Estimating Equations for Glomerular Filtration Rate in the Era of Creatinine Standardization: A Systematic Review.

Ann Intern Med. 2012 Feb 6;

Authors: Earley A, Miskulin D, Lamb EJ, Levey AS, Uhlig K

Abstract

Background: Clinical laboratories are increasingly reporting estimated glomerular filtration rate (GFR) by using serum creatinine assays traceable to a standard reference material. Purpose: To review the performance of GFR estimating equations to inform the selection of a single equation by laboratories and the interpretation of estimated GFR by clinicians. Data Sources: A systematic search of MEDLINE, without language restriction, between 1999 and 21 October 2011. Study Selection: Cross-sectional studies in adults that compared the performance of 2 or more creatinine-based GFR estimating equations with a reference GFR measurement. Eligible equations were derived or reexpressed and validated by using creatinine measurements traceable to the standard reference material. Data Extraction: Reviewers extracted data on population characteristics, measured GFR, creatinine assay, and equation performance. Data Synthesis: Eligible studies compared the MDRD (Modification of Diet in Renal Disease) Study and CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration) equations or modifications thereof. In 12 studies in North America, Europe, and Australia, the CKD-EPI equation performed better at higher GFRs (approximately >60 mL/min per 1.73 m(2)) and the MDRD Study equation performed better at lower GFRs. In 5 of 8 studies in Asia and Africa, the equations were modified to improve their performance by adding a coefficient derived in the local population or removing a coefficient. Limitation: Methods of GFR measurement and study populations were heterogeneous. Conclusion: Neither the CKD-EPI nor the MDRD Study equation is optimal for all populations and GFR ranges. Using a single equation for reporting requires a tradeoff to optimize performance at either higher or lower GFR ranges. A general practice and public health perspective favors the CKD-EPI equation. Primary Funding Source: Kidney Disease: Improving Global Outcomes foundation.

PMID: 22312131 [PubMed - as supplied by publisher]

Effects of school closure on incidence of pandemic influenza in alberta, Canada.

Ann Intern Med. 2012 Feb 7;156(3):173-81

Authors: Earn DJ, He D, Loeb MB, Fonseca K, Lee BE, Dushoff J

Abstract

Background: Control of pandemic influenza by social-distancing measures, such as school closures, is a controversial aspect of pandemic planning. However, investigations of the extent to which these measures actually affect the progression of a pandemic have been limited. Objective: To examine correlations between the incidence of pandemic H1N1 (pH1N1) influenza in Alberta, Canada, in 2009 and school closures or weather changes, and to estimate the effects of school closures and weather changes on pH1N1 transmission. Design: Mathematical transmission models were fit to data that compared the pattern of confirmed pH1N1 cases with the school calendar and weather patterns. Setting: Alberta, Canada, from 19 April 2009 to 2 January 2010. Data Sources: 2009 virologic test results, 2006 census data, 2009 daily temperature and humidity data, and 2009 school calendars. Measurements: Age-specific daily counts of positive results for pH1N1 from the complete database of 35 510 specimens submitted to the Alberta Provincial Laboratory for Public Health for virologic testing from 19 April 2009 to 2 January 2010. Results: The ending and restarting of school terms had a major effect in attenuating the first wave and starting the second wave of pandemic influenza cases. Mathematical models suggested that school closure reduced transmission among school-age children by more than 50% and that this was a key factor in interrupting transmission. The models also indicated that seasonal changes in weather had a significant effect on the temporal pattern of the epidemic. Limitations: Data probably represent a small sample of all viral infections. The mathematical models make simplifying assumptions in order to make simulations and analysis feasible. Conclusion: Analysis of data from unrestricted virologic testing during an influenza pandemic provides compelling evidence that closing schools can have dramatic effects on transmission of pandemic influenza. School closure seems to be an effective strategy for slowing the spread of pandemic influenza in countries with social contact networks similar to those in Canada. Primary Funding Source: Canadian Institutes of Health Research, Natural Sciences and Engineering Research Council of Canada, and Public Health Agency of Canada.

PMID: 22312137 [PubMed - in process]

Vignette-based study of ovarian cancer screening: do u.s. Physicians report adhering to evidence-based recommendations?

Ann Intern Med. 2012 Feb 7;156(3):182-94

Authors: Baldwin LM, Trivers KF, Matthews B, Andrilla CH, Miller JW, Berry DL, Lishner DM, Goff BA

Abstract

Background: No professional society or group recommends routine ovarian cancer screening, yet physicians’ enthusiasm for several cancer screening tests before benefit has been proven suggests that some women may be exposed to potential harms. Objective: To provide nationally representative estimates of physicians’ reported nonadherence to recommendations against ovarian cancer screening. Design: Cross-sectional survey of physicians offering women’s primary care. The 12-page questionnaire contained a woman’s annual examination vignette and questions about offers or orders for transvaginal ultrasonography (TVU) and cancer antigen 125 (CA-125). Setting: United States. Participants: 3200 physicians randomly sampled equally from the 2008 American Medical Association Physician Masterfile lists of family physicians, general internists, and obstetrician-gynecologists; 61.7% responded. After exclusions, 1088 respondents were included; their responses were weighted to represent the specialty distribution of practicing U.S. physicians nationally. Measurements: Reported nonadherence to screening recommendations (defined as sometimes or almost always ordering screening TVU or CA-125 or both). Results: Twenty-eight percent (95% CI, 24.5% to 32.9%) of physicians reported nonadherence to screening recommendations for women at low risk for ovarian cancer; 65.4% (CI, 61.1% to 69.4%) did so for women at medium risk for ovarian cancer. Six percent (CI, 4.4% to 8.9%) reported routinely ordering or offering ovarian cancer screening for low-risk women, as did 24.0% (CI, 20.5% to 28.0%) for medium-risk women (P ≤ 0.001). Thirty-three percent believed TVU or CA-125 was an effective screening test. In adjusted analysis, actual and physician-perceived patient risk, patient request for ovarian cancer screening, and physician belief that TVU or CA-125 was an effective screening test were the strongest predictors of physician-reported nonadherence to published recommendations. Limitation: The results are limited by their reliance on survey methods; there may be respondent-nonrespondent bias. Conclusion: One in 3 physicians believed that ovarian cancer screening was effective, despite evidence to the contrary. Substantial proportions of physicians reported routinely offering or ordering ovarian cancer screening, thereby exposing women to the documented risks of these tests. Primary Funding Source: Centers for Disease Control and Prevention and the National Cancer Institute.

PMID: 22312138 [PubMed - in process]

Sex differences in implantable cardioverter-defibrillator outcomes: findings from a prospective defibrillator database.

Ann Intern Med. 2012 Feb 7;156(3):195-203

Authors: Macfadden DR, Crystal E, Krahn AD, Mangat I, Healey JS, Dorian P, Birnie D, Simpson CS, Khaykin Y, Pinter A, Nanthakumar K, Calzavara AJ, Austin PC, Tu JV, Lee DS

Abstract

Background: Sex differences in the use and outcomes of implantable cardioverter-defibrillators (ICDs) have not been fully studied. Objective: To examine potential sex differences in ICD implantation and device outcomes. Design: Health payer-mandated, prospective study of patients referred for ICD implantation, with comprehensive, longitudinal follow-up for complications, deaths, and device outcomes. Setting: 18 ICD implantation and follow-up centers in Ontario, Canada. Patients: 6021 patients (4733 men) referred for ICD implantation from February 2007 to July 2010. Measurements: Multivariate-adjusted ICD implantation rate, complications up to day 45, multivariate-adjusted complications, device outcomes (including appropriate shocks and therapies), and deaths occurring during 1-year follow-up. Results: Rates of ICD implantation were similar in men and women (relative risk, 0.99 [95% CI, 0.97 to 1.02]; P = 0.60). However, women were significantly more likely to experience major complications by 45 days (odds ratio, 1.78 [CI, 1.24 to 2.58]; P = 0.002) and 1 year (hazard ratio [HR], 1.91 [CI, 1.48 to 2.47]; P < 0.001) after implantation. Occurrence of any major or minor complication was also increased in women at both 45-day follow-up (odds ratio, 1.50 [CI, 1.12 to 2.00]; P = 0.006) and 1-year follow-up (HR, 1.55 [CI, 1.25 to 1.93]; P < 0.001). After implantation, women were less likely than men to receive appropriate ICD shock (HR, 0.69 [CI, 0.51 to 0.93]; P = 0.015) or appropriate therapy via shock or antitachycardia pacing (HR, 0.73 [CI, 0.59 to 0.90]; P = 0.003). Total mortality among defibrillator recipients did not differ between men and women (HR, 1.00 [CI, 0.64 to 1.55]; P = 0.99). Limitation: The differential effects of sex on prereferral events were not examined. Conclusion: Although ICD implantation rates were similar after referral to an electrophysiologist, women who underwent ICD implantation had greater risks for complications and were less likely to experience appropriate ICD-delivered therapies than men. Primary Funding Source: Canadian Institutes of Health Research and Ontario Ministry of Health and Long-Term Care.

PMID: 22312139 [PubMed - in process]

Oral Pharmacologic Treatment of Type 2 Diabetes Mellitus: A Clinical Practice Guideline From the American College of Physicians.

Ann Intern Med. 2012 Feb 7;156(3):218-231

Authors: Qaseem A, Humphrey LL, Sweet DE, Starkey M, Shekelle P,

Abstract

Description: The American College of Physicians (ACP) developed this guideline to present the evidence and provide clinical recommendations on the comparative effectiveness and safety of type 2 diabetes medications. Methods: This guideline is based on a systematic evidence review evaluating literature published on this topic from 1966 through April 2010 that was identified by using MEDLINE (updated through December 2010), EMBASE, and the Cochrane Central Register of Controlled Trials. Searches were limited to English-language publications. The clinical outcomes evaluated for this guideline included all-cause mortality, cardiovascular morbidity and mortality, cerebrovascular morbidity, neuropathy, nephropathy, and retinopathy. This guideline grades the evidence and recommendations by using the American College of Physicians clinical practice guidelines grading system. Recommendation 1: ACP recommends that clinicians add oral pharmacologic therapy in patients diagnosed with type 2 diabetes when lifestyle modifications, including diet, exercise, and weight loss, have failed to adequately improve hyperglycemia (Grade: strong recommendation; high-quality evidence). Recommendation 2: ACP recommends that clinicians prescribe monotherapy with metformin for initial pharmacologic therapy to treat most patients with type 2 diabetes (Grade: strong recommendation; high-quality evidence). Recommendation 3: ACP recommends that clinicians add a second agent to metformin to treat patients with persistent hyperglycemia when lifestyle modifications and monotherapy with metformin fail to control hyperglycemia (Grade: strong recommendation; high-quality evidence).

PMID: 22312141 [PubMed - as supplied by publisher]

End-of-Life Care Discussions Among Patients With Advanced Cancer: A Cohort Study.

Ann Intern Med. 2012 Feb 7;156(3):204-10

Authors: Mack JW, Cronin A, Taback N, Huskamp HA, Keating NL, Malin JL, Earle CC, Weeks JC

Abstract

Background: National guidelines recommend that physicians discuss end-of-life (EOL) care planning with patients with cancer whose life expectancy is less than 1 year. Objective: To evaluate the incidence of EOL care discussions for patients with stage IV lung or colorectal cancer and where, when, and with whom these discussions take place. Design: Prospective cohort study of patients diagnosed with lung or colorectal cancer from 2003 to 2005. Setting: Participants lived in Northern California, Los Angeles County, North Carolina, Iowa, or Alabama or received care in 1 of 5 large HMOs or 1 of 15 Veterans Health Administration sites. Patients: 2155 patients with stage IV lung or colorectal cancer. Measurements: End-of-life care discussions reported in patient and surrogate interviews or documented in medical records through 15 months after diagnosis. Results: 73% of patients had EOL care discussions identified by at least 1 source. Among the 1470 patients who died during follow-up, 87% had EOL care discussions, compared with 41% of the 685 patients who were alive at the end of follow-up. Of the 1081 first EOL care discussions documented in records, 55% occurred in the hospital. Oncologists documented EOL care discussions with only 27% of their patients. Among 959 patients with documented EOL care discussions who died during follow-up, discussions took place a median of 33 days before death. Limitations: The depth and quality of EOL care discussions was not evaluated. Much of the information about discussions came from surrogates of patients who died before baseline interviews could be obtained. Conclusion: Although most patients with stage IV lung or colorectal cancer discuss EOL care planning with physicians before death, many discussions occur during acute hospital care, with providers other than oncologists, and late in the course of illness. Primary Funding Source: National Cancer Institute and Department of Veterans Affairs.

PMID: 22312140 [PubMed - in process]

Launching complex medical workups from an urgent care platform.

Ann Intern Med. 2012 Feb 7;156(3):232-3

Authors: Paschal D

Abstract

The basic parameters for medical workups have scarcely changed in the past 30 years. That is, what the internal medicine community has deemed acceptable for outpatient, inpatient, emergency department, and urgent care evaluation has remained pretty much stable or stagnant during all that time. We are failing to take advantage of the phenomenal speed and accuracy of new laboratory and imaging technologies. Due to Hurricane Katrina, which destroyed the Veterans Administration Hospital in New Orleans, those of us who work in its urgent care clinic were forced to undertake complex medical workups from an 8-to-5, walk-in platform. We have been amazed at the efficiency of this. Workups that used to take weeks can often be done in a few hours or days. What we have discovered here serendipitously may be worth deliberately duplicating elsewhere.

PMID: 22312142 [PubMed - in process]

Lifelong curiosity: frederick novy and the rat virus.

Ann Intern Med. 2012 Feb 7;156(3):234-7

Authors: Kazanjian P

Abstract

Frederick Novy (1864-1957) was a U.S. physician, medical researcher, and influential microbiologist of the early 20th century who devised culture techniques to visualize anaerobic bacteria, parasites, and spirochetes. In 1909 he began to investigate the cause of unexplained deaths in his laboratory rats, which he hypothesized were due to an “ultramicroscopic organism” or “filterable virus.” But in 1918, the test tubes he had been using for these experiments vanished from his laboratory. His dream of finding a virus as the likely cause of the mysterious deaths of his rats apparently was lost. Novy retired in 1935. Thirty-three years later, in 1951, a box containing the test tubes was discovered by chance during clean-up in preparation for a laboratory move. Novy’s curiosity had not waned with time. Notified of the find, and 16 years into his retirement, he returned to his laboratory at the age of 88 to continue the experiments that he had begun more than 40 years earlier. He completed his investigations in 1953 and published his findings that a virus was indeed the unidentified organism that had swiftly killed his laboratory rats in 1909.

PMID: 22312143 [PubMed - in process]

Getting schooled: school closure, age distribution, and pandemic mitigation.

Ann Intern Med. 2012 Feb 7;156(3):238-40

Authors: Fisman DN

PMID: 22312144 [PubMed - in process]

Is biology destiny or can we optimize care for all patients?

Ann Intern Med. 2012 Feb 7;156(3):241-2

Authors: Douglas PS, Curtis LH

PMID: 22312145 [PubMed - in process]

A case of racism and reconciliation.

Ann Intern Med. 2012 Feb 7;156(3):246-7

Authors: Tweedy DS

PMID: 22312146 [PubMed - in process]

Effectiveness of primary care-relevant treatments for obesity in adults.

Ann Intern Med. 2012 Feb 7;156(3):248

Authors: Kuller LH

PMID: 22312147 [PubMed - in process]

Effectiveness of primary care-relevant treatments for obesity in adults.

Ann Intern Med. 2012 Feb 7;156(3):248-9

Authors: Moses AC, Handelsman Y, Einhorn D

PMID: 22312148 [PubMed - in process]

Comparative effectiveness of digital versus film-screen mammography.

Ann Intern Med. 2012 Feb 7;156(3):249-50

Authors: Keen JD

PMID: 22312149 [PubMed - in process]

Comparative effectiveness of digital versus film-screen mammography.

Ann Intern Med. 2012 Feb 7;156(3):250

Authors: Imfeld S

PMID: 22312150 [PubMed - in process]

Comparative effectiveness of digital versus film-screen mammography.

Ann Intern Med. 2012 Feb 7;156(3):250

Authors: Pinsky PF

PMID: 22312151 [PubMed - in process]

Reducing 30-day rehospitalization.

Ann Intern Med. 2012 Feb 7;156(3):251

Authors: Sandy LG

PMID: 22312152 [PubMed - in process]

Reducing 30-day rehospitalization.

Ann Intern Med. 2012 Feb 7;156(3):252

Authors: Majeed A

PMID: 22312153 [PubMed - in process]

Effects of school closure on incidence of pandemic influenza in alberta, Canada.

Ann Intern Med. 2012 Feb 7;156(3):I28

Authors:

PMID: 22312154 [PubMed - in process]

Implantable cardioverter-defibrillators in women.

Ann Intern Med. 2012 Feb 7;156(3):I30

Authors:

PMID: 22312155 [PubMed - in process]

End-of-Life Care Discussions Between Patients With Advanced Cancer and Doctors.

Ann Intern Med. 2012 Feb 7;156(3):I34

Authors:

PMID: 22312156 [PubMed - in process]

Oral drug treatment of type 2 diabetes mellitus: a clinical practice guideline from the american college of physicians.

Ann Intern Med. 2012 Feb 7;156(3):I36

Authors:

PMID: 22312157 [PubMed - in process]

Palliative care.

Ann Intern Med. 2012 Feb 7;156(3):ITC21

Authors: Swetz KM, Kamal AH

Abstract

This issue provides a clinical overview of palliative care 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.

PMID: 22312158 [PubMed - in process]

Adult Immunization 2012: Politics, Process, and Progress.

Ann Intern Med. 2012 Jan 31;

Authors: Fryhofer SA

PMID: 22298575 [PubMed - as supplied by publisher]

Recommended Adult Immunization Schedule: United States, 2012.

Ann Intern Med. 2012 Jan 31;

Authors:

PMID: 22298576 [PubMed - as supplied by publisher]

Laboratory Creation of a Highly Transmissible H5N1 Influenza Virus: Balancing Substantial Risks and Real Benefits.

Ann Intern Med. 2012 Jan 26;

Authors: Pavia AT

Abstract

Controversy erupted when influenza researchers announced that they had created an H5N1 influenza virus that was transmissible between ferrets. The controversy escalated when the National Science Advisory Board for Biosecurity (NSABB) recommended that the work be published but recommended significant voluntary redactions. The responses to the NSABB action and to the research itself have been polarized. A readily transmitted H5N1 virus could be extraordinarily lethal; therefore, the risk for accidental release is significant, and deliberate misuse of the data to create a biological weapon is possible. However, the knowledge gained by these and future experiments under appropriate safeguards is likely to allow critical understanding of influenza transmission and virulence. It would be irresponsible to adopt either extreme solution: to prevent and censor the research or to allow unlimited distribution without careful review by an independent group, such as the NSABB.

PMID: 22282172 [PubMed - as supplied by publisher]

Engineered H5N1: A Rare Time for Restraint in Science.

Ann Intern Med. 2012 Jan 26;

Authors: Inglesby TV

Abstract

Two scientific teams have recently engineered the H5N1 virus to make it readily transmissible between ferrets. Given that ferrets are considered the most reliable animal surrogate for human influenza infection, the newly engineered H5N1 strain is probably transmissible between humans as well. The potential consequences of an engineered human transmissible H5N1 strain are stunning. Although seasonal flu infects as much as 20% of the world’s population-more than 1 billion persons-each year, only a small fraction of those with seasonal flu dies, most often the oldest, youngest, and sickest. If the newly engineered strain were to escape the laboratory (either by design or by accident) and spread as widely as seasonal flu with anywhere near the current confirmed H5N1 human case-fatality rate, it could endanger the lives of hundreds of millions of persons. The possible benefits of this work do not justify taking such risks. As clinicians, we have a stake in this issue with our responsibilities for the diagnosis and treatment of influenza. We embrace the principle of free and open exchange of scientific information, but we also believe in the principle of “first, do no harm.” These 2 principles have come into a moment of rare conflict. It seems most reasonable and prudent to request that the involved scientific community and its institutions exercise restraint by restricting dissemination of the experimental results and discontinuing work on the engineered H5N1 strains. If a highly compelling case is made for continued work on this strain despite the risks, the work should be controlled and should merit the greatest scrutiny.

PMID: 22282173 [PubMed - as supplied by publisher]

Antiretroviral Medication and HIV Prevention: New Steps Forward and New Questions.

Ann Intern Med. 2012 Jan 16;

Authors: Mayer KH, Krakower D

Abstract

During the past 2 years, several pivotal clinical trials have proven that the use of antiretrovirals by HIV-infected and at-risk uninfected persons can decrease the probability of HIV being transmitted sexually. The initial chemoprophylaxis studies evaluated tenofovir administered topically or orally (with or without emtricitabine). However, multiple questions remain. Some subsequent primary prevention studies did not replicate the results of the initial studies, raising questions about differences in the behaviors of participants in each study (in particular about medication adherence), as well as whether pharmacologic or local mucosal factors might explain the variable efficacy estimates. Other antiretrovirals and delivery systems are being evaluated to maximize the efficacy of primary chemoprophylactic approaches. At present, increasing access to antiretroviral treatment globally is a priority, because expanding access to medication that can prevent morbidity and mortality is itself an important public health goal and may reasonably be expected to decrease HIV incidence. However, for treatment as prevention to be maximally effective, increases in HIV testing, health care workers, and infrastructure are needed, in addition to medications and laboratory support for clinical monitoring. A combination of approaches is needed to most quickly decrease the current trends in HIV incidence, including early diagnosis and initiation of treatment for HIV-infected persons. These approaches can be coupled with appropriately tailored interventions for populations at greatest risk for infection (for example, men who have sex with men and sex workers), including male circumcision, behavioral interventions, and chemoprophylaxis. However, a substantial gap exists between current expenditures and unmet needs, which suggests that mobilization of political will is needed for this combination approach to be successful.

PMID: 22250077 [PubMed - as supplied by publisher]

High doses of vitamin d to reduce exacerbations in chronic obstructive pulmonary disease: a randomized trial.

Ann Intern Med. 2012 Jan 17;156(2):105-14

Authors: Lehouck A, Mathieu C, Carremans C, Baeke F, Verhaegen J, Van Eldere J, Decallonne B, Bouillon R, Decramer M, Janssens W

Abstract

Background: Low serum 25-hydroxyvitamin D (25-[OH]D) levels have been associated with lower FEV(1), impaired immunologic control, and increased airway inflammation. Because many patients with chronic obstructive pulmonary disease (COPD) have vitamin D deficiency, effects of vitamin D supplementation may extend beyond preventing osteoporosis. Objective: To explore whether supplementation with high doses of vitamin D could reduce the incidence of COPD exacerbations. Design: Randomized, single-center, double-blind, placebo-controlled trial. (ClinicalTrials.gov registration number: NCT00666367) Setting: University Hospitals Leuven, Leuven, Belgium. Patients: 182 patients with moderate to very severe COPD and a history of recent exacerbations. Intervention: 100 000 IU of vitamin D supplementation or placebo every 4 weeks for 1 year. Measurements: The primary outcome was time to first exacerbation. Secondary outcomes were exacerbation rate, time to first hospitalization, time to second exacerbation, FEV(1), quality of life, and death. Results: Mean serum 25-(OH)D levels increased significantly in the vitamin D group compared with the placebo group (mean between-group difference, 30 ng/mL [95% CI, 27 to 33 ng/mL]; P < 0.001). The median time to first exacerbation did not significantly differ between the groups (hazard ratio, 1.1 [CI, 0.82 to 1.56]; P = 0.41), nor did exacerbation rates, FEV(1), hospitalization, quality of life, and death. However, a post hoc analysis in 30 participants with severe vitamin D deficiency (serum 25-[OH]D levels <10 ng/mL) at baseline showed a significant reduction in exacerbations in the vitamin D group (rate ratio, 0.57 [CI, 0.33 to 0.98]; P = 0.042). Limitation: This was a single-center study with a small sample size. Conclusion: High-dose vitamin D supplementation in a sample of patients with COPD did not reduce the incidence of exacerbations. In participants with severe vitamin D deficiency at baseline, supplementation may reduce exacerbations. Primary Funding Source: Applied Biomedical Research Program, Agency for Innovation by Science and Technology (IWT-TBM).

PMID: 22250141 [PubMed - in process]

Cardiovascular mortality in women with obstructive sleep apnea with or without continuous positive airway pressure treatment: a cohort study.

Ann Intern Med. 2012 Jan 17;156(2):115-22

Authors: Campos-Rodriguez F, Martinez-Garcia MA, de la Cruz-Moron I, Almeida-Gonzalez C, Catalan-Serra P, Montserrat JM

Abstract

Background: Obstructive sleep apnea (OSA) is a risk factor for cardiovascular death in men, but whether it is also a risk factor in women is unknown. Objective: To investigate whether OSA is a risk factor for cardiovascular death in women and assess whether continuous positive airway pressure (CPAP) treatment is associated with a change in risk. Design: Prospective, observational cohort study. Setting: 2 sleep clinics in Spain. Patients: All women consecutively referred for suspected OSA between 1998 and 2007. Intervention: Every woman had a diagnostic sleep study. Women with an apnea-hypopnea index (AHI) less than 10 were the control group. Obstructive sleep apnea was diagnosed when the AHI was 10 or higher (classified as mild to moderate [AHI of 10 to 29] or severe [AHI ≥30]). Patients with OSA were classified as CPAP-treated (adherence ≥4 hours per day) or untreated (adherence <4 hours per day or not prescribed). Participants were followed until December 2009. Measurements: The end point was cardiovascular death. Results: 1116 women were studied (median follow-up, 72 months [interquartile range, 52 to 88 months]). The control group had a lower cardiovascular mortality rate (0.28 per 100 person-years [95% CI, 0.10 to 0.91]) than the untreated groups with mild to moderate OSA (0.94 per 100 person-years [CI, 0.10 to 2.40]; P = 0.034) or severe OSA (3.71 per 100 person-years [CI, 0.09 to 7.50]; P < 0.001). Compared with the control group, the fully adjusted hazard ratios for cardiovascular mortality were 3.50 (CI, 1.23 to 9.98) for the untreated, severe OSA group; 0.55 (CI, 0.17 to 1.74) for the CPAP-treated, severe OSA group; 1.60 (CI, 0.52 to 4.90) for the untreated, mild to moderate OSA group; and 0.19 (CI, 0.02 to 1.67) for the CPAP-treated, mild to moderate OSA group. Limitation: The study was observational and not randomized, and OSA was diagnosed by 2 different methods. Conclusion: Severe OSA is associated with cardiovascular death in women, and adequate CPAP treatment may reduce this risk. Primary Funding Source: None.

PMID: 22250142 [PubMed - in process]

Virtual autopsy as an alternative to traditional medical autopsy in the intensive care unit: a prospective cohort study.

Ann Intern Med. 2012 Jan 17;156(2):123-30

Authors: Wichmann D, Obbelode F, Vogel H, Hoepker WW, Nierhaus A, Braune S, Sauter G, Pueschel K, Kluge S

Abstract

Background: Autopsy is an important educational and quality-control tool in the intensive care unit (ICU), but rates of traditional medical autopsies have declined worldwide. “Virtual” autopsy involving only advanced radiographic techniques might provide an alternative approach to postmortem examinations. Objective: To assess the value of postmortem multidetector computed tomography as an alternative to medical autopsy. Design: Prospective cohort study. (ClinicalTrials.gov registration number: NCT01040520) Setting: 9 ICUs in a single academic medical center. Consent for both medical and virtual autopsies was sought from the families of all consecutive patients who died in the ICU between 1 January and 30 June 2010. Clinical records were reviewed to determine whether unsuspected autopsy findings would have altered care if known (major diagnosis) or would not have altered care (minor diagnosis). Results: Of 285 patients, 47 underwent both virtual and medical autopsy. Of 196 clinical diagnoses made before death, 173 (88%) were identified by virtual autopsy and 183 (93%) by medical autopsy. Fourteen new major and 88 new minor diagnoses were detected by any autopsy method. The main diagnoses missed by virtual autopsy were cardiovascular events (9 of 72) and cancer (12 of 30). In contrast, medical autopsy missed 13 traumatic fractures and 2 pneumothoraces. Among 115 additional patients in whom only virtual autopsy was performed, 11 new major diagnoses were made. Limitation: Virtual autopsy was performed in only 57% of patients (n = 162); among this group, consent for traditional medical autopsy was obtained for only one third. Conclusion: Virtual autopsy may be useful for identifying diagnoses that traditionally have been identified by medical autopsy. This may also hold true, at least in part, for the educational aspect of medical autopsy (confirming antemortem clinical diagnoses). Further studies are required to confirm these preliminary results. Primary Funding Source: University Medical Center Hamburg-Eppendorf, Germany.

PMID: 22250143 [PubMed - in process]

Risk factors and precipitants of long-term disability in community mobility: a cohort study of older persons.

Ann Intern Med. 2012 Jan 17;156(2):131-40

Authors: Gill TM, Gahbauer EA, Murphy TE, Han L, Allore HG

Abstract

Background: Relatively little is known about why older persons develop long-term disability in community mobility. Objective: To identify the risk factors and precipitants for long-term disability in walking a quarter mile and driving a car. Design: Prospective cohort study from March 1998 to December 2009. Setting: Greater New Haven, Connecticut. Participants: 641 persons, aged 70 years or older, who were active drivers or nondisabled in walking a quarter mile. Persons who were physically frail were oversampled. Measurements: Candidate risk factors were assessed every 18 months. Disability in community mobility and exposure to potential precipitants, including illnesses or injuries leading to hospitalization or restricted activity, were assessed every month. Disability that lasted 6 or more consecutive months was considered long-term. Results: 318 (56.0%) and 269 (53.1%) participants developed long-term disability in walking and driving, respectively. Seven risk factors were independently associated with walking disability and 8 were associated with driving disability; the strongest associations for each outcome were found for older age and lower score on the Short Physical Performance Battery. The precipitants had a large effect on long-term disability, with multivariate hazard ratios for each outcome greater than 6.2 for hospitalization and greater than 2.4 for restricted activity. The largest differences in absolute risk were generally observed in participants with a specific risk factor who were subsequently hospitalized. Limitations: The observed associations may not be causal. The severity of precipitants was not assessed. The effect of the precipitants may have been underestimated because their exposure after the initial onset of disability was not evaluated. Conclusion: Long-term disability in community mobility is common among older persons. Multiple risk factors, together with subsequent precipitants, greatly increase the likelihood of long-term mobility disability. Primary Funding Source: National Institute on Aging, National Institutes of Health.

PMID: 22250144 [PubMed - in process]

Wheeled mobility (wheelchair) service delivery: scope of the evidence.

Ann Intern Med. 2012 Jan 17;156(2):141-6

Authors: Greer N, Brasure M, Wilt TJ

Abstract

Identifying the appropriate wheelchair for a person who needs one has implications for both disabled persons and society. For someone with severe locomotive problems, the right wheelchair can affect mobility and quality of life. However, policymakers are concerned about the increasing demand for unnecessarily elaborate chairs. The Office of Inspector General, U.S. Department of Health and Human Services, issued 4 reports between 2009 and 2011 detailing fraud and misapplication of Medicare funds for powered wheelchairs, more than a decade after similar concerns were first raised by 4 contractors who process claims for durable medical equipment. Subsequent concerns have arisen about whether some impaired persons who need wheeled mobility devices may now be inappropriately denied coverage. A transparent, evidence-based approach to wheeled mobility service delivery (the matching of mobility-impaired persons to appropriate devices and supporting services) might lessen these concerns. This review describes the process of wheeled mobility service delivery for long-term wheelchair users with complex rehabilitation needs and presents findings from a survey of the literature (published and gray) and interviews with key informants. Recommended steps in the delivery process were identified in textbooks, guidelines, and published literature. Delivery processes shared many commonalities; however, no research supports the recommended approaches. A search of bibliographic databases through March 2011 identified 24 studies that evaluated aspects of wheeled mobility service delivery. Most were observational, exploratory studies designed to determine consumer use of and satisfaction with the process. The evidence base for the effectiveness of approaches to wheeled mobility service delivery is insufficient, and additional research is needed to develop standards and guidelines.

PMID: 22250145 [PubMed - in process]

Appropriate Use of Screening and Diagnostic Tests to Foster High-Value, Cost-Conscious Care.

Ann Intern Med. 2012 Jan 17;156(2):147-149

Authors: Qaseem A, Alguire P, Dallas P, Feinberg LE, Fitzgerald FT, Horwitch C, Humphrey L, Leblond R, Moyer D, Wiese JG, Weinberger S

Abstract

Reader Survey: Which testing scenarios are low value? Unsustainable rising health care costs in the United States have made reducing costs while maintaining high-quality health care a national priority. The overuse of some screening and diagnostic tests is an important component of unnecessary health care costs. More judicious use of such tests will improve quality and reflect responsible awareness of costs. Efforts to control expenditures should focus not only on benefits, harms, and costs but on the value of diagnostic tests-meaning an assessment of whether a test provides health benefits that are worth its costs or harms. To begin to identify ways that practicing clinicians can contribute to the delivery of high-value, cost-conscious health care, the American College of Physicians convened a workgroup of physicians to identify, using a consensus-based process, common clinical situations in which screening and diagnostic tests are used in ways that do not reflect high-value care. The intent of this exercise is to promote thoughtful discussions about these tests and other health care interventions to promote high-value, cost-conscious care.

PMID: 22250146 [PubMed - as supplied by publisher]

Exposing unethical human research: the transatlantic correspondence of beecher and pappworth.

Ann Intern Med. 2012 Jan 17;156(2):150-5

Authors: Gaw A

Abstract

Henry K. Beecher and Maurice H. Pappworth were the 2 most prominent medical whistleblowers in research ethics of the 20th century. Independently, both wrote highly controversial and ultimately influential articles and books. Although their work is now well-known in clinical research circles, their collaboration is not. Pappworth’s article “Human Guinea Pigs: A Warning” was published in 1962; in it, he discussed a series of published studies that he considered unethical. Beecher read it and wrote to Pappworth seeking help. The current article reconstructs, from Beecher and Pappworth’s correspondence in 1965-1966, an important juncture in the genesis of modern clinical research ethics. Although they shared much in common, they differed radically in the strategies they adopted: Beecher chose to conceal the identities of individuals, whereas Pappworth believed that only by naming and shaming could any exposé act as a deterrent. Their correspondence reveals how the 2 men shared their ideas and their material and provided each other with much-needed support. It also tracks the development of Beecher’s shift from a position initially indistinguishable from Pappworth’s toward the one he adopted when his seminal article of 1966 was published.

PMID: 22250147 [PubMed - in process]

Severe Vitamin D Deficiency: A Prerequisite for COPD Responsiveness to Vitamin D Supplementation?

Ann Intern Med. 2012 Jan 17;156(2):156-7

Authors: Gold DR, Manson JE

PMID: 22250148 [PubMed - in process]

To image or to autopsy?

Ann Intern Med. 2012 Jan 17;156(2):158-9

Authors: Burton EC, Mossa-Basha M

PMID: 22250149 [PubMed - in process]

Mobilizing to address increasing population disability.

Ann Intern Med. 2012 Jan 17;156(2):160-1

Authors: Iezzoni LI

PMID: 22250150 [PubMed - in process]

High-value testing begins with a few simple questions.

Ann Intern Med. 2012 Jan 17;156(2):162-3

Authors: Laine C

PMID: 22250151 [PubMed - in process]

The waiting room.

Ann Intern Med. 2012 Jan 17;156(2):164-5

Authors: Kansagara D

PMID: 22250152 [PubMed - in process]

Traditional Chinese Herbal Therapy as a Treatment Option for H1N1 Influenza.

Ann Intern Med. 2012 Jan 17;156(2):166

Authors: Wang CZ, Li P, Yuan CS

PMID: 22250153 [PubMed - in process]

Impact of the “july effect” on patient outcomes.

Ann Intern Med. 2012 Jan 17;156(2):167

Authors: Glick SS

PMID: 22250154 [PubMed - in process]

Impact of the “july effect” on patient outcomes.

Ann Intern Med. 2012 Jan 17;156(2):167-8

Authors: Vaughan L, Bell D, McAlister G

PMID: 22250155 [PubMed - in process]

Impact of the “july effect” on patient outcomes.

Ann Intern Med. 2012 Jan 17;156(2):168

Authors: Jarrett MP

PMID: 22250156 [PubMed - in process]

Clinical decision rules for excluding pulmonary embolism.

Ann Intern Med. 2012 Jan 17;156(2):168-9

Authors: Giusti G, Coerezza A, Cernuschi G

PMID: 22250157 [PubMed - in process]

The bedside evaluation.

Ann Intern Med. 2012 Jan 17;156(2):170

Authors: Ogedegbe AO

PMID: 22250158 [PubMed - in process]

The bedside evaluation.

Ann Intern Med. 2012 Jan 17;156(2):170

Authors: Louwrens NA

PMID: 22250159 [PubMed - in process]

Recurrent Stress Cardiomyopathy Induced by Sudafed PE.

Ann Intern Med. 2012 Jan 17;156(2):171-2

Authors: Zlotnick DM, Helisch A

PMID: 22250160 [PubMed - in process]

Risk for death from cardiovascular disease in women with obstructive sleep apnea.

Ann Intern Med. 2012 Jan 17;156(2):I38

Authors:

PMID: 22250162 [PubMed - in process]

Vitamin d treatment of chronic obstructive pulmonary disease.

Ann Intern Med. 2012 Jan 17;156(2):I26

Authors:

PMID: 22250161 [PubMed - in process]

Why do many older persons become disabled in walking and driving?

Ann Intern Med. 2012 Jan 17;156(2):I44

Authors:

PMID: 22250163 [PubMed - in process]

Rivaroxaban reduced stroke and systemic embolism compared with warfarin in nonvalvular AF.

Ann Intern Med. 2012 Jan 17;156(2):JC103

Authors:

PMID: 22250165 [PubMed - in process]

Apixaban reduced stroke and systemic embolism compared with warfarin in atrial fibrillation.

Ann Intern Med. 2012 Jan 17;156(2):JC102

Authors:

PMID: 22250164 [PubMed - in process]

Review: Interventions to reduce or modify dietary fat reduce cardiovascular events.

Ann Intern Med. 2012 Jan 17;156(2):JC105

Authors:

PMID: 22250167 [PubMed - in process]

Review: Interventions to reduce dietary salt do not reduce mortality or morbidity.

Ann Intern Med. 2012 Jan 17;156(2):JC104

Authors:

PMID: 22250166 [PubMed - in process]

Cytisine increased smoking cessation in adults.

Ann Intern Med. 2012 Jan 17;156(2):JC106

Authors:

PMID: 22250168 [PubMed - in process]

Acetylcysteine did not reduce kidney injury in at-risk patients having vascular angiography.

Ann Intern Med. 2012 Jan 17;156(2):JC108

Authors:

PMID: 22250170 [PubMed - in process]

Insulin secretagogues were associated with increased mortality compared with metformin in type 2 diabetes.

Ann Intern Med. 2012 Jan 17;156(2):JC107

Authors:

PMID: 22250169 [PubMed - in process]

The RenalGuard system reduced kidney injury more than a control system in high-risk patients.

Ann Intern Med. 2012 Jan 17;156(2):JC109

Authors:

PMID: 22250171 [PubMed - in process]

Azithromycin once daily for 1 year reduced acute COPD exacerbations.

Ann Intern Med. 2012 Jan 17;156(2):JC110

Authors:

PMID: 22250172 [PubMed - in process]

Review: Gestalt or clinical decision rules have limited sensitivity and specificity for detecting acute PE.

Ann Intern Med. 2012 Jan 17;156(2):JC111

Authors:

PMID: 22250173 [PubMed - in process]

An 11-item index predicted 5-year and 9-year mortality in community-dwelling elderly adults.

Ann Intern Med. 2012 Jan 17;156(2):JC113

Authors:

PMID: 22250175 [PubMed - in process]

Adding a panel manager to EMR reminders improved some preventive care processes.

Ann Intern Med. 2012 Jan 17;156(2):JC112

Authors:

PMID: 22250174 [PubMed - in process]

Spinal manipulation, medication, or home exercise with advice for acute and subacute neck pain: a randomized trial.

Ann Intern Med. 2012 Jan 3;156(1 Pt 1):1-10

Authors: Bronfort G, Evans R, Anderson AV, Svendsen KH, Bracha Y, Grimm RH

Abstract

Background: Mechanical neck pain is a common condition that affects an estimated 70% of persons at some point in their lives. Little research exists to guide the choice of therapy for acute and subacute neck pain. Objective: To determine the relative efficacy of spinal manipulation therapy (SMT), medication, and home exercise with advice (HEA) for acute and subacute neck pain in both the short and long term. Design: Randomized, controlled trial. (ClinicalTrials.gov registration number: NCT00029770) Setting: 1 university research center and 1 pain management clinic in Minnesota. Participants: 272 persons aged 18 to 65 years who had nonspecific neck pain for 2 to 12 weeks. Intervention: 12 weeks of SMT, medication, or HEA. Measurements: The primary outcome was participant-rated pain, measured at 2, 4, 8, 12, 26, and 52 weeks after randomization. Secondary measures were self-reported disability, global improvement, medication use, satisfaction, general health status (Short Form-36 Health Survey physical and mental health scales), and adverse events. Blinded evaluation of neck motion was performed at 4 and 12 weeks. Results: For pain, SMT had a statistically significant advantage over medication after 8, 12, 26, and 52 weeks (P ≤ 0.010), and HEA was superior to medication at 26 weeks (P = 0.02). No important differences in pain were found between SMT and HEA at any time point. Results for most of the secondary outcomes were similar to those of the primary outcome. Limitations: Participants and providers could not be blinded. No specific criteria for defining clinically important group differences were prespecified or available from the literature. Conclusion: For participants with acute and subacute neck pain, SMT was more effective than medication in both the short and long term. However, a few instructional sessions of HEA resulted in similar outcomes at most time points. Primary Funding Source: National Center for Complementary and Alternative Medicine, National Institutes of Health.

PMID: 22213489 [PubMed - in process]

Comparison of natural language processing biosurveillance methods for identifying influenza from encounter notes.

Ann Intern Med. 2012 Jan 3;156(1 Pt 1):11-8

Authors: Elkin PL, Froehling DA, Wahner-Roedler DL, Brown SH, Bailey KR

Abstract

Background: An effective national biosurveillance system expedites outbreak recognition and facilitates response coordination at the federal, state, and local levels. The BioSense system, used at the Centers for Disease Control and Prevention, incorporates chief complaints but not data from the whole encounter note into its surveillance algorithms. Objective: To evaluate whether biosurveillance by using data from the whole encounter note is superior to that using data from the chief complaint field alone. Design: 6-year retrospective case-control cohort study. Setting: Mayo Clinic, Rochester, Minnesota. Participants: 17 243 persons tested for influenza A or B virus between 1 January 2000 and 31 December 2006. Measurements: The accuracy of a model based on signs and symptoms to predict influenza virus infection in patients with upper respiratory tract symptoms, and the ability of a natural language processing technique to identify definitional clinical features from free-text encounter notes. Results: Surveillance based on the whole encounter note was superior to the chief complaint field alone. For the case definition used by surveillance of the whole encounter note, the normalized partial area under the receiver-operating characteristic curve (specificity, 0.1 to 0.4) for surveillance using the whole encounter note was 92.9% versus 70.3% for surveillance with the chief complaint field (difference, 22.6%; P < 0.001). Comparison of the 2 models at the fixed specificity of 0.4 resulted in sensitivities of 89.0% and 74.4%, respectively (P < 0.001). The relative risk for missing a true case of influenza was 2.3 by using the chief complaint field model. Limitations: Participants were seen at 1 tertiary referral center. The cost of comprehensive biosurveillance monitoring was not studied. Conclusion: A biosurveillance model for influenza using the whole encounter note is more accurate than a model that uses only the chief complaint field. Because case-defining signs and symptoms of influenza are commonly available in health records, the investigators believe that the national strategy for biosurveillance should be changed to incorporate data from the whole health record. Primary Funding Source: Centers for Disease Control and Prevention.

PMID: 22213490 [PubMed - in process]

Comparison of hospital risk-standardized mortality rates calculated by using in-hospital and 30-day models: an observational study with implications for hospital profiling.

Ann Intern Med. 2012 Jan 3;156(1 Pt 1):19-26

Authors: Drye EE, Normand SL, Wang Y, Ross JS, Schreiner GC, Han L, Rapp M, Krumholz HM

Abstract

Background: In-hospital mortality measures, which are widely used to assess hospital quality, are not based on a standardized follow-up period and may systematically favor hospitals with shorter lengths of stay (LOSs). Objective: To assess the agreement between performance measures of U.S. hospitals by using risk-standardized in-hospital and 30-day mortality rates. Design: Observational study. Setting: Nonfederal acute care hospitals in the United States with at least 30 admissions for acute myocardial infarction (AMI), heart failure (HF), and pneumonia from 2004 to 2006. Patients: Medicare fee-for-service patients admitted for AMI, HF, or pneumonia from 2004 to 2006. Measurements: The primary outcomes were in-hospital and 30-day risk-standardized mortality rates (RSMRs). Results: Included patients comprised 718 508 admissions to 3135 hospitals for AMI, 1 315 845 admissions to 4209 hospitals for HF, and 1 415 237 admissions to 4498 hospitals for pneumonia. The hospital-level mean patient LOS varied across hospitals for each condition, ranging from 2.3 to 13.7 days for AMI, 3.5 to 11.9 days for HF, and 3.8 to 14.8 days for pneumonia. The mean RSMR differences (30-day RSMR minus in-hospital RSMR) were 5.3% (SD, 1.3) for AMI, 6.0% (SD, 1.3) for HF, and 5.7% (SD, 1.4) for pneumonia; distributions varied widely across hospitals. Performance classifications differed between the in-hospital and 30-day models for 257 hospitals (8.2%) for AMI, 456 (10.8%) for HF, and 662 (14.7%) for pneumonia. Hospital mean LOS was positively correlated with in-hospital RSMRs for all 3 conditions. Limitation: Medicare claims data were used for risk adjustment. Conclusion: In-hospital mortality measures provide a different assessment of hospital performance than 30-day mortality and are biased in favor of hospitals with shorter LOSs. Primary Funding Source: The Centers for Medicare & Medicaid Services and National Heart, Lung, and Blood Institute.

PMID: 22213491 [PubMed - in process]

Evaluation of guideline recommendations on oral medications for type 2 diabetes mellitus: a systematic review.

Ann Intern Med. 2012 Jan 3;156(1 Pt 1):27-36

Authors: Bennett WL, Odelola OA, Wilson LM, Bolen S, Selvaraj S, Robinson KA, Bass EB, Puhan MA

Abstract

Background: Clinical practice guidelines have an important role in guiding choices among the numerous medications available to treat type 2 diabetes mellitus, but little is known about their quality. Purpose: To assess whether guidelines on oral medications for type 2 diabetes are consistent with a systematic review of the current evidence and whether the consistency of the guidelines depends on the quality of guideline development. Data Sources: MEDLINE, CINAHL, and guideline-specific databases were searched between July 2007 and August 2011, after the 2007 publication of a peer-reviewed systematic review on oral diabetes medications. Study Selection: Two reviewers independently screened citations to identify English-language guidelines on oral medications to treat type 2 diabetes that were applied in the United States, United Kingdom, and Canada. Data Extraction: Reviewers assessed whether the guidelines addressed and agreed with 7 evidence-based conclusions from the 2007 systematic review. Two reviewers independently rated guideline quality by using 2 domains from the Appraisal of Guidelines Research and Evaluation instrument. Data Synthesis: Of the 1000 screened citations, 11 guidelines met the inclusion criteria. Seven guidelines agreed with the conclusion that metformin is favored as the first-line agent. Ten guidelines agreed that thiazolidinediones are associated with higher rates of edema and congestive heart failure compared with other oral medications to treat type 2 diabetes. One guideline addressed no evidence-based conclusions, and 5 guidelines agreed with all 7 conclusions. The summary scores of the rigor of development (median, 28.6% [range, 16.7% to 100.0%]) and editorial independence (median, 75.0% [range, 8.3% to 100.0%]) domains varied greatly across guidelines. Guidelines that received higher quality scores contained more recommendations that were consistent with the evidence-based conclusions. Limitation: Only English-language guidelines targeting users in the United States, United Kingdom, and Canada that contained recommendations on oral medications were included. Conclusion: Not all practice guidelines on oral treatment of type 2 diabetes were consistent with available evidence from a systematic review. Guidelines judged to be of higher quality contained more recommendations consistent with evidence-based conclusions. The quality of guideline development processes varied substantially. Primary Funding Source: Agency for Healthcare Research and Quality.

PMID: 22213492 [PubMed - in process]

Distinguishing case series from cohort studies.

Ann Intern Med. 2012 Jan 3;156(1 Pt 1):37-40

Authors: Dekkers OM, Egger M, Altman DG, Vandenbroucke JP

Abstract

Case series are a commonly reported study design, but the label “case series” is used inconsistently and sometimes incorrectly. Mislabeling impairs the appropriate indexing and sorting of evidence. This article tries to clarify the concept of case series and proposes a way to distinguish them from cohort studies. In a cohort study, patients are sampled on the basis of exposure and are followed over time, and the occurrence of outcomes is assessed. A cohort study may include a comparison group, although this is not a necessary feature. A case series may be a study that samples patients with both a specific outcome and a specific exposure, or one that samples patients with a specific outcome and includes patients regardless of whether they have specific exposures. Whereas a cohort study, in principle, enables the calculation of an absolute risk or a rate for the outcome, such a calculation is not possible in a case series.

PMID: 22213493 [PubMed - in process]

Advanced Dementia: State of the Art and Priorities for the Next Decade.

Ann Intern Med. 2012 Jan 3;156(1_Part_1):45-51

Authors: Mitchell SL, Black BS, Ersek M, Hanson LC, Miller SC, Sachs GA, Teno JM, Morrison RS

Abstract

Dementia is a leading cause of death in the United States. This article outlines the current understanding of advanced dementia and identifies research priorities for the next decade. Research over the past 25 years has largely focused on describing the experience of patients with advanced dementia. This work has delineated abundant opportunities for improvement, including greater recognition of advanced dementia as a terminal illness, better treatment of distressing symptoms, increased access to hospice and palliative care services, and less use of costly and aggressive treatments that may be of limited clinical benefit. Addressing those opportunities must be the overarching objective for the field in the coming decade. Priority areas include designing and testing interventions that promote high-quality, goal-directed care; health policy research to identify strategies that incentivize cost-effective and evidence-based care; implementation studies of promising interventions and policies; and further development of disease-specific outcome measures. There is great need and opportunity to improve outcomes, contain expenditures, reduce disparities, and better coordinate care for the millions of persons in the United States who have advanced dementia.

PMID: 22213494 [PubMed - as supplied by publisher]

Pain in the neck: many (marginally different) treatment choices.

Ann Intern Med. 2012 Jan 3;156(1 Pt 1):52-3

Authors: Walker BF, French SD

PMID: 22213495 [PubMed - in process]

Fortune favors a prepared health care system.

Ann Intern Med. 2012 Jan 3;156(1 Pt 1):54-5

Authors: Palmore TN, Henderson DK

PMID: 22213496 [PubMed - in process]

Review of the american college of physicians ethics manual, sixth edition.

Ann Intern Med. 2012 Jan 3;156(1 Pt 1):56-7

Authors: Emanuel EJ

PMID: 22213497 [PubMed - in process]

Ethics of the fathers.

Ann Intern Med. 2012 Jan 3;156(1 Pt 1):58-9

Authors: Haber AD

PMID: 22213498 [PubMed - in process]

Chemotherapy in the rwandan countryside: universal issues a world away.

Ann Intern Med. 2012 Jan 3;156(1 Pt 1):60-1

Authors: Postow M

PMID: 22213499 [PubMed - in process]

My stethoscope.

Ann Intern Med. 2012 Jan 3;156(1 Pt 1):62-3

Authors: Sarosi GA

PMID: 22213500 [PubMed - in process]

Doctor and son.

Ann Intern Med. 2012 Jan 3;156(1 Pt 1):64-5

Authors: Elliott CG

PMID: 22213501 [PubMed - in process]

Redesigning after-hours primary care.

Ann Intern Med. 2012 Jan 3;156(1 Pt 1):67

Authors: Miller ME

PMID: 22213502 [PubMed - in process]

Redesigning after-hours primary care.

Ann Intern Med. 2012 Jan 3;156(1 Pt 1):67-8

Authors: Majeed A

PMID: 22213503 [PubMed - in process]

A clinical practice guideline update on the diagnosis and management of stable chronic obstructive pulmonary disease.

Ann Intern Med. 2012 Jan 3;156(1 Pt 1):68-9

Authors: Young RP, Hopkins RJ

PMID: 22213504 [PubMed - in process]

NICE Guideline for Management of Chronic Heart Failure in Adults.

Ann Intern Med. 2012 Jan 3;156(1 Pt 1):69

Authors: Finucane TE

PMID: 22213505 [PubMed - in process]

NICE Guideline for Management of Chronic Heart Failure in Adults.

Ann Intern Med. 2012 Jan 3;156(1 Pt 1):69-70

Authors: Simel DL

PMID: 22213506 [PubMed - in process]

Hip fracture: a complex illness among complex patients.

Ann Intern Med. 2012 Jan 3;156(1 Pt 1):70-1

Authors: Lynn J

PMID: 22213507 [PubMed - in process]

Hip fracture: a complex illness among complex patients.

Ann Intern Med. 2012 Jan 3;156(1 Pt 1):71

Authors: Dixit RK

PMID: 22213508 [PubMed - in process]

Is spinal manipulation an effective treatment for neck pain?

Ann Intern Med. 2012 Jan 3;156(1 Pt 1):I30

Authors:

PMID: 22213509 [PubMed - in process]

Plantar fasciitis.

Ann Intern Med. 2012 Jan 3;156(1 Pt 1):ITC11

Authors: Young C

Abstract

This issue provides a clinical overview of plantar fasciitis 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.

PMID: 22213510 [PubMed - in process]

American College of Physicians Ethics Manual: Sixth Edition.

Ann Intern Med. 2012 Jan 3;156(1_Part_2):73-104

Authors: Snyder L,

Abstract

Medicine, law, and social values are not static. Reexamining the ethical tenets of medicine and their application in new circumstances is a necessary exercise. The sixth edition of the American College of Physicians (ACP) Ethics Manual covers emerging issues in medical ethics and revisits older ones that are still very pertinent. It reflects on many of the ethical tensions in medicine and attempts to shed light on how existing principles extend to emerging concerns. In addition, by reiterating ethical principles that have provided guidance in resolving past ethical problems, the Manual may help physicians avert future problems. The Manual is not a substitute for the experience and integrity of individual physicians, but it may serve as a reminder of the shared duties of the medical profession.

PMID: 22213573 [PubMed - as supplied by publisher]

Defining Patient Complexity From the Primary Care Physician’s Perspective: A Cohort Study.

Ann Intern Med. 2011 Dec 20;155(12):797-804

Authors: Grant RW, Ashburner JM, Hong CC, Chang Y, Barry MJ, Atlas SJ

Abstract

Background: Patients with complex health needs are increasingly the focus of health system redesign. Objective: To characterize complex patients, as defined by their primary care physicians (PCPs), and to compare this definition with other commonly used algorithms. Design: Cohort study. Setting: 1 hospital-based practice, 4 community health centers, and 7 private practices in a primary care network in the United States. Participants: 40 physicians who reviewed a random sample of 120 of their own patients. Measurements: After excluding patients for whom they were not directly responsible, PCPs indicated which of their patients they considered complex. These patients were characterized, independent predictors of complexity were identified, and PCP-defined complexity was compared with 3 comorbidity-based methods (Charlson score, Higashi score, and a proprietary Centers for Medicare & Medicaid Services algorithm). Results: Physicians identified 1126 of their 4302 eligible patients (26.2%) as complex and assigned a mean of 2.2 domains of complexity per patient (median, 2.0 [interquartile range, 1 to 3]). Mental health and substance use were identified as major issues in younger complex patients, whereas medical decision making and care coordination predominated in older patients (P < 0.001 for trends by decade). Major independent predictors of PCP-defined complexity (P < 0.001) included age (probability of complexity increased from 14.8% to 19.8% with age increasing from 55 to 65 years), poorly controlled diabetes (from 12.7% to 47.6% if hemoglobin A(1c) level ≥9%), use of antipsychotics (from 12.7% to 31.8%), alcohol-related diagnoses (from 12.9% to 27.4%), and inadequate insurance (from 12.5% to 19.2%). Classification agreement for complex patients ranged from 26.2% to 56.0% when PCP assignment was compared with each of the other methods. Limitation: Results may not be generalizable to other primary care settings. Conclusion: Primary care physicians identified approximately one quarter of their patients as complex. Medical, social, and behavioral factors all contributed to PCP-defined complexity. Physician-defined complexity had only modest agreement with 3 comorbidity-based algorithms. Primary Funding Source: Partners Community Healthcare, Inc.

PMID: 22184686 [PubMed - in process]

Patient Interest in Sharing Personal Health Record Information: A Web-Based Survey.

Ann Intern Med. 2011 Dec 20;155(12):805-810

Authors: Zulman DM, Nazi KM, Turvey CL, Wagner TH, Woods SS, An LC

Abstract

Background: Electronic personal health record (PHR) systems are proliferating but largely have not realized their potential for enhancing communication among patients and their network of care providers. Objective: To explore preferences about sharing electronic health information among users of the U.S. Department of Veterans Affairs (VA) PHR system, My HealtheVet. Design: Web-based survey of a convenience sample. Setting: My HealtheVet Web site from 7 July through 4 October 2010. Participants: 18 471 users of My HealtheVet. Measurements: Interest in shared PHR access and preferences about who would receive access, the information that would be shared, and the activities that users would delegate. Results: Survey respondents were predominantly men (92%) and aged 50 to 64 years (51%) or 65 years or older (39%); approximately 39% reported poor or fair health status. Almost 4 of 5 respondents (79%) were interested in sharing access to their PHR with someone outside of their health system (62% with a spouse or partner, 23% with a child, 15% with another family member, and 25% with a non-VA health care provider). Among those who selected a family member other than a spouse or partner, 47% lived apart from the specified person. Preferences about degree of access varied on the basis of the type of information being shared, the type of activity being performed, and the respondent’s relationship with the selected person. Limitations: The survey completion rate was 40.8%. Results might not be generalizable to all My HealtheVet users. Conclusion: In a large survey of PHR users in the VA system, most respondents were interested in sharing access to their electronic health information with caregivers and non-VA providers. Existing and evolving PHR systems should explore secure mechanisms for shared PHR access to improve information exchange among patients and the multiple persons involved in their health care. Primary Funding Source: Veterans Health Administration and The Robert Wood Johnson Foundation Clinical Scholars Program.

PMID: 22184687 [PubMed - as supplied by publisher]

Inviting patients to read their doctors’ notes: patients and doctors look ahead: patient and physician surveys.

Ann Intern Med. 2011 Dec 20;155(12):811-9

Authors: Walker J, Leveille SG, Ngo L, Vodicka E, Darer JD, Dhanireddy S, Elmore JG, Feldman HJ, Lichtenfeld MJ, Oster N, Ralston JD, Ross SE, Delbanco T

Abstract

Background: Little is known about what primary care physicians (PCPs) and patients would expect if patients were invited to read their doctors’ office notes. Objective: To explore attitudes toward potential benefits or harms if PCPs offered patients ready access to visit notes. Design: The PCPs and patients completed surveys before joining a voluntary program that provided electronic links to doctors’ notes. Setting: Primary care practices in 3 U.S. states. Participants: Participating and nonparticipating PCPs and adult patients at primary care practices in Massachusetts, Pennsylvania, and Washington. Measurements: Doctors’ and patients’ attitudes toward and expectations of open visit notes, their ideas about the potential benefits and risks, and demographic characteristics. Results: 110 of 114 participating PCPs (96%), 63 of 140 nonparticipating PCPs (45%), and 37 856 of 90 203 patients (42%) completed surveys. Overall, 69% to 81% of participating PCPs across the 3 sites and 92% to 97% of patients thought open visit notes were a good idea, compared with 16% to 33% of nonparticipating PCPs. Similarly, participating PCPs and patients generally agreed with statements about potential benefits of open visit notes, whereas nonparticipating PCPs were less likely to agree. Among participating PCPs, 74% to 92% anticipated improved communication and patient education, in contrast to 45% to 67% of nonparticipating PCPs. More than one half of participating PCPs (50% to 58%) and most nonparticipating PCPs (88% to 92%) expected that open visit notes would result in greater worry among patients; far fewer patients concurred (12% to 16%). Thirty-six percent to 50% of participating PCPs and 83% to 84% of nonparticipating PCPs anticipated more patient questions between visits. Few PCPs (0% to 33%) anticipated increased risk for lawsuits. Patient enthusiasm extended across age, education, and health status, and 22% anticipated sharing visit notes with others, including other doctors. Limitations: Access to electronic patient portals is not widespread, and participation was limited to patients using such portals. Response rates were higher among participating PCPs than nonparticipating PCPs; many participating PCPs had small patient panels. Conclusion: Among PCPs, opinions about open visit notes varied widely in terms of predicting the effect on their practices and benefits for patients. In contrast, patients expressed considerable enthusiasm and few fears, anticipating both improved understanding and more involvement in care. Sharing visit notes has broad implications for quality of care, privacy, and shared accountability. Primary Funding Source: The Robert Wood Johnson Foundation’s Pioneer Portfolio, Drane Family Fund, and Koplow Charitable Foundation.

PMID: 22184688 [PubMed - in process]

New insights about vitamin d and cardiovascular disease: a narrative review.

Ann Intern Med. 2011 Dec 20;155(12):820-6

Authors: McGreevy C, Williams D

Abstract

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.

PMID: 22184689 [PubMed - in process]

Vitamin D With or Without Calcium Supplementation for Prevention of Cancer and Fractures: An Updated Meta-analysis for the U.S. Preventive Services Task Force.

Ann Intern Med. 2011 Dec 20;155(12):827-38

Authors: Chung M, Lee J, Terasawa T, Lau J, Trikalinos TA

Abstract

Background: Studies suggest that vitamin D supplementation may reduce cancer and fracture risks. Purpose: To examine the benefits and harms of vitamin D with or without calcium supplementation on clinical outcomes of cancer and fractures in adults. Data Sources: English-language studies identified from MEDLINE and the Cochrane Central Register of Controlled Trials through July 2011. Study Selection: Randomized, controlled trials (RCTs), prospective cohort studies, and nested case-control studies reporting incidence of or death from cancer and fracture outcomes. Data Extraction: Multiple reviewers extracted details about participant characteristics, including baseline vitamin D status and use of supplements; details of statistical analyses, including adjustments for confounding; and methodological quality. Differences were resolved by consensus. Data Synthesis: 19 RCTs (3 for cancer and 16 for fracture outcomes) and 28 observational studies (for cancer outcomes) were analyzed. Limited data from RCTs suggested that high-dose (1000 IU/d) vitamin D supplementation can reduce the risk for total cancer, and data from observational studies suggested that higher blood 25-hydroxyvitamin D (25-[OH]D) concentrations might be associated with increased risk for cancer. Mixed-effects dose-response meta-analyses showed that each 10-nmol/L increase in blood 25-(OH)D concentration was associated with a 6% (95% CI, 3% to 9%) reduced risk for colorectal cancer but no statistically significant dose-response relationships for prostate and breast cancer. Random-effects model meta-analysis showed that combined vitamin D and calcium supplementation reduced fracture risk (pooled relative risk, 0.88 [CI, 0.78 to 0.99]) in older adults, but the effects differed according to study setting: institution (relative risk, 0.71 [CI, 0.57 to 0.89]) versus community-dwelling (relative risk, 0.89 [CI, 0.76 to 1.04]). One RCT showed adverse outcomes associated with supplementation, including increased risk for renal and urinary tract stones. Limitations: Most trial participants were older (aged ≥65 years) postmenopausal women. Observational studies were heterogeneous and were limited by potential confounders. Conclusion: Combined vitamin D and calcium supplementation can reduce fracture risk, but the effects may be smaller among community-dwelling older adults than among institutionalized elderly persons. Appropriate dose and dosing regimens, however, require further study. Evidence is not sufficiently robust to draw conclusions regarding the benefits or harms of vitamin D supplementation for the prevention of cancer. Primary Funding Source: Agency for Healthcare Research and Quality.

PMID: 22184690 [PubMed - in process]

Comparative Effectiveness of Clostridium difficile Treatments: A Systematic Review.

Ann Intern Med. 2011 Dec 20;155(12):839-47

Authors: Drekonja DM, Butler M, Macdonald R, Bliss D, Filice GA, Rector TS, Wilt TJ

Abstract

Background: Clostridium difficile infection is increasing in incidence and severity. The optimal treatment is unknown. Purpose: To determine whether, among adults with C. difficile infection, treatment with certain antibiotics compared with others results in differences in initial cure, recurrence, and harms. Data Sources: MEDLINE, AMED, ClinicalTrials.gov, and Cochrane databases (search dates: inception through August 2011, limited to English-language reports); bibliography review. Study Selection: Randomized, controlled trials of adults with C. difficile infection, independent of outcomes, who were treated with medications available in the United States. Observational studies reporting strain were included. Data Extraction: Study design, inclusion and exclusion criteria, quality and strength of evidence as assessed by 2 reviewers, study definitions, and duration of treatment and follow-up. Outcomes included initial cure, recurrence, and treatment harms. Data Synthesis: 11 trials that included 1463 participants were identified. Three trials compared metronidazole with vancomycin; 8 compared metronidazole or vancomycin with another agent, combined agents, or placebo. Strain was analyzed in 1 trial and 2 cohort studies. No study comparing 2 antimicrobial agents demonstrated a statistically significant difference for initial cure; all comparisons were of low to moderate strength of evidence. Moderate-strength evidence from 1 study demonstrated that recurrence was decreased with fidaxomicin versus vancomycin (15% vs. 25%; difference, -10 percentage points [95% CI, -17 to -3 percentage points]; P = 0.005). Subgroup analysis of a single study comparing metronidazole with vancomycin for patients who have severe C. difficile infection showed no difference by intention-to-treat analysis; this was rated as insufficient-strength evidence. Harms, when reported, did not differ between treatments in any study. Limitations: Definitions of diarrhea, C. difficile infection, initial cure, and relapse varied. Some studies reported insufficient detail to allow assessment of all randomly assigned participants or of harms. Conclusion: No antimicrobial agent is clearly superior for the initial cure of C. difficile infection. Recurrence is less frequent with fidaxomicin than with vancomycin. Primary Funding Source: U.S. Department of Health and Human Services.

PMID: 22184691 [PubMed - in process]

Prescription medication abuse and illegitimate internet-based pharmacies.

Ann Intern Med. 2011 Dec 20;155(12):848-50

Authors: Jena AB, Goldman DP, Foster SE, Califano JA

Abstract

Abuse of controlled prescription medications in the United States exceeds that of all illicit drugs combined except marijuana and has grown considerably in the past decade. Although available through traditional channels, controlled prescription medications can also be purchased on the Internet without a prescription. This issue has gained the attention of federal regulators, law enforcement, and the media, but physician awareness of the problem is scarce. This article describes the nature of the problem and its magnitude, discusses the challenges to federal and private efforts to combat illegitimate online pharmacies, and outlines strategies for physicians to recognize and minimize the unwarranted effects of the availability of these medications on the Internet.

PMID: 22184692 [PubMed - in process]

The complexity of measuring clinical complexity.

Ann Intern Med. 2011 Dec 20;155(12):851-2

Authors: Turner BJ, Cuttler L

PMID: 22184693 [PubMed - in process]

Access to the medical record for patients and involved providers: transparency through electronic tools.

Ann Intern Med. 2011 Dec 20;155(12):853-4

Authors: Feeley TW, Shine KI

PMID: 22184694 [PubMed - in process]

Daily dilemmas.

Ann Intern Med. 2011 Dec 20;155(12):855-6

Authors: Rosenbaum JR

PMID: 22184695 [PubMed - in process]

Providing high-value, cost-conscious care.

Ann Intern Med. 2011 Dec 20;155(12):857

Authors: Pollak B

PMID: 22184696 [PubMed - in process]

Providing high-value, cost-conscious care.

Ann Intern Med. 2011 Dec 20;155(12):857

Authors: Graham JD, Potyk DK, Raimi ED

PMID: 22184697 [PubMed - in process]

Providing high-value, cost-conscious care.

Ann Intern Med. 2011 Dec 20;155(12):857-8

Authors: Cassel CK

PMID: 22184698 [PubMed - in process]

Providing high-value, cost-conscious care.

Ann Intern Med. 2011 Dec 20;155(12):858

Authors: Weiss CO, Holden M, McNabney M

PMID: 22184699 [PubMed - in process]