Here are what the editors at HealthDay consider to be the most important developments in Geriatrics for July 2018. This roundup includes the latest research news from journal articles, as well as the FDA approvals and regulatory changes that are the most likely to affect clinical practice.

Learning to Change Important for Improving Practice

TUESDAY, July 31, 2018 (HealthDay News) — Although physicians typically struggle with change, relying on habits created in their practice, learning to change is important in order to improve practices and better deal with the changes sweeping through medicine, according to an article published in Medical Economics.

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Flu Vaccine Cuts Mortality in Rheumatoid Arthritis Patients

TUESDAY, July 31, 2018 (HealthDay News) — Patients with rheumatoid arthritis (RA), particularly elderly patients, who receive the influenza vaccine have significantly lower morbidity and mortality, according to a study published in the June issue of the International Journal of Rheumatic Diseases.

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Front Desk Staff Can Set Up a Practice for Successful Billing

TUESDAY, July 31, 2018 (HealthDay News) — Allowing front desk staff adequate time and an uninterrupted environment to focus on billing can prevent problems later on, according to an article published in Physicians Practice.

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One in Four Older Adults With Diabetes Uses Alternative Meds

TUESDAY, July 31, 2018 (HealthDay News) — More than 25 percent of older U.S. adults with diabetes use some type of complementary and alternative medicine (CAM), according to a research letter published in the June issue of Diabetes Care.

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Few Published Programs Address Medical Trainee Mistreatment

TUESDAY, July 31, 2018 (HealthDay News) — There are very few published descriptions of programs that address the mistreatment of medical trainees, according to a review published online July 27 in JAMA Network Open.

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Editorial

Medical Boards May Contribute to Mental Health Stigma for Doctors

MONDAY, July 30, 2018 (HealthDay News) — Existing policy has been amended to encourage licensing boards to require disclosure of physical or mental health conditions only when these would negatively impact a physicians’ ability to practice medicine, according to an article published in the American Medical Association’s AMA Wire.

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Four Strategies Help Doctors Make Personal, Professional Gains

MONDAY, July 30, 2018 (HealthDay News) — In an article published in Physicians Practice, four strategies are presented to help physicians make personal and professional gains.

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Cross-Continuum Communication Beneficial After Discharge

FRIDAY, July 27, 2018 (HealthDay News) — Cross-continuum communication after hospital discharge can improve patient outcomes and overall health, according to an article published in Physicians Practice.

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Drop in Osteoporosis Treatment Initiation After Hip Fracture

FRIDAY, July 27, 2018 (HealthDay News) — In recent years there have been low rates of osteoporosis treatment initiation after a hip fracture, according to research published in the July 20 issue of JAMA Network Open.

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Editorial

July 28 Is World Hepatitis Day

FRIDAY, July 27, 2018 (HealthDay News) — July 28 is World Hepatitis Day, according to an announcement published in the July 20 issue of the U.S. Centers for Disease Control and Prevention’s Morbidity and Mortality Weekly Report.

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World Hepatitis Day

Assessing, Improving Patient Satisfaction Cuts Malpractice Risk

THURSDAY, July 26, 2018 (HealthDay News) — Assessing and improving patient satisfaction can help physicians avoid being sued for malpractice, according to an article published in Physicians Practice.

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Use of 2017 ACC/AHA Guidelines Would Increase HTN Prevalence

THURSDAY, July 26, 2018 (HealthDay News) — Adoption of the 2017 American College of Cardiology (ACC)/American Heart Association (AHA) hypertension guidelines would increase the proportion of 45- to 75-year-olds labeled as having hypertension in the United States and China, according to a study published online July 11 in The BMJ.

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Late-Life Blood Pressure Tied to Higher Number of Brain Infarcts

THURSDAY, July 26, 2018 (HealthDay News) — Higher average late-life blood pressure (BP) is associated with an increased number of brain infarcts, according to a study published online July 11 in Neurology.

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Insurers May Be Underpaying Doctors

THURSDAY, July 26, 2018 (HealthDay News) — Insurance companies sometimes underpay doctors the contracted amount for a service or procedure, according to an article published in Medical Economics.

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Steroid Abuse Put 60-Year-Old Bodybuilder in the Hospital

THURSDAY, July 26, 2018 (HealthDay News) — In a report published online July 23 in BMJ Case Reports, doctors present the case of an amateur weight-lifter who developed non-ischemic cardiomyopathy after using anabolic-androgenic steroids (AAS).

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Many U.S. Adults View Marijuana Use Positively

WEDNESDAY, July 25, 2018 (HealthDay News) — Most U.S. adults believe that marijuana has at least one benefit, according to a study published online July 24 in the Annals of Internal Medicine.

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Tools, Methods of RCTs Can Be Adapted to Real-World Settings

WEDNESDAY, July 25, 2018 (HealthDay News) — Use of appropriate statistical methodology can allow for the synthesis of data collected as part of traditional clinical trials with real-world data, according to an Ideas and Opinions piece published online July 24 in the Annals of Internal Medicine.

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HerbList App Launched to Provide Information on Herbal Products

WEDNESDAY, July 25, 2018 (HealthDay News) — The National Institutes of Health’s National Center for Complementary and Integrative Health (NCCIH) has announced the launch of an app for easy access to research-based information on the safety and effectiveness of herbal products.

NIH Press Release
Herbs at a Glance

Majority of Those in Residential Care Have Advance Directives

WEDNESDAY, July 25, 2018 (HealthDay News) — More than three-quarters of those living in residential care facilities have an advance directive, according to a QuickStats report published in the July 20 issue of the U.S. Centers for Disease Control and Prevention’s Morbidity and Mortality Weekly Report.

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Physicians and Practices Should Prepare for Emergencies

TUESDAY, July 24, 2018 (HealthDay News) — Practices and physicians should prepare for emergency situations, such as natural disasters, network communications failures, and active shooter situations, according to an article published in Medical Economics.

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Reproductive, Hormonal Factors Tied to Knee OA in Women

TUESDAY, July 24, 2018 (HealthDay News) — Female reproductive and hormonal factors are associated with incidence of knee osteoarthritis (OA), according to a study published in the July issue of Arthritis & Rheumatology.

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VA MISSION Act May Up Costs, Lower Vet Health Care Quality

TUESDAY, July 24, 2018 (HealthDay News) — The Veterans Affairs Maintaining Internal Systems and Strengthening Integrated Outside Networks (VA MISSION) Act may increase costs and reduce quality of health care for veterans, according to an Ideas and Opinions piece published online July 24 in the Annals of Internal Medicine.

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Walmart Generic Drug Discounts Often Offer More Patient Savings

MONDAY, July 23 2018 (HealthDay News) — Walmart’s Generic Drug Discount Program (GDDP), which sells many commonly used generic medications for $4 per 30-day supply, offers savings over Medicare for some generic cardiovascular medications, according to a research letter published online July 24 in the Annals of Internal Medicine.

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Monthly Vitamin D Supplement May Not Cut Cancer Risk

MONDAY, July 23, 2018 (HealthDay News) — Monthly high-dose vitamin D supplementation may not prevent the risk of cancer among adults aged 50 to 84 years, according to a study published online July 19 in JAMA Oncology.

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Medical Organizations Must Address Sexual Harassment

MONDAY, July 23, 2018 (HealthDay News) — Medical institutions and organizations need to ensure there are proactive interventions to transform the workplace in order to address sexual harassment and discrimination, according to an article published in the American Medical Association’s AMA Wire.

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Portable Sleep Monitoring Accurate in Heart Failure Patients

MONDAY, July 23, 2018 (HealthDay News) — For patients hospitalized with decompensated heart failure, portable sleep monitoring with respiratory polygraphy can accurately diagnose sleep apnea, according to a study published in the July issue of CHEST.

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Intermittent Energy Restriction Effectively Cuts HbA1c in T2DM

MONDAY, July 23, 2018 (HealthDay News) — For patients with type 2 diabetes, intermittent energy restriction is comparable to continuous energy restriction for reduction of hemoglobin A1c (HbA1c), according to a study published online July 20 in JAMA Network Open.

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Embezzlement Not Uncommon in Medical Practices

MONDAY, July 23, 2018 (HealthDay News) — Embezzlement occurs frequently in medical practices and steps should be taken to prevent it, according to an article published in Medical Economics.

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Poor Outcomes for Prefrail/Frail at Risk of Malnutrition

MONDAY, July 23, 2018 (HealthDay News) — Prefrail/frail seniors at risk of malnutrition have poor health outcomes and increased mortality, according to a study published online July 13 in JAMA Network Open.

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CDC: More People With High Cholesterol Taking Medications

MONDAY, July 23, 2018 (HealthDay News) — There has been a substantial increase in the percentage of patients with high cholesterol over age 60 years taking lipid-lowering medications from 2005 to 2016, but such increases have not been seen among younger patients with high cholesterol, according to a QuickStats report published in the July 13 issue of the U.S. Centers for Disease Control and Prevention’s Morbidity and Mortality Weekly Report.

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Increased Coverage in States With Medicaid Expansion

FRIDAY, July 20, 2018 (HealthDay News) — Coverage rates and access to care are significantly higher in states with Medicaid expansion, compared with non-expansion states, according to a study published in the July issue of Health Affairs.

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Same-Day Appointment System Implemented in Health Network

THURSDAY, July 19, 2018 (HealthDay News) — A same-day appointment system can feasibly be introduced, according to the experiences of one health network presented in an article published in Managed Healthcare Executive.

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FDA Recalls Drugs Containing Active Ingredient Valsartan

THURSDAY, July 19, 2018 (HealthDay News) — Several drug products containing the active ingredient valsartan, used to treat high blood pressure and heart failure, are being recalled due to an impurity, N-nitrosodimethylamine, that has been found in the recalled products, according to the U.S. Food and Drug Administration.

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Patients Care About the Clothes Doctors Wear

THURSDAY, July 19, 2018 (HealthDay News) — Patients do in fact care what doctors wear, according to a study recently published in BMJ Open.

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Seven Strategies Can Help Practices Manage Staff Time Off

WEDNESDAY, July 18, 2018 (HealthDay News) — Several strategies can be implemented to help address management of staff time off, allowing mutual respect for the employee and employer requests, according to an article published in Medical Economics.

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Overall Cancer Mortality Rates Decreasing for Men and Women

WEDNESDAY, July 18, 2018 (HealthDay News) — Cancer incidence rates have decreased among men but remained stable among women, while cancer death rates are decreasing for both men and women, according to a report published in the July 1 issue of Cancer.

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Mobility Plan Can Neutralize the Harms of Bedrest in the Hospital

WEDNESDAY, July 18, 2018 (HealthDay News) — Having a mobility plan can prevent the functional decline associated with lack of mobility among hospitalized patients, according to a study published online July 17 in the Annals of Internal Medicine.

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Testosterone Prescribing Down Since 2013

WEDNESDAY, July 18, 2018 (HealthDay News) — The percentage of U.S. men receiving testosterone prescriptions decreased from 2013 through 2016, according to a research letter published in the July 10 issue of the Journal of the American Medical Association.

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CDC: ‘Tips’ Campaign Has Helped a Number of Smokers Quit

WEDNESDAY, July 18, 2018 (HealthDay News) — The ongoing Tips from Former Smokers (Tips) campaign, which features stories of former smokers living with smoking-related diseases and disabilities, has had a considerable impact, according to a report from the U.S. Centers for Disease Control and Prevention.

Impact of the Campaign
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Trials Supporting FDA Approval of Breakthrough Drugs Examined

TUESDAY, July 17, 2018 (HealthDay News) — Pivotal trials supporting U.S. Food and Drug Administration approvals granted Breakthrough Therapy designation often lack randomization, double-blinding, and control groups, according to a research letter published in the July 17 issue of the Journal of the American Medical Association.

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Alternative Payment Models Should Include Precision Medicine

TUESDAY, July 17, 2018 (HealthDay News) — The American Medical Association has committed to working to integrate precision medicine into alternative payment models (APMs), according to an article published in the association’s AMA Wire.

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Cataract Surgery May Cut Risk of Serious Car Accidents

TUESDAY, July 17, 2018 (HealthDay News) — Cataract surgery is associated with a modest decrease in the risk of the patient being in a serious traffic crash as the driver, according to a study published online June 28 in JAMA Ophthalmology.

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FDA Establishes New Task Force on Drug Shortages

TUESDAY, July 17, 2018 (HealthDay News) — In a recent statement, U.S. Food and Drug Administration Commissioner Scott Gottlieb, M.D., announced the formation of a new drug shortages task force to thoroughly explore the reasons why drug shortages remain a persistent challenge.

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Immediate Monitoring With ECG Patch Ups A-Fib Diagnosis Rate

TUESDAY, July 17, 2018 (HealthDay News) — Immediate monitoring with a self-applied wearable electrocardiogram (ECG) patch results in a higher rate of atrial fibrillation (AF) diagnosis among individuals at high risk, according to a study published in the July 10 issue of the Journal of the American Medical Association.

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Adoption of EHR Linked to Reduction in Mortality Rates

MONDAY, July 16, 2018 (HealthDay News) — Adoption of electronic health records (EHRs) is associated with a reduction in mortality rates in U.S. hospitals, according to a study published in the July issue of Health Affairs.

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Harms Reporting Limited in Trials of Prebiotics, Probiotics, Synbiotics

MONDAY, July 16, 2018 (HealthDay News) — A considerable number of randomized controlled trials (RCTs) of probiotics, prebiotics, or synbiotics do not report harms-related data and/or safety results, according to a review published online July 17 in the Annals of Internal Medicine.

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Inappropriate Prescribing of Abx High in Urgent Care Centers

MONDAY, July 16, 2018 (HealthDay News) — There is considerable variability in the proportion of visits at which antibiotics are prescribed among traditional medical and retail clinic settings, according to a research letter published online July 16 in JAMA Internal Medicine.

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Declines in Vision Tied to Age-Related Cognitive Decline

MONDAY, July 16, 2018 (HealthDay News) — Older adults’ worsening vision may drive declines in cognitive function, according to a study published online July 10 in JAMA Ophthalmology.

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Fake FDA Warning Letters Being Sent to Consumers

MONDAY, July 16, 2018 (HealthDay News) — Criminals are sending fake U.S. Food and Drug Administration warning letters to people who tried to buy medicines online or over the phone. The agency notes that it does not typically send warning letters to individuals, and this appears to be an extortion scam.

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eCare Plan Set to Improve Doctor/Pharmacist Relationship

MONDAY, July 16, 2018 (HealthDay News) — The Pharmacist eCare Plan is designed to improve communication between pharmacists and physicians by allowing documentation to be available via electronic health records (EHRs), according to an article published online in Drug Topics.

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Physician Burnout Tied to Higher Risk of Medical Errors

MONDAY, July 16, 2018 (HealthDay News) — Physician burnout, fatigue, and work-unit safety grades are independently associated with medical errors, according to a study published online July 9 in the Mayo Clinic Proceedings.

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Virtual Assistants Not HIPAA Compliant

FRIDAY, July 13, 2018 (HealthDay News) — Virtual assistant programs like Google Assistant, Siri, and Alexa are not yet in compliance with the Health Insurance Portability and Accountability Act (HIPAA), warns an article published in Medical Economics.

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Gender Bias in Medicine Has Far-Reaching Consequences

FRIDAY, July 13, 2018 (HealthDay News) — Overlooking women in medicine can have far-reaching consequences, according to a perspective piece published in the June 14 issue of the New England Journal of Medicine.

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Sociodemographic Disparities in Eyeglass Use Among Elderly

FRIDAY, July 13, 2018 (HealthDay News) — There are sociodemographic disparities in eyeglass use by age, race/ethnicity, education level, and income, according to a study published online July 12 in JAMA Ophthalmology.

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2001 to 2015 Saw Decline in Self-Employment in Health Care

THURSDAY, July 12, 2018 (HealthDay News) — From 2001 to 2015 there was a decrease in the percentage of health care professionals who are self-employed and a decrease in the earning gap between self-employed and employed health care professionals, according to a study published online July 12 in JAMA Network Open.

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AMA Aims to Boost Affordability of ACA Marketplace Plans

THURSDAY, July 12, 2018 (HealthDay News) — The American Medical Association (AMA) House of Delegates has adopted policy to increase the number of people who obtain coverage through the Affordable Care Act (ACA) by making marketplace plans more affordable.

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Patient Experience Officers Can Play Key Role in Medical Offices

THURSDAY, July 12, 2018 (HealthDay News) — A patient experience officer is an increasingly important new role in physician practices, according to an article recently published in Physicians Practice.

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Peer-Led Education Helps Physicians Save Time With EHRs

THURSDAY, July 12, 2018 (HealthDay News) — A peer-based education program can improve the efficiency of electronic health record (EHR) use, according to an article published in the American Medical Association’s AMA Wire.

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Taking Multivitamins/Minerals Doesn’t Improve CVD Outcomes

WEDNESDAY, July 11, 2018 (HealthDay News) — Multivitamin/mineral (MVM) supplementation seems not to be associated with cardiovascular disease (CVD) outcomes, according to a review published online July 10 in Circulation: Cardiovascular Quality and Outcomes.

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USPSTF: Evidence Lacking for Nontraditional CVD Risk Factors

WEDNESDAY, July 11, 2018 (HealthDay News) — The U.S. Preventive Services Task Force concludes that there is currently insufficient evidence to assess the benefits and harms of adding nontraditional risk factors to traditional cardiovascular disease (CVD) risk assessment in asymptomatic adults. These findings form the basis for a final recommendation statement published online July 10 in the Journal of the American Medical Association.

Final Recommendation
Evidence Report
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USPSTF: Evidence Lacking for ABI for PAD Screen in Asymptomatic

WEDNESDAY, July 11, 2018 (HealthDay News) — The U.S. Preventive Services Task Force (USPSTF) concludes that there is currently insufficient evidence to assess the benefits and harms of screening for peripheral artery disease (PAD) with the ankle branchial index (ABI) in asymptomatic adults. These findings form the basis of a final recommendation statement published in the July 10 issue of the Journal of the American Medical Association.

Final Recommendation
Evidence Report
Editorial

FDA Requires Safety Label Changes for Fluoroquinolones

WEDNESDAY, July 11, 2018 (HealthDay News) — The U.S. Food and Drug Administration has strengthened current warnings in the prescribing information about fluoroquinolone antibiotics causing significant decreases in blood glucose as well as mental health side effects.

Press Release
Safety Announcement

CDC: Nearly One-Third of Injury Deaths Occur at Home

WEDNESDAY, July 11, 2018 (HealthDay News) — Just under one-third of deaths from all causes of injury occur in the person’s home, according to a QuickStats report published in the July 6 issue of the U.S. Centers for Disease Control and Prevention’s Morbidity and Mortality Weekly Report.

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International Group Develops Best Practices for Drug Packaging

TUESDAY, July 10, 2018 (HealthDay News) — Nine new drug labeling and packaging guidelines have been developed with an aim of reducing medication errors, according to a report published in Drug Topics.

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AMA Calls for Inclusive Family, Medical Leave Policies

TUESDAY, July 10, 2018 (HealthDay News) — The American Medical Association (AMA) calls for inclusive family and medical leave policies to support lesbian, gay, bisexual, transgender, and queer (LGBTQ) workers who care for relatives, spouses, and partners.

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Error Rate 7.4 Percent in Speech Recognition-Assisted Notes

TUESDAY, July 10, 2018 (HealthDay News) — The error rate in speech recognition (SR)-assisted documentation is 7.4 percent, according to a study published online July 6 in JAMA Network Open.

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CDC: Wildfire Smoke Poses Health Risks

MONDAY, July 9, 2018 (HealthDay News) — Wildfire activity continues to increase throughout the western states, as well as in Alaska, Florida, Oklahoma, and Texas, but there are steps those living in wild fire areas can take to minimize smoke exposure.

CDC Recommendations
National Interagency Fire Center

Sleep Apnea Linked to Changes in the Brain in Older Adults

MONDAY, July 9, 2018 (HealthDay News) — Obstructive sleep apnea (OSA) is associated with changes to the structure of the brain that are seen in the early stages of dementia, according to a study published online July 5 in the European Respiratory Journal.

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Mammography Use Tied to Other Preventive Tests in Older Women

MONDAY, July 9, 2018 (HealthDay News) — Women enrolled in Medicare who undergo screening mammography seem to have increased awareness and use of other preventive screening measures, according to a study published online June 5 in Radiology.

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IT Solutions for Easier EHRs Save Physicians Time, Burnout

FRIDAY, July 6, 2018 (HealthDay News) — Yale Medicine is effectively targeting electronic health record (EHR) use and functionality as a way to improve physician job satisfaction and reduce burnout, according to an article published in the American Medical Association’s AMA Wire.

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PCPs Often Not Meeting Needs of Seniors With Chronic Conditions

FRIDAY, July 6, 2018 (HealthDay News) — Most primary care physicians (PCPs) report being unable to adequately address the needs of patients with multiple chronic conditions, according to a report published by Quest Diagnostics.

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Health Gains, Cost Savings Projected for Sodium Goals

FRIDAY, July 6, 2018 (HealthDay News) — Substantial health gains and cost savings could be achieved with implementation and achievement of the U.S. Food and Drug Administration sodium reformulation targets, according to a study recently published in PLOS Medicine.

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NIH Warns of Increased Risk of Heat-Related Illness for Seniors

THURSDAY, July 5, 2018 (HealthDay News) — Older adults are at significantly increased risk of heat-related illnesses, which can include heat stroke, heat edema, heat syncope, heat cramps, and heat exhaustion, according to the National Institutes of Health.

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Hospitals Face $218B in Federal Payment Cuts From 2010 to 2028

THURSDAY, July 5, 2018 (HealthDay News) — Cumulative reductions in federal payments to hospitals from 2010 to 2028 are estimated to reach $218.2 billion, according to a study commissioned by the Federation of American Hospitals and the American Hospital Association (AHA).

News Release
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Patient Complaints Mainly About Rudeness, Rushing, Reproach

THURSDAY, July 5, 2018 (HealthDay News) — Understanding patients’ complaints about practice can be instructive for physicians, according to an article published June 6 in Physicians Practice.

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WHO Calls for Renewed Effort to Combat Chronic Disease

THURSDAY, July 5, 2018 (HealthDay News) — The World Health Organization (WHO) Independent High-Level Commission has proposed six recommendations to address the growing epidemic of non-communicable diseases (NCDs), according to a report published online June 1 in The Lancet.

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Marriage May Protect Against Cardiovascular Disease

THURSDAY, July 5, 2018 (HealthDay News) — Marital status may influence cardiovascular disease (CVD) risk and prognosis after CVD, according to a review published online June 19 in Heart.

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Patients Comfortable With Doctors Having Tattoos, Piercings

THURSDAY, July 5, 2018 (HealthDay News) — Patients do not appear to mind if doctors have tattoos or piercings, according to a study published online July 2 in the Emergency Medicine Journal.

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1996 to 2013 Saw Large Increase in Diabetes Spending

THURSDAY, July 5, 2018 (HealthDay News) — In 2013, $101 billion was spent in the United States on diabetes, almost a three-fold increase since 1996, according to a study published in the July issue of Diabetes Care.

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U.K. Campaign Hasn’t Aided Patient Presentations for TIA, Minor CVA

THURSDAY, July 5, 2018 (HealthDay News) — The Face, Arm, Speech, Time (FAST) public education campaign in the United Kingdom has not improved the response to transient ischemic attack (TIA) and minor stroke, according to a study published online July 2 in JAMA Neurology.

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Coffee Drinking Found to Lower Risk of All-Cause Mortality

TUESDAY, July 3, 2018 (HealthDay News) — Increased coffee intake may be a beneficial addition to a healthy diet, according to a study published online July 2 in JAMA Internal Medicine.

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AMA Adopts Policy to Cut Sugar Sweetened Drink Consumption

TUESDAY, July 3, 2018 (HealthDay News) — At the annual meeting of the American Medical Association (AMA), a policy was adopted to reduce the consumption of sugar-sweetened beverages (SSBs) as a way to reduce the amount of sugar that Americans consume.

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Intensive Management Program Benefits High-Risk Patients

MONDAY, July 2, 2018 (HealthDay News) — For high-risk patients, use of an intensive management program is associated with greater receipt of outpatient care with no increase in total costs, according to a study published in the June 19 issue of the Annals of Internal Medicine.

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Conservative Management Up for Low-Risk Prostate CA in Veterans

MONDAY, July 2, 2018 (HealthDay News) — Among U.S. veterans with low-risk prostate cancer, use of conservative management increased from 2005 to 2015, according to a research letter published online June 5 in the Journal of the American Medical Association.

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Socioeconomic Factors Linked to Hearing Aid Access, Use

MONDAY, July 2, 2018 (HealthDay News) — Socioeconomic factors may hinder individuals’ ability to obtain and use hearing aids, according to a study published online May 21 in The Gerontologist.

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Patient Engagement in Asthma Treatment Plans May Improve Quality of Life

MONDAY, July 2, 2018 (HealthDay News) — Older adults with asthma and a greater desire for involvement in decision making have higher asthma-related quality of life, according to a study published in the July issue of the Annals of Allergy, Asthma & Immunology.

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