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Katherine A. Moon, MPH; Eliseo Guallar, MD, DrPH; Jason G. Umans, MD, PhD; Richard B. Devereux, MD; Lyle G. Best, MD; Kevin A. Francesconi, PhD; Walter Goessler, PhD; Jonathan Pollak, MPP; Ellen K. Silbergeld, PhD; Barbara V. Howard, PhD; and Ana Navas-Acien, MD, PhD

Long-term exposure to high levels of inorganic arsenic in water and food is associated with increased risk for cardiovascular disease, but risk from lower levels of exposure has been unclear. This prospective cohort study found that long-term exposure to low to moderate levels of arsenic, as measured by testing urine levels, was associated with increased risk for fatal and nonfatal cardiovascular events.

Topics: cardiovascular diseases, arsenic, urinary tract
  
Hitinder S. Gurm, MD; Carrie Hosman, PhD; David Share, MD; Mauro Moscucci, MD; Ben B. Hansen, PhD, for the Blue Cross Blue Shield of Michigan Cardiovascular Consortium

The use of vascular closure devices to prevent arterial bleeding in patients after transfemoral percutaneous coronary intervention is controversial. This study of patients who had percutaneous coronary intervention found that those with vascular closure devices had fewer hematomas and pseudoaneurysms but more retroperitoneal bleeding events. Patients with lean or moderate body mass indexes and those receiving glycoprotein IIb/IIIa inhibitors did not benefit from the devices. These findings should guide the appropriate use of vascular closure devices.

Topics: percutaneous coronary intervention, closure device, vascular, vascular complications, vocal cord dysfunction, safety, ...
  
Hyunsoon Cho, PhD; Carrie N. Klabunde, PhD; K. Robin Yabroff, PhD, MBA; Zhuoqiao Wang, MS; Angela Meekins, BS; Iris Lansdorp-Vogelaar, PhD; and Angela B. Mariotto, PhD

Guidelines recommend considering health status and life expectancy when making cancer screening decisions in elderly persons, but accurate estimation of an individual patient's life expectancy is challenging. This study aimed to estimate life expectancy of Medicare beneficiaries with and without comorbid conditions. Compared with U.S. population-based estimates, life expectancies at age 75 years were about 3 years longer for persons with no comorbidity and 3 years shorter for those with high comorbidity. Comorbidity-adjusted life expectancy could help physicians tailor cancer screening recommendations.

Topics: comorbidity, life expectancy
  
Caroline Lubick Goldzweig, MD, MSHS; Greg Orshansky, MD; Neil M. Paige, MD, MSHS; Ali Alexander Towfigh, MD; David A. Haggstrom, MD, MAS; Isomi Miake-Lye, BA; Jessica M. Beroes, BS; and Paul G. Shekelle, MD, PhD

Patient portals tied to electronic health record systems give patients secure access to health information and methods for communication and information sharing. This systematic review found mixed evidence of their effect on patient outcomes and satisfaction, although they may be more effective when used with case management. Their effect on utilization and efficiency is unclear, although patient race and ethnicity, education level or literacy, and degree of comorbid conditions may influence use. Patient portals represent a new technology with benefits that are still unclear.

Topics: attitude, health outcomes, diabetes mellitus, type 2
  
Karl Richardson, MD; Marisa Schoen, BA; Benjamin French, PhD; Craig A. Umscheid, MD, MSCE; Matthew D. Mitchell, PhD; Steven E. Arnold, MD; Paul A. Heidenreich, MD, MS; Daniel J. Rader, MD; and Emil M. deGoma, MD

This systematic review examined the association between statin therapy and cognitive function. Low-quality evidence suggests no increased incidence of Alzheimer disease and no difference in cognitive performance in procedural memory, attention, or motor speed, and moderate-quality evidence suggests no increased incidence of dementia or mild cognitive impairment nor any change in cognitive performance related to global cognitive performance scores, executive function, declarative memory, processing speed, or visuoperception. Larger and better-designed studies are needed to definitively determine the effect of statins on cognition.

Topics: statins, cognitive ability, alzheimer's disease
  
Virginia A. Moyer, MD, MPH, on behalf of the U.S. Preventive Services Task Force

The U.S. Preventive Services Task Force updated its recommendation on medications to reduce breast cancer risk. The Task Force recommends that clinicians engage in shared, informed decision making with women who are at increased risk for breast cancer and recommends against the routine use of medications for women who are not at increased risk.

Topics: raloxifene, tamoxifen, breast cancer, risk reduction, united states preventive services task force, ...
  
Eric J. Warm, MD; and Celine Goetz, MD

This commentary discusses the shortage of primary care physicians, framed by encounters where mentors have asserted that students are “too smart” for primary care. The authors discuss how this assertion discourages medical students from seeking careers in primary care.

Topics: primary health care
  
William G. Kussmaul III, MD

This commentary discusses the shortage of primary care physicians and its implications. The author asks whether specialists shun primary care because it is too difficult— perhaps some physicians are too lazy for primary care?

Topics: primary health care
  

In this issue, Moon and colleagues report results from the Strong Heart Study, documenting an association between urinary arsenic levels and cardiovascular disease. The editorialists discuss the study and ask questions about the effect of this common exposure not only from water but from foods, such as grains, and about populations in which arsenic exposure presents the highest risks.

Topics: cardiovascular diseases, arsenic
  
Jason H. Maley, MD
Includes: Audio/Video

I chose to volunteer in a primary care clinic serving a residential men's substance abuse treatment center. As I turned a corner near the building, I caught a glimpse of the houses lining the street. My anxiety was finally hitting me, along with a fear that as a new medical student, I wouldn't be much help to these patients.

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William V. Padula, PhD, MS; Heidi M. Wald, MD, MSPH; and Mary Beth F. Makic, PhD, RN
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Marjorie Jenkins, MD; Tedd L. Mitchell, MD; and Steven L. Berk, MD
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Megan C. McNamara, MD, MS; and Judith M.E. Walsh, MD., MPH
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Sarah Hartley, BMBChir
Includes: Audio/Video
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Topics: kidney failure, chronic, calcium, mortality, phosphate binding agent
  
Topics: smoking, mortality, lung cancer, low-dose spiral ct
  
Topics: argipressin, cardiac arrest, epinephrine, hospitals, steroids, follow-up
  
Topics: weight reduction, support groups for weight loss, follow-up
  
Topics: pharmacist, safety, elderly
  
Topics: antipsychotic agents, schizophrenia
  
Topics: bell palsy, needle device, acupuncture procedure, follow-up
  
Topics: antibiotics, diarrhea, follow-up, inpatient
  
Topics: inpatient, thromboprophylaxis, venous thromboembolism
  
Topics: thromboprophylaxis, venous thromboembolism, follow-up
  
Topics: crohn's disease, mortality
  
Topics: cancer, radical prostatectomy, prostate cancer
  
Geno J. Merli, MD; and Howard H. Weitz, MD

The Consult Guys bring a new perspective to the art and science of medicine with lively discussion and analysis of real-world cases and situations.

Topics: consultation, pain
  
Topics: cardiovascular diseases, arsenic
  
Topics: advisory committees, breast cancer, prevention, united states preventive services task force
  
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