JAMA Internal Medicine Current Issue

Debunking Atypical Chest Pain in Women Comment on “Reconstructing Angina: Cardiac Symptoms Are the Same in Women and Men” Comment on “Reconstructing Angina”

Redberg RF. — Mon, 13 May 2013 00:00:00 GMT

Awareness campaigns for heart disease in women have led to increased recognition for women of the importance of preventing heart disease via healthy lifestyle choices and recognizing the symptoms of heart disease. There also has been focus on the idea that women somehow present differently than men with ischemic coronary artery disease (CAD). Kreatsoulas et al reassure us that women and men are more alike than we think in presentation of CAD, and both are most likely to experience chest pain, pressure, and tightness. It is likely that atypical symptoms represent women who do not have ischemic CAD. These findings should be a great relief to the many women who have been concerned that they could be having a myocardial infarction unbeknownst to them because they would not get the typical warning symptoms of chest pain.

Demand of Words Demand of Words

Rousseau P. — Mon, 13 May 2013 00:00:00 GMT

In medicine, there is a brittle demand of words—once spoken, they cannot be called back, for their footprint is forever—particularly at the end of life. They embed themselves in the hearts of patients and families and hold dominion over understanding or uncertainty, acceptance or denial. They can also hurt or heal, or harm or help, and bear witness to the suffering of disease—and the manner of the physician.

Is There a Role for Further Risk Stratification of Patients With Stable Coronary Artery Disease? Comment on “High-Sensitivity Cardiac Troponin T Levels and Secondary Events in Outpatients With Coronary Heart Disease From the Heart and Soul Study” Risk Stratification in Coronary Artery Disease

O’Malley PG. — Mon, 13 May 2013 00:00:00 GMT

The article by Beatty et al demonstrated an independent association between high-sensitivity cardiac troponin T levels and recurrent events among patients with known stable coronary artery disease, even after controlling for important potential confounders, including structural and functional heart disease factors. This association implies that we have the capability to refine risk prediction further among such already high-risk patients. However, whether we should do so is another question, because it is unclear how such information would change clinical management. Patients with low troponin levels still had a high risk for recurrent events (an approximately 20% 10-year risk), and would not warrant cessation of conventionally accepted treatments for the prevention of recurrent events. Among patients with high troponin levels, one can consider having a more nuanced discussion about prognosis, or consider enrollment in clinical trials to assess new advances in the secondary prevention of coronary syndromes; but whether this results in improved patient-centered outcomes is unknown. As is the case with obtaining any new clinical information, we would not recommend the routine use of this laboratory test unless the results are tied to an evidence-based management decision that leads to improved outcomes, and the patient is adequately informed of its uncertain utility.

Serious Adverse Effects Can Occur With Minor Procedures Comment on “Risk of Topical Anesthetic–Induced Methemoglobinemia” Serious Adverse Effects With Minor Procedures

Katz MH. — Mon, 13 May 2013 00:00:00 GMT

Minor procedures can have serious adverse effects. The article by Chowdhary et al quantitates a serious but rare adverse effect, namely, methemoglobinemia associated with the use of topical oropharyngeal anesthetics for invasive procedures. The studies for which the topical anesthetics are used are common procedures that are typically thought to be safe, such as transesophageal echocardiography and upper gastrointestinal tract endoscopy. The association of methemoglobinemia with topical anesthetics cannot be eliminated, although it was less common when the anesthetics did not contain benzocaine. However, before any procedure is performed, even one we think of as very safe, we can ensure that the benefits outweigh the risks.

Weighing Benefits and Risks Comment on “Use of Glucocorticoids and Risk of Venous Thromboembolism” Weighing Benefits and Risks

Katz MH. — Mon, 13 May 2013 00:00:00 GMT

Glucocorticoids are one of the most widely prescribed medications. They are effective for a large and diverse set of illnesses ranging from asthma to systemic lupus erythematosus. Unfortunately, their efficacy is accompanied by many adverse effects, including increased infection risk, hyperglycemia, hypertension, and mania.

Womb to Grow Womb to Grow

Mu EW. — Mon, 13 May 2013 00:00:00 GMT

I first met Emily during my third year of medical school, and she deeply impressed upon me that in matters of the womb, patient wishes define when less is more. Emily was a 33-year-old woman (gravida 0, para 0) admitted for fever and right flank pain lasting several weeks. Emily's diagnosis was initially elusive. She had received a full course of antibiotics to treat suspected pyelonephritis. However, when her pain, leukocytosis, and fever persisted, we searched for another source of infection. A transvaginal ultrasound examination ultimately revealed extensive endometriosis and 2 large cystic masses in the right ovary that were the likely source of her infection.

About This Journal

Mon, 13 May 2013 00:00:00 GMT

Adult Mortality in a Randomized Trial of Mass Azithromycin for Trachoma

Keenan JD, Emerson PM, Gaynor BD, et al. — Mon, 13 May 2013 00:00:00 GMT

Annual mass azithromycin treatments are provided to entire communities to clear the ocular strains of Chlamydiatrachomatis that cause blinding trachoma. Mass treatments reduce the community burden of ocular chlamydia and have proven efficacious in community-randomized trials. Since 1999, more than 150 million doses of azithromycin have been distributed for trachoma worldwide.

Availability of Potassium on the Nutrition Facts Panel of US Packaged Foods

Curtis CJ, Niederman SA, Kansagra SM. — Mon, 13 May 2013 00:00:00 GMT

Studies have indicated that diets low in potassium and high in sodium are associated with increased risk for cardiovascular disease, the leading cause of death in the United States, whereas higher potassium intake is associated with reduced risk for both all-cause and cardiovascular disease–related mortality. Yet, the majority of US adults consume considerably less than the 4700 mg/d of potassium that is recommended by the 2010 Dietary Guidelines for Americans.

Can Participation in Mental and Physical Activity Protect Cognition in Old Age? Comment on “The Mental Activity and eXercise (MAX) Trial: A Randomized Controlled Trial to Enhance Cognitive Function in Older Adults” Can Mental and Physical Activity Protect Cognition

Lautenschlager NT, Cox KL. — Mon, 13 May 2013 00:00:00 GMT

With many societies around the globe experiencing increasing longevity, one challenging research question of our times is how to reduce the risk of cognitive decline in old age. Modifiable risk or protective factors for Alzheimer disease (AD) are of specific interest, because probably up to half of AD cases worldwide are potentially attributable to modifiable factors. It has been estimated, for example, that up to 1 million AD cases could be prevented globally if a 25% reduction in physical inactivity could be achieved in the world population. Although the body of literature on this topic is substantial, randomized controlled trials (RCTs) involving older adults at increased risk of cognitive decline are still quite sparse, and RCTs that combine more than a single protective lifestyle factor in their intervention are even less common.

Causal Effect of Public Space Smoking Bans?

Huesch MD. — Mon, 13 May 2013 00:00:00 GMT

Hurt and colleagues present a careful before-and-after study of the association of a workplace smoking ban in Olmsted County, Minnesota, with myocardial infarction and sudden cardiac death rates. There is no doubt that environmental tobacco smoke is a serious and immediate health hazard. Yet the authors acknowledge that their before-and-after designs are not ideal and point to their lack of data on a control area without such smoking bans.

Disregard of Patients' Preferences Is a Medical Error Comment on “Failure to Engage Hospitalized Elderly Patients and Their Families in Advance Care Planning” Disregard of Patients' Preferences

Allison TA, Sudore RL. — Mon, 13 May 2013 00:00:00 GMT

To physicians, what is encompassed by the term medical error may seem self-evident. It is the surgery performed on the wrong limb, the medication given to the wrong patient, or the medical test that falls through the cracks. Medical errors involve acts of omission as well as commission. During the past decade, we have attempted to systematically address diagnostic, treatment, and equipment-related errors and improve patient safety in medicine. Public awareness of the health care system's efforts to improve patient safety has been raised through the groundbreaking Institute of Medicine report calling for system-level change, a physician-authored New York Times bestseller on patient safeguards through checklists, and a privately instigated campaign to save 100 000 lives by reducing medical errors across 3000 American hospitals. However, do we, as clinicians, recognize the full scope of what may constitute medical errors in practice?

Effect of the ACGME 16-Hour Rule on Efficiency and Quality of Care: Duty Hours 2.0

Choma NN, Vasilevskis EE, Sponsler KC, et al. — Mon, 13 May 2013 00:00:00 GMT

In July 2011, the Accreditation Council for Graduate Medical Education (ACGME) reduced the consecutive number of hours that postgraduate year-1 residents can work in a single shift, from 30 to 16. This rule was intended to improve patient safety by reducing residents' fatigue. Many worry that the new duty hour policy increases patient care handovers, which may cause patient harm. The net effect of the 16-hour duty limits on patient outcomes is uncertain.

Failure to Engage Hospitalized Elderly Patients and Their Families in Advance Care Planning Advance Care Planning Between Patient and Families

Heyland DK, Barwich D, Pichora D, et al. — Mon, 13 May 2013 00:00:00 GMT

Importance

Advance care planning can improve patient-centered care and potentially reduce intensification of care at the end of life.

Objectives

To inquire about patients' advance care planning activities before hospitalization and preferences for care from the perspectives of patients and family members, as well as to measure real-time concordance between expressed preferences for care and documentation of those preferences in the medical record.

Design

Prospective study.

Setting

Twelve acute care hospitals in Canada.

Participants

Elderly patients who were at high risk of dying in the next 6 months and their family members.

Main Outcome Measures

Responses to an in-person administered questionnaire and concordance of expressed preferences and orders of care documented in the medical record.

Results

Of 513 patients and 366 family members approached, 278 patients (54.2%) and 225 family members (61.5%) consented to participate. The mean ages of patients and family members were 80.0 and 60.8 years, respectively. Before hospitalization, most patients (76.3%) had thought about end-of-life (EOL) care, and only 11.9% preferred life-prolonging care; 47.9% of patients had completed an advance care plan, and 73.3% had formally named a surrogate decision maker for health care. Of patients who had discussed their wishes, only 30.3% had done so with the family physician and 55.3% with any member of the health care team. Agreement between patients' expressed preferences for EOL care and documentation in the medical record was 30.2%. Family members' perspectives were similar to those of patients.

Conclusions and Relevance

Many elderly patients at high risk of dying and their family members have expressed preferences for medical treatments at the EOL. However, communication with health care professionals and documentation of these preferences remains inadequate. Efforts to reduce this significant medical error of omission are warranted.

Firearm Legislation and Firearm-Related Fatalities in the United States US Firearm Laws and Firearm-Related Fatalities

Fleegler EW, Lee LK, Monuteaux MC, et al. — Mon, 13 May 2013 00:00:00 GMT

Importance

Over 30 000 people die annually in the United States from injuries caused by firearms. Although most firearm laws are enacted by states, whether the laws are associated with rates of firearm deaths is uncertain.

Objective

To evaluate whether more firearm laws in a state are associated with fewer firearm fatalities.

Design

Using an ecological and cross-sectional method, we retrospectively analyzed all firearm-related deaths reported to the Centers for Disease Control and Prevention Web-based Injury Statistics Query and Reporting System from 2007 through 2010. We used state-level firearm legislation across 5 categories of laws to create a “legislative strength score,” and measured the association of the score with state mortality rates using a clustered Poisson regression. States were divided into quartiles based on their score.

Setting

Fifty US states.

Participants

Populations of all US states.

Main Outcome Measures

The outcome measures were state-level firearm-related fatalities per 100 000 individuals per year overall, for suicide, and for homicide. In various models, we controlled for age, sex, race/ethnicity, poverty, unemployment, college education, population density, nonfirearm violence–related deaths, and household firearm ownership.

Results

Over the 4-year study period, there were 121 084 firearm fatalities. The average state-based firearm fatality rates varied from a high of 17.9 (Louisiana) to a low of 2.9 (Hawaii) per 100 000 individuals per year. Annual firearm legislative strength scores ranged from 0 (Utah) to 24 (Massachusetts) of 28 possible points. States in the highest quartile of legislative strength (scores of ≥9) had a lower overall firearm fatality rate than those in the lowest quartile (scores of ≤2) (absolute rate difference, 6.64 deaths/100 000/y; age-adjusted incident rate ratio [IRR], 0.58; 95% CI, 0.37-0.92). Compared with the quartile of states with the fewest laws, the quartile with the most laws had a lower firearm suicide rate (absolute rate difference, 6.25 deaths/100 000/y; IRR, 0.63; 95% CI, 0.48-0.83) and a lower firearm homicide rate (absolute rate difference, 0.40 deaths/100 000/y; IRR, 0.60; 95% CI, 0.38-0.95).

Conclusions and Relevance

A higher number of firearm laws in a state are associated with a lower rate of firearm fatalities in the state, overall and for suicides and homicides individually. As our study could not determine cause-and-effect relationships, further studies are necessary to define the nature of this association.

Forced Smoking Abstinence Not Enough for Smoking Cessation Forced Abstinence and Smoking Cessation

Clarke JG, Stein LR, Martin RA, et al. — Mon, 13 May 2013 00:00:00 GMT

Importance

Millions of Americans are forced to quit smoking as they enter tobacco-free prisons and jails, but most return to smoking within days of release. Interventions are needed to sustain tobacco abstinence after release from incarceration.

Objective

To evaluate the extent to which the WISE intervention (Working Inside for Smoking Elimination), based on motivational interviewing (MI) and cognitive behavioral therapy (CBT), decreases relapse to smoking after release from a smoke-free prison.

Design

Participants were recruited approximately 8 weeks prior to their release from a smoke-free prison and randomized to 6 weekly sessions of either education videos (control) or the WISE intervention.

Setting

A tobacco-free prison in the United States.

Participants

A total of 262 inmates (35% female).

Main Outcome Measure

Continued smoking abstinence was defined as 7-day point-prevalence abstinence validated by urine cotinine measurement.

Results

At the 3-week follow-up, 25% of participants in the WISE intervention (31 of 122) and 7% of the control participants (9 of 125) continued to be tobacco abstinent (odds ratio [OR], 4.4; 95% CI, 2.0-9.7). In addition to the intervention, Hispanic ethnicity, a plan to remain abstinent, and being incarcerated for more than 6 months were all associated with increased likelihood of remaining abstinent. In the logistic regression analysis, participants randomized to the WISE intervention were 6.6 times more likely to remain tobacco abstinent at the 3-week follow up than those randomized to the control condition (95% CI, 2.5-17.0). Nonsmokers at the 3-week follow-up had an additional follow-up 3 months after release, and overall 12% of the participants in the WISE intervention (14 of 122) and 2% of the control participants (3 of 125) were tobacco free at 3 months, as confirmed by urine cotinine measurement (OR, 5.3; 95% CI, 1.4-23.8).

Conclusions and Relevance

Forced tobacco abstinence alone during incarceration has little impact on postrelease smoking status. A behavioral intervention provided prior to release greatly improves cotinine-confirmed smoking cessation in the community.

Trial Registration

clinicaltrials.gov Identifier: NCT01122589

High-Sensitivity Cardiac Troponin T Levels and Secondary Events in Outpatients With Coronary Heart Disease From the Heart and Soul Study High-Sensitivity Cardiac Troponin T Levels

Beatty AL, Ku IA, Christenson RH, et al. — Mon, 13 May 2013 00:00:00 GMT

Importance

Levels of high-sensitivity cardiac troponin T (hs-cTnT) predict secondary cardiovascular events in patients with stable coronary heart disease.

Objectives

To determine the association of hs-cTnT levels with structural and functional measures of heart disease and the extent to which these measures explain the relationship between hs-cTnT and secondary events.

Design

We measured serum concentrations of hs-cTnT and performed exercise treadmill testing with stress echocardiography in a prospective cohort study of outpatients with coronary heart disease who were enrolled from September 11, 2000, through December 20, 2002, and followed up for a median of 8.2 years.

Setting

Twelve outpatient clinics in the San Francisco Bay Area.

Participants

Nine hundred eighty-four patients with stable coronary heart disease.

Main Outcomes and Measures

Cardiovascular events (myocardial infarction, heart failure, or cardiovascular death), determined by review of medical records and death certificates.

Results

Of 984 participants, 794 (80.7%) had detectable hs-cTnT levels. At baseline, higher hs-cTnT levels were associated with greater inducible ischemia and worse left ventricular ejection fraction, left atrial function, diastolic function, left ventricular mass, and treadmill exercise capacity. During follow-up, 317 participants (32.2%) experienced a cardiovascular event. After adjustment for clinical risk factors, baseline cardiac structure and function, and other biomarkers (N-terminal portion of the prohormone of brain-type natriuretic peptide and C-reactive protein levels), each doubling in hs-cTnT level remained associated with a 37% higher rate of cardiovascular events (hazard ratio, 1.37 [95% CI, 1.14-1.65]; P = .001).

Conclusions and Relevance

In outpatients with stable coronary heart disease, higher hs-cTnT levels were associated with multiple abnormalities of cardiac structure and function but remained independently predictive of secondary events. These findings suggest that hs-cTnT levels may detect an element of risk that is not captured by existing measures of cardiac disease severity.

Improving Health Care After Prison Comment on “Forced Smoking Abstinence: Not Enough for Smoking Cessation” Improving Health Care After Prison

Puisis M. — Mon, 13 May 2013 00:00:00 GMT

About 2.3 million people are incarcerated in federal and state prisons and local jails. Annually, 700 000 are discharged from state and federal prisons, and almost 12 million are discharged from local jails. Although prisoners have a constitutional right to medical care, no such right exists once they are discharged. Given that prisoners have a high rate of mental illness, substance abuse, and disease infections, including with human immunodeficiency virus (HIV), hepatitis C, and tuberculosis, their health care once they are discharged is of great public health significance.

In This Issue of JAMA Internal Medicine

Mon, 13 May 2013 00:00:00 GMT

New Oral Anticoagulants in Acute Coronary Syndromes: What Does a Meta-analysis Tell Us?

Kwong JW, Yu C. — Mon, 13 May 2013 00:00:00 GMT

We read with interest the meta-analysis by Komócsi et al, which reported that the use of factor Xa and direct thrombin inhibitors in patients receiving antiplatelet therapy after an acute coronary syndrome (ACS) was associated with a substantial increase in major bleeding and moderate reduction in ischemic events. However, there are a few issues we would like to highlight.

New Oral Anticoagulants in Acute Coronary Syndromes: What Does a Meta-analysis Tell Us?—Reply

Komócsi A, Vorobcsuk A, Aradi D. — Mon, 13 May 2013 00:00:00 GMT

In reply

Nonbenzodiazepine Sleep Medication Use and Hip Fractures in Nursing Home Residents Sleep Medication Use and Nursing Home Hip Fracture

Berry SD, Lee Y, Cai S, et al. — Mon, 13 May 2013 00:00:00 GMT

Importance

It is important to understand the relationship between sleep medication use and injurious falls in nursing home residents.

Objective

To conduct a case-crossover study to estimate the association between nonbenzodiazepine hypnotic drug use (zolpidem tartrate, eszopiclone, or zaleplon) and the risk for hip fracture among a nationwide sample of long-stay nursing home residents, overall and stratified by individual and facility-level characteristics.

Design and Setting

Case-crossover study performed in an academic research setting.

Participants

The study participants included 15 528 long-stay US nursing home residents 50 years or older with a hip fracture documented in Medicare Part A and Part D fee-for-service claims between July 1, 2007, and December 31, 2008.

Main Outcome Measures

Odds ratios (ORs) of hip fracture were estimated using conditional logistic regression models by comparing the exposure to nonbenzodiazepine hypnotic drugs during the 0 to 29 days before the hip fracture (hazard period) with the exposure during the 60 to 89 and 120 to 149 days before the hip fracture (control periods). Analyses were stratified by individual and facility-level characteristics.

Results

Among the study participants, 1715 (11.0%) were dispensed a nonbenzodiazepine hypnotic drug before the hip fracture, with 927 exposure-discordant pairs included in the analyses. The mean (SD) age of participants was 81.0 (9.7) years, and 77.6% were female. The risk for hip fracture was elevated among users of a nonbenzodiazepine hypnotic drug (OR, 1.66; 95% CI, 1.45-1.90). The association between nonbenzodiazepine hypnotic drug use and hip fracture was somes greater in new users (OR, 2.20; 95% CI, 1.76-2.74) and in residents with mild vs moderate to severe impairment in cognition (OR, 1.86 vs 1.43; P = .06), with moderate vs total or severe functional impairment (OR, 1.71 vs 1.16; P = .11), with limited vs full assistance required with transfers (OR, 2.02 vs 1.43; P = .02), or in a facility with fewer Medicaid beds (OR, 1.90 vs 1.46; P = .05).

Conclusions and Relevance

The risk for hip fracture is elevated among nursing home residents using a nonbenzodiazepine hypnotic drug. New users and residents having mild to moderate cognitive impairment or requiring limited assistance with transfers may be most vulnerable to the use of these drugs. Caution should be exercised when prescribing sleep medications to nursing home residents.

Not Just Words Caring for the Patient by Caring About Language

Epstein AS. — Mon, 13 May 2013 00:00:00 GMT

Outcomes of Screening Mammography by Frequency, Breast Density, and Postmenopausal Hormone Therapy Outcomes of Screening Mammography

Kerlikowske K, Zhu W, Hubbard RA, et al. — Mon, 13 May 2013 00:00:00 GMT

Importance

Controversy exists about the frequency women should undergo screening mammography and whether screening interval should vary according to risk factors beyond age.

Objective

To compare the benefits and harms of screening mammography frequencies according to age, breast density, and postmenopausal hormone therapy (HT) use.

Design

Prospective cohort.

Setting

Data collected January 1994 to December 2008 from mammography facilities in community practice that participate in the Breast Cancer Surveillance Consortium (BCSC) mammography registries.

Participants

Data were collected prospectively on 11 474 women with breast cancer and 922 624 without breast cancer who underwent mammography at facilities that participate in the BCSC.

Main Outcomes and Measures

We used logistic regression to calculate the odds of advanced stage (IIb, III, or IV) and large tumors (>20 mm in diameter) and 10-year cumulative probability of a false-positive mammography result by screening frequency, age, breast density, and HT use. The main predictor was screening mammography interval.

Results

Mammography biennially vs annually for women aged 50 to 74 years does not increase risk of tumors with advanced stage or large size regardless of women's breast density or HT use. Among women aged 40 to 49 years with extremely dense breasts, biennial mammography vs annual is associated with increased risk of advanced-stage cancer (odds ratio [OR], 1.89; 95% CI, 1.06-3.39) and large tumors (OR, 2.39; 95% CI, 1.37-4.18). Cumulative probability of a false-positive mammography result was high among women undergoing annual mammography with extremely dense breasts who were either aged 40 to 49 years (65.5%) or used estrogen plus progestogen (65.8%) and was lower among women aged 50 to 74 years who underwent biennial or triennial mammography with scattered fibroglandular densities (30.7% and 21.9%, respectively) or fatty breasts (17.4% and 12.1%, respectively).

Conclusions and Relevance

Women aged 50 to 74 years, even those with high breast density or HT use, who undergo biennial screening mammography have similar risk of advanced-stage disease and lower cumulative risk of false-positive results than those who undergo annual mammography. When deciding whether to undergo mammography, women aged 40 to 49 years who have extremely dense breasts should be informed that annual mammography may minimize their risk of advanced-stage disease but the cumulative risk of false-positive results is high.

Overuse of Magnetic Resonance Imaging

Emery DJ, Shojania KG, Forster AJ, et al. — Mon, 13 May 2013 00:00:00 GMT

Overuse of health care services such as magnetic resonance imaging (MRI) has become an increasingly recognized problem. We studied the appropriateness of requests for outpatient MRI of the lumbar spine and of the head for headache, as these are common indications and might be frequently inappropriate.

Rapid Assessment of Cardiovascular Risk Among Users of Smoking Cessation Drugs Within the US Food and Drug Administration's Mini-Sentinel Program

Toh S, Baker MA, Brown JS, et al. — Mon, 13 May 2013 00:00:00 GMT

In June 2011, the US Food and Drug Administration (FDA) issued a Drug Safety Communication indicating that varenicline tartrate, a drug prescribed for smoking cessation, may increase the risk of certain cardiovascular events in individuals with cardiovascular disease. The finding was based on the FDA's review of a randomized placebo-controlled trial of 714 smokers. In July 2011, the FDA requested that the Mini-Sentinel program perform a rapid safety assessment of the drug.

Reconstructing Angina: Cardiac Symptoms Are the Same in Women and Men

Kreatsoulas C, Shannon HS, Giacomini M, et al. — Mon, 13 May 2013 00:00:00 GMT

Coronary artery disease (CAD) is the leading cause of mortality in the Western world. The prevalence of angina and proportion of deaths from CAD is higher among women than men. Despite this, the perception that CAD is a man's disease prevails. Historic faulty assumptions in the construct of angina, failure to systematically include women in clinical studies, and differences in age-specific incidence rates have perpetuated this perception. As a result, the term typical angina has evolved to describe symptoms in men, whereas atypical angina is applied to women. This lack of clarity has been a source of controversy in understanding CAD in women.

Responding to the Crisis of Firearm Violence in the United States Comment on “Firearm Legislation and Firearm-Related Fatalities in the United States” Responding to the US Crisis of Firearm Violence

Wintemute GJ. — Mon, 13 May 2013 00:00:00 GMT

The United States has belatedly awakened to the knowledge that it is, in effect, under armed attack. More than 30 000 people are purposely shot to death each year—more than 300 000 since the World Trade Center was destroyed in 2001. Rates of firearm-related violent crime have increased 26% since 2008. Physicians have joined others in demanding a strong response to this crisis. We look to scientific research to provide the evidence on which that response should be based. Such evidence should include a thorough exploration of risk and protective factors and, most importantly, controlled studies showing which interventions work to reduce firearm violence and why.

Resumption of Warfarin Therapy After Gastrointestinal Tract Bleeding: Benefit or Bias?

Filion KB, Assayag J, Azoulay L. — Mon, 13 May 2013 00:00:00 GMT

It is with great interest that we read the article by Witt and colleagues, who examined the risk of thromboembolism, recurrent hemorrhage, and death in a retrospective cohort of warfarin users with gastrointestinal tract bleeding. Although no difference was observed in recurrent hemorrhage, the authors found that warfarin therapy resumption after gastrointestinal tract bleeding resulted in substantial decreases in thrombosis (adjusted hazard ratio [HR], 0.05; 95% CI, 0.01-0.58) and death (adjusted HR, 0.31; 95% CI, 0.15-0.62). In contrast, a participant-level meta-analysis estimated that oral anticoagulants reduce the rate of ischemic stroke in patients with atrial fibrillation by 52% (HR, 0.48; 95% CI, 0.37-0.63) but not death (HR, 0.93; 95% CI, 0.76-1.13) relative to aspirin.

Resumption of Warfarin Therapy After Gastrointestinal Tract Bleeding: Benefit or Bias?—Reply

Witt DM, Delate T, Crowther MA. — Mon, 13 May 2013 00:00:00 GMT

In reply

Risk of Topical Anesthetic–Induced Methemoglobinemia A 10-Year Retrospective Case-Control Study Topical Anesthetic–Induced Methemoglobinemia

Chowdhary S, Bukoye B, Bhansali AM, et al. — Mon, 13 May 2013 00:00:00 GMT

Importance

Methemoglobinemia is a rare but serious disorder, defined as an increase in oxidized hemoglobin resulting in a reduction of oxygen-carrying capacity. Although methemoglobinemia is a known complication of topical anesthetic use, few data exist on the incidence of and risk factors for this potentially life-threatening disorder.

Objective

To examine the incidence of and risk factors for procedure-related methemoglobinemia to identify patient populations at high risk for this complication.

Design and Setting

Retrospective study in an academic research setting.

Participants

Medical records for all patients diagnosed as having methemoglobinemia during a 10-year period were reviewed.

Exposures

All cases of methemoglobinemia that occurred after the following procedures were included in the analysis: bronchoscopy, nasogastric tube placement, esophagogastroduodenoscopy, transesophageal echocardiography, and endoscopic retrograde cholangiopancreatography.

Main Outcomes and Measures

Comorbidities, demographics, concurrent laboratory values, and specific topical anesthetic used were recorded for all cases. Each case was compared with matched inpatient and outpatient cases.

Results

In total, 33 cases of methemoglobinemia were identified during the 10-year period among 94 694 total procedures. The mean (SD) methemoglobin concentration was 32.0% (12.4%). The methemoglobinemia prevalence rates were 0.160% for bronchoscopy, 0.005% for esophagogastroduodenoscopy, 0.250% for transesophageal echocardiogram, and 0.030% for endoscopic retrograde cholangiopancreatography. Hospitalization at the time of the procedure was a major risk factor for the development of methemoglobinemia (0.14 cases per 10 000 outpatient procedures vs 13.7 cases per 10 000 inpatient procedures, P < .001).

Conclusions and Relevance

The overall prevalence of methemoglobinemia is low at 0.035%; however, an increased risk was seen in hospitalized patients and with benzocaine-based anesthetics. Given the potential severity of methemoglobinemia, the risks and benefits of the use of topical anesthetics should be carefully considered in inpatient populations.

Routine Noninvasive Testing and Highly Sensitive Troponin Immunoassays

Lippi G, Cervellin G. — Mon, 13 May 2013 00:00:00 GMT

In a recent article published in this journal, Prasad et al reviewed the current practice of routine noninvasive testing in patients with chest pain admitted to the emergency department (ED). Although stress testing is currently recommended in those patients with nondiagnostic results of serial electrocardiograms and biomarkers, the definition of “negative cardiac biomarker findings” may be an important drawback in this approach. At the time when the American College of Cardiology/American Heart Association guidelines were released (ie, 2007), the designation of “nondiagnostic biomarker” was based on the so-called contemporary-sensitive troponin immunoassays, which generate measurable values in approximately 35% of a healthy population, at best. The recent development and gradual commercialization of the novel highly sensitive immunoassays represent a major breakthrough in the management of chest pain in the ED, considering that a large number of these patients have comorbidities that contribute to increase troponin concentration because of an increased turnover of myocardiocytes (eg, nonischemic heart injury) or impaired protein catabolism (eg, kidney disease). With this development, measurable troponin values can now be obtained in up to 96% of cases of a presumably healthy population, and thereby in virtually all subjects admitted to the ED.

Routine Noninvasive Testing and Highly Sensitive Troponin Immunoassays—Reply

Prasad V, Cheung M, Cifu A. — Mon, 13 May 2013 00:00:00 GMT

In reply

Significance of First-Degree Atrioventricular Block in Acute Endocarditis—Diagnosis

Mon, 13 May 2013 00:00:00 GMT

Significance of First-Degree Atrioventricular Block in Acute Endocarditis—Quiz Case

Atallah P. — Mon, 13 May 2013 00:00:00 GMT

A 64-year-old man with a history of congenital bicuspid aortic valve and bioprosthetic valve replacement presented with fever, chills, and dysuria. He was treated with ciprofloxacin as an outpatient for presumed urinary tract infection by his primary care physician. In the emergency center, his urinalysis result was positive. He was given intravenous ceftriaxone sodium and admitted for observation.

Smoking Bans Research

Arnett J, Dunn J. — Mon, 13 May 2013 00:00:00 GMT

In the article on smoking bans by Hurt et al, the results do not justify the claims made that smoking bans had beneficial health effects. As can be seen in Table 2 of the study by Hurt et al

Smoking Bans Research—Reply

Hurt RD, Roger VL, Ebbert JO. — Mon, 13 May 2013 00:00:00 GMT

In reply

The Mental Activity and eXercise (MAX) Trial A Randomized Controlled Trial to Enhance Cognitive Function in Older Adults The Mental Activity and eXercise (MAX) Trial

Barnes DE, Santos-Modesitt W, Poelke G, et al. — Mon, 13 May 2013 00:00:00 GMT

Importance

The prevalence of cognitive impairment and dementia are projected to rise dramatically during the next 40 years, and strategies for maintaining cognitive function with age are critically needed. Physical or mental activity alone result in relatively small, domain-specific improvements in cognitive function in older adults; combined interventions may have more global effects.

Objective

To examine the combined effects of physical plus mental activity on cognitive function in older adults.

Design

Randomized controlled trial with a factorial design.

Setting

San Francisco, California.

Participants

A total of 126 inactive, community-residing older adults with cognitive complaints.

Interventions

All participants engaged in home-based mental activity (1 h/d, 3 d/wk) plus class-based physical activity (1 h/d, 3 d/wk) for 12 weeks and were randomized to either mental activity intervention (MA-I; intensive computer) or mental activity control (MA-C; educational DVDs) plus exercise intervention (EX-I; aerobic) or exercise control (EX-C; stretching and toning); a 2 × 2 factorial design was used so that there were 4 groups: MA-I/EX-I, MA-I/EX-C, MA-C/EX-1, and MA-C/EX-C.

Main Outcome Measures

Global cognitive change based on a comprehensive neuropsychological test battery.

Results

Participants had a mean age of 73.4 years; 62.7% were women, and 34.9% were Hispanic or nonwhite. There were no significant differences between the groups at baseline. Global cognitive scores improved significantly over time (mean, 0.16 SD; P < .001) but did not differ between groups in the comparison between MA-I and MA-C (ignoring exercise, P = .17), the comparison between EX-I and EX-C (ignoring mental activity, P = .74), or across all 4 randomization groups (P = .26).

Conclusions and Relevance

In inactive older adults with cognitive complaints, 12 weeks of physical plus mental activity was associated with significant improvements in global cognitive function with no evidence of difference between intervention and active control groups. These findings may reflect practice effects or may suggest that the amount of activity is more important than the type in this subject population.

Trial Registration

clinicaltrials.gov Identifier: NCT00522899

Time to Publication Among Completed Clinical Trials

Ross JS, Mocanu M, Lampropulos JF, et al. — Mon, 13 May 2013 00:00:00 GMT

Prior studies have shown that 25% to 50% of clinical trials are never published. However, among those published, we know little about the length of time required for publication in the peer-reviewed biomedical literature after study completion. Ioannidis previously demonstrated that a sample of randomized phase 2 and 3 trials conducted between 1986 and 1996 required nearly 2.5 years for publication, while our more recent study of National Institutes of Health (NIH)-funded trials found that the average time to publication was almost 2 years. We sought to determine time to publication for a recent and representative sample of trials published in 2009.

Use of Glucocorticoids and Risk of Venous Thromboembolism A Nationwide Population-Based Case-Control Study Glucocorticoids and Risk of Venous Thromboembolism

Johannesdottir SA, Horváth-Puhó E, Dekkers OM, et al. — Mon, 13 May 2013 00:00:00 GMT

Importance

Excess endogenous cortisol has been linked to venous thromboembolism (VTE) risk, but whether this relationship applies to exogenous glucocorticoids remains uncertain. Because the prevalence of glucocorticoid use and the incidence of VTE are high, an increased risk of VTE associated with glucocorticoid use would have important implications.

Background

To examine the association between glucocorticoid use and VTE.

Design

Population-based case-control study using nationwide databases.

Setting

Denmark (population 5.6 million).

Participants

We identified 38 765 VTE cases diagnosed from January 1, 2005, through December 31, 2011, and 387 650 population controls included through risk-set sampling and matched by birth year and sex. The VTE diagnosis date for the case was the index date for cases and matched controls.

Exposure

We classified individuals who filled their most recent glucocorticoid prescription 90 days or less, 91 to 365 days, and more than 365 days before the index date as present, recent, and former users, respectively. Present users were subdivided into new (first-ever prescription 90 days or less before the index date) and continuing users (others).

Main Outcomes and Measures

We used conditional logistic regression adjusted for VTE risk factors to estimate incidence rate ratios (IRRs) and 95% CIs for glucocorticoid users vs nonusers.

Results

Systemic glucocorticoids increased VTE risk among present (adjusted IRR, 2.31; 95% CI, 2.18-2.45), new (3.06; 2.77-3.38), continuing (2.02; 1.88-2.17), and recent (1.18; 1.10-1.26) users but not among former users (0.94; 0.90-0.99). The adjusted IRR increased from 1.00 (95% CI, 0.93-1.07) for a prednisolone-equivalent cumulative dose of 10 mg or less to 1.98 (1.78-2.20) for more than 1000 to 2000 mg, and to 1.60 (1.49-1.71) for doses higher than 2000 mg. New use of inhaled (adjusted IRR, 2.21; 95% CI, 1.72-2.86) and intestinal-acting (2.17; 1.27-3.71) glucocorticoids also increased VTE risk.

Conclusions and Relevance

The risk of VTE is increased among glucocorticoid users. Although residual confounding may partly explain this finding, we consider a biological mechanism likely because the association followed a clear temporal gradient, persisted after adjustment for indicators of severity of underlying disease, and existed also for noninflammatory conditions. Hence, our observations merit clinical attention.

What's to Blame for Falls and Fractures? Poor Sleep or the Sleeping Medication? Comment on “Nonbenzodiazepine Sleep Medication Use and Hip Fractures in Nursing Home Residents” What's to Blame for Falls and Fractures?

Widera E. — Mon, 13 May 2013 00:00:00 GMT

Sleep in nursing homes is both cherished yet fleeting. Most nursing home residents complain about the quality of their sleep, which is notable for multiple nighttime awakenings, frequent daytime naps, and a high percentage of time spent awake in bed. This fragmented nature of sleep can be attributed to multiple causes, including a high prevalence of primary sleep disorders (eg, central sleep apnea) and a care environment that pays little attention to sleep quality and structure.

Error in Table in: Communication and Medication Refill Adherence: The Diabetes Study of Northern California

Mon, 13 May 2013 00:00:00 GMT

Error in Table. The Original Investigation titled “Communication and Medication Refill Adherence: The Diabetes Study of Northern California,” published in the February 11, 2013, issue (2013;173[3]:210-218) contained an error in Table 3 on page 215. The first column heading should just read “Measure” rather than “CAHPS Measure.”