Cover photograph by Meghan NeSmith, MD
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The ideal blood pressure for adults with chronic kidney disease (CKD) is unclear. This study of U.S. veterans with non–dialysis-dependent CKD found that systolic blood pressure (SBP) of 130 to 159 mm Hg and diastolic blood pressure (DBP) of 70 to 89 mm Hg were associated with the lowest mortality rates. Those with moderately elevated SBP combined with DBP no less than 70 mm Hg had lower mortality rates than those with ideal SBP and DBP less than 70 mm Hg. Achieving ideal SBP at the expense of lower-than-ideal DBP could be harmful in adults with CKD.
African Americans often have limited mental health care options because of system- or patient-level factors. This trial randomly assigned older African Americans with depressive symptoms to a home-based intervention delivered by a social worker or to a wait list. Participants who received the intervention had greater reductions in depressive symptoms and improved quality of life than wait-listed participants. A home-based intervention delivered by social workers could reduce depressive symptoms and enhance quality of life in some older African Americans.
Many patients with rheumatoid arthritis have an inadequate response to disease-modifying antirheumatic drugs. This randomized trial of patients with rheumatoid arthritis and an inadequate response to such therapy found that the addition of tofacitinib improved symptoms and physical function compared with placebo. Tofacitinib may be an option for some patients with rheumatoid arthritis who have an inadequate response to other treatments.
Sodium–glucose cotransporter 2 (SGLT2) inhibitors are a new class of antidiabetic drugs. This systematic review and meta-analysis found that SGLT2 inhibitors had favorable effects on hemoglobin A1c, body weight, and blood pressure in adults with type 2 diabetes. However, urinary and genital tract infections were more common, and results for cardiovascular outcomes and death were inconclusive. Most trials were rated at high risk of bias. In adults with type 2 diabetes, SGLT2 inhibitors may improve short-term outcomes, but effects on long-term outcomes and safety are unclear.
This systematic review evaluated the evidence on the benefits and risks of new oral anticoagulants versus standard thromboprophylaxis after total hip or knee replacement. Six good-quality reviews compared thromboprophylaxis with the newer agents versus low-molecular-weight heparin (LMWH). Clinical benefits of new oral anticoagulants over LMWH were marginal and offset by increased risk for major bleeding. Indirect comparisons suggest only small differences among the various newer oral anticoagulants. For hip and knee replacement recipients, new oral anticoagulants may be reasonable thromboprophylaxis options but should be used with caution in patients at increased risk for bleeding.
Evidence from meta-analysis is only as strong as the findings of its underlying studies. This limitation is present in Vasilakou and colleagues' article in this issue, because many of the included trials did not handle patient withdrawal and rescue medication properly. This article discusses how methods for handling data collected after rescue produces unreliable summary estimates. It suggests that future reports focus on precise questions about the treatment effect of interest and implement appropriate statistical methods to account for missing data, patient withdrawal, and use of rescue medication.
This recommendation from the U.S. Preventive Services Task Force concludes that current evidence is insufficient to assess the balance of benefits and harms of primary care interventions to prevent child maltreatment. The recommendation applies to children who do not have signs or symptoms of maltreatment.
The Affordable Care Act made preliminary efforts to collect and disseminate data on health care price, utilization, and quality in the United States. This commentary proposes that all such data need to be publicly available to achieve a health care system that delivers high value.
This commentary reviews the events leading to the Supreme Court decision regarding Myriad Genetics patents on the BRCA1 and BRCA2 genes. Those developing molecular diagnostics will have to comport with a new rule for U.S. patent jurisprudence: Yes, complementary DNA can be patented—genomic DNA cannot.
This commentary discusses the New York City Department of Health and Mental Hygiene's recommendation for meningococcal vaccination for all men who have sex with men in New York City who have had intimate contact with a man met through an online Web site or digital application or at a bar or party.
Studies report an association between SBP and death in kidney failure and late-stage CKD, and the ideal blood pressure for adults with CKD is unclear. In this issue, Kovesdy and colleagues examine the optimal targets in such patients. The editorialists discuss the study and its findings and conclude that translating them into practice is challenging.
Within seconds of meeting her, I knew she would not be a candidate for experimental therapy. I was about to embark on the heart-wrenching task of discussing goals of care with a woman approaching the end of her life.