JAMA Internal Medicine Current Issue

Pharmaceutically Less and Holistically More

Dam A, Datta N, Mohanty U, et al. — Mon, 10 Jun 2013 00:00:00 GMT

An 80-year-old woman had advanced malignant disease of the left scapula and shoulder joint and a large ulcerated mass in the axilla that bled frequently. She had received radiotherapy and chemotherapy, with the last treatment being given 14 months previously. She lived in a village in a tribal state of India and belonged to the lower socioeconomic class. Her health expenses were being paid by her son, who was the only wage-earning member in a large family of 16 members.

Radiation Minimization Strategies for Medical Imaging Comment on “Radiation Safety in Nuclear Cardiology—Current Knowledge and Practice” Radiation Minimization Strategies

Redberg RF. — Mon, 10 Jun 2013 00:00:00 GMT

On a population basis, radiation exposure from medical imaging substantially increases cancer risk. Nearly 40% of the medical radiation exposure to the US population (excluding therapeutic radiotherapy) is related to cardiovascular imaging and intervention.

About This Journal

Mon, 10 Jun 2013 00:00:00 GMT

ACE, MACE, and GRACE: Time to Put the Pieces Together Comment on “Effects of an Acute Care for Elders Unit on Costs and 30-Day Readmissions” ACE, MACE, and GRACE

Walke LM, Tinetti ME. — Mon, 10 Jun 2013 00:00:00 GMT

Berwick et al challenged the US health care system to achieve the Triple Aim of higher-quality care for individuals, improved health of populations, and lower health care costs. Accomplishing the 3-part aim is a formidable task, perhaps for no group more so than for older adults with complex health problems who are the major users of health care. However, several innovative geriatric health care programs have had modest success.

Additional Considerations to Precede Selection of Enoxaparin Therapy

Miyares MA. — Mon, 10 Jun 2013 00:00:00 GMT

DeCarolis and colleagues are to be commended for their review of patients receiving an unadjusted dosage of enoxaparin sodium regardless of normal or moderate renal function and consequent bleeding episodes, demonstrating major bleeding in 5.7% of those with normal renal function compared with 22% of those with moderate renal function.

Additional Considerations to Precede Selection of Enoxaparin Therapy—Reply

DeCarolis DD, Johnson GJ. — Mon, 10 Jun 2013 00:00:00 GMT

In reply

Benefits and Costs of Improving Depression Treatment in People With Heart Disease Comment on “Centralized, Stepped, Patient Preference–Based Treatment for Patients With Post–Acute Coronary Syndrome Depression” Depression Treatment in People With Heart Disease

Simon GE. — Mon, 10 Jun 2013 00:00:00 GMT

In this issue of JAMA Internal Medicine, Davidson et al describe the benefits of an organized depression care program for outpatients experiencing significant symptoms of depression after acute coronary syndrome (ACS). Patients were screened 2 to 6 months after hospitalization for ACS, and those with significant depressive symptoms were randomly assigned to either a systematic depression treatment program or continued usual care (which might include depression treatment from local medical or mental health providers). The Comparison of Depression Interventions after Acute Coronary Syndrome (CODIACS) treatment program included the essential elements proven effective in previous collaborative care or depression care management programs: availability of antidepressant pharmacotherapy and structured psychotherapy, systematic assessment of outcomes, a stepped care algorithm for treatment adjustment or intensification, and organized supervision by consulting mental health specialists. Those offered the organized depression treatment program experienced significantly greater improvement (both statistically and clinically) over 6 months. This finding adds to the substantial evidence for the clinical benefit of depression screening and systematic treatment among people with varying stages of heart disease ranging from outpatients with poorly controlled cardiovascular risk factors to patients discharged after revascularization.

Bizarre and Wide QRS After Liver Transplant—Diagnosis

Mon, 10 Jun 2013 00:00:00 GMT

Bizarre and Wide QRS After Liver Transplant—Quiz Case

Johnson CJ, Scheinman MA, Turakhia MP. — Mon, 10 Jun 2013 00:00:00 GMT

A 52-year-old woman 3 weeks status post orthotopic liver transplant was noted to have ST-segment elevation on telemetry. The posttransplant course had been complicated by acute rejection treated with increasing tacrolimus doses resulting in status epilepticus from tacrolimus toxicity. She was treated with intravenous fosphenytoin followed by progressively increasing doses of intravenous phenytoin. Fluconazole, vancomycin, and meropenem had also been started empirically owing to decreased immune function and low blood pressure. At the time of the electrocardiogram (Figure 1), the corrected phenytoin level was 26 μg/mL (normal range 10-20, μg/mL).

Centralized, Stepped, Patient Preference–Based Treatment for Patients With Post–Acute Coronary Syndrome Depression CODIACS Vanguard Randomized Controlled Trial CODIACS Vanguard RCT

Davidson KW, Bigger J, Burg MM, et al. — Mon, 10 Jun 2013 00:00:00 GMT

Importance

Controversy remains about whether depression can be successfully managed after acute coronary syndrome (ACS) and the costs and benefits of doing so.

Objective

To determine the effects of providing post-ACS depression care on depressive symptoms and health care costs.

Design

Multicenter randomized controlled trial.

Setting

Patients were recruited from 2 private and 5 academic ambulatory centers across the United States.

Participants

A total of 150 patients with elevated depressive symptoms (Beck Depression Inventory [BDI] score ≥10) 2 to 6 months after an ACS, recruited between March 18, 2010, and January 9, 2012.

Interventions

Patients were randomized to 6 months of centralized depression care (patient preference for problem-solving treatment given via telephone or the Internet, pharmacotherapy, both, or neither), stepped every 6 to 8 weeks (active treatment group; n = 73), or to locally determined depression care after physician notification about the patient's depressive symptoms (usual care group; n = 77).

Main Outcome Measures

Change in depressive symptoms during 6 months and total health care costs.

Results

Depressive symptoms decreased significantly more in the active treatment group than in the usual care group (differential change between groups, −3.5 BDI points; 95% CI, −6.1 to −0.7; P = .01). Although mental health care estimated costs were higher for active treatment than for usual care, overall health care estimated costs were not significantly different (difference adjusting for confounding, −$325; 95% CI, −$2639 to $1989; P = .78).

Conclusions

For patients with post-ACS depression, active treatment had a substantial beneficial effect on depressive symptoms. This kind of depression care is feasible, effective, and may be cost-neutral within 6 months; therefore, it should be tested in a large phase 3 pragmatic trial.

Trial Registration

clinicaltrials.gov Identifier: NCT01032018

Characteristics of Oncology Clinical Trials Insights From a Systematic Analysis of ClinicalTrials.gov Characteristics of Oncology Clinical Trials

Hirsch BR, Califf RM, Cheng SK, et al. — Mon, 10 Jun 2013 00:00:00 GMT

Importance

Clinical trials are essential to cancer care, and data about the current state of research in oncology are needed to develop benchmarks and set the stage for improvement.

Objective

To perform a comprehensive analysis of the national oncology clinical research portfolio.

Design

All interventional clinical studies registered on ClinicalTrials.gov between October 2007 and September 2010 were identified using Medical Subject Heading terms and submitted conditions. They were reviewed to validate classification, subcategorized by cancer type, and stratified by design characteristics to facilitate comparison across cancer types and with other specialties.

Results

Of 40 970 interventional studies registered between October 2007 and September 2010, a total of 8942 (21.8%) focused on oncology. Compared with other specialties, oncology trials were more likely to be single arm (62.3% vs 23.8%; P < .001), open label (87.8% vs 47.3%; P < .001), and nonrandomized (63.9% vs 22.7%; P < .001). There was moderate but significant correlation between number of trials conducted by cancer type and associated incidence and mortality (Spearman rank correlation coefficient, 0.56 [P = .04] and 0.77 [P = .001], respectively). More than one-third of all oncology trials were conducted solely outside North America.

Conclusions and Relevance

There are significant variations between clinical trials in oncology and other diseases, as well as among trials within oncology. The differences must be better understood to improve both the impact of cancer research on clinical practice and the use of constrained resources.

Collecting and Applying Data on Social Determinants of Health in Health Care Settings Social Determinants of Health in Health Care

Gottlieb L, Sandel M, Adler NE. — Mon, 10 Jun 2013 00:00:00 GMT

Despite strong evidence linking patients' social circumstances to their health, little guidance exists for health care practitioners and institutions on addressing social needs in clinical settings. Current approaches to social determinants generally focus on population-level and policy interventions; these overlook individual and clinical innovations within health care that can address patients' social circumstances. This article proposes a framework for how social determinants interventions in the health care system can be construed across 3 tiers—patient, institution, and broader population—and describes ways to collect data and target interventions at these levels.

Comment Regarding the Stability of Active Ingredients in Long-Expired Prescription Medications

Madden MM, Etzler FM, Gant T. — Mon, 10 Jun 2013 00:00:00 GMT

After reading the article by Cantrell and colleagues on the stability of active pharmaceutical ingredients (APIs), we believe it is necessary to comment on some apparent oversimplifications in the article. The term potency is equated with API concentration, which is reasonable only if given a properly stored, well-understood formulation prior to its expiration date. While all of the long-expired medications were in a solid dosage form, it is worthy to note that the compounds tested would show great temperature dependence in their stability as described in Q₁₀ testing. Complications arise with issues such as (1) unintended polymorphic transitions, (2) hydrate formation, (3) dehydration, (4) thermal decomposition, and (5) photoreactivity, to name a few. Moreover, the authors did not address issues associated with solid-state chemistry potentially affecting in vivo dissolution and consequently absorption, nor did they conduct standard dissolution testing.

Comment Regarding the Stability of Active Ingredients in Long-Expired Prescription Medications—Reply

Cantrell L, Suchard J, Gerona R. — Mon, 10 Jun 2013 00:00:00 GMT

In reply

Creative Arts Therapies Defined Comment on “Effects of Creative Arts Therapies on Psychological Symptoms and Quality of Life in Patients with Cancer”

Bradt J, Goodill S. — Mon, 10 Jun 2013 00:00:00 GMT

A diagnosis of cancer and subsequent treatments may result in significant emotional, physical, and social suffering, placing cancer survivors at greater risk for mental health issues. Therefore, the care of cancer patients should incorporate services that help meet patients' psychological, social, and spiritual needs. Creative arts therapies (CATs), such as dance/movement, music, art, poetry, drama, and psychodrama, are increasingly used to aid in the care of cancer patients and in their recovery. The results of several systematic reviews, as referenced in the study by Puetz et al have reported small to moderate effects of music, art, and dance/movement therapies on a variety of psychological outcomes in cancer patients. The systematic review by Puetz and colleagues aims to expand the existing evidence base by identifying potential moderators of the efficacy of CATs during and after cancer treatment.

Developing a Model for Attending Physician Workload and Outcomes

Michtalik HJ, Pronovost PJ, Marsteller JA, et al. — Mon, 10 Jun 2013 00:00:00 GMT

With increased economic pressures on hospitals, limitations on resident physician hours, and payment reductions for preventable harms, hospitals seek to increase productivity while improving the quality of patient care. Frequently, relative value units and patient encounters are used to track physician productivity and establish national benchmarks. However, productivity varies based on a range of characteristics that are not generally reported, limiting the accuracy of comparisons across institutions. Also, comprehensive process and outcome measures from different stakeholders' perspectives need to be established to align diverse health care interests, ensure widespread acceptability, and provide comprehensive goals. In the present study, we (1) identify an actionable measure of attending physician workload; (2) characterize factors accounting for differences in workload; and (3) identify a congruent set of measures that would be valued by disparate stakeholders.

Effects of an Acute Care for Elders Unit on Costs and 30-Day Readmissions ACE Unit Model for Care

Flood KL, MacLennan PA, McGrew D, et al. — Mon, 10 Jun 2013 00:00:00 GMT

Importance

Providing high-quality care while containing cost is essential for the economic stability of our health care system. The United States is experiencing a rapidly growing elderly population. The Acute Care for Elders (ACE) unit interdisciplinary team model of care has been shown to improve outcomes in hospitalized older adults. The University of Alabama at Birmingham ACE unit incorporates evidence-based care processes. We hypothesized that the ACE model would also reduce costs.

Objective

To examine variable direct costs from an interdisciplinary ACE compared with a multidisciplinary usual care (UC) unit.

Design

Retrospective cohort study.

Setting

Tertiary care academic medical center.

Participants

Hospitalists' patients aged 70 years or older spending the entirety of their hospitalization in either the ACE or UC unit in fiscal year 2010.

Main Outcome Measures

Using administrative data, we analyzed variable direct costs for ACE and UC patients. We also conducted a subset analysis restricted to the 25 most common diagnosis related groups (DRGs) shared by ACE and UC patients. Generalized linear regression was used to estimate cost ratios and 95% confidence intervals adjusted for age, sex, comorbidity score, and case mix index (CMI).

Results

A total of 818 hospitalists' patients met inclusion criteria: 428 from the ACE and 390 from the UC unit. For this study group (all DRGs), the mean (SD) variable direct cost per patient was $2109 ($1870) for ACE and $2480 ($2113) for UC (P = .009). Adjusted cost ratios revealed significant cost savings for patients with low (0.82; 95% CI, 0.72-0.94) or moderate (0.74; 95% CI, 0.62-0.89) CMI scores; care was cost neutral for patients with high CMI scores (1.13; 95% CI, 0.93-1.37). Significantly fewer ACE patients than UC patients were readmitted within 30 days of discharge (7.9% vs 12.8%; P = .02). Subset analysis of the 25 most common DRGs revealed a significantly reduced mean (SD) variable direct cost per patient for ACE compared with UC patients ($1693 [$1063] vs $2138 [$1431]; P < .001); cost ratios for total (0.78; 95% CI, 0.70-0.87) and daily (0.89; 95% CI, 0.85-0.94) variable direct costs remained significant after adjustment.

Conclusions and Relevance

The ACE unit team model reduces costs and 30-day readmissions. In an era when improving care processes while reducing costs is a vital objective for the Medicare program and our nation as a whole, the ACE model meets these goals.

Effects of Creative Arts Therapies on Psychological Symptoms and Quality of Life in Patients With Cancer Creative Arts Therapies in Cancer Patients

Puetz TW, Morley CA, Herring MP. — Mon, 10 Jun 2013 00:00:00 GMT

Importance

Creative arts therapies (CATs) can reduce anxiety, depression, pain, and fatigue and increase quality of life (QOL) in patients with cancer. However, no systematic review of randomized clinical trials (RCTs) examining the effects of CAT on psychological symptoms among cancer patients has been conducted.

Objectives

To estimate the effect of CAT on psychological symptoms and QOL in cancer patients during treatment and follow-up and to determine whether the effect varied according to patient, intervention, and design characteristics.

Evidence Review

We searched ERIC, Google Scholar, MEDLINE, PsycInfo, PubMed, and Web of Science from database inception to January 2012. Studies included RCTs in which cancer patients were randomized to a CAT or control condition and anxiety, depression, pain, fatigue and/or QOL were measured pre- and post-intervention. Twenty-seven studies involving 1576 patients were included. We extracted data on effect sizes, moderators, and study quality. Hedges d effect sizes were computed, and random-effects models were used to estimate sampling error and population variance.

Findings

During treatment, CAT significantly reduced anxiety (Δ = 0.28 [95% CI, 0.11-0.44]), depression (Δ = 0.23 [0.05-0.40]), and pain (Δ = 0.54 [0.33-0.75]) and increased QOL (Δ = 0.50 [0.25-0.74]). Pain was significantly reduced during follow-up (Δ = 0.59 [95% CI, 0.42-0.77]). Anxiety reductions were strongest for studies in which (1) a non-CAT therapist administered the intervention compared with studies that used a creative arts therapist and (2) a waiting-list or usual-care comparison was used. Pain reductions were largest during inpatient treatment and for homogeneous cancer groups in outpatient settings; significantly smaller reductions occurred in heterogeneous groups in outpatient settings.

Conclusions and Relevance

Exposure to CAT can improve anxiety, depression, and pain symptoms and QOL among cancer patients, but this effect is reduced during follow-up.

End-of-Round Time Compression in Physician Handoff Sessions

Jones L, Kannampallil T, Franklin A. — Mon, 10 Jun 2013 00:00:00 GMT

The recent Research Letter by Cohen et al contains interesting conclusions regarding progressively declining time allocations for patients discussed later during rounds. The authors cast the solution for streamlining handoff communication time as a portfolio management problem, where physicians allocate their scarce time available across multiple patients. This argument is both theoretically and metaphorically flawed. First, a portfolio allocation problem assumes 3 conditions: having a set of decision variables (eg, patient conditions), a best-case solution defined as an objective function (eg, all information is efficiently transferred), and available constraints (eg, time). The challenge with applying such a model to handoffs is that constraints and decision variables are rarely known in advance, and it is improbable that such planning happens prior to handoffs, making it difficult to make portfolio judgments. While certain judgments are sometimes made (eg, making the sickest patients a priority), these decisions on time allocations are driven by contextual requirements rather than a portfolio-based allocation.

End-of-Round Time Compression in Physician Handoff Sessions—Reply

Christianson MK, Ilan R. — Mon, 10 Jun 2013 00:00:00 GMT

In reply

Evaluation of the Mobile Acute Care of the Elderly (MACE) Service Mobile Acute Care of the Elderly

Hung WW, Ross JS, Farber J, et al. — Mon, 10 Jun 2013 00:00:00 GMT

Importance

Older adults are particularly vulnerable to adverse events during hospitalization for acute medical problems. The Mobile Acute Care of the Elderly (MACE) service is a novel model of care delivered by an interdisciplinary team, designed to deliver specialized care to hospitalized older adults to improve patient outcomes.

Objective

To evaluate the impact of the MACE service when compared with general medical service (usual care).

Design

Prospective, matched cohort study.

Setting

The Mount Sinai Hospital, an urban tertiary acute care hospital.

Participants

Patients aged 75 years or older admitted because of an acute illness to either the MACE service or usual care. Patients were matched for age, diagnosis, and ability to ambulate independently.

Exposures

Admission to the MACE service when compared with admission to usual care.

Main Outcome Measures

Patient outcomes included incidence of adverse events, including falls, pressure ulcers, restraint use, and catheter-associated urinary tract infections, along with length of stay, rehospitalization within 30 days, functional status at 30 days, and patient satisfaction during care transitions, measured with the 3-item Care Transition Measure.

Results

A total of 173 matched pairs of patients were recruited. The mean (SD) age was 85.2 (5.3) and 84.7 (5.4) years in the MACE and usual-care groups, respectively. After adjustment for confounders, patients in the MACE group were less likely to experience adverse events (9.5% vs 17.0%; adjusted odds ratio, 0.11; 95% CI, 0.01-0.88; P = .04) and had shorter hospital stays (0.8 days, 95% CI, 0.7-0.9; P = .001) than patients receiving usual care. Patients in the MACE group were not less likely to have a lower rate of rehospitalization within 30 days than those in the usual-care group (odds ratio, 0.91; 95% CI, 0.39-2.10; P = .83). Functional status did not differ between the 2 groups. Care Transition Measure scores were 7.4 points (95% CI, 2.9-11.9; P = .001) higher in the MACE group.

Conclusions and Relevance

Admission to the MACE service was associated with lower rates of adverse events, shorter hospital stays, and better satisfaction. This model has the potential to improve care outcomes among hospitalized older adults.

Trial Registration

clinicaltrials.gov Identifier: NCT00927160

Extent and Reporting of Patient Nonenrollment in Influential Randomized Clinical Trials, 2002 to 2010

Humphreys K, Maisel NC, Blodgett JC, et al. — Mon, 10 Jun 2013 00:00:00 GMT

Because they assign patients to treatment conditions, randomized clinical trials (RCTs) offer unparalleled internal validity for drawing inferences about the efficacy of a medical treatment. Whether such inferences can be generalized is not always clear because many RCTs enroll a low and unrepresentative proportion of all patients. The challenges of judging the clinical utility of clinical trial results are increased by poor reporting. The study by Gross et al of trials published in leading medical journals from 1999 through 2000 found that only 28% reported the proportion of screened patients who were enrolled. These deficiencies may have been ameliorated in the past decade because the CONSORT statement was revised in 2001 to require more complete information on the enrollment process in reports of clinical trials, and because many treatment research fields have been showing greater concern about generating knowledge that better informs clinical practice. Accordingly, the present study assessed the extent to which low enrollment rates are still characteristic of widely cited clinical trials, and whether reporting of enrollment information has improved.

Impact of a Real-Time Computerized Duplicate Alert System on the Utilization of Computed Tomography

Wasser EJ, Prevedello LM, Sodickson A, et al. — Mon, 10 Jun 2013 00:00:00 GMT

The use of high-cost imaging modalities is rising rapidly. From 1995 through 2007, use of computed tomographic (CT) scans in the United States increased more than 4-fold; by 2006, CT and magnetic resonance imaging examinations were the fastest-growing physician-directed Medicare expenditure. An uncertain proportion of these examinations represent overuse.

In This Issue of JAMA Internal Medicine

Mon, 10 Jun 2013 00:00:00 GMT

Influenza Vaccines Time for a Rethink Influenza Vaccines

Doshi P. — Mon, 10 Jun 2013 00:00:00 GMT

Officials and professional societies treat influenza as a major public health threat for which the annual vaccine offers a safe and effective solution. In this article, I challenge these basic assumptions. I show that there is no good evidence that vaccines reduce serious complications of influenza, the outcomes the policy is meant to address. Moreover, promotional messages conflate “influenza” (disease caused by influenza viruses) with “flu” (a syndrome with many causes, of which influenza viruses appear to be a minor contributor). This lack of precision causes physicians and potential vaccine recipients to have unrealistic assumptions about the vaccine's potential benefit, and impedes dissemination of the evidence on nonpharmaceutical interventions against respiratory diseases. In addition, there are potential vaccine-related harms, as unexpected and serious adverse effects of influenza vaccines have occurred. I argue that decisions surrounding influenza vaccines need to include a discussion of these risks and benefits.

Limit to Benefits of Large Reductions in Low-Density Lipoprotein Cholesterol Levels Use of Fractional Polynomials to Assess the Effect of Low-Density Lipoprotein Cholesterol Level Reduction in Metaregression of Large Statin Randomized Trials

Mon, 10 Jun 2013 00:00:00 GMT

A recent metaregression of 25 large statin randomized trials involving 155 613 participants and 23 791 major vascular events reported a significant reduction in the risk of major vascular events associated with a reduction in low-density lipoprotein cholesterol (LDL-C) level. The question that naturally follows is whether there is a threshold for the benefit of LDL level reduction that can be achieved with statins or whether greater reductions in LDL level would bring greater reductions in vascular events.

Noncommunicable Diseases in Developing Countries: Focus on Research Capacity Building

Odutayo A, Hirji N. — Mon, 10 Jun 2013 00:00:00 GMT

In a well-conceived study, Damasceno et al demonstrated that the etiology of acute heart failure in sub-Saharan Africa differed from that in developed countries. In particular, the causes were often nonischemic in nature, with hypertension being the most predominant etiological factor. It is therefore likely that the best practices in prevention and management of acute heart failure will also differ, and appropriate treatment guidelines will hinge on future studies conducted within sub-Saharan Africa.

Noncommunicable Diseases in Developing Countries: Focus on Research Capacity Building—Reply

Sliwa K, Damasceno A, Mayosi BM. — Mon, 10 Jun 2013 00:00:00 GMT

In reply

Radiation Safety in Nuclear Cardiology—Current Knowledge and Practice: Results From the 2011 American Society of Nuclear Cardiology Member Survey

Einstein AJ, Tilkemeier P, Fazel R, et al. — Mon, 10 Jun 2013 00:00:00 GMT

Nuclear stress testing is well recognized as an effective technique for diagnosing coronary disease, predicting patient outcomes, and guiding management. Numerous evidence-based appropriate indications and practice guideline recommendations have been published regarding accepted uses of nuclear stress tests (NSTs) across a wide spectrum of patients with known or suspected coronary disease. However, the approximate 10 million NSTs performed annually account for greater than 10% of the entire ionizing radiation burden to the US population. One recent study, while pointing out that cancer risk from a single NST is small, projected on a population level that NSTs may result in thousands of radiation-attributable cancers annually, partially offsetting their benefits.

Regarding “Time to Rethink Screening for Abdominal Aortic Aneurysm?”

Cardneau JD, Chang RW, Okuhn SP. — Mon, 10 Jun 2013 00:00:00 GMT

We would like to address the Invited Commentary by Harris et al, which we believe fails to back its assertions with relevant data. The authors suggest a concept of “harm” in screening for abdominal aortic aneurysm (AAA). They imply that the diagnosis of a small aneurysm will never cause physical harm (rupture) or require repair, leaving the patient only with anxiety. The literature to support this is conflicting and not supportive.

Regarding “Time to Rethink Screening for Abdominal Aortic Aneurysm?”—Reply

Harris RP, Sheridan S, Kinsinger L. — Mon, 10 Jun 2013 00:00:00 GMT

In reply

São Paulo, Brazil

Mon, 10 Jun 2013 00:00:00 GMT

Skin Cancer and Shared Decision Making Comment on “Treatment of Nonfatal Conditions at the End of Life” Skin Cancer and Decision Making

Wenger NS. — Mon, 10 Jun 2013 00:00:00 GMT

Shared decision making between patients and their physicians is optimal for choosing a course of medical care. Decision making is shared because it includes both information from the physician about the medical condition and potential approaches and the perspectives of the patient whose values guide selection among the potential options. Usually, decision making occurs in the context of a conversation between the physician and the patient and optimally includes an iterative series of questions and answers to ensure that the patient understands his or her condition and the upsides and downsides of the treatment choices for him or her to make an informed decision.

The Ability of a Retrospective Review of Electronic Health Records to Fully Capture the Frequency of Supratherapeutic Dosing of Acetaminophen

Charpiat B. — Mon, 10 Jun 2013 00:00:00 GMT

I read with great interest the article by Zhou et al and would like to make the following comments. First, I suggest that their findings underestimate the frequency of acetaminophen overexposure because the authors did not take into account the weight of the patients. Indeed, according to guidelines, when body weight is 50 kg or lower, the adult patient should be prescribed 15 mg/kg for a single dose, up to a maximum of 60 mg/kg of body weight for the total daily dose. My colleagues and I recently performed a prospective study aimed at reporting on the nature and frequency of overdosed acetaminophen prescriptions in adults in a teaching hospital. From October 2006 to April 2011, we reviewed 44 404 prescriptions. Pharmacists made 480 alerts related to overdosed acetaminophen prescription. Most pharmacists' alerts (n = 420) were made because of the prescription of single-ingredient acetaminophen only. Among these alerts, body weight was recorded for 353 patients, of whom 312 had a body weight in the range 27 to 50 kg. Our findings highlight that overdosing of acetaminophen for adult patients with low body weight is still frequent. This is a matter of concern because adults with low body weight are at greater risk of liver damage.

The Ability of a Retrospective Review of Electronic Health Records to Fully Capture the Frequency of Supratherapeutic Dosing of Acetaminophen—Reply

Zhou L, Maviglia SM, Rocha RA. — Mon, 10 Jun 2013 00:00:00 GMT

In reply

Toward Accountable Cancer Care Toward Accountable Cancer Care

Bekelman JE, Kim M, Emanuel EJ. — Mon, 10 Jun 2013 00:00:00 GMT

Cancer accounts for over 500 000 deaths and nearly $125 billion in medical costs annually, second only to heart disease. While interventions arising from the Affordable Care Act aim to improve care quality and reduce cost growth for patients with heart disease, reforms directed toward cancer care have received comparatively little attention.

Treatment of Nonfatal Conditions at the End of Life Nonmelanoma Skin Cancer Nonfatal Conditions at the End of Life

Linos E, Parvataneni R, Stuart SE, et al. — Mon, 10 Jun 2013 00:00:00 GMT

Importance

Nonmelanoma skin cancer (NMSC) is the most common cancer and predominantly affects older patients. Because NMSCs do not typically affect survival or short-term quality of life, the decision about whether and how to treat patients with limited life expectancy (LLE) is challenging, especially for asymptomatic tumors.

Objective

To compare treatment patterns and clinical outcomes of patients with NMSC with and without LLE.

Design, Setting, and Participants

A prospective cohort study of 1536 consecutive patients diagnosed with NMSC at 2 dermatology clinics: a university-based private practice and a Veterans Affairs Medical Center in San Francisco, California. Patients were recruited in 1999 through 2000 and followed up for a median of 9 years. A total of 1360 patients with 1739 tumors (90%) were included in the final analysis. Limited life expectancy was defined as patients either 85 years or older at the time of diagnosis or patients with multiple comorbidities (Charlson Comorbidity Index of ≥ 3). Treatment options included no treatment, destruction, or 2 types of surgery—elliptical excision or Mohs surgery.

Main Outcomes and Measures

Treatment type.

Results

Most NMSCs (69%) were treated surgically, regardless of patient life expectancy. The choice of surgery was not influenced by patient prognosis in univariate or multivariable models adjusted for tumor and patient characteristics. Many patients with LLE (43%) died within 5 years, none of NMSC. Tumor recurrence was rare (3.7% at 5 years [95% CI, 2.6%-4.7%]) in all patients. Although serious complications were unusual, approximately 20% of patients with LLE reported complications of therapy, compared with 15% of other patients.

Conclusions and Relevance

Most NMSCs are treated surgically, regardless of the patient's life expectancy. Given the very low tumor recurrence rates and high mortality from causes unrelated to NMSC in patients with LLE, clinicians should consider whether these patients would prefer less invasive treatment strategies.

Visions of Hope in Cancer: Focus on Infrastructure Comment on “Characteristics of Oncology Clinical Trials” and “Toward Accountable Cancer Care” Visions of Hope in Cancer

Bach PB. — Mon, 10 Jun 2013 00:00:00 GMT

It is natural to be frustrated by the slow pace of progress in cancer. Mortality rates in the United States have been declining, but by only 1% or 2% per year. The advent of personalized treatment based on tumor genetics has led to the subtyping of cancers based on their genetic features, but we have learned through these discoveries that many new targeted agents linked to these mutations improve outcomes for only a few patients—a pattern most apparent in lung cancer. Even in cancers for which effective approaches to prevention or treatment are well known, our knowledge yields smaller health gains than it could in part because our health system fails to deliver consistently optimal, or even acceptable, care. Meanwhile, the cost of cancer care continues to rise along with health care costs in general, widening government debt, and hampering private sector growth.

Waste and Harm in the Treatment of Mild Hypertension Waste and Harm in Treatment of Mild Hypertension

Heath I. — Mon, 10 Jun 2013 00:00:00 GMT

The 2012 Cochrane Review on “Pharmacotherapy for Mild Hypertension” concluded that antihypertensive drugs used in the treatment of otherwise healthy adults with mild hypertension (systolic blood pressure [BP], 140-159 mm Hg, and/or diastolic BP, 90-99 mm Hg) have not been shown to reduce mortality or morbidity in randomized clinical trials. Will this landmark conclusion affect clinical practice and slow the inexorable expansion of disease categories? It certainly should because overdiagnosis and overtreatment are potent causes of both waste and harm and seem to be operating in the interests of the pharmaceutical industry rather than in those of the patients whom the industry claims to serve.

Wide-Complex Tachycardia in a Patient With Coronary Disease—Diagnosis

Mon, 10 Jun 2013 00:00:00 GMT

Wide-Complex Tachycardia in a Patient With Coronary Disease—Quiz Case

Williams ES, Viswanathan MN, Prutkin JM. — Mon, 10 Jun 2013 00:00:00 GMT

A 55-year-old man with a history of hypercholesterolemia and symptomatic premature ventricular complexes treated with a β-blocker was admitted to an outside hospital with acute-onset left-sided chest pressure, palpitations, and lightheadedness. Paramedics at the scene obtained a 12-lead electrocardiogram (ECG) revealing a wide-complex tachycardia at 248 beats per minute (Figure 1), which self-terminated as the patient was being prepared for direct-current cardioversion. The patient was then treated with chewable aspirin and intravenous lidocaine.

Error in Title in: Weight Reduction and Increased Physical Activity to Prevent the Progression of Obstructive Sleep Apnea: A 4-Year Observational Postintervention Follow-up of a Randomized Clinical Trial

Mon, 10 Jun 2013 00:00:00 GMT

Error in Title. In the Research Letter by Tuomilehto et al published online April 15, 2013 (2013;173[10]:929-930), the correct title is “Weight Reduction and Increased Physical Activity to Prevent the Progression of Obstructive Sleep Apnea: A 4-Year Observational Postintervention Follow-up of a Randomized Clinical Trial.”