Cover photograph by Octavian Toma, MD, DESA
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IN THIS ISSUE
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Computer decision-support systems (CDSSs) are being incorporated into electronic medical records to improve patient outcomes. Patients with HIV were randomly assigned to have either static provider alerts or interactive provider alerts generated by a CDSS in the event of virologic failure, laboratory toxicity, or suboptimal follow-up. Interactive alerts were designed to facilitate and streamline provider response. This group had a clinically significantly greater increase in mean CD4 cell count and decreased suboptimal follow-up than did the static alert group, and provider satisfaction was high. Use of a CDSS may improve HIV outcomes.
The most accurate approach to the diagnosis of insulinoma in patients with suspected hypoglycemic disorders is not clear. In a review of results from prolonged fasts in patients with suspected hypoglycemia, an “amended” insulin–glucose ratio that accounts for prevailing plasma glucose concentrations was more accurate than current practice guideline definitions for confirming or ruling out insulinoma. This approach may be useful in evaluating patients with suspected insulinoma.
Lung cancer screening with low-dose computed tomography (LDCT) may detect tumors that would never become symptomatic in a patient's life. Such “overdiagnosis” might be reduced if changes in tumor size over time, measured as volume-doubling time, can be used to identify less aggressive tumors. In this analysis of incident cancer detected in a prospective LDCT screening study, lung cancer–specific mortality was low among patients with slow-growing and indolent tumors. Further studies are needed to assess whether volume-doubling time can help to reduce overdiagnosis in lung cancer screening programs.
This review examined the comparative effectiveness of patient, provider, systems, and policy interventions to improve medication adherence for chronic conditions. It found evidence that reduced out-of-pocket expenses, case management, and patient education with behavioral support all improved medication adherence for more than 1 condition. Available evidence on whether these approaches are broadly applicable or affect long-term medication adherence and health outcomes is limited.
New oral anticoagulants (NOACs) are emerging alternatives for prophylaxis and treatment of atrial fibrillation (AF) and venous thromboembolism (VTE). This review evaluated the comparative effectiveness of NOACs and warfarin for AF and VTE. It found that NOACs were superior to warfarin for some clinical outcomes, including mortality, in AF and were similar to warfarin for primary outcomes in VTE. Adverse effects of NOACs versus warfarin were generally consistent across treatment indications, but some varied by class.
Upper endoscopy is commonly used in the diagnosis and management of gastroesophageal reflux disease (GERD). The Clinical Guidelines Committee of the American College of Physicians reviewed evidence regarding the indications for, and yield of, upper endoscopy in the setting of GERD to highlight how clinicians can increase delivery of high-value care. This article reviews their best practice advice.
The Centers for Disease Control and Prevention developed these evidence-based recommendations to increase the proportion of hepatitis C virus (HCV)–infected persons who know their status and are linked to appropriate care and treatment. They recommend that adults born during 1945–1965 receive 1-time testing for HCV without prior ascertainment of HCV risk and that all persons identified with HCV infection receive a brief alcohol screening and intervention as clinically indicated, followed by referral to appropriate care and treatment services for HCV infection and related conditions as indicated.
Cases of West Nile virus in 2012 in the United States have exceeded those of any other year. This commentary discusses the endemic cases and asks whether they stem from a new strain of the virus, a reintroduction, or a mutation. The authors believe that to understand West Nile virus and its manifestations, we need to understand the virus itself and its cycle in nature, including the reservoir and the vector and the contribution of the human-built environment to disease prevalence.
The recent reports of fungal meningitis caused by contaminated corticosteroid injections are a reminder of the importance of sterility and the disease-producing interactions between corticosteroids and fungi. This commentary discusses the lessons learned from the 2002 fungal meningitis outbreak and concludes that in any unfamiliar outbreak, health care providers may need to accept preliminary—and less than robust—recommendations from experts and health care officials and adapt them to the individual patient.
In this issue, the ACP Clinical Guidelines Committee provides best practice advice for using endoscopy to help manage GERD and makes it clear that endoscopy often is not needed. The editorialist discusses how physicians must work to avoid low-value care that generates unnecessary costs if our health care system is to remain dedicated to both quality and economic viability.
In a year that is as much about shaping a life as it is about acquiring basic knowledge, each third-year medical school rotation becomes a multiweek process of repeatedly asking, “Could I do this for the rest of my life?”