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Rheumatoid arthritis (RA) outcomes are best if remission is induced early with disease-modifying antirheumatic drugs (DMARDs). Methotrexate (MTX) is a commonly used DMARD and prednisone has been shown to slow progression of joint damage, so their concurrent use early in disease might improve outcomes. This trial randomly assigned patients with early RA to receive MTX plus either low-dose prednisone or placebo. Patients who received MTX plus prednisone had less joint damage, were more likely to achieve remission, and were less likely to require additional DMARDs than those who received MTX plus placebo.
Because physicians recommend cancer screening to patients, they should be able to interpret studies of screening tests. An Internet survey presented primary care physicians with 2 hypothetical scenarios regarding cancer screening. In one, screening improved 5-year survival and increased early detection; in the other, it decreased cancer mortality and incidence. Most physicians incorrectly equated improved survival and early detection as evidence of lives saved by screening. Few correctly recognized that only reduced mortality constitutes evidence of the benefit of screening.
Nonsteroidal anti-inflammatory drugs (NSAIDs) and aspirin lower the risk for colorectal cancer but have been associated with inflammatory bowel disease in some studies. This observational study identified an increase in the incidence of Crohn disease and ulcerative colitis among women who used 5 or more NSAID tablets per week but not among women who used aspirin. Absolute incidence of both conditions was low, so any increase in risk is unlikely to alter the balance of more common and clinically significant risks and benefits that are associated with NSAIDs.
How surrogate decision makers interpret information about patient prognosis is unknown. In this multicenter study, researchers asked 80 surrogates of critically ill patients to use a probability scale to interpret 16 hypothetical prognostic statements. Their interpretations of statements about low risk for death were reasonably accurate. However, their interpretations of statements that conveyed a high risk for death were overly optimistic. Surrogates may have optimistic biases that interfere with their interpretation of information about poor prognosis.
Comparative effectiveness research is a key element of current efforts to reform U.S. health care, but prioritizing new research to address identified gaps in the evidence is an ongoing challenge. Researchers developed and tested a framework for identifying evidence gaps and prioritizing comparative effectiveness research by using a combination of clinical practice guidelines and systematic reviews. They discuss the utility and limitations of the framework and future adaptations.
The American College of Physicians assessed guidelines on colorectal cancer screening from other organizations. On the basis of this assessment, the College recommends individualized risk assessment in all adults, screening average-risk adults starting at age 50 years and high-risk adults starting at age 40 years or 10 years younger than when their youngest relative was diagnosed; screening with a stool-based test, flexible sigmoidoscopy, or optical colonoscopy for average-risk patients and optical colonoscopy for high-risk patients (based on benefits, harms, availability, and patient preferences), and no screening for adults older than 75 years or with a life expectancy of less than 10 years.
In 2005, the American Association for the Study of Liver Diseases recommended ultrasonography screening for hepatocellular carcinoma (HCC) every 6 months for high-risk patients, including those with cirrhosis. This recommendation was based on a large randomized trial among Chinese hepatitis B carriers. This commentary argues that the recommendation was based on misplaced confidence on this single trial and that currently available data do not show that HCC screening among patients with cirrhosis saves lives.
In this issue, Bakker and colleagues report improved outcomes for patients with early RA treated with MTX plus prednisone compared with those treated with MTX plus placebo. The editorialist notes that biological therapy, treat-to-target strategies, and the intelligent use of glucocorticoids have advanced RA treatment. He concludes that combination DMARD therapy including glucocorticoids should be the gold standard for early RA therapy.
In this issue, Wegwarth and colleagues present results of a survey that suggest that primary care physicians misinterpret data on the effectiveness of screening. The editorialist discusses these results and proposes strategies for improving both physicians' and the public's understanding of the benefits and harms of screening.