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In This Issue of JAMA Internal Medicine |

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JAMA Intern Med. 2014;174(2):173-175. doi:10.1001/jamainternmed.2013.10635.
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Adherence to cardioprotective medications in the year after acute coronary syndrome (ACS) hospitalization is poor. Ho and coauthors conducted a randomized clinical trial of 253 patients to test a multifaceted intervention against usual care. In the intervention group, 89.3% of patients were adherent compared with 73.9% in the usual care group (P = .003). They found no statistically significant differences in the proportion of patients who achieved blood pressure and low-density lipoprotein cholesterol goals or in clinical events. In an Editor’s Note, Redberg urges caution in implementing costly interventions before significant improvement in patient outcomes is demonstrated.

While bystander cardiopulmonary resuscitation (CPR) can improve the likelihood of surviving an out-of-hospital cardiac arrest, its use varies among communities in observational studies. Anderson and coauthors sought to determine if regional variations in county-level CPR training exist across the United States and factors associated with low CPR training, using data from the American Heart Association, the American Red Cross, and the Health and Safety Institute on more than 13 100 000 persons trained from July 1, 2010, through June 30, 2011. They found that annual CPR training rates in the United States are low and vary widely across communities: counties located in the South and those with a higher proportion of rural populations, residents of black race and Hispanic ethnicity, and lower median household incomes have lower CPR training than their counterparts. Blewer and Abella discuss the topic in an Invited Commentary.

Data from large, real-world practice samples are needed to improve risk factor estimates for late-stage liver events and death in hepatitis C virus (HCV). In an observational cohort study of 128 769 patients from the Department of Veterans Affairs HCV clinical registry, McCombs and coauthors found a relationship between HCV infection and nonfatal hepatic events in a significant percentage of patients with milder disease based on early fibrosis stage. A subgroup of patients achieving undetectable viral load with interferon treatment exhibited a 27% reduction in the incidence of nonfatal hepatic events (cirrhosis, liver cancer, and liver-related hospitalizations) and a 45% reduction in mortality. In an Editor’s Note, Katz describes the clinician’s challenges in effectively treating patients with HCV.

Comparative effects of coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) on long-term mortality and morbidity are not clear. Sipahi and coauthors performed a meta-analysis of contemporary randomized clinical trials examining this issue. Analysis of more than 6000 patients with an average follow-up of 4.1 years revealed a significant 27% relative reduction in total mortality with CABG compared with PCI. Myocardial infarctions and repeat revascularizations were also significantly reduced by CABG, while there was a trend for increase in strokes with CABG compared with PCI. Katz places the findings in historical context in an Editor’s Note.

Whether an acute myocardial infarction (AMI) presents with different symptoms in the 2 sexes is still unknown. In a prospective multicenter trial of 2475 consecutive patients of both sexes with acute chest pain, Rubini Gimenez and coauthors sought to describe sex-specific chest pain characteristics. They found that differences in the sex-specific diagnostic performance of 34 chest pain characteristics are small and do not support female-specific chest pain characteristics in the early diagnosis of AMI. In an Invited Commentary, Pilote discusses the diagnostic context of sex-specific chest pain and calls for further research on the topic.

In the coming decades, the population of older adults with diabetes is expected to grow substantially. To guide care guidelines and policy decisions, Huang and coauthors characterized the contemporary clinical course of diabetes by age and diabetes duration categories, using a cohort of 72 310 patients older than 60 years with type 2 diabetes mellitus enrolled in an integrated health care delivery system. They found that among older adults with diabetes of short duration, cardiovascular complications followed by hypoglycemia were the most common nonfatal complications. For a given age group, rates of each outcome, particularly hypoglycemia and microvascular complications, increased dramatically with longer duration. However, for a given duration of diabetes, rates of hypoglycemia, cardiovascular complications, and mortality increased steeply with advancing age, while rates of microvascular complications remained stable or declined.

Screening for lung cancer can potentially reduce mortality but may also detect indolent tumors that otherwise may not cause symptoms. Patz and coauthors used data from the National Lung Screening Trial to calculate the probability that a lung cancer detected by screening with low-dose computed tomography is a case of overdiagnosis and then estimated the number of cases considered overdiagnosis relative to the number of persons needed to screen to prevent 1 death from lung cancer. They found a probability of 18.5% that any lung cancer detected by screening with low-dose computed tomography was overdiagnosis, and there were approximately 1.4 cases of overdiagnosis found among those participants needed to be screened to prevent 1 death from lung cancer.

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Less Is More

Decisions about screening are often made considering only the benefits, ignoring the harms; one contributing factor is the lack of a framework for conceptualizing and organizing the thinking about harms. Harris and coauthors developed a taxonomy of the harms of screening, including 4 domains: physical harm, psychological harm, financial strain, and opportunity costs. When applied to the issue of lung cancer screening, the taxonomy illustrates the multiple ways that screening can cause harm and what we know and do not know about these harms.

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