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Efforts to promote the completion of advance directives implicitly assume that completion rates of these documents, which help ensure care consistent with people's preferences in the event of incapacity, are undesirably low. However, data regarding completion of advance directives in the United States are inconsistent and of variable quality. We systematically reviewed studies published in the period 2011-16 to determine the proportion of US adults with a completed living will, health care power of attorney, or both. Among the 795,909 people in the 150 studies we analyzed, 36.7 percent had completed an advance directive, including 29.3 percent with living wills. These proportions were similar across the years reviewed. Similar proportions of patients with chronic illnesses (38.2 percent) and healthy adults (32.7 percent) had completed advance directives. The findings provide benchmarks for gauging future policies and practices designed to motivate completion of advance directives, particularly among those people most likely to benefit from having these documents on record.

In this randomized trial of financial incentives in smokers, both reward-based and deposit-based incentive programs were more effective than usual care in achieving smoking cessation. Reward programs were much more commonly accepted than deposit-based programs. Financial incentives have been shown to promote a variety of health behaviors. 1 – 8 For example, in a randomized, clinical trial involving 878 General Electric employees, a bundle of incentives worth $750 for smoking cessation nearly tripled quit rates, from 5.0% to 14.7%, 8 and led to a program adapted by General Electric for its U.S. employees. 9 Although incentive programs are increasingly used by governments, employers, and insurers to motivate changes in health behavior, 10 , 11 their design is usually based on the traditional economic assumption that the size of the incentive determines its effectiveness. In contrast, behavioral economic theory suggests that incentives . . .

ChatGPT is a large language model trained on text corpora and reinforced with human supervision. Because ChatGPT can provide human-like responses to complex questions, it could become an easily accessible source of medical advice for patients. However, its ability to answer medical questions appropriately and equitably remains unknown. We presented ChatGPT with 96 advice-seeking vignettes that varied across clinical contexts, medical histories, and social characteristics. We analyzed responses for clinical appropriateness by concordance with guidelines, recommendation type, and consideration of social factors. Ninety-three (97%) responses were appropriate and did not explicitly violate clinical guidelines. Recommendations in response to advice-seeking questions were completely absent (N = 34, 35%), general (N = 18, 18%), or specific (N = 44, 46%). 53 (55%) explicitly considered social factors like race or insurance status, which in some cases changed clinical recommendations. ChatGPT consistently provided background information in response to medical questions but did not reliably offer appropriate and personalized medical advice.

The importance of delivering goal-concordant care to seriously ill patients is widely recognized. Yet there are no methods that can reliably and accurately be used to measure whether care that was provided to patients was concordant with their goals.

In this single-center, controlled trial at a U.S. academic medical center, investigators found that having in-house intensivists available at night did not have a significant effect on the length of stay in the ICU. Most studies suggest that intensivist physicians improve patient outcomes in intensive care units (ICUs). 1 – 3 It is thus tempting to conclude that a “dose–response effect” might exist, such that greater exposure to intensivists would be associated with even better outcomes. 4 Indeed, some authors argue that 24-hour presence of seasoned intensivists at the bedside of patients would improve diagnostic and therapeutic efficiency, particularly for high-risk patients. 5 – 7 As a result, many ICUs, including one third of academic ICUs in the United States 8 and nearly three quarters of ICUs in Europe, 9 , 10 use in-hospital intensivist staffing at night. Before-and-after studies of nighttime . . .

In a pragmatic trial involving smokers, financial incentives were more effective than free cessation aids; free cessation aids or e-cigarettes were no more effective than usual care. Cessation rates among smokers assigned to financial incentives were less than 3%.

Background Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines recommend the diagnosis of chronic obstructive pulmonary disease (COPD) only in patients with a post-bronchodilator forced expiratory volume in 1 s to forced vital capacity ratio (FEV 1 /FVC) less than 0.7. However the impact of this recommendation on clinical practice is unknown. Objective To estimate the effect of a documented post-bronchodilator FEV 1 /FVC < 0.7 on the diagnosis and treatment of COPD. Design We used a regression discontinuity design to measure the effect of a post-bronchodilator FEV 1 /FVC < 0.7 on COPD diagnosis and treatment. Participants Patients included in a national electronic health record database who were 18 years of age and older and had a clinical encounter between 2007 and 2022 in which a post-bronchodilator FEV 1 /FVC value was documented. Main measures An encounter was associated with a COPD diagnosis if an international classification of disease code for COPD was assigned, and was associated with COPD treatment if a prescription for a medication commonly used to treat COPD was filled within 90 days. Results Among 27,817 clinical encounters, involving 18,991 patients, a post-bronchodilator FEV 1 /FVC < 0.7 was present in 14,876 (53.4%). The presence of a documented post-bronchodilator FEV 1 /FVC < 0.7 increased the probability of a COPD diagnosis by 6.0% (95% confidence interval [CI] 1.1–10.9%) from 38.0% just above the 0.7 cutoff to 44.0% just below this cutoff. The presence of a documented post-bronchodilator FEV 1 /FVC < 0.7 had no effect on the probability of COPD treatment (−2.1%, 95% CI −7.2 to 3.0%). Conclusions The presence of a documented post-bronchodilator FEV 1 /FVC < 0.7 had only a small effect on the diagnosis of COPD and no effect on corresponding treatment decisions.

Background Phelan-McDermid syndrome (PMS) is caused by haploinsufficiency of the SHANK3 gene and is characterized by global developmental delays and autism spectrum disorder (ASD). Based on several converging lines of preclinical and clinical evidence supporting the use of insulin-like growth factor-1 (IGF-1) in PMS, this study aims to follow-up a previous pilot study with IGF-1 to further evaluate this novel therapeutic for core symptoms of ASD in children with PMS. Methods Ten children aged 5–9 with PMS were enrolled. Participants were randomized to receive IGF-1 or placebo (saline) using a 12-week, double-blind, crossover design. Efficacy was assessed using the primary outcome of the Aberrant Behavior Checklist—Social Withdrawal (ABC-SW) subscale as well as secondary outcome measures reflecting core symptoms of ASD. To increase power and sample size, we jointly analyzed the effect of IGF-1 reported here together with results from our previous controlled trail of IGF-1 in children with PMS (combined N = 19). Results Results on the ABC-SW did not reach statistical significance, however significant improvements in sensory reactivity symptoms were observed. In our pooled analyses, IGF-1 treatment also led to significant improvements in repetitive behaviors and hyperactivity. There were no other statistically significant effects seen across other clinical outcome measures. IGF-1 was well tolerated and there were no serious adverse events. Limitations The small sample size and expectancy bias due to relying on parent reported outcome measures may contribute to limitations in interpreting results. Conclusion IGF-1 is efficacious in improving sensory reactivity symptoms, repetitive behaviors, and hyperactivity  in children with PMS. Trial registration NCT01525901.

In this review, we seek to highlight how critical illness and critical care affect longer-term outcomes, to underline the contribution of ICU delirium to cognitive dysfunction several months after ICU discharge, to give new insights into ICU acquired weakness, to emphasize the importance of value-based healthcare, and to delineate the elements of family-centered care. This consensus of 29 also provides a perspective and a research agenda about post-ICU recovery.