostic accuracy studies of risk assessment. Data Extraction:Investigators independently extracted data on participants, study design, analysis, follow-up, and results, and a second investigator confirmed key data. Investigators independently dual-rated study quality and applicability using established criteria.Data Synthesis: Seven good-and fair-quality trials indicated that tamoxifen and raloxifene reduced incidence of invasive breast cancer by 7 to 9 cases in 1000 women over 5 years compared with placebo. New results from STAR (Study of Tamoxifen and Raloxifene) showed that tamoxifen reduced breast cancer incidence more than raloxifene by 5 cases in 1000 women. Neither reduced breast cancer-specific or all-cause mortality rates. Both reduced the incidence of fractures, but tamoxifen increased the incidence of thromboembolic events more than raloxifene by 4 cases in 1000 women. Tamoxifen increased the incidence of endometrial cancer and cataracts compared with placebo and raloxifene. Trials provided limited and heterogeneous data on medication adherence and persistence. Many women do not take tamoxifen because of associated harms. Thirteen risk-stratification models were modest predictors of breast cancer.Limitation: Data on mortality and adherence measures and for women who are nonwhite, are premenopausal, or have comorbid conditions were lacking. Conclusion:Medications reduced the incidence of invasive breast cancer and fractures and increased the incidence of thromboembolic events. Tamoxifen was more effective than raloxifene but also increased the incidence of endometrial cancer and cataracts. Use is limited by adverse effects and inaccurate methods to identify candidates. Primary Funding Source: Agency for Healthcare Research and Quality.Ann Intern Med. 2013;158:604-614. www.annals.org For author affiliations, see end of text. In 2002, the U.S. Preventive Services Task Force (USPSTF) recommended that clinicians discuss the potential benefits and harms of tamoxifen and raloxifene for reducing risk for primary breast cancer with women at high risk for breast cancer and low risk for adverse effects (1, 2). The USPSTF also recommended against routine use in women at low or average risk for breast cancer.Clinical trials demonstrate the efficacy of several medications to reduce the risk for invasive breast cancer in women without preexisting cancer (3-8), but onl...

Trials of rintatolimod, counseling therapies, and graded exercise therapy suggest benefit for some patients meeting case definitions for CFS, whereas evidence for other treatments and harms is insufficient. More definitive studies comparing participants meeting different case definitions, including ME, and providing subgroup analysis are needed to fill research gaps.

Background Nurses working in intensive care units may lack knowledge and skills in end-of-life care, find caring for dying patients and the patients' families stressful, and lack support to provide this care. Objectives To describe nurses' perceptions of (1) knowledge and ability, (2) work environment, (3) support for staff, (4) support for patients and patients' families, and (5) stress related to specific work situations in the context of end-of-life care before (phase 1) and after (phase 2) implementation of approaches to improve end-of-life care. The approaches were a nurse-developed bereavement program for patients' families, use of a palliative medicine and comfort care team, preprinted orders for the withdrawal of life-sustaining treatment, hiring of a mental health clinical nurse specialist, and staff education in end-of-life care. Methods Nurses in 4 intensive care units at a university medical center reported their perceptions of end-of-life care by using a 5-subscale tool consisting of 30 items scored on a 4-point Likert scale. The tool was completed by 91 nurses in phase 1 and 127 in phase 2. Results Improvements in overall mean scores on the 5 subscales indicated that the approaches succeeded in improving nurses' perceptions. In phase 2, most of the subscale overall mean scores were higher than a desired criterion (<2.0, good). Analysis of variance indicated that some improvements occurred over time differently in the units; other improvements occurred uniformly. Conclusions Notice to CE enrollees:A closed-book, multiple-choice examination following this article tests your under standing of the following objectives:1. Describe current trends used in handling endof-life issues. 2. Recognize how moral distress is associated with nurses' inability to influence end-of-life decisions between nurses, physicians, and families. 3. Identify some key strategies that will help nurses with interventions when dealing with end-of-life decisions.

We have evaluated a patient with Jacobsen syndrome. The patient presented with growth retardation, hypotonia, trigonocephaly, telecanthus, downward slanting palpebral fissures, bilateral inferior colobomas (of the iris, choroid, and retina

We characterized patient outcomes following inpatient palliative care consultation: where patients are discharged, how long they live, and where they die. Two thirds of patients were able to be discharged, even when death occurred within two weeks. The low rates of readmission and death in an acute care hospital support that the decision to discharge the patients was reasonable and the discharge plan was adequate. Hospital based palliative care teams can play an important and unique role in discharge planning--allowing even patients very near death to leave the hospital if they wish.

Background. It is widely believed that exercise improves mobility in people with Parkinson's disease (PD). However, it is difficult to determine whether a specific type of exercise is the most effective. The purpose of this study was to determine which outcome measures were sensitive to exercise intervention and to explore the effects of two different exercise programs for improving mobility in patients with PD. Methods. Participants were randomized into either the Agility Boot Camp (ABC) or treadmill training; 4x/week for 4 weeks. Outcome measures were grouped by the International Classification of Function/Disability (ICF). To determine the responsiveness to exercise, we calculated the standardized response means. t-tests were used to compare the relative benefits of each exercise program. Results. Four of five variables at the structure/function level changed after exercise: turn duration (P = 0.03), stride velocity (P = 0.001), peak arm speed (P = 0.001), and horizontal trunk ROM during gait (P = 0.02). Most measures improved similarly for both interventions. The only variable that detected a difference between groups was postural sway in ABC group (F = 4.95; P = 0.03). Conclusion. Outcome measures at ICF body structure/function level were most effective at detecting change after exercise and revealing differences in improvement between interventions.

Nine sets of clinical criteria are available to define ME/CFS, yet none of the current diagnostic methods have been adequately tested to identify patients with ME/CFS when diagnostic uncertainty exists. More definitive studies in broader populations are needed to address these research gaps.