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Information about a patient's family history can improve assessment of risk for cardiovascular disease. To determine whether Framingham score–based risk assessment performed better when using systematically collected family history data than using medical record–based family history data, this cluster randomized trial involved 748 adult patients with no previously diagnosed cardiovascular risk across 24 family practices. Use of data on family history from mailed patient questionnaires identified more high-risk patients who were eligible for targeted prevention than did usual practice. Systematic collection of family history data could help target patients who are most in need of cardiovascular preventive interventions.
Hepatitis C virus (HCV) infection is most prevalent among adults born from 1945 through 1965, and most of them are currently undiagnosed. Whether screening based on birth cohort is more cost-effective than screening based on other risk factors is unknown. This cost-effectiveness analysis from published evidence plus census and Medicare data estimated that 1-time screening for HCV of persons born between 1945 to 1963 followed by treatment with currently available therapies was cost-effective. A change from solely risk-based screening for HCV to 1-time screening of this birth cohort should be considered.
Hepatitis B and C virus infections result in significant morbidity and mortality but are often unrecognized and thus go untreated. This study used death certificate data to examine temporal trends in deaths from hepatitis B and C virus and HIV infections in the United States. Annual deaths from hepatitis C now exceed those from HIV, and deaths from hepatitis B and C are concentrated among middle-aged persons. Hepatitis B and C are critical and relatively unrecognized public health issues in the United States that have reached epidemic proportions.
Protease inhibitors increase the effectiveness of standard hepatitis C therapy but are costly. Interleukin-28B (IL-28B) genotyping can identify patients most likely to derive benefit from the addition of protease inhibitors to standard therapy. This decision-analytic model suggests that a strategy of adding protease inhibitors to standard therapy for all patients and a targeted treatment strategy based on genetic testing improve quality-adjusted life expectancy compared with standard therapy alone. Universal treatment led to greater benefit but at higher cost than IL-28B–guided therapy. Estimates were sensitive to the costs of protease inhibitors and adherence rates.
High levels of dietary fructose are implicated as an important contributor to obesity in developed countries. This systematic review of controlled feeding trials examined the effect of fructose on body weight under both isocaloric (31 trials) and hypercaloric (10 trials) conditions. Evidence suggests that fructose does not seem to cause weight gain when substituted for other carbohydrates providing a similar number of calories. Pure fructose had no effect on weight compared with diets that provided the same daily calories using nonfructose carbohydrate. Increased calories, not fructose consumption in itself, contribute to weight gain.
New models of continuing medical education (CME) aim not only to impart knowledge but to change physicians' behavior and help facilitate improvement in care. Thus, CME shares some of the same goals as the field of quality improvement, namely behavioral change and systems redesign to improve patient outcomes. This article speculates about how CME providers and quality improvement experts may beneficially integrate these fields.
Nonceliac gluten sensitivity manifests as intestinal or extraintestinal symptoms that improve or disappear after gluten withdrawal in persons in whom celiac disease has been ruled out. The optimal diagnostic algorithm necessary to define nonceliac gluten sensitivity, however, is still under debate. The authors discuss this condition and suggest that open or single-blind gluten challenge tests are reasonable approaches to recognize it until a valuable biomarker is identified.
Results of trials of antiretroviral therapy to decrease the probability of sexual transmission of HIV have been mixed. Other antiretrovirals and delivery systems are being evaluated to maximize the efficacy of primary chemoprophylactic approaches. This commentary discusses the evidence to date and appropriately tailored interventions for populations at greatest risk for infection that are needed to reduce HIV transmission.
In this issue, Qureshi and colleagues report on the value of adding systematic collection of family history data to routine cardiovascular risk assessment. The editorialist discusses the study's findings and asks whether the promising intervention should change practice.
In this issue, articles by Rein and colleagues, Ly and coworkers, and Liu and associates examine HCV prevalence and the cost-effectiveness of screening and treatment. The editorialists discuss these studies and other developments in our understanding of HCV and herald an era during which HCV will become a largely curable disease.