Using a computer model, this study sought to determine the threshold breast cancer risk at which the balance of benefits and harms of starting mammography screening at age 40 years equals that of currently recommended biennial screening for average-risk women starting at age 50 years. The researchers found that women aged 40 to 49 years with a 2-fold increased risk for breast cancer have a similar net benefit from biennial screening mammography as average-risk women aged 50 to 74 years.

Mortality after acute myocardial infarction (AMI) varies greatly between U.S. hospitals, even accounting for patient factors. This cross-sectional survey of 537 U.S. hospitals identified several hospital strategies associated with lower mortality after AMI: a culture that encouraged physicians to solve problems creatively, physicians and nurses acting as quality-of-care champions, hospital and emergency department clinicians meeting at least monthly to review care, cardiologists always being present in the hospital, and not cross-training nurses to work in both intensive care and cardiac catheterization settings. However, less than 10% of hospitals reported using at least 4 of the 5 strategies.

Although low vitamin D levels are associated with a variety of diseases, the optimal levels are uncertain. This study followed 1621 white, elderly people to examine the relationship of 25-hydroxyvitamin D concentration with major clinical disease events that have been inversely associated with vitamin D levels. Baseline levels less than 50 nmol/L (20 ng/mL) were associated with a composite outcome of hip fracture, myocardial infarction, incident cancer, and death. The Institute of Medicine recently recommended this same threshold, which is lower than that recommended by other professional societies and expert panels.

Knowing which factors influence breast cancer risk for women aged 40 to 49 years could help target screening. This systematic review of 65 studies found that the following factors increased breast cancer risk in women aged 40 to 49 years: extremely or heterogeneously dense breasts, first-degree relatives with breast cancer, previous breast biopsy, second-degree relatives with any cancer, current oral contraceptive use, nulliparity, and age 30 years or older at first birth. These factors may inform the decisions of both women and their physicians about whether to initiate breast cancer screening when a woman is in her 40s or to wait until age 50 years.

This Update summarizes studies published in 2011 that the authors consider highly relevant to the practice of general internal medicine. Topics include hyperlipidemia, anticoagulation and thromboembolism, cancer screening and prevention, and hypertension.

The individual mandate, the centerpiece of the Patient Protection and Affordable Care Act, is constitutional. Detractors contend that compelling the purchase of health insurance will be the first step toward government mandates that, for example, people eat broccoli and drive American cars. Not so, say the authors of this commentary—making people buy health insurance simply amounts to making them pay for something they will inevitably use anyway.

Although substantial academic resources are directed to encourage interest in geriatric medicine, fewer internal medicine and family medicine residents are seeking geriatric medicine fellowship training. This commentary argues that the specialty is not viable. Rather than continue these efforts to promote the training of geriatric medicine specialists, the authors suggest that the medical profession devote resources to develop geriatric competencies in nongeriatrician physicians.

Because the U.S. population is rapidly aging and longevity is increasing, this commentary argues that expanding geriatric medicine training is necessary to optimize outcomes for older adults. The authors note that geriatricians have developed effective strategies for managing complex comorbid conditions in older adults and that the skills of geriatricians are exactly what the United States needs to deal with the Medicare crisis. They propose strategies to promote expansion of the geriatric workforce.

Two papers in this issue address mammography screening for women aged 40 to 49 years. van Ravesteyn and colleagues' comparative modeling study found that screening women in their 40s who have a 2-fold greater relative risk for breast cancer yields the same benefits as screening normal-risk women aged 50 to 74 years, and Nelson and colleagues' review defined and validated the personal factors associated with increased relative risk for breast cancer in this age group. The editorialist discusses these articles and how risk-based screening may be a more effective use of resources.

In this issue, Bradley and colleagues examined the imperfections in care implicit in the wide variation in risk-standardized mortality rates (11% to 25%) for patients hospitalized with AMI in U.S. hospitals. The editorialist discusses the study in light of the Japanese concept of kaizen, which holds that “every defect is a treasure,” and speculates how organizations can best convert the discovery of imperfections into improvements in care.

I was totally baffled by Dalia's request. Not to tell him? It's a home hospice we're talking about here, for God's sake, not to mention that it's my first time. He should have been informed, and certainly not by me. We've never met, but he obviously has dreams, so why not tell him? Why deny him all of the last things he could do?