Risk for postoperative venous thromboembolism in women was increased for 12 weeks and varied by type of surgery.

Ann Intern Med. 2010 Mar 16;152(6):JC311

Authors:

PMID: 20231553 [PubMed - in process]

A brief psychosocial-behavioral intervention reduced depression after stroke more than usual care.

Ann Intern Med. 2010 Mar 16;152(6):JC310

Authors:

PMID: 20231552 [PubMed - in process]

The ethics of offering payment to living people who donate a kidney.

Ann Intern Med. 2010 Mar 16;152(6):I46

Authors:

PMID: 20231551 [PubMed - in process]

The effects of salsalate on blood sugar control in people with type 2 diabetes.

Ann Intern Med. 2010 Mar 16;152(6):I40

Authors:

PMID: 20231550 [PubMed - in process]

Disability Legacy of the Haitian Earthquake.

Ann Intern Med. 2010 Mar 15;

Authors: Iezzoni LI, Ronan LJ

Haiti's earthquake caused untold numbers of new disabilities across the age spectrum, from infants and children to elderly individuals. Amputations, spinal cord and brain injuries, complex multiple fractures, and other massive trauma will leave residual impairments, precipitating pressing needs at both individual and societal levels. Short-term priorities include clinical stabilization, wound healing, and surgical revisions of suboptimal repairs. Afterward, in the near term, comprehensive rehabilitation must commence to ensure the best possible functional outcomes. Even before the earthquake struck, Haiti had few rehabilitation professionals and little capacity to manufacture essential assistive technologies, including prostheses and wheelchairs. While international organizations are assisting to fill these gaps, ultimately rehabilitation programs and assistive technologies will need to fit the specific demands of Haiti's culture and rugged natural physical environments. As Haiti rebuilds its public and private spaces, ensuring accessibility to persons with disabilities will be critical. Ultimately, one positive legacy of Haiti's earthquake could be the emergence of social attitudes, public policies, and physical environments that more fully accommodate disability across the lifespan.

PMID: 20231547 [PubMed - as supplied by publisher]

Review: Extended-duration chemoprophylaxis with neuraminidase inhibitors prevents symptomatic influenza.

Ann Intern Med. 2010 Mar 16;152(6):JC33

Authors:

PMID: 20231557 [PubMed - in process]

Surgical masks were noninferior to N95 respirators for preventing influenza in health care providers.

Ann Intern Med. 2010 Mar 16;152(6):JC32

Authors:

PMID: 20231556 [PubMed - in process]

Simple models predicted 10-year fracture risk in older women as accurately as more complex FRAX models.

Ann Intern Med. 2010 Mar 16;152(6):JC313

Authors:

PMID: 20231555 [PubMed - in process]

Review: Preoperative brain natriuretic peptide level is an independent predictor of adverse cardiovascular events after noncardiac surgery.

Ann Intern Med. 2010 Mar 16;152(6):JC312

Authors:

PMID: 20231554 [PubMed - in process]

Withholding intravenous drugs did not improve survival to hospital discharge in out-of-hospital cardiac arrest.

Ann Intern Med. 2010 Mar 16;152(6):JC38

Authors:

PMID: 20231562 [PubMed - in process]

On-demand ordering of chest radiographs reduced the number of chest radiographs in mechanically ventilated adults.

Ann Intern Med. 2010 Mar 16;152(6):JC37

Authors:

PMID: 20231561 [PubMed - in process]

Gabapentin and nortriptyline combined was better than either drug alone for relief of neuropathic pain.

Ann Intern Med. 2010 Mar 16;152(6):JC36

Authors:

PMID: 20231560 [PubMed - in process]

Review: Addition of inhaled corticosteroids to long-acting {beta}2-agonists does not improve outcomes in stable COPD.

Ann Intern Med. 2010 Mar 16;152(6):JC35

Authors:

PMID: 20231559 [PubMed - in process]

Review: Tamoxifen, raloxifene, and tibolone prevent primary invasive breast cancer but increase risk for adverse outcomes.

Ann Intern Med. 2010 Mar 16;152(6):JC34

Authors:

PMID: 20231558 [PubMed - in process]

Outcomes with concurrent use of clopidogrel and proton-pump inhibitors: a cohort study.

Ann Intern Med. 2010 Mar 16;152(6):337-45

Authors: Ray WA, Murray KT, Griffin MR, Chung CP, Smalley WE, Hall K, Daugherty JR, Kaltenbach LA, Stein CM

Background: Proton-pump inhibitors (PPIs) and clopidogrel are frequently coprescribed, although the benefits and harms of their concurrent use are unclear. Objective: To examine the association between concurrent use of PPIs and clopidogrel and the risks for hospitalizations for gastroduodenal bleeding and serious cardiovascular disease. Design: Retrospective cohort study using automated data to identify patients who received clopidogrel between 1999 through 2005 after hospitalization for coronary heart disease. Setting: Tennessee Medicaid program. Patients: 20 596 patients (including 7593 concurrent users of clopidogrel and PPIs) hospitalized for myocardial infarction, coronary artery revascularization, or unstable angina pectoris. Measurements: Baseline and follow-up drug use was assessed from automated records of dispensed prescriptions. Primary outcomes were hospitalizations for gastroduodenal bleeding and serious cardiovascular disease (fatal or nonfatal myocardial infarction or sudden cardiac death, stroke, or other cardiovascular death). Results: Pantoprazole and omeprazole accounted for 62% and 9% of concurrent PPI use, respectively. Adjusted incidence of hospitalization for gastroduodenal bleeding in concurrent PPI users was 50% lower than that in nonusers (hazard ratio, 0.50 [95% CI, 0.39 to 0.65]). For patients at highest risk for bleeding, PPI use was associated with an absolute reduction of 28.5 (CI, 11.7 to 36.9) hospitalizations for gastroduodenal bleeding per 1000 person-years. The hazard ratio associated with concurrent PPI use for risk for serious cardiovascular disease was 0.99 (CI, 0.82 to 1.19) for the entire cohort and 1.01 (CI, 0.76 to 1.34) for the subgroup of patients who had percutaneous coronary interventions with stenting during the qualifying hospitalization. Limitations: Unmeasured confounding and misclassification of exposure (no information on adherence or over-the-counter use of drugs) and end points (not confirmed by medical record review) were possible. Because many patients entered the cohort from hospitals with relatively few cohort members, the analysis relied on the assumption that after adjustment for observed covariates, PPI users from one such hospital could be compared with nonusers from a different hospital. Conclusion: In patients with serious coronary heart disease treated with clopidogrel, concurrent PPI use was associated with reduced incidence of hospitalizations for gastroduodenal bleeding. The corresponding point estimate for serious cardiovascular disease was not increased; however, the 95% CI included a clinically important increased risk. Primary Funding Source: Agency for Healthcare Research and Quality and National Heart, Lung, and Blood Institute.

PMID: 20231564 [PubMed - in process]

Darbepoetin decreased transfusions and fatigue, but increased adverse effects in patients with chronic kidney disease, diabetes, and anemia.

Ann Intern Med. 2010 Mar 16;152(6):JC39

Authors:

PMID: 20231563 [PubMed - in process]

Regulated payments for living kidney donation: an empirical assessment of the ethical concerns.

Ann Intern Med. 2010 Mar 16;152(6):358-65

Authors: Halpern SD, Raz A, Kohn R, Rey M, Asch DA, Reese P

Background: Although regulated payments to encourage living kidney donation could reduce morbidity and mortality among patients waiting for a kidney transplant, doing so raises several ethical concerns. Objective: To determine the extent to which the 3 main concerns with paying kidney donors might manifest if a regulated market were created. Design: Cross-sectional study of participants' willingness to donate a kidney in 12 scenarios. Setting: Regional rail and urban trolley lines in Philadelphia County, Philadelphia, Pennsylvania. Participants: Of 550 potential participants, 409 completed the questionnaire (response rate, 74.4%); 342 of these participants were medically eligible to donate. Intervention: Across scenarios, researchers experimentally manipulated the amount of money that participants would receive, the participants' risk for subsequently developing kidney failure themselves, and who would receive the donated kidney. Measurements: The researchers determined whether payment represents an undue inducement by evaluating participants' sensitivity to risk in relation to the payment offered or an unjust inducement by evaluating participants' sensitivity to payment as a function of their annual income. The researchers also evaluated whether introducing payment would hinder altruistic donations by comparing participants' willingness to donate altruistically before versus after the introduction of payments. Results: Generalized estimating equation models revealed that participants' willingness to donate increased significantly as their risk for kidney failure decreased, as the payment offered increased, and when the kidney recipient was a family member rather than a patient on a public waiting list (P < 0.001 for each). No statistical interactions were identified between payment and risk (odds ratio, 1.00 [95% CI, 0.96 to 1.03]) or between payment and income (odds ratio, 1.01 [CI, 0.99 to 1.03]). The proximity of these estimates to 1.0 and narrowness of the CIs suggest that payment is neither an undue nor an unjust inducement, respectively. Alerting participants to the possibility of payment did not alter their willingness to donate for altruistic reasons (P = 0.40). Limitation: Choices revealed in hypothetical scenarios may not reflect real-world behaviors. Conclusion: Theoretical concerns about paying persons for living kidney donation are not corroborated by empirical evidence. A real-world test of regulated payments for kidney donation is needed to definitively show whether payment provides a viable and ethical method to increase the supply of kidneys available for transplantation. Primary Funding Source: None.

PMID: 20231566 [PubMed - in process]

The Effects of Salsalate on Glycemic Control in Patients With Type 2 Diabetes: A Randomized Trial.

Ann Intern Med. 2010 Mar 16;152(6):346-357

Authors: Goldfine AB, Fonseca V, Jablonski KA, Pyle L, Staten MA, Shoelson SE,

Background: Salsalate, a nonacetylated prodrug of salicylate, has been shown to decrease blood glucose concentration in small studies. Objective: To compare the efficacy and safety of salsalate at different doses in patients with type 2 diabetes. Design: Parallel randomized trial with computer-generated randomization and centralized allocation. Patients and investigators, including those assessing outcomes and performing analyses, were masked to group assignment. (ClinicalTrials.gov registration number: NCT00392678) Setting: 3 private practices and 14 universities in the United States. Patients: Persons aged 18 to 75 years with fasting plasma glucose concentrations of 12.5 mmol/L or less (</=225 mg/dL) and hemoglobin A(1c) (HbA(1c)) levels of 7.0% to 9.5% treated by diet, exercise, and oral medication at stable doses for at least 8 weeks. Intervention: After a 4-week, single-masked run-in period, patients were randomly assigned to receive placebo or salsalate in dosages of 3.0, 3.5, or 4.0 g/d for 14 weeks (27 patients each) in addition to their current therapy. Measurements: Change in HbA(1c) was the primary outcome. Adverse effects and changes in measures of coronary risk and renal function were secondary outcomes. Results: Higher proportions of patients in the 3 salsalate treatment groups experienced decreases in HbA(1c) levels of 0.5% or more from baseline (P = 0.009). Mean HbA(1c) changes were -0.36% (P = 0.02) at 3.0 g/d, -0.34% (P = 0.02) at 3.5 g/d, and -0.49% (P = 0.001) at 4.0 g/d compared with placebo. Other markers of glycemic control also improved in the 3 salsalate groups, as did circulating triglyceride and adiponectin concentrations. Mild hypoglycemia was more common with salsalate; documented events occurred only in patients taking sulfonylureas. Urine albumin concentrations increased in all salsalate groups compared with placebo. The drug was otherwise well tolerated. Limitation: The number of patients studied and the trial duration were insufficient to warrant recommending the use of salsalate for type 2 diabetes at this time. Conclusion: Salsalate lowers HbA(1c) levels and improves other markers of glycemic control in patients with type 2 diabetes and may therefore provide a new avenue for treatment. Renal and cardiac safety of the drug require further evaluation. Primary Funding Source: National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health.

PMID: 20231565 [PubMed - as supplied by publisher]

Meta-analysis: Effects of Percutaneous Coronary Intervention Versus Medical Therapy on Angina Relief.

Ann Intern Med. 2010 Mar 16;152(6):370-9

Authors: Wijeysundera HC, Nallamothu BK, Krumholz HM, Tu JV, Ko DT

Background: Several meta-analyses have evaluated the efficacy of percutaneous coronary intervention (PCI) compared with medical therapy, but none has focused on angina relief. Purpose: To summarize the evidence on the degree of angina relief from PCI compared with medical therapy in patients with stable coronary artery disease. Data Sources: The Cochrane Library (1993 to June 2009), EMBASE (1980 to June 2009), and MEDLINE (1950 to June 2009), with no language restrictions. Study Selection: Two independent reviewers screened citations to identify randomized, controlled trials of PCI versus medical therapy in patients with stable coronary artery disease. Data Extraction: Two independent reviewers abstracted data on patient characteristics, study conduct, and outcomes. A random-effects model was used to combine data on freedom from angina and to perform stratified analyses based on duration of follow-up, inclusion of patients with recent myocardial infarction, coronary stent utilization, recruitment period, and utilization of evidence-based medications. Data Synthesis: A total of 14 trials, enrolling 7818 patients, met the inclusion criteria. Although PCI was associated with an overall benefit on angina relief (odds ratio, 1.69 [95% CI, 1.24 to 2.30]), important heterogeneity across trials was observed. The incremental benefit of PCI observed in older trials (odds ratio, 3.38 [CI, 1.89 to 6.04]) was substantially less and possibly absent in recent trials (odds ratio, 1.13 [CI, 0.76 to 1.68]). An inverse relationship between use of evidence-based therapies and the incremental benefit of PCI was observed. Limitations: Information about the long-term use of medication was incomplete in most trials. Few trials used drug-eluting stents. Meta-regression analyses used aggregated study-level data from few trials. Conclusion: Percutaneous coronary intervention was associated with greater freedom from angina compared with medical therapy, but this benefit was largely attenuated in contemporary studies. This observation may be related to greater use of evidence-based medications in contemporary trials. Primary Funding Source: Canadian Institutes of Health Research.

PMID: 20231568 [PubMed - in process]

Pay for performance through the lens of medical professionalism.

Ann Intern Med. 2010 Mar 16;152(6):366-9

Authors: Qaseem A, Snow V, Gosfield A, Gregg D, Michl K, Wennberg D, Weiss KB, Schneider EC

Lagging quality of care in the U.S. health care system has been a persistent problem and challenge. In the past, medical professionalism and professional certification have served as cornerstones for improving quality in health care. Among newer efforts to improve quality, pay for performance has been proposed to propel better results, but many observers are concerned that pay for performance is at odds with medical professionalism. The authors examine the potential conflicts between pay for performance and medical professionalism and conclude that properly designed pay-for-performance models can support professional objectives.

PMID: 20231567 [PubMed - in process]

Concierge Medicine: A "Regular" Physician's Perspective.

Ann Intern Med. 2010 Mar 16;152(6):391-2

Authors: Stillman M

Concierge medical practices, which advertise expanded access to care and individualized attention, collect charges both from insurance companies and directly from their patients. Some bill hundreds of dollars for one-time "executive" physicals, whereas others have patients pay annual retainer fees. Yet, virtually no data are available about these "luxury" practices. It is not known how many physicians have "turned concierge," whether they have altered their testing and prescribing patterns, or whether their clinical outcomes are superior to those of their colleagues in traditional practices. Although some have voiced concern that concierge physicians create a 2-tiered system and may contribute to the difficulty that many patients have with access to care, the medical community has largely remained silent on the matter. The mere existence of concierge medicine may reflect our need as physicians to do better by our patients. Yet our responsibility as a professional community is to engage in-not run from-that monumental challenge.

PMID: 20231570 [PubMed - in process]

Meta-analysis: Excess Mortality After Hip Fracture Among Older Women and Men.

Ann Intern Med. 2010 Mar 16;152(6):380-90

Authors: Haentjens P, Magaziner J, Colón-Emeric CS, Vanderschueren D, Milisen K, Velkeniers B, Boonen S

Background: Although an increased risk for death after hip fracture is well established, whether this excess mortality persists over time is unclear. Purpose: To determine the magnitude and duration of excess mortality after hip fracture in older men and women. Data Sources: Electronic search of MEDLINE and EMBASE for English and non-English articles from 1957 to May 2009 and manual search of article references. Study Selection: Prospective cohort studies were selected by 2 independent reviewers. The studies had to assess mortality in women (22 cohorts) or men (17 cohorts) aged 50 years or older with hip fracture, carry out a life-table analysis, and display the survival curves of the hip fracture group and age- and sex-matched control groups. Data Extraction: Survival curve data and items relevant to study validity and generalizability were independently extracted by 2 reviewers. Data Synthesis: Time-to-event meta-analyses showed that the relative hazard for all-cause mortality in the first 3 months after hip fracture was 5.75 (95% CI, 4.94 to 6.67) in women and 7.95 (CI, 6.13 to 10.30) in men. Relative hazards decreased substantially over time but did not return to rates seen in age- and sex-matched control groups. Through use of life-table methods, investigators estimated that white women having a hip fracture at age 80 years have excess annual mortality compared with white women of the same age without a fracture of 8%, 11%, 18%, and 22% at 1, 2, 5, and 10 years after injury, respectively. Men with a hip fracture at age 80 years have excess annual mortality of 18%, 22%, 26%, and 20% at 1, 2, 5, and 10 years after injury, respectively. Limitations: Cohort studies varied, sometimes markedly, in size, duration of observation, selection of control populations, ascertainment of death, and adjustment for comorbid conditions. Only published data that displayed findings with survival curves were examined. Publication bias was possible. Conclusion: Older adults have a 5- to 8-fold increased risk for all-cause mortality during the first 3 months after hip fracture. Excess annual mortality persists over time for both women and men, but at any given age, excess annual mortality after hip fracture is higher in men than in women. Primary Funding Source: Fund for Scientific Research and Willy Gepts Foundation, Universitair Ziekenhuis Brussel.

PMID: 20231569 [PubMed - in process]

Elegy.

Ann Intern Med. 2010 Mar 16;152(6):398-9

Authors: Samelson-Jones E

PMID: 20231573 [PubMed - in process]

Empirical methods in bioethics: a cautionary tale.

Ann Intern Med. 2010 Mar 16;152(6):396-7

Authors: Braddock CH, Magnus D

PMID: 20231572 [PubMed - in process]

Propensity score adjustment with multilevel data: setting your sites on decreasing selection bias.

Ann Intern Med. 2010 Mar 16;152(6):393-5

Authors: Griswold ME, Localio AR, Mulrow C

PMID: 20231571 [PubMed - in process]

A party before dying.

Ann Intern Med. 2010 Mar 16;152(6):402

Authors: Sankey C

PMID: 20231575 [PubMed - in process]

Through a glass darkly.

Ann Intern Med. 2010 Mar 16;152(6):400-1

Authors: Johnson T

PMID: 20231574 [PubMed - in process]

The USPSTF Recommendation Statement on Coronary Heart Disease Risk Assessment.

Ann Intern Med. 2010 Mar 16;152(6):403

Authors: Glynn RJ

PMID: 20231577 [PubMed - in process]

The USPSTF Recommendation Statement on Coronary Heart Disease Risk Assessment.

Ann Intern Med. 2010 Mar 16;152(6):403-4

Authors: Budoff MJ

PMID: 20231576 [PubMed - in process]

The USPSTF Recommendation Statement on Coronary Heart Disease Risk Assessment.

Ann Intern Med. 2010 Mar 16;152(6):405-6

Authors: Calonge N, Pettiti D

PMID: 20231579 [PubMed - in process]

The USPSTF Recommendation Statement on Coronary Heart Disease Risk Assessment.

Ann Intern Med. 2010 Mar 16;152(6):404-5

Authors: Blaha MJ, Campbell CY, Horne A

PMID: 20231578 [PubMed - in process]

The case for C-reactive protein as a risk marker for coronary heart disease.

Ann Intern Med. 2010 Mar 16;152(6):406

Authors: Cook NR

PMID: 20231582 [PubMed - in process]

The case for C-reactive protein as a risk marker for coronary heart disease.

Ann Intern Med. 2010 Mar 16;152(6):406-7

Authors: Buckley DI, Helfand M

PMID: 20231581 [PubMed - in process]

The USPSTF Recommendation Statement on Coronary Heart Disease Risk Assessment.

Ann Intern Med. 2010 Mar 16;152(6):405

Authors: Matteson EL, Crowson CS, Gabriel SE

PMID: 20231580 [PubMed - in process]

Correction: chronic noncancer pain management and opioid overdose.

Ann Intern Med. 2010 Mar 16;152(6):408

Authors:

PMID: 20231584 [PubMed - in process]

Pseudohypoglycemia in a patient with the eisenmenger syndrome.

Ann Intern Med. 2010 Mar 16;152(6):407-8

Authors: Theofilogiannakos EK, Giannakoulas G, Ziakas A, Karvounis HI, Styliadis IH

PMID: 20231583 [PubMed - in process]

Are There Cost-Effective Ways to Help People Eat Less Salt?

Ann Intern Med. 2010 Mar 1;

Authors:

PMID: 20194227 [PubMed - as supplied by publisher]

We Can Reduce Dietary Sodium, Save Money, and Save Lives.

Ann Intern Med. 2010 Mar 1;

Authors: Frieden TR, Briss PA

PMID: 20194226 [PubMed - as supplied by publisher]

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

Ann Intern Med. 2010 Mar 1;

Authors: 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.

PMID: 20194225 [PubMed - as supplied by publisher]

Type 2 diabetes.

Ann Intern Med. 2010 Mar 2;152(5):ITC31

Authors: Vijan S

This issue provides a clinical overview of type 2 diabetes 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: 20194231 [PubMed - in process]

Unequal leg length and knee osteoarthritis.

Ann Intern Med. 2010 Mar 2;152(5):I46

Authors:

PMID: 20194230 [PubMed - in process]

Cost-effectiveness of different types of evaluations before sports participation in young athletes.

Ann Intern Med. 2010 Mar 2;152(5):I40

Authors:

PMID: 20194229 [PubMed - in process]

Adding electrocardiography to medical history and physical examination for evaluation before sports participation in college athletes.

Ann Intern Med. 2010 Mar 2;152(5):I13

Authors:

PMID: 20194228 [PubMed - in process]

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

Ann Intern Med. 2010 Mar 2;152(5):287-95

Authors: Harvey WF, Yang M, Cooke TD, Segal NA, Lane N, 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.

PMID: 20194234 [PubMed - in process]

Cost-effectiveness of preparticipation screening for prevention of sudden cardiac death in young athletes.

Ann Intern Med. 2010 Mar 2;152(5):276-86

Authors: Wheeler MT, Heidenreich PA, Froelicher VF, Hlatky MA, Ashley EA

Background: Inclusion of 12-lead electrocardiography (ECG) in preparticipation screening of young athletes is controversial because of concerns about cost-effectiveness. Objective: To evaluate the cost-effectiveness of ECG plus cardiovascular-focused history and physical examination compared with cardiovascular-focused history and physical examination alone for preparticipation screening. Design: Decision-analysis, cost-effectiveness model. Data Sources: Published epidemiologic and preparticipation screening data, vital statistics, and other publicly available data. Target Population: Competitive athletes in high school and college aged 14 to 22 years. Time Horizon: Lifetime. Perspective: Societal. Intervention: Nonparticipation in competitive athletic activity and disease-specific treatment for identified athletes with heart disease. Outcome Measure: Incremental health care cost per life-year gained. Results of Base-Case Analysis: Addition of ECG to preparticipation screening saves 2.06 life-years per 1000 athletes at an incremental total cost of $89 per athlete and yields a cost-effectiveness ratio of $42 900 per life-year saved (95% CI, $21 200 to $71 300 per life-year saved) compared with cardiovascular-focused history and physical examination alone. Compared with no screening, ECG plus cardiovascular-focused history and physical examination saves 2.6 life-years per 1000 athletes screened and costs $199 per athlete, yielding a cost-effectiveness ratio of $76 100 per life-year saved ($62 400 to $130 000). Results of Sensitivity Analysis: Results are sensitive to the relative risk reduction associated with nonparticipation and the cost of initial screening. Limitations: Effectiveness data are derived from 1 major European study. Patterns of causes of sudden death may vary among countries. Conclusion: Screening young athletes with 12-lead ECG plus cardiovascular-focused history and physical examination may be cost-effective. Primary Funding Source: Stanford Cardiovascular Institute and the Breetwor Foundation.

PMID: 20194233 [PubMed - in process]

Cardiovascular Screening in College Athletes With and Without Electrocardiography: A Cross-sectional Study.

Ann Intern Med. 2010 Mar 2;152(5):269-75

Authors: Baggish AL, Hutter AM, Wang F, Yared K, Weiner RB, Kupperman E, Picard MH, Wood MJ

Background: Although cardiovascular screening is recommended for athletes before participating in sports, the role of 12-lead electrocardiography (ECG) remains uncertain. To date, no prospective data that compare screening with and without ECG have been available. Objective: To compare the performance of preparticipation screening limited to medical history and physical examination with a strategy that integrates these with ECG. Design: Cross-sectional comparison of screening strategies. Setting: University Health Services, Harvard University, Cambridge, Massachusetts. Participants: 510 collegiate athletes who received cardiovascular screening before athletic participation. Measurements: Each participant had routine history and examination-limited screening and ECG. They received transthoracic echocardiography (TTE) to detect or exclude cardiac findings with relevance to sports participation. The performance of screening with history and examination only was compared with that of screening that integrated history, examination, and ECG. Results: Cardiac abnormalities with relevance to sports participation risk were observed on TTE in 11 of 510 participants (prevalence, 2.2%). Screening with history and examination alone detected abnormalities in 5 of these 11 athletes (sensitivity, 45.5% [95% CI, 16.8% to 76.2%]; specificity, 94.4% [CI, 92.0% to 96.2%]). Electrocardiography detected 5 additional participants with cardiac abnormalities (for a total of 10 of 11 participants), thereby improving the overall sensitivity of screening to 90.9% (CI, 58.7% to 99.8%). However, including ECG reduced the specificity of screening to 82.7% (CI, 79.1% to 86.0%) and was associated with a false-positive rate of 16.9% (vs. 5.5% for screening with history and examination only). Limitation: Definitive conclusions regarding the effect of ECG inclusion on sudden death rates cannot be made. Conclusion: Adding ECG to medical history and physical examination improves the overall sensitivity of preparticipation cardiovascular screening in athletes. However, this strategy is associated with an increased rate of false-positive results when current ECG interpretation criteria are used. Primary Funding Source: None.

PMID: 20194232 [PubMed - in process]

Narrative Review: Thrombocytosis, Polycythemia Vera, and JAK2 Mutations: The Phenotypic Mimicry of Chronic Myeloproliferation.

Ann Intern Med. 2010 Mar 2;152(5):300-6

Authors: Spivak JL

The myeloproliferative disorders polycythemia vera, essential thrombocytosis, and primary myelofibrosis are clonal disorders arising in a pluripotent hematopoietic stem cell, causing an unregulated increase in the number of erythrocytes, leukocytes, or platelets, alone or in combination; eventual marrow dominance by the progeny of the involved stem cell; and a tendency to arterial or venous thrombosis, marrow fibrosis, splenomegaly, or transformation to acute leukemia, albeit at widely varying frequencies. The discovery of an activating mutation (V617F) in the gene for JAK2 (Janus kinase 2), a tyrosine kinase utilized by hematopoietic cell receptors for erythropoietin, thrombopoietin, and granulocyte colony-stimulating factor, provided an explanation for the shared clinical features of these 3 disorders. Constitutive JAK2 activation provides a growth and survival advantage to the hematopoietic cells of the affected clone. Because signaling by the mutated kinase utilizes normal pathways, the result is overproduction of morphologically normal blood cells, an often indolent course, and (in essential thrombocytosis) usually a normal life span. Because the erythropoietin, thrombopoietin, and granulocyte colony-stimulating factor receptors are all constitutively activated, polycythemia vera is the potential ultimate clinical phenotype of the JAK2 V617F mutation and, as a corollary, is the most common of the 3 disorders. The number of cells expressing the JAK2 V617F mutation (the allele burden) seems to correlate with the clinical phenotype. Preliminary results of clinical trials with agents that inhibit the mutated kinase indicate a reduction in splenomegaly and alleviation of night sweats, fatigue, and pruritus.

PMID: 20194236 [PubMed - in process]

Brief communication: management of implantable cardioverter-defibrillators in hospice: a nationwide survey.

Ann Intern Med. 2010 Mar 2;152(5):296-9

Authors: Goldstein N, Carlson M, Livote E, Kutner JS

Background: Communication about the deactivation of implantable cardioverter-defibrillators (ICDs) in patients near the end of life is rare. Objective: To determine whether hospices are admitting patients with ICDs, whether such patients are receiving shocks, and how hospices manage ICDs. Design: Cross-sectional survey. Setting: Randomly selected hospice facilities. Participants: 900 hospices, 414 of which responded fully. Measurements: Frequency of admission of patients with ICDs, frequency with which patients received shocks, existence of ICD deactivation policies, and frequency of deactivation. Results: 97% of hospices admitted patients with ICDs, and 58% reported that in the past year, a patient had been shocked. Only 10% of hospices had a policy that addressed deactivation. On average, 42% (95% CI, 37% to 48%) of patients with ICDs had the shocking function deactivated. Limitation: The study relied on the knowledge of hospice administrators. Conclusion: Hospices are admitting patients with ICDs, and patients are being shocked at the end of life. Ensuring that hospices have policies in place to address deactivation may improve the care for patients with these devices. The authors provide a sample deactivation policy. Primary Funding Source: National Institute of Aging and National Institute of Nursing Research.

PMID: 20194235 [PubMed - in process]

Systematic review: vitamin d and calcium supplementation in prevention of cardiovascular events.

Ann Intern Med. 2010 Mar 2;152(5):315-23

Authors: Wang L, Manson JE, Song Y, Sesso HD

Background: Vitamin D and calcium may affect the cardiovascular system independently and interactively. Purpose: To assess whether vitamin D and calcium supplements reduce the risk for cardiovascular events in adults. Data Sources: Studies published in English from 1966 to July 2009 in MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials. Study Selection: Two investigators independently selected 17 prospective studies and randomized trials that examined vitamin D supplementation, calcium supplementation, or both and subsequent cardiovascular events. Data Extraction: Three investigators extracted and checked data about study designs, participants, exposures or interventions, outcomes, and data quality. Data Synthesis: Five prospective studies of patients receiving dialysis and 1 study involving a general population showed consistent reductions in cardiovascular disease (CVD) mortality among adults who received vitamin D supplements. Four prospective studies of initially healthy persons found no differences in incidence of CVD between calcium supplement recipients and nonrecipients. Results of secondary analyses in 8 randomized trials showed a slight but statistically nonsignificant reduction in CVD risk (pooled relative risk, 0.90 [95% CI, 0.77 to 1.05]) with vitamin D supplementation at moderate to high doses (approximately 1000 IU/d) but not with calcium supplementation (pooled relative risk, 1.14 [CI, 0.92 to 1.41]), or a combination of vitamin D and calcium supplementation (pooled relative risk, 1.04 [CI, 0.92 to 1.18]) compared with placebo. Limitations: Only articles published in English that reported cardiovascular event outcomes were included. The small number of studies, the lack of trials designed specifically to assess primary effects on cardiovascular outcomes, and important between-study heterogeneity preclude definitive conclusions. Conclusion: Evidence from limited data suggests that vitamin D supplements at moderate to high doses may reduce CVD risk, whereas calcium supplements seem to have minimal cardiovascular effects. Further research is needed to elucidate the role of these supplements in CVD prevention. Primary Funding Source: The American Heart Association and the National Heart, Lung, and Blood Institute.

PMID: 20194238 [PubMed - in process]

Systematic review: vitamin d and cardiometabolic outcomes.

Ann Intern Med. 2010 Mar 2;152(5):307-14

Authors: Pittas AG, Chung M, Trikalinos T, Mitri J, Brendel M, Patel K, Lichtenstein AH, Lau J, Balk EM

Background: Vitamin D may modify risk for cardiometabolic outcomes (type 2 diabetes, hypertension, or cardiovascular disease). Purpose: To examine the association between vitamin D status, including the effect of vitamin D supplementation, and cardiometabolic outcomes in generally healthy adults. Data Sources: English-language studies in MEDLINE (inception to 4 November 2009) and the Cochrane Central Register of Controlled Trials (fourth quarter of 2009). Study Selection: 11 reviewers screened citations to identify longitudinal cohort studies that reported associations between vitamin D status and cardiometabolic outcomes, including randomized trials of vitamin D supplementation. Data Extraction: 5 independent reviewers extracted data about study conduct, participant characteristics, outcomes, and quality. Differences were resolved by consensus. Data Synthesis: 13 observational studies (14 cohorts) and 18 trials were eligible. Three of 6 analyses (from 4 different cohorts) reported a lower incident diabetes risk in the highest versus the lowest vitamin D status groups. Eight trials found no effect of vitamin D supplementation on glycemia or incident diabetes. In meta-analysis of 3 cohorts, lower 25-hydroxyvitamin D concentration was associated with incident hypertension (relative risk, 1.8 [95% CI, 1.3 to 2.4]). In meta-analyses of 10 trials, supplementation nonsignificantly reduced systolic blood pressure (weighted mean difference, -1.9 mm Hg [CI, -4.2 to 0.4 mm Hg]) and did not affect diastolic blood pressure (weighted mean difference, -0.1 mm Hg [CI, -0.7 to 0.5 mm Hg]). Lower 25-hydroxyvitamin D concentration was associated with incident cardiovascular disease in 5 of 7 analyses (6 cohorts). Four trials found no effect of supplementation on cardiovascular outcomes. Limitations: Studies included primarily white participants. Observational studies were heterogeneous. Several trials reported post hoc analyses. Conclusion: The association between vitamin D status and cardiometabolic outcomes is uncertain. Trials showed no clinically significant effect of vitamin D supplementation at the dosages given. Primary Funding Source: National Institute of Diabetes and Digestive and Kidney Disease, the National Institutes of Health Office of Dietary Supplements, U.S. Food and Drug Administration, Agency for Healthcare Research and Quality, and Public Health Agency of Canada.

PMID: 20194237 [PubMed - in process]

In transition.

Ann Intern Med. 2010 Mar 2;152(5):330-1

Authors: Luo AK

PMID: 20194241 [PubMed - in process]

Vitamin d supplementation in the age of lost innocence.

Ann Intern Med. 2010 Mar 2;152(5):327-9

Authors: Guallar E, Miller ER, Ordovas JM, Stranges S

PMID: 20194240 [PubMed - in process]

National electrocardiography screening for competitive athletes: feasible in the United States?

Ann Intern Med. 2010 Mar 2;152(5):324-6

Authors: Maron BJ

PMID: 20194239 [PubMed - in process]

Cost-effectiveness of biologics in early rheumatoid arthritis.

Ann Intern Med. 2010 Mar 2;152(5):333-4

Authors: Finckh A, Bansback N, Liang MH

PMID: 20194244 [PubMed - in process]

Justifying different levels of palliative sedation.

Ann Intern Med. 2010 Mar 2;152(5):332

Authors: Cellarius V, Henry B

PMID: 20194243 [PubMed - in process]

Justifying different levels of palliative sedation.

Ann Intern Med. 2010 Mar 2;152(5):332-3

Authors: Sulmasy DP, Curlin F, Brungardt GS, Cavanaugh T

PMID: 20194242 [PubMed - in process]

Cost-effectiveness of biologics in early rheumatoid arthritis.

Ann Intern Med. 2010 Mar 2;152(5):334

Authors: Boers M

PMID: 20194247 [PubMed - in process]

Long-term effects of low-carbohydrate versus low-fat diets in obese persons.

Ann Intern Med. 2010 Mar 2;152(5):334-5

Authors: Vetter ML, Iqbal N, Dalton-Bakes C, Volger S, Wadden TA

PMID: 20194246 [PubMed - in process]

Justifying different levels of palliative sedation.

Ann Intern Med. 2010 Mar 2;152(5):333

Authors: Quill TE, Brock D, Lo B, Meisel A

PMID: 20194245 [PubMed - in process]

Practicing Internal Medicine Onboard the USNS COMFORT in the Aftermath of the Haitian Earthquake.

Ann Intern Med. 2010 Mar 2;

Authors: Amundson D, Dadekian G, Etienne M, Gleeson T, Hicks T, Killian D, Kratovil K, Lewis C, Monsour M, Pasiuk B, Rhodes D, Miller EJ

On 12 January 2010, a 7.0-magnitude earthquake devastated the island nation of Haiti, leading to the world's largest humanitarian effort in over 6 decades. The catastrophe caused massive destruction of homes and buildings and overwhelmed the Haitian health care system. The United States responded immediately with a massive relief effort, sending U.S. military forces and civilian volunteers to Haiti's aid and providing a tertiary care medical center aboard the USNS COMFORT hospital ship. The COMFORT offered sophisticated medical care to a geographically isolated population, thereby helping to transfer resource-intensive patients from other treatment facilities. Working collaboratively with the surgical staff, ancillary services, and nursing staff, internists aboard the COMFORT were integral to supporting the mission of the hospital ship and provided high-level care to the casualties. This article provides the perspective of the group of U.S. Navy internists who participated in the initial response to the Haitian earthquake disaster onboard the USNS COMFORT.

PMID: 20197507 [PubMed - as supplied by publisher]

Varenicline and pheochromocytoma.

Ann Intern Med. 2010 Mar 2;152(5):335-6

Authors: Hukkanen J, Ukkola O, Benowitz NL

PMID: 20194248 [PubMed - in process]

A Doctor Heads Home to Haiti.

Ann Intern Med. 2010 Feb 18;

Authors: Malebranche LJ

A second-year medical resident returned to Haiti, his native country, in the aftermath of the 12 January 2010 earthquake. He witnessed the total devastation of Port-au-Prince, the city of his birth, and great human suffering. He describes the emotional and logistical challenges of providing care to the wounded of this impoverished nation.

PMID: 20167652 [PubMed - as supplied by publisher]

When Evidence Collides With Anecdote, Politics, and Emotion: Breast Cancer Screening.

Ann Intern Med. 2010 Feb 15;

Authors:

PMID: 20157099 [PubMed - as supplied by publisher]

Comments and Response on the USPSTF Recommendation on Screening for Breast Cancer.

Ann Intern Med. 2010 Feb 15;

Authors: Yoast R

PMID: 20157098 [PubMed - as supplied by publisher]

The Background Review for the USPSTF Recommendation on Screening for Breast Cancer.

Ann Intern Med. 2010 Feb 15;

Authors: Jã Rgensen KJ, Gã Tzsche PC

PMID: 20157097 [PubMed - as supplied by publisher]

Comments and Response on the USPSTF Recommendation on Screening for Breast Cancer.

Ann Intern Med. 2010 Feb 15;

Authors: Braithwaite RS

PMID: 20157104 [PubMed - as supplied by publisher]

The Background Review for the USPSTF Recommendation on Screening for Breast Cancer.

Ann Intern Med. 2010 Feb 15;

Authors: Nelson HD, Naik A, Humphrey L, Tyne K

PMID: 20157103 [PubMed - as supplied by publisher]

Comments and Response on the USPSTF Recommendation on Screening for Breast Cancer.

Ann Intern Med. 2010 Feb 15;

Authors: Gail MH, Schairer C

PMID: 20157102 [PubMed - as supplied by publisher]

Comments and Response on the USPSTF Recommendation on Screening for Breast Cancer.

Ann Intern Med. 2010 Feb 15;

Authors: Begg CB

PMID: 20157101 [PubMed - as supplied by publisher]

Comments and Response on the USPSTF Recommendation on Screening for Breast Cancer.

Ann Intern Med. 2010 Feb 15;

Authors: Col NF, Hansen MH, Fischhoff B, Pauker SG

PMID: 20157100 [PubMed - as supplied by publisher]

The Background Review for the USPSTF Recommendation on Screening for Breast Cancer.

Ann Intern Med. 2010 Feb 15;

Authors: Dickersin K, Tovey D, Wilcken N, Ghersi D

PMID: 20157109 [PubMed - as supplied by publisher]

Comments and Response on the USPSTF Recommendation on Screening for Breast Cancer.

Ann Intern Med. 2010 Feb 15;

Authors: Dean PB

PMID: 20157108 [PubMed - as supplied by publisher]

Comments and Response on the USPSTF Recommendation on Screening for Breast Cancer.

Ann Intern Med. 2010 Feb 15;

Authors: Ho A

PMID: 20157107 [PubMed - as supplied by publisher]

Editors' Note on the USPSTF Recommendation on Screening for Breast Cancer.

Ann Intern Med. 2010 Feb 15;

Authors:

PMID: 20157106 [PubMed - as supplied by publisher]

Comments and Response on the USPSTF Recommendation on Screening for Breast Cancer.

Ann Intern Med. 2010 Feb 15;

Authors: Seewaldt VL

PMID: 20157105 [PubMed - as supplied by publisher]

Review: Neuraminidase inhibitors relieve influenza symptoms and reduce laboratory-confirmed influenza in healthy adults.

Ann Intern Med. 2010 Feb 16;152(4):JC211

Authors:

PMID: 20157123 [PubMed - in process]

Review: Adding antiviral drugs to steroids did not improve facial muscle recovery in Bell palsy.

Ann Intern Med. 2010 Feb 16;152(4):JC210

Authors:

PMID: 20157122 [PubMed - in process]

Observations of the relationship between surface and deep leg blood vein clotting.

Ann Intern Med. 2010 Feb 16;152(4):I48

Authors:

PMID: 20157121 [PubMed - in process]

The effect of estrogen plus progestin on coronary heart disease.

Ann Intern Med. 2010 Feb 16;152(4):I40

Authors:

PMID: 20157120 [PubMed - in process]

Pipe and cigar smoking and lung function.

Ann Intern Med. 2010 Feb 16;152(4):I28

Authors:

PMID: 20157119 [PubMed - in process]

The Background Review for the USPSTF Recommendation on Screening for Breast Cancer.

Ann Intern Med. 2010 Feb 15;

Authors: Defrank JT, Brewer NT

PMID: 20157111 [PubMed - as supplied by publisher]

Comments and Response on the USPSTF Recommendation on Screening for Breast Cancer.

Ann Intern Med. 2010 Feb 15;

Authors: Pettiti D, Calonge N

PMID: 20157110 [PubMed - as supplied by publisher]

Estrogen plus progestin increased lung cancer mortality but not incidence in postmenopausal women.

Ann Intern Med. 2010 Feb 16;152(4):JC28

Authors:

PMID: 20157132 [PubMed - in process]

Review: In women 39 to 69 years of age, screening with mammography reduces breast cancer mortality.

Ann Intern Med. 2010 Feb 16;152(4):JC27

Authors:

PMID: 20157131 [PubMed - in process]

Adding revascularization to medical therapy did not improve renal function in atherosclerotic renal artery stenosis.

Ann Intern Med. 2010 Feb 16;152(4):JC26

Authors:

PMID: 20157130 [PubMed - in process]

Higher-intensity continuous renal-replacement therapy did not reduce mortality in critically ill patients with kidney injury.

Ann Intern Med. 2010 Feb 16;152(4):JC25

Authors:

PMID: 20157129 [PubMed - in process]

Noninvasive ventilation after extubation reduced respiratory failure and 90-day mortality in hypercapnic patients.

Ann Intern Med. 2010 Feb 16;152(4):JC24

Authors:

PMID: 20157128 [PubMed - in process]

Review: Early treatment of a cardiovascular event with nitrates or ACE inhibitors reduces short-term mortality.

Ann Intern Med. 2010 Feb 16;152(4):JC23

Authors:

PMID: 20157127 [PubMed - in process]

Review: Therapeutic hypothermia improves neurologic outcome and survival to discharge after cardiac arrest.

Ann Intern Med. 2010 Feb 16;152(4):JC22

Authors:

PMID: 20157126 [PubMed - in process]

Pioglitazone was associated with lower risk for adverse cardiovascular events than rosiglitazone in older patients.

Ann Intern Med. 2010 Feb 16;152(4):JC213

Authors:

PMID: 20157125 [PubMed - in process]

Either cholesterol or apolipoprotein levels can be used to determine risk for CVD; triglycerides are not useful.

Ann Intern Med. 2010 Feb 16;152(4):JC212

Authors:

PMID: 20157124 [PubMed - in process]

Superficial Venous Thrombosis and Venous Thromboembolism: A Large, Prospective Epidemiologic Study.

Ann Intern Med. 2010 Feb 16;152(4):218-224

Authors: Decousus H, Quéré I, Presles E, Becker F, Barrellier MT, Chanut M, Gillet JL, Guenneguez H, Leandri C, Mismetti P, Pichot O, Leizorovicz A,

Background: Superficial venous thrombosis (SVT) is perceived to have a benign prognosis. Objective: To assess the prevalence of venous thromboembolism in patients with SVT and to determine the 3-month incidence of thromboembolic complications. Design: National cross-sectional and prospective epidemiologic cohort study. (ClinicalTrials.gov registration number: NCT00818688) Setting: French office- and hospital-based vascular medicine specialists. Patients: 844 consecutive patients with symptomatic SVT of the lower limbs that was at least 5 cm on compression ultrasonography. Measurements: Incidence of venous thromboembolism and extension or recurrence of SVT in patients with isolated SVT at presentation. Results: Among 844 patients with SVT at inclusion (median age, 65 years; 547 women), 210 (24.9%) also had deep venous thrombosis (DVT) or symptomatic pulmonary embolism. Among 600 patients without DVT or pulmonary embolism at inclusion who were eligible for 3-month follow-up, 58 (10.2%) developed thromboembolic complications at 3 months (pulmonary embolism, 3 [0.5%]; DVT, 15 [2.8%]; extension of SVT, 18 [3.3%]; and recurrence of SVT, 10 [1.9%]), despite 540 patients (90.5%) having received anticoagulants. Risk factors for complications at 3 months were male sex, history of DVT or pulmonary embolism, previous cancer, and absence of varicose veins. Limitation: The findings are from a specialist referral setting, and the study was terminated before the target patient population was reached because of slow recruitment. Conclusion: A substantial number of patients with SVT exhibit venous thromboembolism at presentation, and some that do not can develop this complication in the subsequent 3 months. Primary Funding Source: GlaxoSmithKline, sanofi-aventis, and the Ministère Francais de la Santé et des Sports (Programme Hospitalier de Recherche Clinique).

PMID: 20157136 [PubMed - as supplied by publisher]

Coronary heart disease in postmenopausal recipients of estrogen plus progestin therapy: does the increased risk ever disappear? A randomized trial.

Ann Intern Med. 2010 Feb 16;152(4):211-7

Authors: Toh S, Hernández-Díaz S, Logan R, Rossouw JE, Hernán MA

Background: Estrogen plus progestin therapy increases the risk for coronary heart disease (CHD) in postmenopausal women. However, this increased risk might be limited to the first years of use and to women who start therapy late in menopause. Objective: To estimate the effect of continuous estrogen plus progestin therapy on CHD risk over time and stratified by years since menopause. Design: Women's Health Initiative randomized, double-blinded, placebo-controlled trial. (ClinicalTrials.gov registration number: NCT00000611) Setting: 40 U.S. clinical centers. Patients: 16 608 postmenopausal women with an intact uterus at baseline from 1993 to 1998. Intervention: Conjugated equine estrogens, 0.625 mg/d, plus medroxyprogesterone acetate, 2.5 mg/d, or placebo. Measurements: Adherence-adjusted hazard ratios and CHD-free survival curves estimated through inverse probability weighting. Results: Compared with no use of hormone therapy, the hazard ratio for continuous use of estrogen plus progestin therapy was 2.36 (95% CI, 1.55 to 3.62) for the first 2 years and 1.69 (CI, 0.98 to 2.89) for the first 8 years. For women within 10 years after menopause, the hazard ratios were 1.29 (CI, 0.52 to 3.18) for the first 2 years and 0.64 (CI, 0.21 to 1.99) for the first 8 years, and the CHD-free survival curves for continuous use and no use of estrogen plus progestin crossed at about 6 years (CI, 2 years to 10 years). Limitation: The analysis may not have fully adjusted for joint determinants of adherence and CHD risk. Sample sizes for some subgroup analyses were small. Conclusion: No suggestion of a decreased risk for CHD was found within the first 2 years of estrogen plus progestin use, including in women who initiated therapy within 10 years after menopause. A possible cardioprotective effect in these women who initiated therapy closer to menopause became apparent only after 6 years of use. Primary Funding Source: National Heart, Lung, and Blood Institute.

PMID: 20157135 [PubMed - in process]

The Association of Pipe and Cigar Use With Cotinine Levels, Lung Function, and Airflow Obstruction: A Cross-sectional Study.

Ann Intern Med. 2010 Feb 16;152(4):201-10

Authors: Rodriguez J, Jiang R, Johnson WC, Mackenzie BA, Smith LJ, Barr RG

Background: Cigarette smoking is the major cause of chronic obstructive pulmonary disease, but studies on the contribution of other smoking techniques are sparse. Objective: To determine whether pipe and cigar smoking was associated with elevated cotinine levels, decrements in lung function, and increased odds of airflow obstruction. Design: Cross-sectional study. Setting: Population-based sample from 6 U.S. communities. Participants: Men and women aged 48 to 90 years without clinical cardiovascular disease at enrollment who were part of MESA (Multi-Ethnic Study of Atherosclerosis). Measurements: The MESA Lung Study measured spirometry according to American Thoracic Society guidelines and urine cotinine levels by immunoassay on a subsample of MESA. Pipe-years and cigar-years were calculated as years from self-reported age of starting to age of quitting (or to current age in current users) multiplied by pipe-bowls or cigars per day. Results: Of 3528 participants, 9% reported pipe smoking (median, 15 pipe-years), 11% reported cigar smoking (median, 6 cigar-years), and 52% reported cigarette smoking (median, 18 pack-years). Self-reported current pipe and cigar smokers had elevated urine cotinine levels compared with never-smokers. Pipe-years were associated with decrements in FEV(1), and cigar-years were associated with decrements in the FEV(1)-FVC ratio. Participants who smoked pipes or cigars had increased odds of airflow obstruction whether they had also smoked cigarettes (odds ratio, 3.43 [95% CI, 1.75 to 6.71]; P < 0.001) or not (odds ratio, 2.31 [CI, 1.04 to 5.11]; P = 0.039) compared with participants with no smoking history. Limitation: Cross-sectional design. Conclusion: Pipe and cigar smoking increased urine cotinine levels and was associated with decreased lung function and increased odds of airflow obstruction, even in participants who had never smoked cigarettes. Primary Funding Source: National Heart, Lung, and Blood Institute, National Institutes of Health.

PMID: 20157134 [PubMed - in process]

A cervical collar or physiotherapy was better than a wait-and-see policy for early pain relief in cervical radiculopathy.

Ann Intern Med. 2010 Feb 16;152(4):JC29

Authors:

PMID: 20157133 [PubMed - in process]

Meta-analysis: Effect of Interactive Communication Between Collaborating Primary Care Physicians and Specialists.

Ann Intern Med. 2010 Feb 16;152(4):247-58

Authors: Foy R, Hempel S, Rubenstein L, Suttorp M, Seelig M, Shanman R, Shekelle PG

Background: Whether collaborative care models that enable interactive communication (timely, 2-way exchange of pertinent clinical information directly between primary care and specialist physicians) improve patient outcomes is uncertain. Purpose: To assess the effects of interactive communication between collaborating primary care physicians and key specialists on outcomes for patients receiving ambulatory care. Data Sources: PubMed, PsycInfo, EMBASE, CINAHL, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, and Web of Science through June 2008 and secondary references, with no language restriction. Study Selection: Studies that evaluated the effects of interactive communication between collaborating primary care physicians and specialists on outcomes for patients with diabetes, psychiatric conditions, or cancer. Data Extraction: Contextual, intervention, and outcome data from 23 studies were extracted by one reviewer and checked by another. Study quality was assessed with a 13-item checklist. Disagreement was resolved by consensus. Main outcomes for analysis were selected by reviewers who were blinded to study results. Data Synthesis: Meta-analysis indicated consistent effects across 11 randomized mental health studies (pooled effect size, -0.41 [95% CI, -0.73 to -0.10]), 7 nonrandomized mental health studies (pooled effect size, -0.47 [CI, -0.84 to -0.09]), and 5 nonrandomized diabetes studies (pooled effect size, -0.64 [CI, -0.93 to -0.34]). These findings remained robust to sensitivity analyses. Meta-regression indicated studies that included interventions to enhance the quality of information exchange had larger effects on patient outcomes than those that did not (-0.84 vs. -0.27; P = 0.002). Limitations: Because collaborative interventions were inherently multifaceted, the efficacy of interactive communication by itself cannot be established. Inclusion of study designs with lower internal validity increased risk for bias. No studies involved oncologists. Conclusion: Consistent and clinically important effects suggest a potential role of interactive communication for improving the effectiveness of primary care-specialist collaboration. Primary Funding Source: RAND Health's Comprehensive Assessment of Reform Options Initiative, the Veterans Affairs Center for the Study of Provider Behavior, The Commonwealth Fund, and the Health Foundation.

PMID: 20157139 [PubMed - in process]

Narrative review: the role of th2 immune pathway modulation in the treatment of severe asthma and its phenotypes.

Ann Intern Med. 2010 Feb 16;152(4):232-7

Authors: Levine SJ, Wenzel SE

New therapeutic approaches are needed for patients with severe asthma who are refractory to standard therapy comprising high doses of inhaled corticosteroids plus long-acting beta(2)-agonists. Current treatment guidelines for patients with severe asthma from the National Asthma Education and Prevention Program recommend the addition of oral corticosteroids, which are associated with substantial morbidity, and, for those with allergic asthma, anti-IgE. Genetic and translational studies, as well as clinical trials, suggest that in a subgroup of patients, the pathobiology of severe asthma is mediated by immune pathways driven by T-helper 2 (Th2)-type CD4(+) T cells, which produce a characteristic repertoire of interleukins (ILs), including IL-4, IL-5, and IL-13. Therefore, biological modifiers of Th2-type ILs, such as monoclonal antibodies, soluble receptors, and receptor antagonists, are a rational strategy for developing new treatment approaches but will need to be targeted to selected patients in whom the appropriate Th2 immune pathway is "active." The benefits of immune-modifier therapies targeting Th2-type cytokines, however, need to be weighed against the toxicities associated with inhibition of key biological pathways, as well as the expense of future medications. Therefore, future clinical trials need to clearly establish the efficacy and safety of biological modifiers of Th2 immune pathways before these approaches can enter routine clinical practice for the treatment of severe asthma.

PMID: 20157138 [PubMed - in process]

Frequency of inappropriate medical exceptions to quality measures.

Ann Intern Med. 2010 Feb 16;152(4):225-31

Authors: Persell SD, Dolan NC, Friesema EM, Thompson JA, Kaiser D, Baker DW

Background: Quality improvement programs that allow physicians to document medical reasons for deviating from guidelines preserve clinicians' judgment while enabling them to strive for high performance. However, physician misconceptions or gaming potentially limit programs. Objective: To implement computerized decision support with mechanisms to document medical exceptions to quality measures and to perform peer review of exceptions and provide feedback when appropriate. Design: Observational study. Setting: Large internal medicine practice. Participants: Patients eligible for 1 or more quality measures. Measurements: A peer-review panel judged medical exceptions to 16 chronic disease and prevention quality measures as appropriate, inappropriate, or of uncertain appropriateness. Medical records were reviewed after feedback was given to determine whether care changed. Results: Physicians recorded 650 standardized medical exceptions during 7 months. The reporting tool was used without any medical reason 36 times (5.5%). Of the remaining 614 exceptions, 93.6% were medically appropriate, 3.1% were inappropriate, and 3.3% were of uncertain appropriateness. Frequencies of inappropriate exceptions were 7 (6.9%) for coronary heart disease, 0 (0%) for heart failure, 10 (10.8%) for diabetes, and 2 (0.6%) for preventive services. After physicians received direct feedback about inappropriate exceptions, 8 of 19 (42%) changed management. The peer-review process took less than 5 minutes per case, but for each change in clinical care, 65 reviews were required. Limitation: The findings could differ at other sites or if financial incentives were in place. Conclusion: Physician-recorded medical exceptions were correct most of the time. Peer review of medical exceptions can identify myths and misconceptions, but the process needs to be more efficient to be sustainable. Primary Funding Source: Agency for Healthcare Research and Quality.

PMID: 20157137 [PubMed - in process]

Prediction rules must be developed according to methodological guidelines.

Ann Intern Med. 2010 Feb 16;152(4):263

Authors: Janssen KJ, Moons KG, Harrell FE

PMID: 20157143 [PubMed - in process]

Prediction rules must be developed according to methodological guidelines.

Ann Intern Med. 2010 Feb 16;152(4):263-4

Authors: Chan WS, Ramsay T, Ginsberg JS

PMID: 20157142 [PubMed - in process]