Journal: Ann Intern Med

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Abstract

Should We Screen for Type 2 Diabetes?: Grand Rounds Discussion From Beth Israel Deaconess Medical Center.

Smetana GW, Abrahamson MJ, Rind DM
The prevalence of diabetes in the United States is rising. Twelve percent of U.S. adults have diabetes and another 37% have impaired fasting glucose or impaired glucose tolerance. Diabetes is a major risk factor for such outcomes as cardiovascular disease, blindness, chronic kidney disease, and limb amputation. An important consideration is whether screening for abnormal glucose levels or diabetes reduces cardiovascular or all-cause morbidity and mortality. In October 2015, the U.S. Preventive Services Task Force published recommendations on screening for abnormal blood glucose and concluded that intensive lifestyle interventions have a moderate benefit in reducing progression to diabetes in patients who have abnormal blood glucose levels detected by screening. It found inadequate evidence that such screening reduces cardiovascular or all-cause mortality and no evidence of psychological or other harms from screening. The Task Force recommends glucose screening every 3 years for adults aged 40 to 70 years who are overweight or obese and do not have symptoms of diabetes. In this article, we present the case of a man who meets these criteria and explore his preferences and concerns regarding screening. Two experts then debate screening merits and benefits, the significance of abnormal blood glucose levels and diabetes as cardiovascular risk factors, and application of the guidelines to this particular patient.

Ann Intern Med: 03 Oct 2016; 165:509-516
Smetana GW, Abrahamson MJ, Rind DM
Ann Intern Med: 03 Oct 2016; 165:509-516 | PMID: 27699399
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Abstract

Red Blood Cell Transfusion: A Clinical Practice Guideline From the AABB.

Carson JL, Grossman BJ, Kleinman S, Tinmouth AT, ... Djulbegovic B, for the Clinical Transfusion Medicine Committee of the AABB
Description: Although approximately 85 million units of red blood cells (RBCs) are transfused annually worldwide, transfusion practices vary widely. The AABB (formerly, the American Association of Blood Banks) developed this guideline to provide clinical recommendations about hemoglobin concentration thresholds and other clinical variables that trigger RBC transfusions in hemodynamically stable adults and children. Methods: These guidelines are based on a systematic review of the literature on randomized clinical trials evaluating transfusion thresholds. We performed a literature search from 1950 to February 2011 with no language restrictions. We examined the proportion of patients who received any RBC transfusion and the number of RBC units transfused to describe the effect of restrictive transfusion strategies on RBC use. To determine the clinical consequences of restrictive transfusion strategies, we examined overall mortality, nonfatal myocardial infarction, cardiac events, pulmonary edema, stroke, thromboembolism, renal failure, infection, hemorrhage, mental confusion, functional recovery, and length of hospital stay. Recommendation 1: The AABB recommends adhering to a restrictive transfusion strategy (7 to 8 g/dL) in hospitalized, stable patients (Grade: strong recommendation; high-quality evidence). Recommendation 2: The AABB suggests adhering to a restrictive strategy in hospitalized patients with preexisting cardiovascular disease and considering transfusion for patients with symptoms or a hemoglobin level of 8 g/dL or less (Grade: weak recommendation; moderate-quality evidence). Recommendation 3: The AABB cannot recommend for or against a liberal or restrictive transfusion threshold for hospitalized, hemodynamically stable patients with the acute coronary syndrome (Grade: uncertain recommendation; very low-quality evidence). Recommendation 4: The AABB suggests that transfusion decisions be influenced by symptoms as well as hemoglobin concentration (Grade: weak recommendation; low-quality evidence).

Ann Intern Med: 27 Mar 2012; epub ahead of print
Carson JL, Grossman BJ, Kleinman S, Tinmouth AT, ... Djulbegovic B, for the Clinical Transfusion Medicine Committee of the AABB
Ann Intern Med: 27 Mar 2012; epub ahead of print | PMID: 22454395
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Abstract

Evaluation of newer risk markers for coronary heart disease risk classification: a cohort study.

Kavousi M, Elias-Smale S, Rutten JH, Leening MJ, ... van den Meiracker AH, Witteman JC
Background: Whether newer risk markers for coronary heart disease (CHD) improve CHD risk prediction remains unclear. Objective: To assess whether newer risk markers for CHD risk prediction and stratification improve Framingham risk score (FRS) predictions. Design: Prospective population-based study. Setting: The Rotterdam Study, Rotterdam, the Netherlands. Participants: 5933 asymptomatic, community-dwelling participants (mean age, 69.1 years [SD, 8.5]). Measurements: Traditional CHD risk factors used in the FRS (age, sex, systolic blood pressure, treatment of hypertension, total and high-density lipoprotein cholesterol levels, smoking, and diabetes) and newer CHD risk factors (N-terminal fragment of prohormone B-type natriuretic peptide levels, von Willebrand factor antigen levels, fibrinogen levels, chronic kidney disease, leukocyte count, C-reactive protein levels, homocysteine levels, uric acid levels, coronary artery calcium [CAC] scores, carotid intima-media thickness, peripheral arterial disease, and pulse wave velocity). Results: Adding CAC scores to the FRS improved the accuracy of risk predictions (c-statistic increase, 0.05 [95% CI, 0.02 to 0.06]; net reclassification index, 19.3% overall [39.3% in those at intermediate risk, by FRS]). Levels of N-terminal fragment of prohormone B-type natriuretic peptide also improved risk predictions but to a lesser extent (c-statistic increase, 0.02 [CI, 0.01 to 0.04]; net reclassification index, 7.6% overall [33.0% in those at intermediate risk, by FRS]). Improvements in predictions with other newer markers were marginal. Limitation: The findings may not be generalizable to younger or nonwhite populations. Conclusion: Among 12 CHD risk markers, improvements in FRS predictions were most statistically and clinically significant with the addition of CAC scores. Further investigation is needed to assess whether risk refinements using CAC scores lead to a meaningful change in clinical outcome. Whether to use CAC score screening as a more routine test for risk prediction requires full consideration of the financial and clinical costs of performing versus not performing the test for both persons and health systems. Primary Funding Source: Netherlands Organization for Health Research and Development (ZonMw).

Ann Intern Med: 19 Mar 2012; 156:438-44
Kavousi M, Elias-Smale S, Rutten JH, Leening MJ, ... van den Meiracker AH, Witteman JC
Ann Intern Med: 19 Mar 2012; 156:438-44 | PMID: 22431676
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Abstract

Calibration of the Pooled Cohort Equations for Atherosclerotic Cardiovascular Disease: An Update.

Cook NR, Ridker PM
The latest guidelines from the American College of Cardiology and American Heart Association, released in fall 2013, provide a long-anticipated update to the recommendations of the Third Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). The guidelines incorporate a new risk score for atherosclerotic cardiovascular disease that includes stroke as well as coronary heart disease. After publication, the new pooled cohort equations (PCEs) were evaluated in 15 studies from the United States and Europe, most of which used cohorts that were more contemporary than those used in developing the guidelines. In almost all of these external validation cohorts, the PCEs overestimated the observed risk. This narrative review provides an update of the published reports, an overview of the strengths and weaknesses of these validation efforts, and a discussion of possible reasons for the discrepancies. These issues may be useful in a recalibration process designed to better match predicted and observed risks relevant for current clinical practice.

Ann Intern Med: 09 Oct 2016; epub ahead of print
Cook NR, Ridker PM
Ann Intern Med: 09 Oct 2016; epub ahead of print | PMID: 27723890
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Abstract

Meta-analysis: Age and Effectiveness of Prophylactic Implantable Cardioverter-Defibrillators.

Santangeli P, Di Biase L, Dello Russo A, Casella M, ... Pelargonio G, Natale A
Background: Implantable cardioverter-defibrillators (ICDs) for the primary prevention of sudden cardiac death have been proven effective in several clinical trials. Purpose: To summarize evidence about the effectiveness of ICDs versus standard medical therapy for the primary prevention of sudden cardiac death in different age groups of patients with severe left ventricular dysfunction. Data sources: MEDLINE, Embase, CENTRAL, BioMed Central, Cardiosource, ClinicalTrials.gov, and ISI Web of Science (January 1970 to April 2010) were searched with no language restrictions. Study Selection: Two independent reviewers screened titles and abstracts to identify randomized, controlled trials of prophylactic ICD versus medical therapy in patients with severe left ventricular dysfunction that provided data about mortality outcomes for different age groups. Data extraction: Two independent reviewers assessed risk for bias of trials and extracted patient and study characteristics and hazard ratios (HRs) relevant to all-cause mortality. Data Synthesis: Five trials (MADIT-II, DEFINITE, DINAMIT, SCD-HeFT, and IRIS) that enrolled 5783 patients (44% were elderly) were included. The primary analysis, which excluded the 2 trials enrolling patients early after acute myocardial infarction (DINAMIT and IRIS), found that prophylactic ICD therapy reduced mortality in younger patients (HR, 0.65 [95% CI, 0.50 to 0.83]; P < 0.001). A smaller and statistically nonsignificant survival benefit was found in elderly patients (HR, 0.81 [CI, 0.62 to 1.05]; P = 0.11). The inclusion of data from DINAMIT and IRIS did not change these results. Limitations: Four potentially eligible trials were not included in the meta-analysis because mortality data by age group were not available. Adjustment for differences in comorbid conditions and medical therapies among patients enrolled in the trials was not possible. Conclusion: Available data do not conclusively show that prophylactic ICD therapy improves survival in elderly patients with severe left ventricular dysfunction. Primary Funding Source: None.

Ann Intern Med: 02 Nov 2010; 153:592-9
Santangeli P, Di Biase L, Dello Russo A, Casella M, ... Pelargonio G, Natale A
Ann Intern Med: 02 Nov 2010; 153:592-9 | PMID: 21041579
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Effects of Antiplatelet Therapy on Mortality and Cardiovascular and Bleeding Outcomes in Persons With Chronic Kidney Disease: A Systematic Review and Meta-analysis.

Palmer SC, Di Micco L, Razavian M, Craig JC, ... Zoungas S, Strippoli GF
Background: Antiplatelet agents are used to prevent cardiovascular events; however, treatment effects may differ in persons with chronic kidney disease (CKD) because atherosclerotic disease is less prevalent, whereas bleeding hazards may be increased in this population. Purpose: To summarize the effects of antiplatelet treatment on cardiovascular events, mortality, and bleeding in persons with CKD. Data sources: Embase and Cochrane databases through November 2011 without language restriction. Study Selection: Randomized trials that included adults with CKD and compared antiplatelet agents with standard care, placebo, or no treatment. Data extraction: Data for populations, interventions, outcomes, and risk for bias were extracted. Quality of evidence for treatment effects on myocardial infarction, death, and bleeding was summarized by using Grading of Recommendations Assessment, Development, and Evaluation guidelines. Data Synthesis: Nine trials (all post hoc subgroup analyses for CKD) involving 9969 persons who had acute coronary syndromes or were undergoing percutaneous coronary intervention and 31 trials involving 11 701 persons with stable or no cardiovascular disease were identified. Low-quality evidence has found that in persons with acute coronary syndromes, glycoprotein IIb/IIIa inhibitors or clopidogrel plus standard care compared with standard care alone had little or no effect on all-cause or cardiovascular mortality or on myocardial infarction but increased serious bleeding. Compared with placebo or no treatment in persons with stable or no cardiovascular disease, antiplatelet agents prevented myocardial infarction but had uncertain effects on mortality and increased minor bleeding according to generally low-quality evidence. Limitations: Data for antiplatelet agents in persons with CKD are frequently derived from post hoc analyses of trials of broader populations. Definitions for bleeding outcomes and trial duration were heterogeneous. Conclusion: Benefits for antiplatelet therapy among persons with CKD are uncertain and are potentially outweighed by bleeding hazards. Primary Funding Source: None.

Ann Intern Med: 19 Mar 2012; 156:445-59
Palmer SC, Di Micco L, Razavian M, Craig JC, ... Zoungas S, Strippoli GF
Ann Intern Med: 19 Mar 2012; 156:445-59 | PMID: 22431677
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Abstract

Role of Ambulatory and Home Blood Pressure Monitoring in Clinical Practice: A Narrative Review.

Shimbo D, Abdalla M, Falzon L, Townsend RR, Muntner P
Hypertension, a common risk factor for cardiovascular disease, is usually diagnosed and treated based on blood pressure readings obtained in the clinic setting. Blood pressure may differ considerably when measured inside versus outside of the clinic setting. Over the past several decades, evidence has accumulated on the following 2 approaches for measuring blood pressure outside of the clinic: ambulatory blood pressure monitoring (ABPM) and home blood pressure monitoring (HBPM). Both of these methods have a stronger association with cardiovascular disease outcomes than clinic blood pressure measurement. Controversy exists about whether ABPM or HBPM is superior for estimating risk for cardiovascular disease and under what circumstances these methods should be used in clinical practice for assessing blood pressure outside of the clinic. This review describes ABPM and HBPM procedures, the blood pressure phenotypic measurements that can be ascertained, and the evidence that supports the use of each approach to measuring blood pressure outside of the clinic. It also describes barriers to the successful implementation of ABPM and HBPM in clinical practice, proposes core competencies for the conduct of these procedures, and highlights important areas for future research.

Ann Intern Med: 11 Oct 2015; epub ahead of print
Shimbo D, Abdalla M, Falzon L, Townsend RR, Muntner P
Ann Intern Med: 11 Oct 2015; epub ahead of print | PMID: 26457954
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Abstract

Should We Treat for Subclinical Hypothyroidism?: Grand Rounds Discussion From Beth Israel Deaconess Medical Center.

Burns RB, Bates CK, Hartzband P, Smetana GW
In May 2015, the U.S. Preventive Services Task Force issued a guideline on screening for thyroid disease that included a systematic evidence review and an update of its 2004 recommendations. The review assessed the effect of treating screen-detected subclinical thyroid dysfunction on health outcomes. It found adequate evidence that treating subclinical hypothyroidism does not provide clinically meaningful improvements in blood pressure, body mass index, bone mineral density, lipid levels, or quality-of-life measures. The review also concluded that evidence was inadequate to determine whether screening for thyroid dysfunction reduced cardiovascular disease or related morbidity and mortality. In separate guidelines, the American Association of Clinical Endocrinologists and American Thyroid Association advocated aggressive case-finding and recommended screening persons with certain clinical conditions or characteristics rather than the general population. These societies argue that subclinical hypothyroidism adversely affects cardiovascular outcomes and thus merits case-finding. Here, 2 experts discuss their perspectives on whether treating subclinical hypothyroidism reduces morbidity and mortality, whether there are harms of treatment, and how they would balance the benefits and harms of treatment both in general and for a specific patient.

Ann Intern Med: 07 Jun 2016; 164:764-770
Burns RB, Bates CK, Hartzband P, Smetana GW
Ann Intern Med: 07 Jun 2016; 164:764-770 | PMID: 27270659
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Abstract

Should We Screen for Coronary Heart Disease in Asymptomatic Persons?: Grand Rounds Discussion From Beth Israel Deaconess Medical Center.

Smetana GW, Cutlip DE, Pinto DS
In March 2015, the American College of Physicians (ACP) released a clinical guideline on the value of screening for coronary heart disease (CHD) in asymptomatic persons. The guideline authors found that results of screening studies are unlikely to change patient management or the intensity of risk factor reduction strategies. Most events occur in patients who are at low to intermediate risk for CHD; and in low-risk asymptomatic patients, percutaneous coronary intervention in "screen-positive" patients does not improve outcomes and creates unnecessary risks. As a result, the ACP recommended against screening for asymptomatic patients who are at low risk for CHD. Instead, it recommended a focus on proven strategies, such as treatment of hypertension and hypercholesterolemia, to reduce risk in appropriately selected asymptomatic persons. Two discussants weigh the evidence for and against screening for CHD in asymptomatic patients with varying degrees of risk and provide recommendations for a specific patient who is uncertain whether to proceed to screening.

Ann Intern Med: 03 Apr 2016; 164:479-487
Smetana GW, Cutlip DE, Pinto DS
Ann Intern Med: 03 Apr 2016; 164:479-487 | PMID: 27043981
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Abstract

Proprotein Convertase Subtilisin/Kexin Type 9 Monoclonal Antibodies for Acute Coronary Syndrome: A Narrative Review.

Navarese EP, Kolodziejczak M, Kereiakes DJ, Tantry US, O\'Connor C, Gurbel PA
Monoclonal antibodies that inhibit proprotein convertase subtilisin/kexin type 9 (PCSK9) are an emerging therapy for dyslipidemia. Acute coronary events induce a dynamic increase of PCSK9 levels that may play a role in plaque vulnerability of both culprit and nonculprit coronary vessels. Growing evidence highlights a potential key role of PCSK9 antibodies in managing acute coronary syndrome. This review describes the influence of PCSK9 antibodies on plaque composition and instability, as well as the pharmacokinetic profile and the potential anti-inflammatory and antithrombotic mechanisms associated with PCSK9 inhibition that may confer benefits during the early phase of acute coronary syndrome. The authors posit a rationale for the use of PCSK9 antibodies in patients with acute coronary syndrome and highlight the need for further investigation in this area.

Ann Intern Med: 20 Mar 2016; epub ahead of print
Navarese EP, Kolodziejczak M, Kereiakes DJ, Tantry US, O'Connor C, Gurbel PA
Ann Intern Med: 20 Mar 2016; epub ahead of print | PMID: 26999484
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Abstract

Impact of obesity and knee osteoarthritis on morbidity and mortality in older americans.

Losina E, Walensky RP, Reichmann WM, Holt HL, ... Paltiel AD, Katz JN
Background: Obesity and knee osteoarthritis are among the most frequent chronic conditions affecting Americans aged 50 to 84 years. Objective: To estimate quality-adjusted life-years lost due to obesity and knee osteoarthritis and health benefits of reducing obesity prevalence to levels observed a decade ago. Design: The U.S. Census and obesity data from national data sources were combined with estimated prevalence of symptomatic knee osteoarthritis to assign persons aged 50 to 84 years to 4 subpopulations: nonobese without knee osteoarthritis (reference group), nonobese with knee osteoarthritis, obese without knee osteoarthritis, and obese with knee osteoarthritis. The Osteoarthritis Policy Model, a computer simulation model of knee osteoarthritis and obesity, was used to estimate quality-adjusted life-year losses due to knee osteoarthritis and obesity in comparison with the reference group. Setting: United States. Participants: U.S. population aged 50 to 84 years. Measurements: Quality-adjusted life-years lost owing to knee osteoarthritis and obesity. Results: Estimated total losses of per-person quality-adjusted life-years ranged from 1.857 in nonobese persons with knee osteoarthritis to 3.501 for persons affected by both conditions, resulting in a total of 86.0 million quality-adjusted life-years lost due to obesity, knee osteoarthritis, or both. Quality-adjusted life-years lost due to knee osteoarthritis and/or obesity represent 10% to 25% of the remaining quality-adjusted survival of persons aged 50 to 84 years. Hispanic and black women had disproportionately high losses. Model findings suggested that reversing obesity prevalence to levels seen 10 years ago would avert 178 071 cases of coronary heart disease, 889 872 cases of diabetes, and 111 206 total knee replacements. Such a reduction in obesity would increase the quantity of life by 6 318 030 years and improve life expectancy by 7 812 120 quality-adjusted years in U.S. adults aged 50 to 84 years. Limitations: Comorbidity incidences were derived from prevalence estimates on the basis of life expectancy of the general population, potentially resulting in conservative underestimates. Calibration analyses were conducted to ensure comparability of model-based projections and data from external sources. Conclusion: The number of quality-adjusted life-years lost owing to knee osteoarthritis and obesity seems to be substantial, with black and Hispanic women experiencing disproportionate losses. Reducing mean body mass index to the levels observed a decade ago in this population would yield substantial health benefits. Primary Funding Source: The National Institutes of Health and the Arthritis Foundation.

Ann Intern Med: 15 Feb 2011; 154:217-26
Losina E, Walensky RP, Reichmann WM, Holt HL, ... Paltiel AD, Katz JN
Ann Intern Med: 15 Feb 2011; 154:217-26 | PMID: 21320937
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Risks for Stroke, Bleeding, and Death in Patients With Atrial Fibrillation Receiving Dabigatran or Warfarin in Relation to the CHADS2 Score: A Subgroup Analysis of the RE-LY Trial.

Oldgren J, Alings M, Darius H, Diener HC, ... Connolly SJ, on behalf of the RE-LY Investigators
Background: CHADS(2) is a simple, validated risk score for predicting the risk for stroke in patients with atrial fibrillation not treated with anticoagulants. There are sparse data on the risk for thrombotic and bleeding complications according to the CHADS(2) score in patients receiving anticoagulant therapy. Objective: To evaluate the prognostic importance of CHADS(2) risk score in patients with atrial fibrillation receiving oral anticoagulants, including the vitamin K antagonist warfarin and the direct thrombin inhibitor dabigatran. Design: Subgroup analysis of a randomized, controlled trial. (ClinicalTrials.gov registration number: NCT00262600) Setting: Multinational study setting. Patients: 18 112 patients with atrial fibrillation who were receiving oral anticoagulants. Measurements: Baseline CHADS(2) score, which assigns 1 point each for congestive heart failure, hypertension, age 75 years or older, and diabetes mellitus and 2 points for stroke. Results: Distribution of CHADS(2) scores were as follows: 0 to 1-5775 patients; 2-6455 patients; and 3 to 6-5882 patients. Annual rates of the primary outcome of stroke or systemic embolism among all participants were 0.93% in patients with a CHADS(2) score of 0 to 1, 1.22% in those with a score of 2, and 2.24% in those with a score of 3 to 6. Annual rates of other outcomes among all participants with CHADS(2) scores of 0 to 1, 2, and 3 to 6, respectively, were the following: major bleeding, 2.26%, 3.11%, and 4.42%; intracranial bleeding, 0.31%, 0.40%, and 0.61%; and vascular mortality, 1.35%, 2.39%, and 3.68% (P < 0.001 for all comparisons). Rates of stroke or systemic embolism, major and intracranial bleeding, and vascular and total mortality each increased in the warfarin and dabigatran groups as CHADS(2) score increased. The rates of stroke or systemic embolism with dabigatran, 150 mg twice daily, and of intracranial bleeding with dabigatran, 150 mg or 110 mg twice daily, were lower than those with warfarin; there was no significant heterogeneity in subgroups defined by CHADS(2) scores. Limitation: These analyses were not prespecified and should be deemed exploratory. Conclusion: Higher CHADS(2) scores were associated with increased risks for stroke or systemic embolism, bleeding, and death in patients with atrial fibrillation receiving oral anticoagulants. Primary Funding Source: Boehringer Ingelheim.

Ann Intern Med: 15 Nov 2011; 155:660-667
Oldgren J, Alings M, Darius H, Diener HC, ... Connolly SJ, on behalf of the RE-LY Investigators
Ann Intern Med: 15 Nov 2011; 155:660-667 | PMID: 22084332
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Abstract

Cardiovascular hospitalizations and mortality among recipients of hematopoietic stem cell transplantation.

Chow EJ, Mueller BA, Baker KS, Cushing-Haugen KL, ... Friedman DL, Lee SJ
Background: Hematopoietic stem cell transplantation (HSCT) is increasingly used to treat multiple malignant and nonmalignant conditions. The risk for cardiovascular disease after the procedure has not been well-described. Objective: To compare rates and hazards of cardiovascular-related hospitalization and death among persons who were still alive at least 2 years after HSCT with those in a population-based sample. Design: Retrospective cohort study. Setting: Comprehensive cancer center. Patients: 1491 patients who had survived 2 years or longer after HSCT received between 1985 and 2006, and frequency-matched persons who were randomly selected from drivers\' license files in the state of Washington. Measurements: Cardiovascular hospitalizations and death, as determined from statewide hospital discharge records and death registries in Washington. Results: Compared with the general population, transplant recipients experienced increased cardiovascular death (adjusted incidence rate difference, 3.6 per 1000 person-years [95% CI, 1.7 to 5.5]). Recipients also had an increased cumulative incidence of ischemic heart disease, cardiomyopathy or heart failure, stroke, vascular diseases, and rhythm disorders and an increased incidence of related conditions that predispose toward more serious cardiovascular disease (hypertension, renal disease, dyslipidemia, and diabetes). No consistent differences in hazards were observed after total-body irradiation or receipt of an allogeneic versus an autologous graft, aside from an increased rate of hypertension among recipients of allogeneic grafts. Disease relapse after transplantation was associated with an increased hazard of cardiovascular death (hazard ratio, 2.3 [CI, 1.1 to 4.8]). Limitation: All patients received HSCT at a single institution, and no information was available on pretransplantation treatment and lifestyle factors that may influence risk for cardiovascular disease. Conclusion: Increased rates of cardiovascular disease should be taken into account when caring for patients who have received HSCT. Future efforts should be directed toward improved screening and controlling of factors that predispose toward cardiovascular disease. Primary Funding Source: The American Society for Blood and Marrow Transplantation, the Leukemia and Lymphoma Society, and the Seattle Children\'s Research Institute.

Ann Intern Med: 05 Jul 2011; 155:21-32
Chow EJ, Mueller BA, Baker KS, Cushing-Haugen KL, ... Friedman DL, Lee SJ
Ann Intern Med: 05 Jul 2011; 155:21-32 | PMID: 21727290
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Abstract

Effect of Adding Systematic Family History Enquiry to Cardiovascular Disease Risk Assessment in Primary Care: A Matched-Pair, Cluster Randomized Trial.

Qureshi N, Armstrong S, Dhiman P, Saukko P, ... Kai J, for the ADDFAM (Added Value of Family History in CVD Risk Assessment) Study Group
Background: Evidence of the value of systematically collecting family history in primary care is limited. Objective: To evaluate the feasibility of systematically collecting family history of coronary heart disease in primary care and the effect of incorporating these data into cardiovascular risk assessment. Design: Pragmatic, matched-pair, cluster randomized, controlled trial. (International Standardized Randomized Controlled Trial Number Register: ISRCTN 17943542). Setting: 24 family practices in the United Kingdom. Participants: 748 persons aged 30 to 65 years with no previously diagnosed cardiovascular risk, seen between July 2007 and March 2009. Intervention: Participants in control practices had the usual Framingham-based cardiovascular risk assessment with and without use of existing family history information in their medical records. Participants in intervention practices also completed a questionnaire to systematically collect their family history. All participants were informed of their risk status. Participants with high cardiovascular risk were invited for a consultation. Measurements: The primary outcome was the proportion of participants with high cardiovascular risk (10-year risk ≥20%). Other measures included questionnaire completion rate and anxiety score. Results: 98% of participants completed the family history questionnaire. The mean increase in proportion of participants classified as having high cardiovascular risk was 4.8 percentage points in the intervention practices, compared with 0.3 percentage point in control practices when family history from patient records was incorporated. The 4.5-percentage point difference between groups (95% CI, 1.7 to 7.2 percentage points) remained significant after adjustment for participant and practice characteristics (P = 0.007). Anxiety scores were similar between groups. Limitations: Relatively few participants were from ethnic minority or less-educated groups. The potential to explore behavioral change and clinical outcomes was limited. Many data were missing for anxiety scores. Conclusion: Systematically collecting family history increases the proportion of persons identified as having high cardiovascular risk for further targeted prevention and seems to have little or no effect on anxiety. Primary Funding Source: Genetics Health Services Research program of the United Kingdom Department of Health.

Ann Intern Med: 20 Feb 2012; 156:253-262
Qureshi N, Armstrong S, Dhiman P, Saukko P, ... Kai J, for the ADDFAM (Added Value of Family History in CVD Risk Assessment) Study Group
Ann Intern Med: 20 Feb 2012; 156:253-262 | PMID: 22351711
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Abstract

The epidemiology of pain during the last 2 years of life.

Smith AK, Cenzer IS, Knight SJ, Puntillo KA, ... Boscardin WJ, Covinsky KE
Background: The epidemiology of pain during the last years of life has not been well described. Objective: To describe the prevalence and correlates of pain during the last 2 years of life. Design: Observational study. Data from participants who died while enrolled in the Health and Retirement Study were analyzed. The survey interview closest to death was used. Each participant or proxy was interviewed once in the last 24 months of life and was classified into 1 of 24 cohorts on the basis of the number of months between the interview and death. The relationship between time before death and pain was modeled and was adjusted for age, sex, race or ethnicity, education level, net worth, income, terminal diagnosis category, presence of arthritis, and proxy status. Setting: The Health and Retirement Study, a nationally representative survey of community-living older adults (1994 to 2006). Participants: Older adult decedents. Measurements: Clinically significant pain, as indicated by a report that the participant was "often troubled" by pain of at least moderate severity. Results: The sample included 4703 decedents. Mean age (SD) of participants was 75.7 years (SD, 10.8); 83.1% were white, 10.7% were black, 4.7% were Hispanic; and 52.3% were men. The adjusted prevalence of pain 24 months before death was 26% (95% CI, 23% to 30%). The prevalence remained flat until 4 months before death (28% [CI, 25% to 32%]), then it increased, reaching 46% (CI, 38% to 55%) in the last month of life. The prevalence of pain in the last month of life was 60% among patients with arthritis versus 26% among patients without arthritis (P < 0.001) and did not differ by terminal diagnosis category (cancer [45%], heart disease [48%], frailty [50%], sudden death [42%], or other causes [47%]; P = 0.195). Limitation: Data are cross-sectional; 19% of responses were from proxies; and information about cause, location, and treatment of pain was not available. Conclusion: Although the prevalence of pain increases in the last 4 months of life, pain is present in more than one quarter of elderly persons during the last 2 years of life. Arthritis is strongly associated with pain at the end of life. Primary Funding Source: National Institute on Aging, National Center for Research Resources, National Institute on Musculoskeletal and Skin Diseases, and National Palliative Care Research Center.

Ann Intern Med: 02 Nov 2010; 153:563-9
Smith AK, Cenzer IS, Knight SJ, Puntillo KA, ... Boscardin WJ, Covinsky KE
Ann Intern Med: 02 Nov 2010; 153:563-9 | PMID: 21041575
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New insights about vitamin d and cardiovascular disease: a narrative review.

McGreevy C, Williams D
The worsening worldwide trend toward nutritional insufficiency and the emerging knowledge of the nonhormonal actions of vitamin D and its metabolites have increased interest in the synthesis, metabolism, and action of vitamin D. Vitamin D deficiency has been linked with hypertension, myocardial infarction, and stroke, as well as other cardiovascular-related diseases, such as diabetes, congestive heart failure, peripheral vascular disease, atherosclerosis, and endothelial dysfunction. This review discusses the physiology and definition of vitamin D deficiency, evaluates the worldwide prevalence of vitamin D deficiency, and discusses recent evidence for the association between hypovitaminosis D and cardiovascular disease. Few randomized, controlled trials have evaluated the effect of vitamin D replacement on cardiovascular outcomes, and the results have been inconclusive or contradictory. Carefully designed randomized, controlled trials are essential to evaluate the role of vitamin D supplementation in reducing cardiovascular disease.

Ann Intern Med: 20 Dec 2011; 155:820-6
McGreevy C, Williams D
Ann Intern Med: 20 Dec 2011; 155:820-6 | PMID: 22184689
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Recognition of tuberous sclerosis in adult women: delayed presentation with life-threatening consequences.

Seibert D, Hong CH, Takeuchi F, Olsen C, ... Moss J, Darling TN
Background: Tuberous sclerosis complex (TSC) is associated with tumor development in the brain, retina, kidney, skin, heart, and lung. Seizures, intellectual disability, and characteristic skin lesions commonly manifest in early childhood, but some findings, notably renal angiomyolipomas and pulmonary lymphangioleiomyomatosis (LAM), emerge later, placing adults with undiagnosed TSC at increased risk for morbidity and mortality. Objective: To describe the clinical presentation and severity of TSC in adult women. Design: Retrospective cohort study. Setting: National Institutes of Health Clinical Center, Bethesda, Maryland, 1995 to 2010. Patients: 79 women aged 18 years or older who were enrolled in an observational cohort study of TSC to evaluate disease manifestations. Measurements: History, physical examination, pulmonary function testing, chest radiography, abdominal computed tomography, high-resolution chest computed tomography, and brain magnetic resonance imaging were used to evaluate patients. Results: Among the 45 patients who received a diagnosis of TSC in adulthood, 21 presented with symptoms due to LAM, 19 with renal angiomyolipomas, and 10 with seizures. Of the 45 patients, 30 met clinical criteria for TSC in childhood that remained undiagnosed for a median of 21.5 years and 15 were older than 18 years before meeting the clinical criteria for TSC. Patients diagnosed in adulthood and those diagnosed in childhood had similar occurrences of pneumothorax, shortness of breath, hemoptysis, nephrectomy, and death. Limitation: No men were included in the study, and selection was biased toward patients having pulmonary LAM. Conclusion: Women who received a TSC diagnosis in adulthood had minimal morbidity during childhood but were still at risk for life-threatening pulmonary and renal manifestations. Primary Funding Source: Intramural Research Program, National Institutes of Health, National Heart, Lung, and Blood Institute.

Ann Intern Med: 21 Jun 2011; 154:806-13
Seibert D, Hong CH, Takeuchi F, Olsen C, ... Moss J, Darling TN
Ann Intern Med: 21 Jun 2011; 154:806-13 | PMID: 21690595
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Abstract

Health Care System Delay and Heart Failure in Patients With ST-Segment Elevation Myocardial Infarction Treated With Primary Percutaneous Coronary Intervention: Follow-up of Population-Based Medical Registry Data.

Terkelsen CJ, Jensen LO, Tilsted HH, Trautner S, ... Thuesen L, Lassen JF
Background: In patients with ST-segment elevation myocardial infarction (STEMI), delay between contact with the health care system and initiation of reperfusion therapy (system delay) is associated with mortality, but data on the associated risk for congestive heart failure (CHF) among survivors are limited. Objective: To evaluate the association between system delay and the risk for readmissions or outpatient contacts due to CHF after primary percutaneous coronary intervention (PPCI) in patients with STEMI. Design: Historical follow-up study using population-based medical registries. Setting: Western Denmark. Patients: Patients with STEMI who were transported by emergency medical service from 1 January 1999 to 7 February 2010 and treated with PPCI within 12 hours of symptom onset and who had a system delay of 6 hours or less (n = 7952). The median duration of follow-up was 3.1 years. Measurements: Cumulative incidence of readmissions or outpatient contacts due to CHF was determined by using competing-risk regression analysis, with death as the competing risk. Crude and adjusted cause-specific hazard ratios for readmissions or outpatient contacts due to CHF were determined for system delay and other covariates. Results: System delays of 60 minutes or less (n = 451), 61 to 120 minutes (n = 3457), 121 to 180 minutes (n = 2655), and 181 to 360 minutes (n = 1389) corresponded with long-term risks for readmissions or outpatient contacts due to CHF of 10.1%, 10.6%, 12.3%, and 14.1%, respectively (P < 0.001). In multivariable analysis, system delay was an independent predictor of readmissions or outpatient contacts due to CHF (adjusted hazard ratio per hour increase in delay, 1.10 [95% CI, 1.02 to 1.17]). Limitation: In any nonrandomized study, there are risks for selection bias and residual confounding. Conclusion: In patients with STEMI, shorter delay to PPCI is associated with lower risk for readmissions or outpatient contacts due to CHF during follow-up. Primary Funding Source: The Karl G. Andersen Foundation, the Helga and Peter Korning Foundation, the Health Research Fund of Central Denmark Region, the Research Foundation at Skejby University Hospital, the Riisfort Foundation, and the Arvid Nilsson Foundation.

Ann Intern Med: 20 Sep 2011; 155:361-7
Terkelsen CJ, Jensen LO, Tilsted HH, Trautner S, ... Thuesen L, Lassen JF
Ann Intern Med: 20 Sep 2011; 155:361-7 | PMID: 21930853
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Abstract

Characteristics and Short-Term Prognosis of Perioperative Myocardial Infarction in Patients Undergoing Noncardiac Surgery: A Cohort Study.

Devereaux PJ, Xavier D, Pogue J, Guyatt G, ... Yusuf S, on behalf of the POISE (PeriOperative ISchemic Evaluation) Investigators
Background: Each year, millions of patients worldwide have a perioperative myocardial infarction (MI) after noncardiac surgery. Objective: To examine the characteristics and short-term outcome of perioperative MI. Design: Cohort study. (ClinicalTrials.gov registration number: NCT00182039) Setting: 190 centers in 23 countries. Patients: 8351 patients included in the POISE (PeriOperative ISchemic Evaluation) trial. Measurements: Four cardiac biomarker or enzyme assays were measured within 3 days of surgery. The definition of perioperative MI included either autopsy findings of acute MI or an elevated level of a cardiac biomarker or enzyme and at least 1 of the following defining features: ischemic symptoms, development of pathologic Q waves, ischemic changes on electrocardiography, coronary artery intervention, or cardiac imaging evidence of MI. Results: Within 30 days of random assignment, 415 patients (5.0%) had a perioperative MI. Most MIs (74.1%) occurred within 48 hours of surgery; 65.3% of patients did not experience ischemic symptoms. The 30-day mortality rate was 11.6% (48 of 415 patients) among patients who had a perioperative MI and 2.2% (178 of 7936 patients) among those who did not (P < 0.001). Among patients with a perioperative MI, mortality rates were elevated and similar between those with (9.7%; adjusted odds ratio, 4.76 [95% CI, 2.68 to 8.43]) and without (12.5%; adjusted odds ratio, 4.00 [CI, 2.65 to 6.06]) ischemic symptoms. Limitation: Cardiac markers were measured only until day 3 after surgery, and additional asymptomatic MIs may have been missed. Conclusion: Most patients with a perioperative MI will not experience ischemic symptoms. Data suggest that routine monitoring of troponin levels in at-risk patients is needed after surgery to detect most MIs, which have an equally poor prognosis regardless of whether they are symptomatic or asymptomatic. Primary Funding Source: Canadian Institutes of Health Research.

Ann Intern Med: 19 Apr 2011; 154:523-528
Devereaux PJ, Xavier D, Pogue J, Guyatt G, ... Yusuf S, on behalf of the POISE (PeriOperative ISchemic Evaluation) Investigators
Ann Intern Med: 19 Apr 2011; 154:523-528 | PMID: 21502650
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Abstract

Hospital spending and inpatient mortality: evidence from california: an observational study.

Romley JA, Jena AB, Goldman DP
Background: Evidence shows that high Medicare spending is not associated with better health outcomes at a regional level and that high spending in hospitals is not associated with better process quality. The relationship between hospital spending and inpatient mortality is less well understood. Objective: To determine the association between hospital spending and risk-adjusted inpatient mortality. Design: Retrospective cohort study. Setting: Database of discharge records from 1999 to 2008 for 208 California hospitals included in The Dartmouth Atlas of Health Care. Patients: 2 545 352 patients hospitalized during 1999 to 2008 with 1 of 6 major medical conditions. Measurements: Inpatient mortality rates among patients admitted to hospitals with varying levels of end-of-life hospital spending. Results: For each of 6 diagnoses at admission-acute myocardial infarction, congestive heart failure, acute stroke, gastrointestinal hemorrhage, hip fracture, and pneumonia-patient admission to higher-spending hospitals was associated with lower risk-adjusted inpatient mortality. During 1999 to 2003, for example, patients admitted with acute myocardial infarction to California hospitals in the highest quintile of hospital spending had lower inpatient mortality than did those admitted to hospitals in the lowest quintile (odds ratio, 0.862 [95% CI, 0.742 to 0.983]). Predicted inpatient deaths would increase by 1831 if all patients admitted with acute myocardial infarction were cared for in hospitals in the lowest quintile of spending rather than the highest. The association between hospital spending and inpatient mortality did not vary by region or hospital size. Limitation: Unobserved predictors of mortality create uncertainty about whether greater inpatient hospital spending leads to lower inpatient mortality. Conclusion: Hospitals that spend more have lower inpatient mortality for 6 common medical conditions. Primary Funding Source: National Institute on Aging and RAND Health Bing Center for Health Economics.

Ann Intern Med: 01 Feb 2011; 154:160-7
Romley JA, Jena AB, Goldman DP
Ann Intern Med: 01 Feb 2011; 154:160-7 | PMID: 21282695
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Abstract

Systematic Review: Erythropoiesis-Stimulating Agents in Patients With Chronic Kidney Disease.

Palmer SC, Navaneethan SD, Craig JC, Johnson DW, ... Tognoni G, Strippoli GF
Background: Previous meta-analyses suggest that treatment with erythropoiesis-stimulating agents (ESAs) in chronic kidney disease (CKD) increases the risk for death. Additional randomized trials have been recently completed. Purpose: To summarize the effects of ESA treatment on clinical outcomes in patients with anemia and CKD. Data sources: MEDLINE (January 1966 to November 2009), EMBASE (January 1980 to November 2009), and the Cochrane database (to March 2010) were searched without language restriction. Study Selection: Two authors independently screened reports to identify randomized trials evaluating ESA treatment in people with CKD. Hemoglobin target trials or trials of ESA versus no treatment or placebo were included. Data extraction: Two authors independently extracted data on patient characteristics, study risks for bias, and the effects of ESA therapy. Data Synthesis: 27 trials (10 452 patients) were identified. A higher hemoglobin target was associated with increased risks for stroke (relative risk [RR], 1.51 [95% CI, 1.03 to 2.21]), hypertension (RR, 1.67 [CI, 1.31 to 2.12]), and vascular access thrombosis (RR, 1.33 [CI, 1.16 to 1.53]) compared with a lower hemoglobin target. No statistically significant differences in the risks for mortality (RR, 1.09 [CI, 0.99 to 1.20]), serious cardiovascular events (RR, 1.15 [CI, 0.98 to 1.33]), or end-stage kidney disease (RR, 1.08 [CI, 0.97 to 1.20]) were observed, although point estimates favored a lower hemoglobin target. Treatment effects were consistent across subgroups, including all stages of CKD. Limitations: The evidence for effects on quality of life was limited by selective reporting. Trials also reported insufficient information to allow analysis of the independent effects of ESA dose on clinical outcomes. Conclusion: Targeting higher hemoglobin levels in CKD increases risks for stroke, hypertension, and vascular access thrombosis and probably increases risks for death, serious cardiovascular events, and end-stage renal disease. The mechanisms for harm remain unclear, and meta-analysis of individual-patient data and trials on fixed ESA doses are recommended to elucidate these mechanisms. Primary Funding Source: None.

Ann Intern Med: 04 May 2010; epub ahead of print
Palmer SC, Navaneethan SD, Craig JC, Johnson DW, ... Tognoni G, Strippoli GF
Ann Intern Med: 04 May 2010; epub ahead of print | PMID: 20439566
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Abstract

Meta-analysis: Cardiac Resynchronization Therapy for Patients With Less Symptomatic Heart Failure.

Al-Majed NS, McAlister FA, Bakal JA, Ezekowitz JA
Background: Cardiac resynchronization therapy (CRT) reduces morbidity and mortality in patients with advanced symptoms of heart failure. Purpose: To assess the benefits and harms of CRT in patients with advanced heart failure and those with less symptomatic disease. Data sources: A search of electronic databases (1950 to December 2010), hand-searching of reference lists, and unpublished data from principal investigators. Searches were not limited to the English language. Study Selection: Randomized, controlled trials of CRT compared with usual care and right or left ventricular pacing in adults with heart failure and a left ventricular ejection fraction of 0.40 or less. Data extraction: Two reviewers performed independent study selection, data abstraction, and quality assessment by using the Cochrane tool for assessing risk for bias. Data Synthesis: There were 9082 patients in 25 trials. In patients with New York Heart Association (NYHA) class I and II symptoms, CRT reduced all-cause mortality (6 trials, 4572 participants; risk ratio [RR], 0.83 [95% CI, 0.72 to 0.96]) and heart failure hospitalizations (4 trials, 4349 participants; RR, 0.71 [CI, 0.57 to 0.87]) without improving functional outcomes or quality of life. In patients with NYHA class III or IV symptoms, CRT improved functional outcomes and reduced both all-cause mortality (19 trials, 4510 participants; RR, 0.78 [CI, 0.67 to 0.91]) and heart failure hospitalizations (11 trials, 2663 participants; RR, 0.65 [CI, 0.50 to 0.86]). The implant success rate was 94.4%; peri-implantation deaths occurred in 0.3% of trial participants, mechanical complications in 3.2%, lead problems in 6.2%, and infections in 1.4%. Limitation: Subgroup analyses were underpowered and lack data for persons with NYHA class I symptoms, atrial fibrillation, chronic kidney disease, or right bundle branch block. Conclusion: Cardiac resynchronization therapy is beneficial for patients with reduced left ventricular ejection fraction, symptoms of heart failure, and prolonged QRS, regardless of NYHA class. Primary Funding Source: None.

Ann Intern Med: 15 Feb 2011; epub ahead of print
Al-Majed NS, McAlister FA, Bakal JA, Ezekowitz JA
Ann Intern Med: 15 Feb 2011; epub ahead of print | PMID: 21320922
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Abstract

Proton-Pump Inhibitors Are Associated With Increased Cardiovascular Risk Independent of Clopidogrel Use: A Nationwide Cohort Study.

Charlot M, Ahlehoff O, Norgaard ML, Jørgensen CH, ... Torp-Pedersen C, Gislason G
Background: Controversy remains on whether the dual use of clopidogrel and proton-pump inhibitors (PPIs) affects clinical efficacy of clopidogrel. Objective: To examine the risk for adverse cardiovascular outcomes related to concomitant use of PPIs and clopidogrel compared with that of PPIs alone in adults hospitalized for myocardial infarction. Design: A nationwide cohort study based on linked administrative registry data. Setting: All hospitals in Denmark. Patients: All patients discharged after first-time myocardial infarction from 2000 to 2006. Measurements: The primary outcome was a composite of rehospitalization for myocardial infarction or stroke or cardiovascular death. Patients were examined at several assembly time points, including 7, 14, 21, and 30 days after myocardial infarction. Follow-up was 1 year. Results: Of 56 406 included patients, 9137 (16.2%) were re-hospitalized for myocardial infarction or stroke or experienced cardiovascular death. Of the 24 702 patients (43.8%) who received clopidogrel, 6753 (27.3%) received concomitant PPIs. The hazard ratio for cardiovascular death or rehospitalization for myocardial infarction or stroke for concomitant use of a PPI and clopidogrel among the cohort assembled at day 30 after discharge was 1.29 (95% CI, 1.17 to 1.42). The corresponding ratio for use of a PPI in patients who did not receive clopidogrel was 1.29 (CI, 1.21 to 1.37). No statistically significant interaction occurred between a PPI and clopidogrel (P = 0.72). Limitations: Unmeasured and residual confounding, time-varying measurement errors of exposure, and biases from survival effects were possible. Conclusion: Proton-pump inhibitors seem to be associated with increased risk for adverse cardiovascular outcomes after discharge, regardless of clopidogrel use for myocardial infarction. Dual PPI and clopidogrel use was not associated with any additional risk for adverse cardiovascular events over that observed for patients prescribed a PPI alone. Primary Funding Source: The Danish Medical Research Council and the Danish Heart Foundation.

Ann Intern Med: 21 Sep 2010; 153:378-386
Charlot M, Ahlehoff O, Norgaard ML, Jørgensen CH, ... Torp-Pedersen C, Gislason G
Ann Intern Med: 21 Sep 2010; 153:378-386 | PMID: 20855802
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Abstract

Smoking, smoking status, and risk for symptomatic peripheral artery disease in women: a cohort study.

Conen D, Everett BM, Kurth T, Creager MA, ... Ridker PM, Pradhan AD
Background: Smoking has a well-documented detrimental effect on risk for myocardial infarction and stroke, but less information is available regarding peripheral artery disease (PAD), particularly among women. Objective: To prospectively assess the association of current smoking status, cumulative smoking exposure, and smoking cessation with incident symptomatic PAD in women. Design: Prospective cohort study. Setting: U.S. female health care professionals in the Women\'s Health Study. Participants: 39 825 women with no cardiovascular disease who were prospectively followed for a median of 12.7 years. Measurements: Incidence of symptomatic PAD. Cox proportional hazards models were used to compare PAD risk across smoking categories. Results: 178 confirmed PAD events occurred. Across the 4 smoking categories (never, former, <15 cigarettes/d, and ≥15 cigarettes/d), age-adjusted incidence rates were 0.12, 0.34, 0.95, and 1.63 per 1000 person-years of follow-up, respectively. Multivariate adjustment had little effect on this relationship (adjusted hazard ratios [HRs], 3.14 [95% CI, 2.01 to 4.90], 8.93 [CI, 5.02 to 15.89], and 16.95 [CI, 10.77 to 26.67], respectively, vs. women who never smoked). Additional adjustment for high-sensitivity C-reactive protein and soluble intercellular adhesion molecule-1 levels among women with available blood samples (28 314 participants, 117 events) attenuated risk estimates (HR, 5.58 [CI, 2.61 to 11.93] for smoking <15 cigarettes/d and 9.52 [CI, 5.17 to 17.53] for smoking ≥15 cigarettes/d). Lifetime exposure showed a strong dose-response relationship; fully adjusted HRs for smoking abstinence of fewer than 10, 10 to 29, and 30 or more pack-years were 2.52 (CI, 1.49 to 4.25), 6.75 (CI, 4.33 to 10.52), and 11.09 (CI, 6.94 to 17.72), respectively. Compared with current smokers, the adjusted HRs for fewer than 10 years, 10 to 20 years, more than 20 years, or lifelong abstinence were 0.39 (CI, 0.24 to 0.66), 0.28 (CI, 0.17 to 0.46), 0.16 (CI, 0.10 to 0.26), and 0.08 (CI, 0.05 to 0.12), respectively. Limitation: The use of symptomatic PAD as the a priori primary end point excludes asymptomatic disease. Conclusion: Among initially healthy women, smoking is a potent risk factor for symptomatic PAD and was associated with subclinical inflammation. Smoking cessation substantially reduces risk for PAD, but an increased occurrence of PAD persists even among former smokers who maintain abstinence. Primary Funding Source: The National Heart, Lung, and Blood Institute and National Cancer Institute.

Ann Intern Med: 07 Jun 2011; 154:719-26
Conen D, Everett BM, Kurth T, Creager MA, ... Ridker PM, Pradhan AD
Ann Intern Med: 07 Jun 2011; 154:719-26 | PMID: 21646555
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Comparative Effectiveness and Safety of Medications for Type 2 Diabetes: An Update Including New Drugs and 2-Drug Combinations.

Bennett WL, Maruthur NM, Singh S, Segal JB, ... Bass EB, Bolen S
Background: Given the increase in medications for type 2 diabetes mellitus, clinicians and patients need information about their effectiveness and safety to make informed choices. Purpose: To summarize the benefits and harms of metformin, second-generation sulfonylureas, thiazolidinediones, meglitinides, dipeptidyl peptidase-4 (DPP-4) inhibitors, and glucagon-like peptide-1 receptor agonists, as monotherapy and in combination, to treat adults with type 2 diabetes. Data sources: MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were searched from inception through April 2010 for English-language observational studies and trials. The MEDLINE search was updated to December 2010 for long-term clinical outcomes. Study Selection: Two reviewers independently screened reports and identified 140 trials and 26 observational studies of head-to-head comparisons of monotherapy or combination therapy that reported intermediate or long-term clinical outcomes or harms. Data extraction: Two reviewers following standardized protocols serially extracted data, assessed applicability, and independently evaluated study quality. Data Synthesis: Evidence on long-term clinical outcomes (all-cause mortality, cardiovascular disease, nephropathy, and neuropathy) was of low strength or insufficient. Most medications decreased the hemoglobin A(1c) level by about 1 percentage point and most 2-drug combinations produced similar reductions. Metformin was more efficacious than the DPP-4 inhibitors, and compared with thiazolidinediones or sulfonylureas, the mean differences in body weight were about -2.5 kg. Metformin decreased low-density lipoprotein cholesterol levels compared with pioglitazone, sulfonylureas, and DPP-4 inhibitors. Sulfonylureas had a 4-fold higher risk for mild or moderate hypoglycemia than metformin alone and, in combination with metformin, had more than a 5-fold increased risk compared with metformin plus thiazolidinediones. Thiazolidinediones increased risk for congestive heart failure compared with sulfonylureas and increased risk for bone fractures compared with metformin. Diarrhea occurred more often with metformin than with thiazolidinediones. Limitations: Only English-language publications were reviewed. Some studies may have selectively reported outcomes. Many studies were small, were of short duration, and had limited ability to assess clinically important harms and benefits. Conclusion: Evidence supports metformin as a first-line agent to treat type 2 diabetes. Most 2-drug combinations similarly reduce hemoglobin A(1c) levels, but some increased risk for hypoglycemia and other adverse events. Primary Funding Source: Agency for Healthcare Research and Quality.

Ann Intern Med: 15 Mar 2011; epub ahead of print
Bennett WL, Maruthur NM, Singh S, Segal JB, ... Bass EB, Bolen S
Ann Intern Med: 15 Mar 2011; epub ahead of print | PMID: 21403054
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Abstract

Individualizing glycemic targets in type 2 diabetes mellitus: implications of recent clinical trials.

Ismail-Beigi F, Moghissi E, Tiktin M, Hirsch IB, Inzucchi SE, Genuth S
One of the first steps in the management of patients with type 2 diabetes mellitus is setting glycemic goals. Professional organizations advise setting specific hemoglobin A(1c) (HbA(1c)) targets for patients, and individualization of these goals has more recently been emphasized. However, the operational meaning of glycemic goals, and specific methods for individualizing them, have not been well-described. Choosing a specific HbA(1c) target range for a given patient requires taking several factors into consideration, including an assessment of the patient\'s risk for hyperglycemia-related complications versus the risks of therapy, all in the context of the overall clinical setting. Comorbid conditions, psychological status, capacity for self-care, economic considerations, and family and social support systems also play a key role in the intensity of therapy. The individualization of HbA(1c) targets has gained more traction after recent clinical trials in older patients with established type 2 diabetes mellitus failed to show a benefit from intensive glucose-lowering therapy on cardiovascular disease (CVD) outcomes. The limited available evidence suggests that near-normal glycemic targets should be the standard for younger patients with relatively recent onset of type 2 diabetes mellitus and little or no micro- or macrovascular complications, with the aim of preventing complications over the many years of life. However, somewhat higher targets should be considered for older patients with long-standing type 2 diabetes mellitus and evidence of CVD (or multiple CVD risk factors). This review explores these issues further and proposes a framework for considering an appropriate and safe HbA(1c) target range for each patient.

Ann Intern Med: 19 Apr 2011; 154:554-9
Ismail-Beigi F, Moghissi E, Tiktin M, Hirsch IB, Inzucchi SE, Genuth S
Ann Intern Med: 19 Apr 2011; 154:554-9 | PMID: 21502652
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Management of Chronic Heart Failure in Adults: Synopsis of the National Institute for Health and Clinical Excellence Guideline.

Mant J, Al-Mohammad A, Swain S, Laramée P, for the Guideline Development Group
Description: The National Institute for Health and Clinical Excellence released its first clinical guideline on heart failure in 2003. This synopsis describes the update of that guideline, which was released in August 2010 and discusses the diagnosis, treatment, and monitoring of heart failure. Methods: Guideline developers considered clinical evidence, health economic analyses, clinical expert opinion, and patient views. Systematic literature searches were performed, and an original decision model assessed the cost-effectiveness of serial measurement of serum natriuretic peptide to monitor patients with chronic heart failure. Recommendations: First, this guideline update describes the role of serum natriuretic peptide measurement, echocardiography, and specialist assessment in the diagnosis of heart failure. Second, it presents a pathway for pharmacologic treatment, rehabilitation, and pacing therapy (including implantable cardioverter-defibrillator and cardiac resynchronization therapy) for patients with heart failure and left ventricular systolic dysfunction and patients with heart failure and preserved ejection fraction. Finally, it explains the recommendation to monitor patients with heart failure by using serial measurement of serum natriuretic peptide.

Ann Intern Med: 16 Aug 2011; 155:252-259
Mant J, Al-Mohammad A, Swain S, Laramée P, for the Guideline Development Group
Ann Intern Med: 16 Aug 2011; 155:252-259 | PMID: 21844551
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Abstract

Dyslipidemia.

Kopin L, Lowenstein C
Dyslipidemia is an important risk factor for coronary artery disease and stroke. Long-term, prospective epidemiologic studies have consistently shown that persons with healthier lifestyles and fewer risk factors for coronary heart disease, and particularly those with favorable lipid profiles, have reduced incidence of coronary heart disease. Prevention and sensible management of dyslipidemia can markedly alter cardiovascular morbidity and mortality.

Ann Intern Med: 04 Dec 2017; 167:ITC81-ITC96
Kopin L, Lowenstein C
Ann Intern Med: 04 Dec 2017; 167:ITC81-ITC96 | PMID: 29204622
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Engaging patients and stakeholders in research proposal review: the patient-centered outcomes research institute.

Fleurence RL, Forsythe LP, Lauer M, Rotter J, ... Frank L, Selby JV
The inaugural round of merit review for the Patient-Centered Outcomes Research Institute (PCORI) in November 2012 included patients and other stakeholders, as well as scientists. This article examines relationships among scores of the 3 reviewer types, changes in scoring after in-person discussion, and the effect of inclusion of patient and stakeholder reviewers on the review process. In the first phase, 363 scientists scored 480 applications. In the second phase, 59 scientists, 21 patients, and 31 stakeholders provided a "prediscussion" score and a final "postdiscussion" score after an in-person meeting for applications. Bland-Altman plots were used to characterize levels of agreement among and within reviewer types before and after discussion. Before discussion, there was little agreement among average scores given by the 4 lead scientific reviewers and patient and stakeholder reviewers. After discussion, the 4 primary reviewers showed mild convergence in their scores, and the 21-member panel came to a much stronger agreement. Of the 25 awards with the best (and lowest) scores after phase 2, only 13 had ranked in the top 25 after the phase 1 review by scientists. Five percent of the 480 proposals submitted were funded. The authors conclude that patient and stakeholder reviewers brought different perspectives to the review process but that in-person discussion led to closer agreement among reviewer types. It is not yet known whether these conclusions are generalizable to future rounds of peer review. Future work would benefit from additional data collection for evaluation purposes and from long-term evaluation of the effect on the funded research.

Ann Intern Med: 14 Jul 2014; 161:122-30
Fleurence RL, Forsythe LP, Lauer M, Rotter J, ... Frank L, Selby JV
Ann Intern Med: 14 Jul 2014; 161:122-30 | PMID: 25023251
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Abstract

National Institutes of Health Pathways to Prevention Workshop: The Role of Opioids in the Treatment of Chronic Pain.

Reuben DB, H Alvanzo AA, Ashikaga T, Bogat GA, ... Ruffing V, Steffens DC
This National Institutes of Health (NIH) workshop was cosponsored by the NIH Office of Disease Prevention (ODP), the NIH Pain Consortium, the National Institute on Drug Abuse, and the National Institute of Neurological Disorders and Stroke. A multidisciplinary working group developed the workshop agenda, and an evidence-based practice center prepared an evidence report through a contract with the Agency for Healthcare Research and Quality to facilitate the workshop discussion. During the 1.5-day workshop, invited experts discussed the body of evidence, and attendees had opportunities to provide comments during open discussion periods. After weighing evidence from the evidence report, expert presentations, and public comments, an unbiased, independent panel prepared a draft report that identified research gaps and future research priorities. The report was posted on the ODP Web site for 2 weeks for public comment. This article is an abridged version of the panel\'s report, the full version of which is available at at https://prevention.nih.gov/programs-events/pathways-to-prevention/workshops/opioids-chronic-pain/workshop-resources#finalreport.

Ann Intern Med: 11 Jan 2015; epub ahead of print
Reuben DB, H Alvanzo AA, Ashikaga T, Bogat GA, ... Ruffing V, Steffens DC
Ann Intern Med: 11 Jan 2015; epub ahead of print | PMID: 25581341
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Abstract

Narrative review: harnessing molecular genetics for the diagnosis and management of hypertrophic cardiomyopathy.

Wang L, Seidman JG, Seidman CE
Unexplained cardiac hypertrophy, the diagnostic criterion for hypertrophic cardiomyopathy (HCM), occurs in 1 in 500 adults. Insights into the genetic cause and molecular pathophysiology of HCM are reshaping clinical paradigms for diagnosis and treatment of this common myocardial disorder. Human genetic studies have established that dominant mutations in the proteins that make up the contractile apparatus (the sarcomere) cause HCM. With the current availability of clinical gene-based diagnostics, pathogenic mutations in affected patients can be defined, which can suggest a clinical course and allow definitive preclinical identification of family members at risk for HCM. Genetic discoveries have also fostered mechanistic investigations in model organisms that are engineered to carry human HCM mutations. Novel therapeutic targets have emerged from these fundamental studies and are currently under clinical assessment in humans. The combination of contemporary gene-based diagnosis with new strategies to attenuate disease development and progression is changing the natural history of lifelong cardiac symptoms, arrhythmias, and heart failure from HCM.

Ann Intern Med: 20 Apr 2010; 152:513-20,
Wang L, Seidman JG, Seidman CE
Ann Intern Med: 20 Apr 2010; 152:513-20, | PMID: 20404382
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Decision Aids for Advance Care Planning: An Overview of the State of the Science.

Butler M, Ratner E, McCreedy E, Shippee N, Kane RL
Advance care planning honors patients\' goals and preferences for future care by creating a plan for when illness or injury impedes the ability to think or communicate about health decisions. Fewer than 50% of severely or terminally ill patients have an advance directive in their medical record, and physicians are accurate only about 65% of the time when predicting patient preferences for intensive care. Decision aids can support the advance care planning process by providing a structured approach to informing patients about care options and prompting them to document and communicate their preferences. This review, commissioned as a technical brief by the Agency for Healthcare Research and Quality Effective Health Care Program, provides a broad overview of current use of and research related to decision aids for adult advance care planning. Using interviews of key informants and a search of the gray and published literature from January 1990 to May 2014, the authors found that many decision aids are widely available but are not assessed in the empirical literature. The 16 published studies testing decision aids as interventions for adult advance care planning found that most are proprietary or not publicly available. Some are constructed for the general population, whereas others address disease-specific conditions that have more predictable end-of-life scenarios and, therefore, more discrete choices. New decision aids should be designed that are responsive to diverse philosophical perspectives and flexible enough to change as patients gain experience with their personal illness courses. Future efforts should include further research, training of advance care planning facilitators, dissemination and access, and tapping the potential opportunities that lie in social media or other technologies.

Ann Intern Med: 28 Jul 2014; epub ahead of print
Butler M, Ratner E, McCreedy E, Shippee N, Kane RL
Ann Intern Med: 28 Jul 2014; epub ahead of print | PMID: 25069709
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Abstract

Dementia.

Rabins PV, Blass DM
This issue provides a clinical overview of dementia, focusing on prevention, diagnosis, treatment, practice improvement, and patient information. The content of In the Clinic is drawn from the clinical information and education resources of the American College of Physicians (ACP), including ACP Smart Medicine and MKSAP (Medical Knowledge and Self-Assessment Program). Annals of Internal Medicine editors develop In the Clinic from these primary sources in collaboration with the ACP\'s Medical Education and Publishing divisions and with the assistance of science writers and physician writers. Editorial consultants from ACP Smart Medicine and MKSAP provide expert review of the content. Readers who are interested in these primary resources for more detail can consult http://smartmedicine.acponline.org, https://mksap.acponline.org/, and other resources referenced in each issue of In the Clinic.

Ann Intern Med: 04 Aug 2014; 161:ITC1
Rabins PV, Blass DM
Ann Intern Med: 04 Aug 2014; 161:ITC1 | PMID: 25089871
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Abstract

Systematic Review: Benefits and Harms of In-Hospital Use of Recombinant Factor VIIa for Off-Label Indications.

Yank V, Tuohy CV, Logan AC, Bravata DM, ... Owens DK, Stafford RS
Background: Recombinant factor VIIa (rFVIIa), a hemostatic agent approved for hemophilia, is increasingly used for off-label indications. Purpose: To evaluate the benefits and harms of rFVIIa use for 5 off-label, in-hospital indications: intracranial hemorrhage, cardiac surgery, trauma, liver transplantation, and prostatectomy. Data sources: Ten databases (including PubMed, EMBASE, and the Cochrane Library) queried from inception through December 2010. Articles published in English were analyzed. Study Selection: Two reviewers independently screened titles and abstracts to identify clinical use of rFVIIa for the selected indications and identified all randomized, controlled trials (RCTs) and observational studies for full-text review. Data extraction: Two reviewers independently assessed study characteristics and rated study quality and indication-wide strength of evidence. Data Synthesis: 16 RCTs, 26 comparative observational studies, and 22 noncomparative observational studies met inclusion criteria. Identified comparators were limited to placebo (RCTs) or usual care (observational studies). For intracranial hemorrhage, mortality was not improved with rFVIIa use across a range of doses. Arterial thromboembolism was increased with medium-dose rFVIIa use (risk difference [RD], 0.03 [95% CI, 0.01 to 0.06]) and high-dose rFVIIa use (RD, 0.06 [CI, 0.01 to 0.11]). For adult cardiac surgery, there was no mortality difference, but there was an increased risk for thromboembolism (RD, 0.05 [CI, 0.01 to 0.10]) with rFVIIa. For body trauma, there were no differences in mortality or thromboembolism, but there was a reduced risk for the acute respiratory distress syndrome (RD, -0.05 [CI, -0.02 to -0.08]). Mortality was higher in observational studies than in RCTs. Limitations: The amount and strength of evidence were low for most outcomes and indications. Publication bias could not be excluded. Conclusion: Limited available evidence for 5 off-label indications suggests no mortality reduction with rFVIIa use. For some indications, it increases thromboembolism. Primary Funding Source: Agency for Healthcare Research and Quality.

Ann Intern Med: 19 Apr 2011; 154:529-40
Yank V, Tuohy CV, Logan AC, Bravata DM, ... Owens DK, Stafford RS
Ann Intern Med: 19 Apr 2011; 154:529-40 | PMID: 21502651
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Impact:
Abstract

Small Area Variations in Out-of-Hospital Cardiac Arrest: Does the Neighborhood Matter?

Sasson C, Keirns CC, Smith D, Sayre M, ... Iwashyna TJ, for the CARES Study Group
Background: The incidence and outcomes of out-of-hospital cardiac arrest vary widely across cities. It is unknown whether similar differences exist at the neighborhood level. Objective: To determine the extent to which neighborhoods have persistently high rates of cardiac arrest but low rates of bystander cardiopulmonary resuscitation (CPR). Design: Multilevel Poisson regression of 1108 cardiac arrests from 161 census tracts as captured by the Cardiac Arrest Registry to Enhance Survival (CARES). Setting: Fulton County, Georgia, between 1 October 2005 to 30 November 2008. Measurements: Incidence of cardiac arrest by census tract and year and by rates of bystander CPR. Results: Adjusted rates of cardiac arrest varied across neighborhoods (interquartile range [IQR], 0.57 to 0.73 per 1000 persons; mean, 0.64 per 1000 persons [SD, 0.11]), but were stable from year to year, (intraclass correlation, 0.36 [95% CI, 0.26 to 0.50]; P < 0.001). Adjusted bystander CPR rates also varied by census tract (IQR, 19% to 29%; mean, 25% [SD, 10%]). Limitation: Analysis was based on data from a single city. Conclusion: Surveillance data can identify neighborhoods with persistently high incidence of cardiac arrest and low rates of bystander CPR. These neighborhoods are promising targets for community-based interventions. Primary Funding Source: Robert Wood Johnson Clinical Scholars Program, National Institutes of Health, and Centers for Disease Control and Prevention.

Ann Intern Med: 02 Jun 2010; epub ahead of print
Sasson C, Keirns CC, Smith D, Sayre M, ... Iwashyna TJ, for the CARES Study Group
Ann Intern Med: 02 Jun 2010; epub ahead of print | PMID: 20516307
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Abstract

Potential bias of instrumental variable analyses for observational comparative effectiveness research.

Garabedian LF, Chu P, Toh S, Zaslavsky AM, Soumerai SB
Instrumental variable analysis is an increasingly popular method in comparative effectiveness research (CER). In theory, the instrument controls for unobserved and observed patient characteristics that affect the outcome. However, the results of instrumental variable analyses in observational settings may be biased if the instrument and outcome are related through an unadjusted third variable: an "instrument-outcome confounder." The authors identified published CER studies that used instrumental variable analysis and searched the literature for potential confounders of the most common instrument-outcome pairs. Of the 187 studies identified, 114 used 1 or more of the 4 most common instrument categories: distance to facility, regional variation, facility variation, and physician variation. Of these, 65 used mortality as an outcome. Potential unadjusted instrument-outcome confounders were observed in all studies, including patient race, socioeconomic status, clinical risk factors, health status, and urban or rural residency; facility and procedure volume; and co-occurring treatments. Only 4 (6%) instrumental variable CER studies considered potential instrument-outcome confounders outside the study data. Many effect estimates may be biased by the failure to adjust for instrument-outcome confounding. The authors caution against overreliance on instrumental variable studies for CER.

Ann Intern Med: 14 Jul 2014; 161:131-8
Garabedian LF, Chu P, Toh S, Zaslavsky AM, Soumerai SB
Ann Intern Med: 14 Jul 2014; 161:131-8 | PMID: 25023252
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Abstract

Osteoarthritis.

Gelber AC
This issue provides a clinical overview of Osteoarthritis focusing on prevention, diagnosis, treatment, practice improvement, and patient information. The content of In the Clinic is drawn from the clinical information and education resources of the American College of Physicians (ACP), including ACP Smart Medicine and MKSAP (Medical Knowledge and Self-Assessment Program). Annals of Internal Medicine editors develop In the Clinic from these primary sources in collaboration with the ACP\'s Medical Education and Publishing divisions and with the assistance of science writers and physician writers. Editorial consultants from ACP Smart Medicine and MKSAP provide expert review of the content. Readers who are interested in these primary resources for more detail can consult http://smartmedicine.acponline.org, https://mksap.acponline.org/, and other resources referenced in each issue of In the Clinic.

Ann Intern Med: 30 Jun 2014; 161
Gelber AC
Ann Intern Med: 30 Jun 2014; 161 | PMID: 24979462
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Abstract

Should This Patient Receive Aspirin?: Grand Rounds Discussion From Beth Israel Deaconess Medical Center.

Burns RB, Graham K, Sawhney MS, Reynolds EE
Aspirin exerts antiplatelet effects through irreversible inhibition of cyclooxygenase-1, whereas its anticancer effects may be due to inhibition of cyclooxygenase-2 and other pathways. In 2009, the U.S. Preventive Services Task Force endorsed aspirin for primary prevention of cardiovascular disease. However, aspirin\'s role in cancer prevention is still emerging, and no groups currently recommend its use for this purpose. To help physicians balance the benefits and harms of aspirin in primary disease prevention, the Task Force issued a guideline titled, \"Aspirin Use for the Primary Prevention of Cardiovascular Disease and Colorectal Cancer\" in 2016. In the evidence review conducted for the guideline, cardiovascular disease mortality and colorectal cancer mortality were significantly reduced among persons taking aspirin. However, there was no difference in nonfatal stroke, cardiovascular disease mortality, or all-cause mortality, nor in total cancer mortality, among those taking aspirin. Aspirin users were found to be at increased risk for major gastrointestinal bleeding. In this Beyond the Guidelines, the guideline is reviewed and 2 experts discuss how they would apply it to a 57-year-old man considering starting aspirin for primary prevention. Our experts review the data on which the guideline is based, discuss how they would balance the benefits and harms of aspirin therapy, and explain how they would incorporate shared decision making into clinical practice.

Ann Intern Med: 04 Dec 2017; 167:786-793
Burns RB, Graham K, Sawhney MS, Reynolds EE
Ann Intern Med: 04 Dec 2017; 167:786-793 | PMID: 29204620
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Abstract

A model-based estimate of cumulative excess mortality in survivors of childhood cancer.

Yeh JM, Nekhlyudov L, Goldie SJ, Mertens AC, Diller L
Background: Although childhood cancer survival rates have dramatically increased, survivors face elevated risk for life-threatening late effects, including secondary cancer. Objective: To estimate the cumulative effect of disease- and treatment-related mortality risks on survivor life expectancy. Design: State-transition model to simulate the lifetime clinical course of childhood cancer survivors. Setting: Childhood Cancer Survivor Study. PATIENTS: Five-year survivors of childhood cancer. Measurements: Probabilities of risk for death from the original cancer diagnosis, excess mortality from subsequent cancer and cardiac, pulmonary, external, and other complications, and background mortality (age-specific mortality rates for the general population) were estimated over the lifetime of survivors of childhood cancer. Results: For a cohort of 5-year survivors aged 15 years who received a diagnosis of cancer at age 10 years, the average lifetime probability was 0.10 for late-recurrence mortality; 0.15 for treatment-related subsequent cancer and death from cardiac, pulmonary, and external causes; and 0.05 for death from other excess risks. Life expectancy for the cohort of persons aged 15 years was 50.6 years, a loss of 10.4 years (17.1%) compared with the general population. Reduction in life expectancy varied by diagnosis, ranging from 4.0 years (6.0%) for kidney tumor survivors to more than 17.8 years (> or =28.0%) for brain and bone tumor survivors, and was sensitive to late-recurrence mortality risk and duration of excess mortality risk. LIMITATION: Estimates are based on data for survivors who received treatment 20 to 40 years ago; patients who received treatment more recently may have more favorable outcomes. Conclusion: Childhood cancer survivors face considerable mortality during adulthood, with excess risks reducing life expectancy by as much as 28%. Monitoring the health of current survivors and carefully evaluating therapies with known late toxicities in patients with newly diagnosed cancer are needed.

Ann Intern Med: 06 Apr 2010; 152:409-17,
Yeh JM, Nekhlyudov L, Goldie SJ, Mertens AC, Diller L
Ann Intern Med: 06 Apr 2010; 152:409-17, | PMID: 20368646
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Abstract

Estimated Glomerular Filtration Rate and Albuminuria as Predictors of Outcomes in Patients With High Cardiovascular Risk: A Cohort Study.

Clase CM, Gao P, Tobe SW, McQueen MJ, ... Mann JF, on behalf of the ONTARGET (ONgoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial) and TRANSCEND (Telmisartan Randomized Assessment Study in Angiotensin-Converting-Enzyme-Inhibitor Intolerant Subjects with Cardiovascular Disease)
Background: Glomerular filtration rate and albuminuria are risk factors for cardiovascular disease and markers of renal function. Objective: To examine the contribution of estimated glomerular filtration rate (eGFR) and urinary albumin-creatinine ratio beyond that of traditional cardiovascular risk factors to classification of patient risk for cardiovascular and renal outcomes. Design: Prospective cohort study that pooled all patients of ONTARGET (ONgoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial) and TRANSCEND (Telmisartan Randomized Assessment Study in Angiotensin-Converting-Enzyme-Inhibitor Intolerant Subjects with Cardiovascular Disease). Patients: 27 620 patients older than 55 years with documented cardiovascular disease, who were followed for a mean of 4.6 years. Measurements: Baseline eGFR, urinary albumin-creatinine ratio, and cardiovascular risk factors. Outcomes were all-cause mortality; a composite of cardiovascular death, myocardial infarction, stroke, and hospitalization for heart failure; long-term dialysis; and a composite of long-term dialysis and doubling of serum creatinine level. Results: Lower eGFRs and higher urinary albumin-creatinine ratios were associated with the primary cardiovascular composite outcome (for example, an adjusted hazard ratio of 2.53 [95% CI, 1.61 to 3.99] for an eGFR <30 mL/min per 1.73 m(2) and a very high urinary albumin-creatinine ratio). However, adding information about eGFR and urinary albumin-creatinine ratio to the risk reclassification analyses led to no meaningful decrease in the proportion of patients assigned to the intermediate-risk category (31% without vs. 32% with renal information). In contrast, eGFR and urinary albumin-creatinine ratio were strongly associated with risk for long-term dialysis and greatly improved both model calibration and risk stratification capacity when added to traditional cardiovascular risk factors (65% assigned to intermediate-risk categories without renal information vs. 18% with renal information). Limitation: Creatinine levels were not standardized. Conclusion: In patients with high vascular risk, eGFR and urinary albumin-creatinine ratio add little to traditional cardiovascular risk factors for stratifying cardiovascular risk but greatly improve risk stratification for renal outcomes. Primary Funding Source: Boehringer Ingelheim, Population Health Research Institute, and the European Commission.

Ann Intern Med: 01 Mar 2011; 154:310-318
Clase CM, Gao P, Tobe SW, McQueen MJ, ... Mann JF, on behalf of the ONTARGET (ONgoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial) and TRANSCEND (Telmisartan Randomized Assessment Study in Angiotensin-Converting-Enzyme-Inhibitor Intolerant Subjects with Cardiovascular Disease)
Ann Intern Med: 01 Mar 2011; 154:310-318 | PMID: 21357908
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Abstract

A prospective evaluation of a protocol for magnetic resonance imaging of patients with implanted cardiac devices.

Nazarian S, Hansford R, Roguin A, Goldsher D, ... Bluemke DA, Halperin HR
Background: Magnetic resonance imaging (MRI) is avoided in most patients with implanted cardiac devices because of safety concerns. Objective: To define the safety of a protocol for MRI at the commonly used magnetic strength of 1.5 T in patients with implanted cardiac devices. Design: Prospective nonrandomized trial. (ClinicalTrials.gov registration number: NCT01130896) Setting: One center in the United States (94% of examinations) and one in Israel. Patients: 438 patients with devices (54% with pacemakers and 46% with defibrillators) who underwent 555 MRI studies. Intervention: Pacing mode was changed to asynchronous for pacemaker-dependent patients and to demand for others. Tachyarrhythmia functions were disabled. Blood pressure, electrocardiography, oximetry, and symptoms were monitored by a nurse with experience in cardiac life support and device programming who had immediate backup from an electrophysiologist. Measurements: Activation or inhibition of pacing, symptoms, and device variables. Results: In 3 patients (0.7% [95% CI, 0% to 1.5%]), the device reverted to a transient back-up programming mode without long-term effects. Right ventricular (RV) sensing (median change, 0 mV [interquartile range {IQR}, -0.7 to 0 V]) and atrial and right and left ventricular lead impedances (median change, -2 Ω [IQR, -13 to 0 Ω], -4 Ω [IQR, -16 to 0 Ω], and -11 Ω [IQR, -40 to 0 Ω], respectively) were reduced immediately after MRI. At long-term follow-up (61% of patients), decreased RV sensing (median, 0 mV, [IQR, -1.1 to 0.3 mV]), decreased RV lead impedance (median, -3 Ω, [IQR, -29 to 15 Ω]), increased RV capture threshold (median, 0 V, IQR, [0 to 0.2 Ω]), and decreased battery voltage (median, -0.01 V, IQR, -0.04 to 0 V) were noted. The observed changes did not require device revision or reprogramming. Limitations: Not all available cardiac devices have been tested. Long-term in-person or telephone follow-up was unavailable in 43 patients (10%), and some data were missing. Those with missing long-term capture threshold data had higher baseline right atrial and right ventricular capture thresholds and were more likely to have undergone thoracic imaging. Defibrillation threshold testing and random assignment to a control group were not performed. Conclusion: With appropriate precautions, MRI can be done safely in patients with selected cardiac devices. Because changes in device variables and programming may occur, electrophysiologic monitoring during MRI is essential. Primary Funding Source: National Institutes of Health.

Ann Intern Med: 04 Oct 2011; 155:415-24
Nazarian S, Hansford R, Roguin A, Goldsher D, ... Bluemke DA, Halperin HR
Ann Intern Med: 04 Oct 2011; 155:415-24 | PMID: 21969340
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Abstract

Behavioral counseling to promote physical activity and a healthful diet to prevent cardiovascular disease in adults: a systematic review for the u.s. Preventive services task force.

Lin JS, O\'Connor E, Whitlock EP, Beil TL
Background: Poor diet and lack of physical activity can worsen cardiovascular health, yet most Americans do not meet diet and physical activity recommendations. Purpose: To assist the U.S. Preventive Services Task Force in updating its previous recommendations by systematically reviewing trials of physical activity or dietary counseling to prevent cardiovascular disease. Data sources: MEDLINE, PsycINFO, Cochrane Central Register of Controlled Trials (2001 to January 2010), experts, and existing systematic reviews. Study Selection: Two investigators independently reviewed 13 562 abstracts and 481 articles against a set of a priori inclusion criteria and critically appraised each study by using design-specific quality criteria. Data Extraction and Analysis: Data from 73 studies (109 articles) were abstracted by one reviewer and checked by a second reviewer. Random-effects meta-analyses were conducted for multiple intermediate health and behavioral outcomes. Data Synthesis: Long-term observational follow-up of intensive sodium reduction counseling showed a decrease in the incidence of cardiovascular disease; however, other direct evidence for reduction in disease morbidity is lacking. High-intensity dietary counseling, with or without physical activity counseling, resulted in changes of -0.3 to -0.7 kg/m(2) in body mass index (adiposity), -1.5 mm Hg (95% CI, -0.9 to -2.1 mm Hg) in systolic blood pressure, -0.7 mm Hg (CI, -0.6 to -0.9 mm Hg) in diastolic pressure, -0.17 mmol/L (CI, -0.09 to -0.25 mmol/L) (-6.56 mg/dL [CI, -3.47 to -9.65 mg/dL]) in total cholesterol level, and -0.13 mmol/L (CI, -0.06 to -0.21 mmol/L) (-5.02 mg/dL [CI, -2.32 to -8.11 mg/dL]) in low-density lipoprotein cholesterol level. Medium- and high-intensity counseling resulted in moderate to large changes in self-reported dietary and physical activity behaviors. Limitations: Meta-analyses for some outcomes had large statistical heterogeneity or evidence for publication bias. Only 11 trials followed outcomes beyond 12 months. Conclusion: Counseling to improve diet or increase physical activity changed health behaviors and was associated with small improvements in adiposity, blood pressure, and lipid levels. Primary Funding Source: Agency for Healthcare Research and Quality.

Ann Intern Med: 07 Dec 2010; 153:736-50
Lin JS, O'Connor E, Whitlock EP, Beil TL
Ann Intern Med: 07 Dec 2010; 153:736-50 | PMID: 21135297
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Abstract

Steroid pretreatment of organ donors to prevent postischemic renal allograft failure: a randomized, controlled trial.

Kainz A, Wilflingseder J, Mitterbauer C, Haller M, ... Heinze G, Oberbauer R
Background: Posttransplantation acute renal failure (ARF) occurs in roughly 25% of recipients of organs from deceased donors. Inflammation in the donor organ is associated with risk for ARF. Objective: To determine whether administering corticosteroids to deceased organ donors reduces the incidence and duration of ARF in organ recipients more than placebo. Design: Parallel, blocked randomized trial, performed between February 2006 and November 2008, with computer-generated randomization and centralized allocation. Investigators were masked to group assignment. (Controlled-trials.com registration number: ISRCTN78828338) Setting: 3 renal transplantation centers in Austria and Hungary. Patients: 306 deceased heart-beating donors and 455 renal transplant recipients. Interventions: Organ donors were administered an intravenous infusion of either 1000 mg of methylprednisolone (136 donors) or placebo (0.9% saline) (133 donors) at least 3 hours before organ harvesting. Measurements: Incidence of ARF, defined as more than 1 dialysis session in the first week after transplantation, was the primary end point. Secondary and other end points included duration of ARF and trajectories of serum creatinine level. The suppression of immune response and inflammation by the intervention was assessed in the donor organ on a genome-wide basis. Results: 52 of 238 recipients (22%) of kidneys from steroid-treated donors and 54 of 217 recipients (25%) of kidneys from placebo-treated donors had ARF (difference, 3 percentage points [95% CI, -11 to 5 percentage points]). One graft was lost on day 1 in each group, and 1 recipient in the placebo group died of cardiac arrest on day 2. The median duration of ARF was 5 days (interquartile range, 2 days) in the steroid group and 4 days (interquartile range, 2 days) in the placebo group (P = 0.31). The groups had similar trajectories of serum creatinine level in the first week (P = 0.72). Genomic analysis showed suppressed inflammation and immune response in kidney biopsies from deceased donors who received corticosteroids. Limitation: Donors and recipients were mainly white, and all were from 3 transplantation centers in central Europe, which may limit generalizability. Conclusion: Systemic suppression of inflammation in deceased donors by corticosteroids did not reduce the incidence or duration of posttransplantation ARF in allograft recipients. Primary Funding Source: Austrian Science Fund and Austrian Academy of Science.

Ann Intern Med: 17 Aug 2010; 153:222-30
Kainz A, Wilflingseder J, Mitterbauer C, Haller M, ... Heinze G, Oberbauer R
Ann Intern Med: 17 Aug 2010; 153:222-30 | PMID: 20713790
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Abstract

The U.S. Health Insurance Marketplace: Are Premiums Truly Affordable?

Graetz I, Kaplan CM, Kaplan EK, Bailey JE, Waters TM
The Patient Protection and Affordable Care Act requires that individuals have health insurance or pay a penalty. Individuals are exempt from paying this penalty if the after-subsidy cost of the least-expensive plan available to them is greater than 8% of their income. For this study, premium data for all health plans offered on the state and federal health insurance marketplaces were collected; the after-subsidy cost of premiums for the least-expensive bronze plan for every county in the United States was calculated; and variations in premium affordability by age, income, and geographic area were assessed. Results indicated that-although marketplace subsidies ensure affordable health insurance for most persons in the United States-many individuals with incomes just above the subsidy threshold will lack affordable coverage and will be exempt from the mandate. Furthermore, young individuals with low incomes often pay as much as or more than older individuals for bronze plans. If substantial numbers of younger, healthier adults choose to remain uninsured because of cost, health insurance premiums across all ages may increase over time.

Ann Intern Med: 08 Sep 2014; epub ahead of print
Graetz I, Kaplan CM, Kaplan EK, Bailey JE, Waters TM
Ann Intern Med: 08 Sep 2014; epub ahead of print | PMID: 25199512
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Abstract

Common cutaneous parasites.

Markova A, Kam SA, Miller DD, Lichtman MK
This issue provides a clinical overview of Common Cutaneous Parasites focusing on prevention, diagnosis, treatment, practice improvement, and patient information. The content of In the Clinic is drawn from the clinical information and education resources of the American College of Physicians (ACP), including ACP Smart Medicine and MKSAP (Medical Knowledge and Self-Assessment Program). Annals of Internal Medicine editors develop In the Clinic from these primary sources in collaboration with the ACP\'s Medical Education and Publishing divisions and with the assistance of science writers and physician writers. Editorial consultants from ACP Smart Medicine and MKSAP provide expert review of the content. Readers who are interested in these primary resources for more detail can consult http://smartmedicine.acponline.org, http://mksap.acponline.org, and other resources referenced in each issue of In the Clinic.

Ann Intern Med: 01 Sep 2014; 161
Markova A, Kam SA, Miller DD, Lichtman MK
Ann Intern Med: 01 Sep 2014; 161 | PMID: 25178582
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Abstract

A Practical and Evidence-Based Approach to Common Symptoms: A Narrative Review.

Kroenke K
Physical symptoms account for more than half of all outpatient visits, yet the predominant disease-focused model of care is inadequate for many of these symptom-prompted encounters. Moreover, the amount of clinician training dedicated to understanding, evaluating, and managing common symptoms is disproportionally small relative to their prevalence, impairment, and health care costs. This narrative review regarding physical symptoms addresses 4 common epidemiologic questions: cause, diagnosis, prognosis, and therapy. Important findings include the following: First, at least one third of common symptoms do not have a clear-cut, disease-based explanation (5 studies in primary care, 1 in specialty clinics, and 2 in the general population). Second, the history and physical examination alone contribute 73% to 94% of the diagnostic information, with costly testing and procedures contributing much less (5 studies of multiple types of symptoms and 4 of specific symptoms). Third, physical and psychological symptoms commonly co-occur, making a dualistic approach impractical. Fourth, because most patients have multiple symptoms rather than a single symptom, focusing on 1 symptom and ignoring the others is unwise. Fifth, symptoms improve in weeks to several months in most patients but become chronic or recur in 20% to 25%. Sixth, serious causes that are not apparent after initial evaluation seldom emerge during long-term follow-up. Seventh, certain pharmacologic and behavioral treatments are effective across multiple types of symptoms. Eighth, measuring treatment response with valid scales can be helpful. Finally, communication has therapeutic value, including providing an explanation and probable prognosis without "normalizing" the symptom.

Ann Intern Med: 19 Oct 2014; 161:579-586
Kroenke K
Ann Intern Med: 19 Oct 2014; 161:579-586 | PMID: 25329205
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Abstract

Clinical Documentation in the 21st Century: Executive Summary of a Policy Position Paper From the American College of Physicians.

Kuhn T, Basch P, Barr M, Yackel T, for the Medical Informatics Committee of the American College of Physicians*
Clinical documentation was developed to track a patient\'s condition and communicate the author\'s actions and thoughts to other members of the care team. Over time, other stakeholders have placed additional requirements on the clinical documentation process for purposes other than direct care of the patient. More recently, new information technologies, such as electronic health record (EHR) systems, have led to further changes in the clinical documentation process. Although computers and EHRs can facilitate and even improve clinical documentation, their use can also add complexities; new challenges; and, in the eyes of some, an increase in inappropriate or even fraudulent documentation. At the same time, many physicians and other health care professionals have argued that the quality of the systems being used for clinical documentation is inadequate. The Medical Informatics Committee of the American College of Physicians has undertaken this review of clinical documentation in an effort to clarify the broad range of complex and interrelated issues surrounding clinical documentation and to suggest a path forward such that care and clinical documentation in the 21st century best serve the needs of patients and families.

Ann Intern Med: 11 Jan 2015; epub ahead of print
Kuhn T, Basch P, Barr M, Yackel T, for the Medical Informatics Committee of the American College of Physicians*
Ann Intern Med: 11 Jan 2015; epub ahead of print | PMID: 25581028
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Abstract

Insomnia.

Masters PA
This issue provides a clinical overview of Insomnia focusing on prevention, diagnosis, treatment, practice improvement, and patient information. The content of In the Clinic is drawn from the clinical information and education resources of the American College of Physicians (ACP), including ACP Smart Medicine and MKSAP (Medical Knowledge and Self-Assessment Program). Annals of Internal Medicine editors develop In the Clinic from these primary sources in collaboration with the ACP\'s Medical Education and Publishing divisions and with the assistance of science writers and physician writers. Editorial consultants from ACP Smart Medicine and MKSAP provide expert review of the content. Readers who are interested in these primary resources for more detail can consult http://smartmedicine.acponline.org, http://mksap.acponline.org, and other resources referenced in each issue of In the Clinic.

Ann Intern Med: 06 Oct 2014; 161
Masters PA
Ann Intern Med: 06 Oct 2014; 161 | PMID: 25285559
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Abstract

Rosuvastatin for primary prevention in older persons with elevated C-reactive protein and low to average low-density lipoprotein cholesterol levels: exploratory analysis of a randomized trial.

Glynn RJ, Koenig W, Nordestgaard BG, Shepherd J, Ridker PM
Background: Randomized data on statins for primary prevention in older persons are limited, and the relative hazard of cardiovascular disease associated with an elevated cholesterol level weakens with advancing age. Objective: To assess the efficacy and safety of rosuvastatin in persons 70 years or older. Design: Secondary analysis of JUPITER (Justification for the Use of statins in Prevention: an Intervention Trial Evaluating Rosuvastatin), a randomized, double-blind, placebo-controlled trial. Setting: 1315 sites in 26 countries randomly assigned participants in JUPITER. Participants: Among the 17 802 participants randomly assigned with low-density lipoprotein (LDL) cholesterol levels less than 3.37 mmol/L (<130 mg/dL) and high-sensitivity C-reactive protein levels of 2.0 mg/L or more without cardiovascular disease, 5695 were 70 years or older. Intervention: Participants were randomly assigned in a 1:1 ratio to receive 20 mg of rosuvastatin daily or placebo. Measurements: The primary end point was the occurrence of a first cardiovascular event (myocardial infarction, stroke, arterial revascularization, hospitalization for unstable angina, or death from cardiovascular causes). Results: The 32% of trial participants 70 years or older accrued 49% (n = 194) of the 393 confirmed primary end points. The rates of the primary end point in this age group were 1.22 and 1.99 per 100 person-years of follow-up in the rosuvastatin and placebo groups, respectively (hazard ratio, 0.61 [95% CI, 0.46 to 0.82]; P < 0.001). Corresponding rates of all-cause mortality in this age group were 1.63 and 2.04 (hazard ratio, 0.80 [CI, 0.62 to 1.04]; P = 0.090). Although no significant heterogeneity was found in treatment effects by age, absolute reductions in event rates associated with rosuvastatin were greater in older persons. The relative rate of any serious adverse event among older persons in the rosuvastatin versus placebo group was 1.05 (CI, 0.93 to 1.17). LIMITATION: Effect estimates from this exploratory analysis with age cut-point chosen after trial completion should be viewed in the context of the overall trial results. Conclusion: In apparently healthy older persons without hyperlipidemia but with elevated high-sensitivity C-reactive protein levels, rosuvastatin reduces the incidence of major cardiovascular events. PRIMARY Funding source: AstraZeneca.

Ann Intern Med: 20 Apr 2010; 152:488-96,
Glynn RJ, Koenig W, Nordestgaard BG, Shepherd J, Ridker PM
Ann Intern Med: 20 Apr 2010; 152:488-96, | PMID: 20404379
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Abstract

Obstructive sleep apnea.

Balachandran JS, Patel SR
This issue provides a clinical overview of Obstructive Sleep Apnea focusing on prevention, diagnosis, treatment, practice improvement, and patient information. The content of In the Clinic is drawn from the clinical information and education resources of the American College of Physicians (ACP), including ACP Smart Medicine and MKSAP (Medical Knowledge and Self-Assessment Program). Annals of Internal Medicine editors develop In the Clinic from these primary sources in collaboration with the ACP\'s Medical Education and Publishing divisions and with the assistance of science writers and physician writers. Editorial consultants from ACP Smart Medicine and MKSAP provide expert review of the content. Readers who are interested in these primary resources for more detail can consult http://smartmedicine.acponline.org, http://mksap.acponline.org, and other resources referenced in each issue of In the Clinic.

Ann Intern Med: 03 Nov 2014; 161
Balachandran JS, Patel SR
Ann Intern Med: 03 Nov 2014; 161 | PMID: 25364899
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Abstract

Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis (TRIPOD): The TRIPOD Statement.

Collins GS, Reitsma JB, Altman DG, Moons KG
Prediction models are developed to aid health care providers in estimating the probability or risk that a specific disease or condition is present (diagnostic models) or that a specific event will occur in the future (prognostic models), to inform their decision making. However, the overwhelming evidence shows that the quality of reporting of prediction model studies is poor. Only with full and clear reporting of information on all aspects of a prediction model can risk of bias and potential usefulness of prediction models be adequately assessed. The Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis (TRIPOD) Initiative developed a set of recommendations for the reporting of studies developing, validating, or updating a prediction model, whether for diagnostic or prognostic purposes. This article describes how the TRIPOD Statement was developed. An extensive list of items based on a review of the literature was created, which was reduced after a Web-based survey and revised during a 3-day meeting in June 2011 with methodologists, health care professionals, and journal editors. The list was refined during several meetings of the steering group and in e-mail discussions with the wider group of TRIPOD contributors. The resulting TRIPOD Statement is a checklist of 22 items, deemed essential for transparent reporting of a prediction model study. The TRIPOD Statement aims to improve the transparency of the reporting of a prediction model study regardless of the study methods used. The TRIPOD Statement is best used in conjunction with the TRIPOD explanation and elaboration document. To aid the editorial process and readers of prediction model studies, it is recommended that authors include a completed checklist in their submission (also available at www.tripod-statement.org).

Ann Intern Med: 05 Jan 2015; 162:55-63
Collins GS, Reitsma JB, Altman DG, Moons KG
Ann Intern Med: 05 Jan 2015; 162:55-63 | PMID: 25560714
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Impact:
Abstract

Hypertension.

Weir MR
This issue provides a clinical overview of Hypertension focusing on prevention, diagnosis, treatment, practice improvement, and patient information. The content of In the Clinic is drawn from the clinical information and education resources of the American College of Physicians (ACP), including ACP Smart Medicine and MKSAP (Medical Knowledge and Self-Assessment Program). Annals of Internal Medicine editors develop In the Clinic from these primary sources in collaboration with the ACP\'s Medical Education and Publishing divisions and with the assistance of science writers and physician writers. Editorial consultants from ACP Smart Medicine and MKSAP provide expert review of the content. Readers who are interested in these primary resources for more detail can consult http://smartmedicine.acponline.org, http://mksap.acponline.org, and other resources referenced in each issue of In the Clinic.

Ann Intern Med: 01 Dec 2014; 161
Weir MR
Ann Intern Med: 01 Dec 2014; 161 | PMID: 25437425
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Impact:
Abstract

Rotator cuff disease.

Whittle S, Buchbinder R
This issue provides a clinical overview of Rotator Cuff Disease focusing on prevention, diagnosis, treatment, practice improvement, and patient information. The content of In the Clinic is drawn from the clinical information and education resources of the American College of Physicians (ACP), including ACP Smart Medicine and MKSAP (Medical Knowledge and Self-Assessment Program). Annals of Internal Medicine editors develop In the Clinic from these primary sources in collaboration with the ACP\'s Medical Education and Publishing divisions and with the assistance of science writers and physician writers. Editorial consultants from ACP Smart Medicine and MKSAP provide expert review of the content. Readers who are interested in these primary resources for more detail can consult http://smartmedicine.acponline.org, http://mksap.acponline.org, and other resources referenced in each issue of In the Clinic.

Ann Intern Med: 05 Jan 2015; 162:ITC1
Whittle S, Buchbinder R
Ann Intern Med: 05 Jan 2015; 162:ITC1 | PMID: 25560729
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Abstract

Models in the development of clinical practice guidelines.

Habbema JD, Wilt TJ, Etzioni R, Nelson HD, ... Owens DK, Feuer EJ
Clinical practice guidelines should be based on the best scientific evidence derived from systematic reviews of primary research. However, these studies often do not provide evidence needed by guideline development groups to evaluate the tradeoffs between benefits and harms. In this article, the authors identify 4 areas where models can bridge the gaps between published evidence and the information needed for guideline development applying new or updated information on disease risk, diagnostic test properties, and treatment efficacy; exploring a more complete array of alternative intervention strategies; assessing benefits and harms over a lifetime horizon; and projecting outcomes for the conditions for which the guideline is intended. The use of modeling as an approach to bridge these gaps (provided that the models are high-quality and adequately validated) is considered. Colorectal and breast cancer screening are used as examples to show the utility of models for these purposes. The authors propose that a modeling study is most useful when strong primary evidence is available to inform the model but critical gaps remain between the evidence and the questions that the guideline group must address. In these cases, model results have a place alongside the findings of systematic reviews to inform health care practice and policy.

Ann Intern Med: 01 Dec 2014; 161:812-8
Habbema JD, Wilt TJ, Etzioni R, Nelson HD, ... Owens DK, Feuer EJ
Ann Intern Med: 01 Dec 2014; 161:812-8 | PMID: 25437409
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Impact:
Abstract

Meta-analysis: Effect of B-Type Natriuretic Peptide Testing on Clinical Outcomes in Patients With Acute Dyspnea in the Emergency Setting.

Lam LL, Cameron PA, Schneider HG, Abramson MJ, Müller C, Krum H
Background: Although the accuracy of B-type natriuretic peptide (BNP) testing for diagnosing acute decompensated heart failure has been extensively evaluated, the effect of this test on clinical outcomes remains unclear. Purpose: To investigate whether BNP testing of patients presenting with acute dyspnea in the emergency department leads to fewer admissions, shorter length of stay, and improved short-term survival compared with usual care without BNP testing. Data sources: Two reviewers searched Ovid MEDLINE and EMBASE, without language restrictions, to identify pertinent studies published from January 1996 to July 2010. Study Selection: Randomized, controlled trials that compared BNP testing to diagnose heart failure with routine care in patients presenting with acute dyspnea and information about 1 or more of the following outcomes: mortality, admission, or length of hospital stay. Data extraction: Two authors independently reviewed articles, extracted data, and assessed quality and risk for bias of studies. Data Synthesis: Five trials conducted in 5 countries and involving 2513 patients met inclusion criteria. Study settings had differing emergency department staffing models and used various BNP testing protocols. The pooled estimate of effect of BNP testing on all-cause mortality had wide confidence bounds and was inconclusive (odds ratio, 0.96 [95% CI, 0.65 to 1.41]). Admission rates decreased in the tested group compared with the control group (odds ratio, 0.82 [CI, 0.67 to 1.01]), although this finding was not statistically significant. Length of hospital and critical care unit stay were both modestly reduced in the tested group compared with the control group, with a mean difference of -1.22 days (CI, -2.31 to -0.14 day) and -0.56 day (CI, -1.06 to -0.05 day), respectively. Limitation: Few relevant trials were studied. Patients included in the trials and the settings in which trials were conducted were heterogeneous. Conclusion: B-type natriuretic peptide testing in the emergency department for patients presenting with acute dyspnea decreased length hospital of stay by about 1 day and possibly reduced admission rates but did not conclusively affect hospital mortality rates. Primary Funding Source: Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.

Ann Intern Med: 07 Dec 2010; 153:728-35
Lam LL, Cameron PA, Schneider HG, Abramson MJ, Müller C, Krum H
Ann Intern Med: 07 Dec 2010; 153:728-35 | PMID: 21135296
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Abstract

Is Pocket Mobile Echocardiography the Next-Generation Stethoscope? A Cross-sectional Comparison of Rapidly Acquired Images With Standard Transthoracic Echocardiography.

Liebo MJ, Israel RL, Lillie EO, Smith MR, Rubenson DS, Topol EJ
Background: A pocket mobile echocardiography (PME) device is commercially available for clinical use, but public data documenting its accuracy compared with standard transthoracic echocardiography (TTE) are not available. Objective: To compare the accuracy of rapidly acquired PME images with those acquired by standard TTE. Design: Cross-sectional study. At the time of referral for TTE, ultrasonographers acquired PME images first in 5 minutes or less. Ultrasonographers were not blinded to the clinical indication for imaging or to the PME image results when obtaining standard TTE images. Two experienced echocardiographers and 2 cardiology fellows who were blinded to the indication for the study and TTE results but not to the device source interpreted the PME images. Setting: Scripps Clinic Torrey Pines and Scripps Green Hospital, La Jolla, California. Patients: Convenience sample of 97 patients consecutively referred for echocardiography. Measurements: Visualizability and accuracy (the sum of proportions of true-positive and true-negative readings and observer variability) for ejection fraction, wall-motion abnormalities, left ventricular end-diastolic dimension, inferior vena cava size, aortic and mitral valve pathology, and pericardial effusion. Results: Physician-readers could visualize some but not all echocardiographic measurements obtained with the PME device in every patient (highest proportions were for ejection fraction and left ventricular end-diastolic dimension [95% each]; the lowest proportion was for inferior vena cava size [75%]). Accuracy also varied by measurement (aortic valve was 96% [highest] and inferior vena cava size was 78% [lowest]) and decreased when nonvisualizability was accounted for (aortic valve was 91% and inferior vena cava size was 58%). Observer agreement was fair to moderate for some measurements among less-experienced readers. Limitation: The study was conducted at a single setting, there was no formal estimate of accuracy given the small convenience sample of patients, and few abnormal echocardiographic measurements occurred. Conclusion: The rapid acquisition of images by skilled ultrasonographers who use PME yields accurate assessments of ejection fraction and some but not all cardiac structures in many patients. Further testing of the device in larger patient cohorts with diverse cardiac abnormalities and with untrained clinicians obtaining and interpreting images is required before wide dissemination of its use can be recommended. Primary Funding Source: National Institutes of Health.

Ann Intern Med: 05 Jul 2011; 155:33-8
Liebo MJ, Israel RL, Lillie EO, Smith MR, Rubenson DS, Topol EJ
Ann Intern Med: 05 Jul 2011; 155:33-8 | PMID: 21727291
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Abstract

Off-Label Use of Recombinant Factor VIIa in U.S. Hospitals: Analysis of Hospital Records.

Logan AC, Yank V, Stafford RS
Background: Recombinant factor VIIa (rFVIIa) is approved for treatment of bleeding in patients who have hemophilia with inhibitors but has been applied to a wide range of off-label indications. Objective: To estimate patterns of off-label rFVIIa use in U.S. hospitals. Design: Retrospective database analysis. Setting: Data were extracted from the Premier Perspectives database (Premier, Charlotte, North Carolina), which contains discharge records from a sample of academic and nonacademic U.S. hospitals. Patients: 12 644 hospitalizations for patients who received rFVIIa during a hospital stay. Measurements: Hospital diagnoses and patient dispositions from 1 January 2000 to 31 December 2008. Statistical weights for each hospital were used to provide national estimates of rFVIIa use. Results: From 2000 to 2008, off-label use of rFVIIa in hospitals increased more than 140-fold, such that in 2008, 97% (95% CI, 96% to 98%) of 18 311 in-hospital uses were off-label. In contrast, in-hospital use for hemophilia increased less than 4-fold and accounted for 2.7% (CI, 1.9% to 3.5%) of use in 2008. Adult and pediatric cardiovascular surgery (29% [CI, 21% to 33%]), body and brain trauma (29% [CI, 19% to 38%]), and intracranial hemorrhage (11% [CI, 7.7% to 14%]) were the most common indications for rFVIIa use. Across all indications, in-hospital mortality was 27% (CI, 19% to 34%) and 43% (CI, 26% to 59%) of patients were discharged to home. Limitation: Accuracy and completeness of the discharge diagnoses and patient medication records in the database sample cannot be verified. Conclusion: Off-label use of rFVIIa in the hospital setting far exceeds use for approved indications. These patterns raise concern about the application of rFVIIa to conditions for which strong supporting evidence is lacking. Primary Funding Source: Agency for Healthcare Research and Quality.

Ann Intern Med: 19 Apr 2011; 154:516-22
Logan AC, Yank V, Stafford RS
Ann Intern Med: 19 Apr 2011; 154:516-22 | PMID: 21502649
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Abstract

National clinical guideline centre cost-effectiveness assessment for the national institute for health and clinical excellence.

Wonderling D, Sawyer L, Fenu E, Lovibond K, Laramée P
The National Clinical Guideline Centre (NCGC) develops evidence-based clinical guidelines on behalf of the National Institute for Health and Clinical Excellence (NICE) in the United Kingdom. The U.K. Department of Health has commissioned NICE to make recommendations on the basis of both clinical effectiveness and cost-effectiveness. This article describes how cost-effectiveness is evaluated and accounted for in NCGC guidelines. Six recent case studies are presented, in which consideration of cost-effectiveness has informed recommendations in various ways for clinical guidelines on alcohol use disorders, chronic obstructive pulmonary disease, glaucoma, lower urinary tract symptoms, non-ST-segment elevation myocardial infarction and unstable angina, and venous thromboembolism prophylaxis. Some of the challenges faced in trying to account for cost-effectiveness in clinical guidelines are outlined, as well as some of the difficulties in adapting cost-effectiveness guidelines for other settings.

Ann Intern Med: 07 Jun 2011; 154:758-65
Wonderling D, Sawyer L, Fenu E, Lovibond K, Laramée P
Ann Intern Med: 07 Jun 2011; 154:758-65 | PMID: 21646559
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Abstract

Innovations in data collection, management, and archiving for systematic reviews.

Li T, Vedula SS, Hadar N, Parkin C, Lau J, Dickersin K
Data abstraction is a key step in conducting systematic reviews because data collected from study reports form the basis of appropriate conclusions. Recent methodological standards and expectations highlight several principles for data collection. To support implementation of these standards, this article provides a step-by-step tutorial for selecting data collection tools; constructing data collection forms; and abstracting, managing, and archiving data for systematic reviews. Examples are drawn from recent experience using the Systematic Review Data Repository for data collection and management. If it is done well, data collection for systematic reviews only needs to be done by 1 team and placed into a publicly accessible database for future use. Technological innovations, such as the Systematic Review Data Repository, will contribute to finding trustworthy answers for many health and health care questions.

Ann Intern Med: 16 Feb 2015; 162:287-94
Li T, Vedula SS, Hadar N, Parkin C, Lau J, Dickersin K
Ann Intern Med: 16 Feb 2015; 162:287-94 | PMID: 25686168
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Abstract

Electronic nicotine delivery systems: executive summary of a policy position paper from the american college of physicians.

Crowley RA, Health Public Policy Committee of the American College of Physicians
Electronic nicotine delivery systems (ENDS), which include electronic cigarettes, or e-cigarettes, are growing in popularity, but their safety and efficacy as a smoking cessation aid are not well understood. Some argue that they have the potential to reduce tobacco-related morbidity and mortality and could be a useful tool for reducing tobacco-related harm. Others express concern that the health effects of ENDS use are unknown, that they may appeal to young people, and that they may encourage dual use of ENDS and traditional tobacco products. Although ENDS are a new and unregulated product, the U.S. Food and Drug Administration has proposed regulations that would deem ENDS to be subject to the Family Smoking Prevention and Tobacco Control Act, which regulates cigarettes and other tobacco products. In this position paper, the American College of Physicians offers policy recommendations on ENDS regulation and oversight, taxation, flavorings, promotion and marketing, indoor and public use, and research. This paper is not intended to offer clinical guidance or serve as an exhaustive literature review of existing ENDS-related evidence but to help direct the College, policymakers, and regulators on how to address these products.

Ann Intern Med: 20 Apr 2015; 162:583-4
Crowley RA, Health Public Policy Committee of the American College of Physicians
Ann Intern Med: 20 Apr 2015; 162:583-4 | PMID: 25894027
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Abstract

The Effect of Financial Incentives on Hospitals That Serve Poor Patients.

Jha AK, Orav EJ, Epstein AM
Background: Providing financial incentives to hospitals to improve quality is increasingly common, yet its effect on hospitals that care for poor patients is largely unknown. Objective: To determine how financial incentives for quality performance affect hospitals with more poor patients compared with those with fewer poor patients. Design: Retrospective study. Setting: U.S. hospitals. Participants: 251 hospitals that participated in the Premier Hospital Quality Incentive Demonstration program and a national sample of 3017 hospitals. Measurements: The association between the disproportionate-share index, a marker of caring for poor patients, and baseline quality performance, changes in performance, and terminal performance for acute myocardial infarction, congestive heart failure, and pneumonia for hospitals in the pay-for-performance program and those in the national sample (which did not receive financial incentives). Results: Among both pay-for-performance hospitals and those in the national sample, hospitals with more poor patients had lower baseline performance than did those with fewer poor patients. A high disproportionate-share index was associated with greater improvements in performance for acute myocardial infarction and pneumonia but not for congestive heart failure, and the gains were greater among hospitals that received financial incentives than among the national sample. After 3 years, hospitals that had more poor patients and received financial incentives caught up for all 3 conditions, whereas those with more poor patients among the national sample continued to lag. Limitation: Hospitals in the Premier Hospital Quality Incentive Demonstration may be atypical, and these results may not be generalizable to all hospitals. Conclusion: No evidence indicated that financial incentives widened the gap in performance between hospitals that serve poor patients and other hospitals. Pay-for-performance programs may be a promising quality improvement strategy for hospitals that serve poor patients. Primary Funding Source: Robert Wood Johnson Foundation.

Ann Intern Med: 07 Sep 2010; 153:299-306
Jha AK, Orav EJ, Epstein AM
Ann Intern Med: 07 Sep 2010; 153:299-306 | PMID: 20820039
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Abstract

Firearm-Related Injury and Death in the United States: A Call to Action From 8 Health Professional Organizations and the American Bar Association.

Weinberger SE, Hoyt DB, Lawrence Iii HC, Levin S, ... Benjamin GC, Hubbard WC
Deaths and injuries related to firearms constitute a major public health problem in the United States. In response to firearm violence and other firearm-related injuries and deaths, an interdisciplinary, interprofessional group of leaders of 8 national health professional organizations and the American Bar Association, representing the official policy positions of their organizations, advocate a series of measures aimed at reducing the health and public health consequences of firearms. The specific recommendations include universal background checks of gun purchasers, elimination of physician "gag laws," restricting the manufacture and sale of military-style assault weapons and large-capacity magazines for civilian use, and research to support strategies for reducing firearm-related injuries and deaths. The health professional organizations also advocate for improved access to mental health services and avoidance of stigmatization of persons with mental and substance use disorders through blanket reporting laws. The American Bar Association, acting through its Standing Committee on Gun Violence, confirms that none of these recommendations conflict with the Second Amendment or previous rulings of the U.S. Supreme Court.

Ann Intern Med: 22 Feb 2015; epub ahead of print
Weinberger SE, Hoyt DB, Lawrence Iii HC, Levin S, ... Benjamin GC, Hubbard WC
Ann Intern Med: 22 Feb 2015; epub ahead of print | PMID: 25706470
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Abstract

Ethics and the Legalization of Physician-Assisted Suicide: An American College of Physicians Position Paper.

Snyder Sulmasy L, Mueller PS
Calls to legalize physician-assisted suicide have increased and public interest in the subject has grown in recent years despite ethical prohibitions. Many people have concerns about how they will die and the emphasis by medicine and society on intervention and cure has sometimes come at the expense of good end-of-life care. Some have advocated strongly, on the basis of autonomy, that physician-assisted suicide should be a legal option at the end of life. As a proponent of patient-centered care, the American College of Physicians (ACP) is attentive to all voices, including those who speak of the desire to control when and how life will end. However, the ACP believes that the ethical arguments against legalizing physician-assisted suicide remain the most compelling. On the basis of substantive ethics, clinical practice, policy, and other concerns articulated in this position paper, the ACP does not support legalization of physician-assisted suicide. It is problematic given the nature of the patient-physician relationship, affects trust in the relationship and in the profession, and fundamentally alters the medical profession\'s role in society. Furthermore, the principles at stake in this debate also underlie medicine\'s responsibilities regarding other issues and the physician\'s duties to provide care based on clinical judgment, evidence, and ethics. Society\'s focus at the end of life should be on efforts to address suffering and the needs of patients and families, including improving access to effective hospice and palliative care. The ACP remains committed to improving care for patients throughout and at the end of life.

Ann Intern Med: 16 Oct 2017; 167:576-578
Snyder Sulmasy L, Mueller PS
Ann Intern Med: 16 Oct 2017; 167:576-578 | PMID: 28975242
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Abstract

Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis (TRIPOD): Explanation and Elaboration.

Moons KG, Altman DG, Reitsma JB, Ioannidis JP, ... Ransohoff DF, Collins GS
The TRIPOD (Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis) Statement includes a 22-item checklist, which aims to improve the reporting of studies developing, validating, or updating a prediction model, whether for diagnostic or prognostic purposes. The TRIPOD Statement aims to improve the transparency of the reporting of a prediction model study regardless of the study methods used. This explanation and elaboration document describes the rationale; clarifies the meaning of each item; and discusses why transparent reporting is important, with a view to assessing risk of bias and clinical usefulness of the prediction model. Each checklist item of the TRIPOD Statement is explained in detail and accompanied by published examples of good reporting. The document also provides a valuable reference of issues to consider when designing, conducting, and analyzing prediction model studies. To aid the editorial process and help peer reviewers and, ultimately, readers and systematic reviewers of prediction model studies, it is recommended that authors include a completed checklist in their submission. The TRIPOD checklist can also be downloaded from www.tripod-statement.org.

Ann Intern Med: 05 Jan 2015; 162:W1-W73
Moons KG, Altman DG, Reitsma JB, Ioannidis JP, ... Ransohoff DF, Collins GS
Ann Intern Med: 05 Jan 2015; 162:W1-W73 | PMID: 25560730
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Impact:
Abstract

Type 2 diabetes.

Vijan S
This issue provides a clinical overview of Type 2 Diabetes focusing on prevention, diagnosis, treatment, practice improvement, and patient information. The content of In the Clinic is drawn from the clinical information and education resources of the American College of Physicians (ACP), including ACP Smart Medicine and MKSAP (Medical Knowledge and Self-Assessment Program). Annals of Internal Medicine editors develop In the Clinic from these primary sources in collaboration with the ACP\'s Medical Education and Publishing divisions and with the assistance of science writers and physician writers. Editorial consultants from ACP Smart Medicine and MKSAP provide expert review of the content. Readers who are interested in these primary resources for more detail can consult http://smartmedicine.acponline.org, http://mksap.acponline.org, and other resources referenced in each issue of In the Clinic.

Ann Intern Med: 02 Mar 2015; 162:ITC1
Vijan S
Ann Intern Med: 02 Mar 2015; 162:ITC1 | PMID: 25732301
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Abstract

Using additional information on working hours to predict coronary heart disease: a cohort study.

Kivimäki M, Batty GD, Hamer M, Ferrie JE, ... Singh-Manoux A, Shipley MJ
Background: Long working hours are associated with increased risk for coronary heart disease (CHD). Adding information on long hours to traditional risk factors for CHD may help to improve risk prediction for this condition. Objective: To examine whether information on long working hours improves the ability of the Framingham risk model to predict CHD in a low-risk, employed population. Design: Cohort study with baseline medical examination performed between 1991 and 1993 and prospective follow-up for incident CHD performed until 2004. Setting: Civil service departments in London (the Whitehall II study). Participants: 7095 adults (2109 women and 4986 men) aged 39 to 62 years working full-time without CHD at baseline. Measurements: Working hours and the Framingham risk score were measured at baseline. Coronary death and nonfatal myocardial infarction were ascertained from medical screenings every 5 years, hospital data, and registry linkage. Results: 192 participants had incident CHD during a median 12.3-year follow-up. After adjustment for their Framingham risk score, participants working 11 hours or more per day had a 1.67-fold (95% CI, 1.10- to 2.55-fold) increased risk for CHD compared with participants working 7 to 8 hours per day. Adding working hours to the Framingham risk score led to a net reclassification improvement of 4.7% (P = 0.034) due to better identification of persons who later developed CHD (sensitivity gain). Limitation: The findings may not be generalizable to populations with a larger proportion of high-risk persons and were not validated in an independent cohort. Conclusion: Information on working hours may improve risk prediction of CHD on the basis of the Framingham risk score in low-risk, working populations. Primary Funding Source: Medical Research Council; British Heart Foundation; Bupa Foundation; and the National Heart, Lung, and Blood Institute and National Institute on Aging of the National Institutes of Health.

Ann Intern Med: 05 Apr 2011; 154:457-63
Kivimäki M, Batty GD, Hamer M, Ferrie JE, ... Singh-Manoux A, Shipley MJ
Ann Intern Med: 05 Apr 2011; 154:457-63 | PMID: 21464347
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Abstract

Meta-analysis: Statin Therapy Does Not Alter the Association Between Low Levels of High-Density Lipoprotein Cholesterol and Increased Cardiovascular Risk.

Jafri H, Alsheikh-Ali AA, Karas RH
Background: Low levels of high-density lipoprotein cholesterol (HDL-C) are associated with an increased risk for myocardial infarction (MI). Although statins reduce the risk for MI, most cardiovascular events still occur despite statin treatment. Purpose: Using meta-analysis of large randomized, controlled trials (RCTs) of statins to determine whether statins alter the relationship between HDL-C level and MI. Data sources: MEDLINE search to February 2010, ClinicalTrials.gov, and reference lists from eligible studies. Study Selection: English-language RCTs of statin-treated patients versus control participants with 1000 or more person-years of follow-up and reported HDL-C levels and MI. Data extraction: Two independent investigators extracted data from eligible RCTs. Data Synthesis: Twenty eligible RCTs were identified (543 210 person-years of follow-up and 7838 MIs). After adjustment for on-treatment LDL-C levels, age, hypertension, diabetes, and tobacco use, there was a significant inverse association between HDL-C levels and risk for MI in statin-treated patients and control participants. In Poisson meta-regressions, every 0.26-mmol/L (10-mg/dL) decrease in HDL-C was associated with 7.1 (95% CI, 6.8 to 7.3) and 8.3 (CI, 8.1 to 8.5) more MIs per 1000 person-years in statin-treated patients and control participants, respectively. The inverse association between HDL-C levels and MI did not differ between statin-treated patients and control participants (P = 0.57). Limitation: The observed associations may be explained by unmeasured confounding and do not imply causality in the relationship between HDL-C level and cardiovascular risk. Conclusion: Statins do not alter the relationship between HDL-C level and cardiovascular risk, such that low levels of HDL-C remain significantly and independently associated with increased risk despite statin treatment. The remaining risk seen in statin-treated patients may be partly explained by low HDL-C levels or other factors associated with low levels of HDL-C. Primary Funding Source: None.

Ann Intern Med: 21 Dec 2010; 153:800-8
Jafri H, Alsheikh-Ali AA, Karas RH
Ann Intern Med: 21 Dec 2010; 153:800-8 | PMID: 21173414
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Abstract

Climate Change and Health: A Position Paper of the American College of Physicians.

Crowley RA, Health and Public Policy Committee of the American College of Physicians
Climate change could have a devastating effect on human and environmental health. Potential effects of climate change on human health include higher rates of respiratory and heat-related illness, increased prevalence of vector-borne and waterborne diseases, food and water insecurity, and malnutrition. Persons who are elderly, sick, or poor are especially vulnerable to these potential consequences. Addressing climate change could have substantial benefits to human health. In this position paper, the American College of Physicians (ACP) recommends that physicians and the broader health care community throughout the world engage in environmentally sustainable practices that reduce carbon emissions; support efforts to mitigate and adapt to the effects of climate change; and educate the public, their colleagues, their community, and lawmakers about the health risks posed by climate change. Tackling climate change is an opportunity to dramatically improve human health and avert dire environmental outcomes, and ACP believes that physicians can play a role in achieving this goal.

Ann Intern Med: 17 Apr 2016; epub ahead of print
Crowley RA, Health and Public Policy Committee of the American College of Physicians
Ann Intern Med: 17 Apr 2016; epub ahead of print | PMID: 27089232
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Abstract

The Relationship of Health Insurance and Mortality: Is Lack of Insurance Deadly?

Woolhandler S, Himmelstein DU
About 28 million Americans are currently uninsured, and millions more could lose coverage under policy reforms proposed in Congress. At the same time, a growing number of policy leaders have called for going beyond the Patient Protection and Affordable Care Act to a single-payer national health insurance system that would cover every American. These policy debates lend particular salience to studies evaluating the health effects of insurance coverage. In 2002, an Institute of Medicine review concluded that lack of insurance increases mortality, but several relevant studies have appeared since that time. This article summarizes current evidence concerning the relationship of insurance and mortality. The evidence strengthens confidence in the Institute of Medicine\'s conclusion that health insurance saves lives: The odds of dying among the insured relative to the uninsured is 0.71 to 0.97.

Ann Intern Med: 18 Sep 2017; 167:424-431
Woolhandler S, Himmelstein DU
Ann Intern Med: 18 Sep 2017; 167:424-431 | PMID: 28655034
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Abstract

Opportunities for quality measurement to improve the value of care for patients with multiple chronic conditions.

Venkatesh A, Goodrich K, Conway PH
Quality measurement efforts have not historically focused on patients with multiple chronic conditions (MCCs), despite them comprising one quarter of the population and two thirds of health care spending. The Patient Protection and Affordable Care Act (ACA) creates several mechanisms for the Centers for Medicare & Medicaid Services (CMS) to transform quality measurement into an organized enterprise designed to support clinicians caring for this vulnerable population. This article highlights 3 emerging policy opportunities for CMS to guide public and private quality measurement efforts for patients with MCCs. First, it discusses infusing an MCC framework into measure development to promote patient-centered, as opposed to single-disease-specific, performance measurement. Second, it describes the importance of using common performance measures for individual clinicians, hospitals, and communities to accelerate meaningful improvement in the prevention and management of chronic conditions across local populations. Finally, the need for longitudinal measurement as a foundation for sustained quality improvement is presented. The ACA\'s expansion of insurance access and portability necessitates collaborative alignment of chronic condition quality measurement efforts between public and private programs to develop a high-value lifelong health system.

Ann Intern Med: 17 Nov 2014; 161:S76-80
Venkatesh A, Goodrich K, Conway PH
Ann Intern Med: 17 Nov 2014; 161:S76-80 | PMID: 25402407
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Abstract

Constipation.

Shah BJ, Rughwani N, Rose S
This issue provides a clinical overview of constipation, focusing on prevention, diagnosis, treatment, and patient information. The content of In the Clinic is drawn from the clinical information and education resources of the American College of Physicians (ACP), including ACP Smart Medicine and MKSAP (Medical Knowledge and Self-Assessment Program). Annals of Internal Medicine editors develop In the Clinic from these primary sources in collaboration with the ACP\'s Medical Education and Publishing divisions and with the assistance of science writers and physician writers. Editorial consultants from ACP Smart Medicine and MKSAP provide expert review of the content. Readers who are interested in these primary resources for more detail can consult http://smartmedicine.acponline.org, http://mksap.acponline.org, and other resources referenced in each issue of In the Clinic.

Ann Intern Med: 06 Apr 2015; 162:ITC1
Shah BJ, Rughwani N, Rose S
Ann Intern Med: 06 Apr 2015; 162:ITC1 | PMID: 25845017
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Abstract

Perimenopause.

McNamara M, Batur P, DeSapri KT
This issue provides a clinical overview of Perimenopause focusing on prevention, diagnosis, treatment, practice improvement, and patient information. The content of In the Clinic is drawn from the clinical information and education resources of the American College of Physicians (ACP), including ACP Smart Medicine and MKSAP (Medical Knowledge and Self-Assessment Program). Annals of Internal Medicine editors develop In the Clinic from these primary sources in collaboration with the ACP\'s Medical Education and Publishing divisions and with the assistance of science writers and physician writers. Editorial consultants from ACP Smart Medicine and MKSAP provide expert review of the content. Readers who are interested in these primary resources for more detail can consult http://smartmedicine.acponline.org, http://mksap.acponline.org, and other resources referenced in each issue of In the Clinic.

Ann Intern Med: 02 Feb 2015; 162:ITC1
McNamara M, Batur P, DeSapri KT
Ann Intern Med: 02 Feb 2015; 162:ITC1 | PMID: 25643316
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Abstract

Association of leg-length inequality with knee osteoarthritis: a cohort study.

Harvey WF, Yang M, Cooke TD, Segal NA, ... Lewis CE, Felson DT
Background: Leg-length inequality is common in the general population and may accelerate development of knee osteoarthritis. Objective: To determine whether leg-length inequality is associated with prevalent, incident, and progressive knee osteoarthritis. Design: Prospective observational cohort study. Setting: Population samples from Birmingham, Alabama, and Iowa City, Iowa. Patients: 3026 participants aged 50 to 79 years with or at high risk for knee osteoarthritis. Measurements: The exposure was leg-length inequality, measured by full-limb radiography. The outcomes were prevalent, incident, and progressive knee osteoarthritis. Radiographic osteoarthritis was defined as Kellgren and Lawrence grade 2 or greater, and symptomatic osteoarthritis was defined as radiographic disease in a consistently painful knee. Results: Compared with leg-length inequality less than 1 cm, leg-length inequality of 1 cm or more was associated with prevalent radiographic (53% vs. 36%; odds ratio [OR], 1.9 [95% CI, 1.5 to 2.4]) and symptomatic (30% vs. 17%; OR, 2.0 [CI, 1.6 to 2.6]) osteoarthritis in the shorter leg, incident symptomatic osteoarthritis in the shorter leg (15% vs. 9%; OR, 1.7 [CI, 1.2 to 2.4]) and the longer leg (13% vs. 9%; OR, 1.5 [CI, 1.0 to 2.1]), and increased odds of progressive osteoarthritis in the shorter leg (29% vs. 24%; OR, 1.3 [CI, 1.0 to 1.7]). Limitations: Duration of follow-up may not be long enough to adequately identify cases of incidence and progression. Measurements of leg length, including radiography, are subject to measurement error, which could result in misclassification. Conclusion: Radiographic leg-length inequality was associated with prevalent, incident symptomatic, and progressive knee osteoarthritis. Leg-length inequality is a potentially modifiable risk factor for knee osteoarthritis. Primary Funding Source: National Institute on Aging.

Ann Intern Med: 02 Mar 2010; 152:287-95
Harvey WF, Yang M, Cooke TD, Segal NA, ... Lewis CE, Felson DT
Ann Intern Med: 02 Mar 2010; 152:287-95 | PMID: 20194234
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Abstract

Quality of after-hours primary care in the Netherlands: a narrative review.

Giesen P, Smits M, Huibers L, Grol R, Wensing M
Many Western countries are seeking an organizational model for after-hours primary care that is safe, efficient, and satisfactory for patients and health care professionals. Around the year 2000, Dutch primary care physicians (PCPs) reorganized their after-hours primary care and shifted from small rotation groups to large-scale PCP cooperatives. This article provides a narrative review of studies on a range of issues about after-hours primary care in the Netherlands, including experiences of health care professionals and patients, patient-safety incidents, adherence to practice guidelines, waiting times, and quality of telephone triage. Physicians expressed high satisfaction with PCP cooperatives; their workload decreased, and job satisfaction increased compared with the situation before the reorganization. In general, patients were also satisfied, but areas for improvement included telephone consultations, patient education, and distance to a pharmacy. A study identified patient-safety incidents in 2.4% of all contacts, of which most did not result in harm to patients. The average adherence to clinical guidelines by physicians was 77%, with lowest adherence scores for prescribing antibiotics and treatment in emergency cases. The average waiting time for home visits was 30 minutes. Seventy percent of patients with life-threatening problems were visited within the time target of 15 minutes. Telephone triage by nurses had positive effects on care efficiency by increasing the proportion of telephone consultations and decreasing the proportion of clinic consultations and home visits. The after-hours primary care system in the Netherlands might set an example for other countries struggling to find a good solution for the problems they encounter with after-hours primary care. Future developments in the Netherlands include integration and extensive collaboration with the accident and emergency departments of hospitals, in which PCPs take care of self-referring patients.

Ann Intern Med: 19 Jul 2011; 155:108-13
Giesen P, Smits M, Huibers L, Grol R, Wensing M
Ann Intern Med: 19 Jul 2011; 155:108-13 | PMID: 21768584
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Abstract

Principles Supporting Dynamic Clinical Care Teams: An American College of Physicians Position Paper.

Doherty RB, Crowley RA, for the Health and Public Policy Committee of the American College of Physicians*
The U.S. health care system is undergoing a shift from individual clinical practice toward team-based care. This move toward team-based care requires fresh thinking about clinical leadership and responsibilities to ensure that the unique skills of each clinician are used to provide the best care for the patient as the patient\'s needs dictate, while the team as a whole must work together to ensure that all aspects of a patient\'s care are coordinated for the benefit of the patient. In this position paper, the American College of Physicians offers principles, definitions, and examples to dissolve barriers that prevent movement toward dynamic clinical care teams. These principles offer a framework for an evolving, updated approach to health care delivery, providing policy guidance that can be useful to clinical teams in organizing the care processes and clinician responsibilities consistent with professionalism.

Ann Intern Med: 16 Sep 2013; epub ahead of print
Doherty RB, Crowley RA, for the Health and Public Policy Committee of the American College of Physicians*
Ann Intern Med: 16 Sep 2013; epub ahead of print | PMID: 24042251
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Abstract

Lost in translation: physicians\' struggle with cost-reduction programs.

Beckman HB
Relationships between health plans and the medical profession are often strained, leading to the inability to create a shared vision for the health care redesign needed to more effectively care for our population. Because of their respective stakeholders, health plans and providers naturally differ in perspective. However, this article suggests that it is the inability of stakeholders to find a common language to effectively communicate interests, needs, and proposed interventions that often derails progress toward common goals. The business and health plan leaders\' focus on cost-containment and cost-efficiency predictably results in physician defensiveness and disengagement. At the same time, physicians\' limited focus on improving quality to only reducing underuse, which in the short term increases costs, does not acknowledge cost concerns of business leaders and health plan executives. However, as divergent as these emphases might seem, there is potential for common ground with effective language translation. Effective translation has been proposed through the Institute of Medicine\'s definition of quality as reducing overuse, misuse, and underuse. Creating a common language provides seemingly opposing groups an opportunity to explore a shared vision. Using the language of clinical appropriateness and reducing unnecessary variation has resulted in agreement on clinical quality improvement projects from which each group can return to its own organizations and translate back into its familiar "stakeholder" language.

Ann Intern Med: 15 Mar 2011; 154:430-3
Beckman HB
Ann Intern Med: 15 Mar 2011; 154:430-3 | PMID: 21403079
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Abstract

Conceptual and Technical Challenges in Network Meta-analysis.

Cipriani A, Higgins JP, Geddes JR, Salanti G
The increase in treatment options creates an urgent need for comparative effectiveness research. Randomized, controlled trials comparing several treatments are usually not feasible, so other methodological approaches are needed. Meta-analyses provide summary estimates of treatment effects by combining data from many studies. However, an important drawback is that standard meta-analyses can compare only 2 interventions at a time. A new meta-analytic technique, called network meta-analysis (or multiple treatments meta-analysis or mixed-treatment comparison), allows assessment of the relative effectiveness of several interventions, synthesizing evidence across a network of randomized trials. Despite the growing prevalence and influence of network meta-analysis in many fields of medicine, several issues need to be addressed when constructing one to avoid conclusions that are inaccurate, invalid, or not clearly justified. This article explores the scope and limitations of network meta-analysis and offers advice on dealing with heterogeneity, inconsistency, and potential sources of bias in the available evidence to increase awareness among physicians about some of the challenges in interpretation.

Ann Intern Med: 15 Jul 2013; 159:130-7
Cipriani A, Higgins JP, Geddes JR, Salanti G
Ann Intern Med: 15 Jul 2013; 159:130-7 | PMID: 23856683
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Abstract

The Ann Arbor Criteria for Appropriate Urinary Catheter Use in Hospitalized Medical Patients: Results Obtained by Using the RAND/UCLA Appropriateness Method.

Meddings J, Saint S, Fowler KE, Gaies E, ... Krein SL, Bernstein SJ
Interventions to reduce urinary catheter use involve lists of "appropriate" indications developed from limited evidence without substantial multidisciplinary input. Implementing these lists, however, is challenging given broad interpretation of indications, such as "critical illness." To refine criteria for appropriate catheter use-defined as use in which benefits outweigh risks-the RAND/UCLA Appropriateness Method was applied. After reviewing the literature, a 15-member multidisciplinary panel of physicians, nurses, and specialists in infection prevention rated scenarios for catheter use as appropriate, inappropriate, or of uncertain appropriateness by using a standardized, multiround rating process. The appropriateness of Foley catheters, intermittent straight catheters (ISCs), and external condom catheters for hospitalized adults on medical services was assessed in 299 scenarios, including urinary retention, incontinence, wounds, urine volume measurement, urine sample collection, and comfort. The scenarios included patient-specific issues, such as difficulty turning and catheter placement challenges. The panel rated 105 Foley scenarios (43 appropriate, 48 inappropriate, 14 uncertain), 97 ISC scenarios (15 appropriate, 66 inappropriate, 16 uncertain), and 97 external catheter scenarios (30 appropriate, 51 inappropriate, 16 uncertain). The refined criteria clarify that Foley catheters are appropriate for measuring and collecting urine only when fluid status or urine cannot be assessed by other means; specify that patients in the intensive care unit (ICU) need specific medical indications for catheters because ICU location alone is not an appropriate indication; and recognize that Foley and external catheters may be pragmatically appropriate to manage urinary incontinence in select patients. These new appropriateness criteria can inform large-scale collaborative and bedside efforts to reduce inappropriate urinary catheter use.

Ann Intern Med: 04 May 2015; 162:S1-S34
Meddings J, Saint S, Fowler KE, Gaies E, ... Krein SL, Bernstein SJ
Ann Intern Med: 04 May 2015; 162:S1-S34 | PMID: 25938928
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Abstract

Population Strategies to Decrease Sodium Intake and the Burden of Cardiovascular Disease: A Cost-Effectiveness Analysis.

Smith-Spangler CM, Juusola JL, Enns EA, Owens DK, Garber AM
Background: Sodium consumption raises blood pressure, increasing the risk for heart attack and stroke. Several countries, including the United States, are considering strategies to decrease population sodium intake. Objective: To assess the cost-effectiveness of 2 population strategies to reduce sodium intake: government collaboration with food manufacturers to voluntarily cut sodium in processed foods, modeled on the United Kingdom experience, and a sodium tax. Design: A Markov model was constructed with 4 health states: well, acute myocardial infarction (MI), acute stroke, and history of MI or stroke. Data sources: Medical Panel Expenditure Survey (2006), Framingham Heart Study (1980 to 2003), Dietary Approaches to Stop Hypertension trial, and other published data. Target Population: U.S. adults aged 40 to 85 years. Time Horizon: Lifetime. Perspective: Societal. Outcome Measures: Incremental costs (2008 U.S. dollars), quality-adjusted life-years (QALYs), and MIs and strokes averted. Results of Base-case Analysis: Collaboration with industry that decreases mean population sodium intake by 9.5% averts 513 885 strokes and 480 358 MIs over the lifetime of adults aged 40 to 85 years who are alive today compared with the status quo, increasing QALYs by 2.1 million and saving $32.1 billion in medical costs. A tax on sodium that decreases population sodium intake by 6% increases QALYs by 1.3 million and saves $22.4 billion over the same period. Results of Sensitivity Analysis: Results are sensitive to the assumption that consumers have no disutility with modest reductions in sodium intake. Limitation: Efforts to reduce population sodium intake could result in other dietary changes that are difficult to predict. Conclusion: Strategies to reduce sodium intake on a population level in the United States are likely to substantially reduce stroke and MI incidence, which would save billions of dollars in medical expenses. Primary Funding Source: Department of Veterans Affairs, Stanford University, and the National Science Foundation.

Ann Intern Med: 02 Mar 2010; epub ahead of print
Smith-Spangler CM, Juusola JL, Enns EA, Owens DK, Garber AM
Ann Intern Med: 02 Mar 2010; epub ahead of print | PMID: 20194225
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Abstract

Corpulence and Correspondence: President William H. Taft and the Medical Management of Obesity.

Levine DI
This article analyzes the letters exchanged as part of the clinical weight management of President William H. Taft, one of the first public figures in U.S. history to be defined popularly in terms of his pathologic obesity. In 1905, Taft hired Dr. Nathaniel E. Yorke-Davies, an English diet expert, to supervise a weight-loss plan. Taft corresponded extensively with Yorke-Davies over the next 10 years, receiving and responding to courses of treatment via post. This correspondence is one of the few archival collections documenting physician and patient perspectives on the treatment of obesity, and it took place at the precise moment when obesity began to be framed as both a serious and medically manageable condition. This intimate clinical history of the 27th president and 10th chief justice of the Supreme Court offers a unique opportunity to examine in detail the history of the obesity experience in the United States, and it sheds light on the almost-timeless challenges of creating and maintaining long-term treatment courses for conditions like obesity.

Ann Intern Med: 14 Oct 2013; 159:565-570
Levine DI
Ann Intern Med: 14 Oct 2013; 159:565-570 | PMID: 24126649
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Abstract

Acute Kidney Injury.

Levey AS, James MT
Acute kidney injury is a heterogeneous group of conditions characterized by a sudden decrease in glomerular filtration rate, manifested by an increase in serum creatinine concentration or oliguria, and classified by stage and cause. This type of injury occurs in approximately 20% of hospitalized patients, with major complications including volume overload, electrolyte disorders, uremic complications, and drug toxicity. Management includes specific treatments according to the underlying cause and supportive treatment to prevent and manage complications. Kidney replacement therapy is used when complications cannot be managed with medical therapy alone. Despite advances in care, the mortality rate in patients requiring kidney replacement therapy remains approximately 50%.

Ann Intern Med: 06 Nov 2017; 167:ITC66-ITC80
Levey AS, James MT
Ann Intern Med: 06 Nov 2017; 167:ITC66-ITC80 | PMID: 29114754
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Abstract

Evaluating diagnostic accuracy in the face of multiple reference standards.

Naaktgeboren CA, de Groot JA, van Smeden M, Moons KG, Reitsma JB
A universal challenge in studies that quantify the accuracy of diagnostic tests is establishing whether each participant has the disease of interest. Ideally, the same preferred reference standard would be used for all participants; however, for practical or ethical reasons, alternative reference standards that are often less accurate are frequently used instead. The use of different reference standards across participants in a single study is known as differential verification.Differential verification can cause severely biased accuracy estimates of the test or model being studied. Many variations of differential verification exist, but not all introduce the same risk of bias. A risk-of-bias assessment requires detailed information about which participants receive which reference standards and an estimate of the accuracy of the alternative reference standard. This article classifies types of differential verification and explores how they can lead to bias. It also provides guidance on how to report results and assess the risk of bias when differential verification occurs and highlights potential ways to correct for the bias.

Ann Intern Med: 06 Aug 2013; 159:195-202
Naaktgeboren CA, de Groot JA, van Smeden M, Moons KG, Reitsma JB
Ann Intern Med: 06 Aug 2013; 159:195-202 | PMID: 23922065
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Abstract

Should We Screen This Patient for Carotid Artery Stenosis?: Grand Rounds Discussion From Beth Israel Deaconess Medical Center.

Smetana GW, Schermerhorn M, Mukamal KJ
In July 2014, the U.S. Preventive Services Task Force (USPSTF) published a clinical guideline on screening for asymptomatic carotid artery stenosis. The guideline recommended against screening in asymptomatic adults, based primarily on the results of 3 large randomized trials (grade D recommendation). The principal screening test was carotid ultrasonography, and the intervention in the 3 trials was carotid endarterectomy for patients with stenosis exceeding 50% to 60%. In a meta-analysis, carotid endarterectomy reduced rates of 1) perioperative stroke, death, or subsequent ipsilateral stroke and 2) perioperative stroke, death, or any subsequent stroke. The corresponding absolute risk differences were -2.0% (95% CI, -3.3% to -0.7%) and -3.5% (CI, -5.1% to -1.8%), respectively. However, perioperative stroke and death were substantially less common among the 3 randomized trials than in contemporaneous cohort studies (1.9% vs. 3.3%). In addition to stroke or death in patients receiving carotid endarterectomy, a harm of screening included the risk for angiography prompted by abnormal results on carotid ultrasonography. In this article, 2 discussants address the risks and benefits of screening for carotid artery disease as well as how to apply the guideline to an individual patient who is deciding whether to be screened.

Ann Intern Med: 02 Oct 2017; 167:484-492
Smetana GW, Schermerhorn M, Mukamal KJ
Ann Intern Med: 02 Oct 2017; 167:484-492 | PMID: 28973212
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Abstract

Effectiveness of primary care-relevant treatments for obesity in adults: a systematic evidence review for the u.s. Preventive services task force.

Leblanc ES, O\'Connor E, Whitlock EP, Patnode CD, Kapka T
Background: Overweight and obesity in adults are common and adversely affect health. Purpose: To summarize effectiveness and harms of primary care-relevant weight-loss interventions for overweight and obese adults. Data sources: MEDLINE, Cochrane Central Register of Controlled Trials, and PsycINFO from January 2005 to September 2010; systematic reviews for identifying trials before 2005. Study Selection: Two investigators appraised 6498 abstracts and 648 articles. Clinical trials were included if control groups received minimal interventions. Articles were rated as good, fair, or poor by using design-specific criteria. Data extraction: One investigator abstracted study characteristics and findings for good- and fair-quality studies; a second checked them. Data Synthesis: Behaviorally based treatment resulted in 3-kg (6.6-lb) greater weight loss in intervention than control participants after 12 to 18 months, with more treatment sessions associated with greater loss. Limited data suggest weight-loss maintenance for 1 year or more. Orlistat plus behavioral intervention resulted in 3-kg (6.6-lb) more weight loss than did placebo after 12 months. Metformin resulted in less weight loss. Data on effects of weight-loss treatment on long-term health outcomes (for example, death and cardiovascular disease) were insufficient. Weight-loss treatment reduced diabetes incidence in participants with prediabetes. Effects on intermediate outcomes (for example, lipids and blood pressure) were mixed and small. Data on serious medication harms were insufficient. Medications commonly caused withdrawals due to gastrointestinal symptoms. Limitations: Few studies reported health outcomes. Behaviorally based treatments were heterogeneous and specific elements were not well-described. Many studies could not be pooled because of insufficient reporting of variance data. Medication trials had high attrition, lacked postdiscontinuation data, and were inadequately powered for rare adverse effects. Conclusion: Behaviorally based treatments are safe and effective for weight loss and maintenance. Primary Funding Source: Agency for Healthcare Research and Quality.

Ann Intern Med: 04 Oct 2011; 155:434-47
Leblanc ES, O'Connor E, Whitlock EP, Patnode CD, Kapka T
Ann Intern Med: 04 Oct 2011; 155:434-47 | PMID: 21969342
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Abstract

Prioritization of Research Addressing Antipsychotics for Adolescents and Young Adults With Bipolar Disorder.

Crowley MJ, McCrory DC, Chatterjee R, Gierisch JM, ... Kendrick AS, Sanders GD
Despite a paucity of high-quality evidence about benefits and harms, antipsychotic medication use among adolescents and young adults with bipolar disorder is increasing. The Patient-Centered Outcomes Research Institute tasked the Duke Evidence Synthesis Group with creating a prioritized agenda for research in this area that would incorporate the perspectives of relevant stakeholders. We identified a list of potential evidence gaps by reviewing existing literature and engaged a diverse group of 9 stakeholders to expand and refine this list. Using a forced-ranking prioritization method, stakeholders prioritized 10 of 23 potential evidence gaps as the most pressing for future research. These evidence gaps relate to 3 areas: the comparative effectiveness of intervention strategies, the effect of antipsychotics on patient-centered outcomes, and the influence of various patient characteristics on antipsychotic effectiveness. In addition to presenting these findings, we suggest appropriate study designs for addressing the stakeholder-prioritized research questions.

Ann Intern Med: 24 Feb 2014; epub ahead of print
Crowley MJ, McCrory DC, Chatterjee R, Gierisch JM, ... Kendrick AS, Sanders GD
Ann Intern Med: 24 Feb 2014; epub ahead of print | PMID: 24567115
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Abstract

Heart failure.

Goldberg LR
This issue provides a clinical overview of heart failure focusing on prevention, diagnosis, treatment, practice improvement, and patient information. Readers can complete the accompanying CME quiz for 1.5 credits. Only ACP members and individual subscribers can access the electronic features of In the Clinic. Non-subscribers who wish to access this issue of In the Clinic can elect "Pay for View." Subscribers can receive 1.5 category 1 CME credits by completing the CME quiz that accompanies this issue of In the Clinic. The content of In the Clinic is drawn from the clinical information and education resources of the American College of Physicians (ACP), including PIER (Physicians\' Information and Education Resource) and MKSAP (Medical Knowledge and Self Assessment Program). Annals of Internal Medicine editors develop In the Clinic from these primary sources in collaboration with the ACP\'s Medical Education and Publishing division and with assistance of science writers and physician writers. Editorial consultants from PIER and MKSAP provide expert review of the content. Readers who are interested in these primary resources for more detail can consult www.acponline.org, http://pier.acponline.org, and other resources referenced within each issue of In the Clinic.

Ann Intern Med: 01 Jun 2010; 152:ITC61
Goldberg LR
Ann Intern Med: 01 Jun 2010; 152:ITC61 | PMID: 20513825
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Abstract

Retail Health Clinics: Executive Summary of a Policy Position Paper From the American College of Physicians.

Daniel H, Erickson S
Retail health clinics are walk-in clinics located in retail stores or pharmacies that are typically staffed by nurse practitioners or physician assistants. When they entered the marketplace in the early 2000s, retail clinics offered a limited number of services for low-acuity conditions that were paid for out of pocket by the consumer. Over the past decade, business models for these clinics have evolved to accept public and private health insurance, and some are expanding their services to include diagnosis, treatment, and management of chronic conditions. Retail health clinics are one of several methods of health care delivery that challenge the traditional primary care delivery model. The positions and recommendations offered by the American College of Physicians in this paper are intended to establish a framework that underscores patient safety, communication, and collaboration among retail health clinics, physicians, and patients.

Ann Intern Med: 11 Oct 2015; epub ahead of print
Daniel H, Erickson S
Ann Intern Med: 11 Oct 2015; epub ahead of print | PMID: 26457377
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Behavioral counseling research and evidence-based practice recommendations: u.s. Preventive services task force perspectives.

Curry SJ, Grossman DC, Whitlock EP, Cantu A
The U.S. Preventive Services Task Force (USPSTF) makes recommendations on which preventive services to routinely incorporate into primary care for specific populations. Behavioral counseling interventions are preventive services designed to help persons engage in healthy behaviors and limit unhealthy ones. The USPSTF\'s evaluation of behavioral counseling interventions asks 2 primary questions: Do interventions in the clinical setting influence persons to change their behavior, and does changing health behavior improve health outcomes with minimal harms?This article discusses challenges encountered by the USPSTF in aggregating the behavioral counseling intervention literature to develop guidelines. The challenges relate broadly to study populations, intervention protocols, assessment of outcomes, and linking behavior changes to health outcomes. Recommendations to address these challenges include use of the PRECIS (Pragmatic-Explanatory Continuum Indicator Summary) tool as a guide for the development of feasible, replicable, and generalizable behavioral counseling interventions; improved reporting of study methods and results; consensus measures for key behavioral outcomes; and use of existing data sets to link behavior change and clinical outcomes.

Ann Intern Med: 10 Apr 2014; 160
Curry SJ, Grossman DC, Whitlock EP, Cantu A
Ann Intern Med: 10 Apr 2014; 160 | PMID: 24723080
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Abstract

Screening for lung cancer with low-dose computed tomography: grand rounds discussion from the beth Israel deaconess medical center.

Smetana GW, Boiselle PM, Schwartzstein RM
In December 2013, the U.S. Preventive Services Task Force recommended screening for lung cancer with low-dose computed tomography (LDCT) for selected current and former smokers. The Task Force based the recommendation primarily on the results of the NLST (National Lung Screening Trial). In this trial, patients randomly assigned to LDCT screening for 3 years had lower rates of both lung cancer-specific mortality and all-cause mortality (relative risk reduction, 6.7% [95% CI, 1.2% to 13.6%]; absolute risk reduction, 0.46% [CI, 0% to 0.9%]). Clinicians and health systems confront questions and challenges as they begin to implement lung cancer screening. This paper summarizes a conference during which an internist and a radiologist discuss the application of the Task Force recommendation to an individual patient.

Ann Intern Med: 20 Apr 2015; 162:577-82
Smetana GW, Boiselle PM, Schwartzstein RM
Ann Intern Med: 20 Apr 2015; 162:577-82 | PMID: 25894026
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Abstract

Deep venous thrombosis.

Spandorfer J, Galanis T
This issue provides a clinical overview of deep venous thrombosis, focusing on prevention, diagnosis, treatment, and patient information. The content of In the Clinic is drawn from the clinical information and education resources of the American College of Physicians (ACP), including ACP Smart Medicine and MKSAP (Medical Knowledge and Self-Assessment Program). Annals of Internal Medicine editors develop In the Clinic from these primary sources in collaboration with the ACP\'s Medical Education and Publishing divisions and with the assistance of science writers and physician writers. Editorial consultants from ACP Smart Medicine and MKSAP provide expert review of the content. Readers who are interested in these primary resources for more detail can consult http://smartmedicine.acponline.org, http://mksap.acponline.org, and other resources referenced in each issue of In the Clinic.

Ann Intern Med: 04 May 2015; 162:ITC1
Spandorfer J, Galanis T
Ann Intern Med: 04 May 2015; 162:ITC1 | PMID: 25939012
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This program is still in alpha version.