Table of Contents

Mann and colleagues compared the long-term renal effects of telmisartan and placebo in 5927 adults with vascular disease but without macroalbuminuria. They used a composite renal outcome of dialysis or doubling of serum creatinine, changes in estimated glomerular filtration rate (GFR), and changes in albuminuria. Patients receiving telmisartan had the same composite outcome results as those receiving placebo. Albuminuria increased less with telmisartan than with placebo, whereas estimated GFR decreased more with telmisartan. On balance, telmisartan had the same effects as placebo on major renal outcomes.

Bilous and associates compared the renal effects of the angiotensin-receptor blocker candesartan and placebo in a large sample of normoalbuminuric patients with type 1 and type 2 diabetes. The main outcomes were microalbuminuria incidence and rate of change in albuminuria. Candesartan had little effect on the incidence of microalbuminuria; the annual rate of change in albuminuria was 5.53% lower with candesartan than with placebo. Candesartan did not prevent microalbuminuria in mainly normotensive patients with type 1 or type 2 diabetes.

Few researchers have measured the effect of failing to notice test results. The authors studied 91 new cases of abdominal aortic dilation observed on computed tomography (CT). Radiologists directly notified clinical teams about 5% of these new dilations. Using comments in the medical record as evidence, the authors found that the clinical team had not noticed the dilation within 3 months of CT in 58% of cases. These failures apparently did not lead to complications or deaths. The results indicate a need for better strategies to ensure documentation of follow-up of tests.

Linzer and colleagues assessed the relationship among adverse primary care work conditions, adverse physician reactions, and quality of patient care. Among 422 family practitioners and general internists, more than half reported time pressure during office visits, 48.1% said their work pace was chaotic, 78.4% felt they had little control over their work, and 26.5% reported burnout. These factors were strongly associated with low physician satisfaction, high stress, burnout, and intent to leave but not worse quality of care.

This article discusses how pandemic influenza viruses get that way, in the context of the new H1N1 triple-reassortant “swine” influenza virus, and recounts some of the lessons that scientists have learned from similar situations in the past. In brief, influenza is a zoonotic infection: The virus usually lives in birds and other animals, but through genetic reassortment, it can acquire the capacity to infect humans. When the virus takes a form in which humans can transmit it to one another, a pandemic can occur.

The U.S. Preventive Services Task Force (USPSTF) updates its 1996 recommendation statement on screening for impaired visual acuity in adults age 65 years or older. It concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for visual acuity for the improvement of outcomes in older adults (I statement).

To support the USPSTF recommendation statement in this issue, Chou and colleagues systematically reviewed the evidence on the benefits and harms of screening for impaired visual acuity in older adults. Direct evidence shows that screening for vision impairment in older adults in primary care settings is not associated with improved visual or other clinical outcomes and may be associated with unintended harms, such as increased falls. The accuracy of the Snellen chart and funduscopy is unknown.

Two articles in this issue examine the effect of angiotensin-receptor blockers on microalbuminuria: Mann and colleagues studied adults with known cardiovascular disease or diabetes with end-organ damage but no albuminuria at baseline, and Bilous and associates studied diabetics at an early phase of nephropathy. The editorialist concludes that use of renin–angiotensin system inhibitors in patients at high risk for vascular disease, regardless of diabetes status, requires clinical judgment of the degree of vascular and renal risk and of the relative efficacy of these agents on the function of different organs.

In this issue, Linzer and colleagues found that family practitioners and general internists report high levels of unhappiness about time pressures and practice pace, little sense of control over work conditions, and deficient organizational culture. Primary care as an indispensable set of functions will persist in one form or another; the challenge is to organize it as part of an integrated system that serves the needs of both patients and physicians, enhances quality, and keeps costs within reasonable limits.

The departing Editor draws some lessons from his tenure at Annals of Internal Medicine. The main lesson is that evaluating research requires intensive effort by editors and statisticians. Journals are the principal societal institution that evaluates research; as such, excellence in journal production benefits everyone. Providing this public good is expensive, however, and the future of funding for journals is unclear.