Basic View | Expanded View
Showing 1-20 of 38 Articles
Original Research | 
Shivani A. Patel, PhD; Munir Winkel, MSc; Mohammed K. Ali, MBChB; K.M. Venkat Narayan, MD; and Neil K. Mehta, PhD
Includes: Supplemental Content
Background:Impressive decreases in cardiovascular mortality have been achieved through risk factor reduction and clinical intervention, yet cardiovascular disease remains a leading cause of death nationally. Objective:To estimate up-to-date preventable fractions of cardiovascular mortality associated with elimination and reduction of 5 leading risk factors nationally and by state in the United States. Design:Cross-sectional and cohort studies. Setting:Nationally representative and state-representative samples of the U.S. population. Participants:Adults aged 45 to 79 years. Measurements:Self-reported risk factor status in the BRFSS (Behavioral Risk Factor Surveillance System) 2009–2010 was corrected to approximate clinical definitions. The relative hazards of cardiovascular death (International Classification of Diseases, 10th Revision, codes I00 to I99) associated with risk factors were estimated using data from NHANES (National Health and Nutrition Examination Survey) (1988–1994 and 1999–2004, followed through 2006). Results:The preventable fraction of cardiovascular mortality associated with complete elimination of elevated cholesterol levels, diabetes, hypertension, obesity, and smoking was 54.0% for men and 49.6% for women in 2009 to 2010. When the more feasible target of reducing risk factors to the best achieved levels in U.S. states was considered, diabetes (1.7% and 4.1%), hypertension (3.8% and 7.3%), and smoking (5.1% and 4.4%) were independently associated with the largest preventable fractions among men and women, respectively. With both targets, southern states had the largest preventable fractions, and western states had the smallest. Limitation:Self-reported state data; mortality hazards relied on baseline risk factor status. Conclusion:Major modifiable cardiovascular risk factors collectively accounted for half of cardiovascular deaths in U.S. adults aged 45 to 79 years in 2009 to 2010. Fewer than 10% of cardiovascular deaths nationally could be prevented if all states were to achieve risk factor levels observed in the best-performing states. Primary Funding Source:Robert Wood Johnson Foundation.
Topics: cardiovascular death
Original Research | 
Shauna Onofrey, MPH; Jasneet Aneja, MPH; Gillian A. Haney, MPH; Ellen H. Nagami, MPH; Alfred DeMaria Jr, MD; Georg M. Lauer, MD, PhD; Kelsey Hills-Evans, MD; Kerri Barton, MPH; Stephanie Kulaga, BA; Melinda J. Bowen, RN; Noelle Cocoros, DSc, MPH; Barbara H. McGovern, MD; Daniel R. Church, MPH; and Arthur Y. Kim, MD
Includes: Supplemental Content
Background:In 2010, the incidence of hepatitis C virus (HCV) infection in the United States was estimated to be 17 000 cases annually, based on 850 acute HCV cases reported to the Centers for Disease Control and Prevention by local public health authorities. Absence of symptomatic disease and lack of a specific laboratory test for acute infection complicates diagnosis and surveillance. Objective:To validate estimates of the incidence of acute HCV infection by determining the reporting rate of clinical diagnoses of acute infection to the Massachusetts Department of Public Health (MDPH) and Centers for Disease Control and Prevention. Design: Case series and chart review. Setting:Two hospitals and the state correctional health care system in Massachusetts. Patients:183 patients clinically diagnosed with acute HCV infection from 2001 to 2011 and participating in a research study. Measurements:Rate of electronic case reporting of acute HCV infection to the MDPH and rate of subsequent confirmation according to national case definitions. Results:149 of 183 (81.4%) clinical cases of acute HCV infection were reported to the MDPH for surveillance classification. The MDPH investigated 43 of these reports as potential acute cases of HCV infection based on their surveillance requirements; ultimately, only 1 met the national case definition and was counted in nationwide statistics published by the Centers for Disease Control and Prevention. Discordance in clinical and surveillance classification was often related to missing clinical or laboratory data at the MDPH as well as restrictive definitions, including requirements for negative hepatitis A and B laboratory results. Limitation:Findings may not apply to other jurisdictions because of differences in resources for surveillance. Conclusion:Clinical diagnoses of acute HCV infection were grossly underascertained by formal surveillance reporting. Incomplete clinician reporting, problematic case definitions, limitations of diagnostic testing, and imperfect data capture remain major limitations to accurate case ascertainment despite automated electronic laboratory reporting. These findings may have implications for national estimates of the incidence of HCV infection. Primary Funding Source:National Institutes of Health.
Topics: hepatitis c, surveillance, medical, acute hepatitis c
Ideas and Opinions | 
Lauren A. Canary, MPH; R. Monina Klevens, DDS, MPH; and Scott D. Holmberg, MD, MPH
Medicaid programs in most states have put restrictions on the receipt of curative therapy for hepatitis C virus infection, including markers of advanced disease, specialist prescribing, and abstinence from alcohol and illicit drugs.
Topics: medicaid, hepatitis c virus, sofosbuvir
Ideas and Opinions | 
Elinore F. McCance-Katz, MD, PhD; and Ronald O. Valdiserri, MD, MPH
Faced with the high cost of new curative treatments for hepatitis C virus infection, Medicaid providers in 35 states and the District of Columbia have requirements limiting their access for persons who use drugs or alcohol.
Topics: intravenous drug user, hepatitis c virus, hepatitis c
Direct oral anticoagulants, which include apixaban, dabigatran, edoxaban, and rivaroxaban, are making anticoagulation simpler for patients with atrial fibrillation who need protection from strokes. However, clinicians still have an important role to play in patient monitoring to ensure that these drugs are used as safely and effectively as possible. The authors of this guide provide essential information in a new and useful format.
Topics: anticoagulants, atrial fibrillation, anticoagulants, oral, thrombosis, cerebrovascular accident, cardiovascular system, pharmacist, stroke prevention, counseling, follow-up
During the summer of 2015, the U.S. Food and Drug Administration will hold a public meeting to discuss whether its restrictions on what drug manufacturers can claim about their products improperly infringes the freedom of those companies. This commentary outlines why, rather than representing an infringement of companies' inherent Constitutional rights, maintaining our current standards for promotional statements can keep us from sinking back into a state of poorly founded drug claims and understated risks.
Topics: united states food and drug administration, pharmaceutical company, prescription drug
Position Papers | 
Ryan A. Crowley, BSJ; Neil Kirschner, PhD, for the Health and Public Policy Committee of the American College of Physicians*
Behavioral health care includes care for patients around mental health and substance abuse conditions, health behavior change, life stresses and crises, and stress-related physical symptoms. Mental and substance use disorders alone have been estimated to surpass all physical diseases as a major cause of disability worldwide by 2020. The literature recognizes the importance of the health care system effectively addressing behavioral health conditions. Recently, there has been a call for the use of the primary care delivery platform and the related patient-centered medical home model to effectively address these conditions. This position paper focuses on the issue of better integration of behavioral health into the primary care setting. It provides an environmental scan of the current state of conditions included in the concept of behavioral health and examines the arguments for and barriers to increased integration into primary care. It also examines various approaches of integrated care delivery and offers a series of policy recommendations that are based on the reviewed information and evidence to inform the actions of the American College of Physicians and its members regarding advocacy, research, and practice.
Topics: mental health, primary health care, behavioral medicine, substance abuse, behavioral health care, american college of physicians
Medicine and Public Issues | 
Soumitri Barua; Robert Greenwald, JD; Jason Grebely, PhD; Gregory J. Dore, MBBS, PhD; Tracy Swan; and Lynn E. Taylor, MD
The aim of this study was to systematically evaluate state Medicaid policies for the treatment of hepatitis C virus (HCV) infection with sofosbuvir in the United States. Medicaid reimbursement criteria for sofosbuvir were evaluated in all 50 states and the District of Columbia. The authors searched state Medicaid Web sites between 23 June and 7 December 2014 and extracted data in duplicate. Any differences were resolved by consensus. Data extracted were whether sofosbuvir was covered and criteria for coverage based on the following categories:liver disease stage, HIV co-infection, prescriber type, and drug or alcohol use. Of the 42 states with known Medicaid reimbursement criteria for sofosbuvir, 74% limit sofosbuvir access to persons with advanced fibrosis (Meta-Analysis of Histologic Data in Viral Hepatitis [METAVIR] fibrosis stage F3) or cirrhosis (F4). One quarter of states require persons co-infected with HCV and HIV to be receiving antiretroviral therapy or to have suppressed HIV RNA levels. Two thirds of states have restrictions based on prescriber type, and 88% include drug or alcohol use in their sofosbuvir eligibility criteria, with 50% requiring a period of abstinence and 64% requiring urine drug screening. Heterogeneity is present in Medicaid reimbursement criteria for sofosbuvir with respect to liver disease staging, HIV co-infection, prescriber type, and drug or alcohol use across the United States. Restrictions do not seem to conform with recommendations from professional organizations, such as the Infectious Diseases Society of America and the American Association for the Study of Liver Diseases. Current restrictions seem to violate federal Medicaid law, which requires states to cover drugs consistent with their U.S. Food and Drug Administration labels.
Topics: hepatitis c, medicaid, reimbursement mechanisms, sofosbuvir, hepatitis c virus, liver diseases
In this issue, Buyon and colleagues report findings from a large prospective study of pregnancy outcomes in ethnically diverse women with lupus. The editorialist discusses the study and why, despite its limitations, the article contains valuable information for clinicians who have the joy and challenge of participating in the medical management of these women.
Topics: pregnancy, systemic lupus erythematosus
Description:In December 2014, the U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense (DoD) approved a joint clinical practice guideline for the management of dyslipidemia for cardiovascular disease risk reduction in adults. This synopsis summarizes the major recommendations. Methods:On 30 September 2013, the VA/DoD Evidence-Based Practice Work Group convened a joint VA/DoD guideline development effort that included clinical stakeholders and conformed to the Institute of Medicine's tenets for trustworthy clinical practice guidelines. The guideline panel developed key questions, systematically searched and evaluated the literature, developed a simple 1-page algorithm, and rated each of 26 recommendations by using the Grading of Recommendations Assessment, Development, and Evaluation system. Recommendations:This synopsis summarizes key features of the guideline in 5 areas: elimination of treatment targets, additional tests for risk prediction, primary and secondary prevention, and laboratory testing.
Topics: dyslipidemias, statins, cardiovascular disease risk factors, laboratory techniques and procedures, united states department of veterans affairs, clinical practice guideline, cholesterol and lipid disorder guidelines, united states department of defense, cardiovascular diseases, secondary prevention, excretory function
Editorials | 
Grant T. Baldwin, PhD, MPH; and Debra Houry, MD, MPH
In this issue, Lee and colleagues document a reduction in motor vehicle fatalities in states with primary seat belt laws compared with states with secondary laws. The Centers for Disease Control and Prevention has identified reducing motor vehicle injury prevention as a “winnable battle” in public health. The editorialists discuss how expansion of primary seat belt laws and other interventions can increase the number of injuries prevented and lives saved by seat belts.
Topics: seat belts, statutes and laws, motor vehicles, centers for disease control and prevention (u.s.)
Summaries for Patients | 
Topics: accidents, traffic, seat belts, statutes and laws
Summaries for Patients | 
Topics: systemic lupus erythematosus, pregnancy outcome
The Institute of Medicine convened a panel to develop recommendations relevant to the public health aspects of cognitive aging and define actions required to better maintain the cognitive health of older adults. This commentary highlights key aspects for clinicians.
Topics: aging, institute of medicine (u.s.)
Ideas and Opinions | 
Trish M. Perl, MD, MSc; and Connie Savor Price, MD
This commentary focuses on the Middle East respiratory syndrome (MERS), which has been overshadowed by news coverage on Ebola virus disease despite the ongoing MERS outbreak in South Korea as of 15 June 2015. Further, MERS coronavirus is still circulating in the Middle East, so the scientific, clinical, and public health communities must combat these outbreaks thorough orchestrated response efforts.
Topics: middle east respiratory syndrome coronavirus, middle east respiratory syndrome
Original Research | 
Lois K. Lee, MD, MPH; Michael C. Monuteaux, ScD; Lindsey C. Burghardt, MD; Eric W. Fleegler, MD, MPH; Lise E. Nigrovic, MD, MPH; William P. Meehan, MD; Sara A. Schutzman, MD; and Rebekah Mannix, MD, MPH
Background:Motor vehicle crashes (MVCs) remain a leading cause of U.S. injury-related deaths. Primary seat belt laws allow vehicle occupants to be ticketed solely for not wearing seat belts, and secondary laws allow ticketing only for failure to wear seat belts in the setting of other violations. Objective:To determine the association between MVC fatality rates and primary versus secondary seat belt laws. Design:Retrospective time-series analysis. Setting:United States, 2001 to 2010. Participants:MVC fatalities in occupants aged 10 years or older identified in the Fatality Analysis Reporting System. Measurements:Population-based rates of fatal crashes. Results:There were 283 183 MVC fatalities in occupants aged 10 years or older from 2001 to 2010 (overall rate, 13.0 per 100 000 persons). In 2001, the mean fatality rate was 14.6 per 100 000 persons, 16 states had primary seat belt laws, and 33 states had secondary laws. In 2010, the mean fatality rate was 9.7 per 100 000 persons, 30 states had primary seat belt laws, and 19 states had secondary laws. In the multivariate regression model, states with primary seat belt laws had lower MVC fatality rates than states with secondary laws (adjusted incidence rate ratio, 0.83 [95% CI, 0.78 to 0.90]). Limitation:Only fatalities were analyzed from the database, and the degree of law enforcement could not be ascertained. Conclusion:States with primary seat belt laws had lower rates of MVC fatalities than those with secondary laws. Adoption of primary seat belt laws may offer optimal occupant protection. Primary Funding Source:None.
Topics: accidents, traffic, seat belts, statutes and laws
Original Research | 
Jill P. Buyon, MD; Mimi Y. Kim, ScD; Marta M. Guerra, MS; Carl A. Laskin, MD; Michelle Petri, MD, MPH; Michael D. Lockshin, MD; Lisa Sammaritano, MD; D. Ware Branch, MD; T. Flint Porter, MD, MPH; Allen Sawitzke, MD; Joan T. Merrill, MD; Mary D. Stephenson, MD, MSc; Elisabeth Cohn, BA; Lamya Garabet, MD; and Jane E. Salmon, MD
Background:Because systemic lupus erythematosus (SLE) affects women of reproductive age, pregnancy is a major concern. Objective:To identify predictors of adverse pregnancy outcomes (APOs) in patients with inactive or stable active SLE. Design:Prospective cohort. Setting:Multicenter. Patients:385 patients (49% non-Hispanic white; 31% with prior nephritis) with SLE in the PROMISSE study. Exclusion criteria were urinary protein–creatinine ratio greater than 1000 mg/g, creatinine level greater than 1.2 mg/dL, prednisone use greater than 20 mg/d, and multifetal pregnancy. Measurements:APOs included fetal or neonatal death; birth before 36 weeks due to placental insufficiency, hypertension, or preeclampsia; and small-for-gestational-age (SGA) neonate (birthweight below the fifth percentile). Disease activity was assessed with the Systemic Lupus Erythematosus Pregnancy Disease Activity Index and the Physician's Global Assessment (PGA). Results:APOs occurred in 19.0% (95% CI, 15.2% to 23.2%) of pregnancies; fetal death occurred in 4%, neonatal death occurred in 1%, preterm delivery occurred in 9%, and SGA neonate occurred in 10%. Severe flares in the second and third trimesters occurred in 2.5% and 3.0%, respectively. Baseline predictors of APOs included presence of lupus anticoagulant (LAC) (odds ratio [OR], 8.32 [CI, 3.59 to 19.26]), antihypertensive use (OR, 7.05 [CI, 3.05 to 16.31]), PGA score greater than 1 (OR, 4.02 [CI, 1.84 to 8.82]), and platelet count (OR, 1.33 [CI, 1.09 to 1.63] per decrease of 50 × 109 cells/L). Non-Hispanic white race was protective (OR, 0.45 [CI, 0.24 to 0.84]). Maternal flares, higher disease activity, and smaller increases in C3 level later in pregnancy also predicted APOs. Among women without baseline risk factors, the APO rate was 7.8%. For those who either were LAC-positive or were LAC-negative but nonwhite or Hispanic and using antihypertensives, the APO rate was 58.0% and fetal or neonatal mortality was 22.0%. Limitation:Patients with high disease activity were excluded. Conclusion:In pregnant patients with inactive or stable mild or moderate SLE, severe flares are infrequent, and absent specific risk factors, outcomes are favorable. Primary Funding Source:National Institutes of Health.
Topics: systemic lupus erythematosus, pregnancy outcome, pregnancy, lupus erythematosus
Original Research | 
Philip J. Molloy, MD; Sam R. Telford III, ScD; Hanumara Ram Chowdri, MD; Timothy J. Lepore, MD; Joseph L. Gugliotta, MD; Karen E. Weeks, BS; Mary Ellen Hewins, BS; Heidi K. Goethert, ScD; and Victor P. Berardi
Background:The first recognized cases of Borrelia miyamotoi disease (BMD) in North America were reported in the northeastern United States in 2013. Objective:To further describe the clinical spectrum and laboratory findings for BMD. Design: Case series. Setting:Patients presenting to primary care offices, emergency departments, or urgent care clinics in 2013 and 2014. Participants:Acutely febrile patients from the northeastern United States in whom the treating health care providers suspected and ordered testing for tick-transmitted infections. Measurements:Whole blood polymerase chain reaction (PCR) testing was performed for the presence of specific DNA sequences of common tickborne infections (including BMD). Serologic testing for B. miyamotoi was performed using a recombinant glycerophosphodiester phosphodiesterase (rGlpQ) protein. Clinical records were analyzed to identify the major features of acute disease. Results:Among 11 515 patients tested, 97 BMD cases were identified by PCR. Most of the 51 case patients on whom clinical histories were reviewed presented with high fever, chills, marked headache, and myalgia or arthralgia. Twenty-four percent were hospitalized. Elevated liver enzyme levels, neutropenia, and thrombocytopenia were common. At presentation, 16% of patients with BMD were seropositive for IgG and/or IgM antibody to B. miyamotoi rGlpQ. Most (78%) had seropositive convalescent specimens. Symptoms resolved after treatment with doxycycline, and no chronic sequelae or symptoms were observed. Limitation:Findings were based on specimens submitted for testing to a reference laboratory, and medical records of only 51 of the 97 case patients with BMD were reviewed. Conclusion:Patients with BMD presented with nonspecific symptoms, including fever, headache, rigors, myalgia, and arthralgia. Laboratory confirmation of BMD was possible by PCR on blood from acutely symptomatic patients who were seronegative at presentation. Borrelia miyamotoi may be an emerging tickborne infection in the northeastern United States. Primary Funding Source:IMUGEN.
Topics: polymerase chain reaction, new england, serologic tests, borrelia miyamotoi, dna, immunoglobulin g, fever, serum, laboratory test finding, phosphoric diester hydrolase
Original Research | 
Jeffrey M. Levsky, MD, PhD; Daniel M. Spevack, MD, MS; Mark I. Travin, MD; Mark A. Menegus, MD; Paul W. Huang, MD; Elana T. Clark, MD; Choo-won Kim, MD; Esther Hirschhorn, BS; Katherine D. Freeman, DrPH; Jonathan N. Tobin, PhD; and Linda B. Haramati, MD, MS
Background:Coronary computed tomography angiography (CCTA) plays an expanding role in the management of symptomatic patients suspected of having coronary artery disease. Prospective intermediate-term outcomes are lacking. Objective:To compare CCTA with conventional noninvasive testing. Design:Randomized, controlled comparative effectiveness trial. Setting:Telemetry-monitored wards of an inner-city medical center. Patients:400 patients with acute chest pain (mean age, 57 years); 63% women; 54% Hispanic, and 37% African-American; low socioeconomic status. Intervention:CCTA or radionuclide stress myocardial perfusion imaging (MPI). Measurements:The primary outcome was cardiac catheterization not leading to revascularization within 1 year. Secondary outcomes included length of stay, resource utilization, and patient experience. Safety outcomes included death, major cardiovascular events, and radiation exposure. Results:Thirty (15%) patients who had CCTA and 32 (16%) who had MPI underwent cardiac catheterization within 1 year. Fifteen (7.5%) and 20 (10%) of these patients, respectively, did not undergo revascularization (difference, −2.5 percentage points [95% CI, −8.6 to 3.5 percentage points]; hazard ratio, 0.77 [CI, 0.40 to 1.49]; P = 0.44). Median length of stay was 28.9 hours for the CCTA group and 30.4 hours for the MPI group (P = 0.057). Median follow-up duration was 40.4 months. For the CCTA and MPI groups, the incidence of death (0.5% versus 3%; P = 0.12), nonfatal cardiovascular events (4.5% versus 4.5%), rehospitalization (43% versus 49%), emergency department visit (63% versus 58%), and outpatient cardiology visit (23% versus 21%) did not differ. Long-term, all-cause radiation exposure was lower for the CCTA group (24 vs 29 mSv; P < 0.001). More patients in the CCTA group graded their experience favorably (P = 0.001) and would undergo the examination again (P = 0.003). Limitation:This was a single-site study, and the primary outcome depended on clinical management decisions. Conclusion:The CCTA and MPI groups did not significantly differ in outcomes or resource utilization over 40 months. Compared with MPI, CCTA was associated with less radiation exposure and with a more positive patient experience. Primary Funding Source:American Heart Association.
Topics: chest pain, telemetry, ct angiography of coronary arteries, diagnostic imaging, follow-up, stress, radionuclide myocardial perfusion study
Reviews | 
James M. Trauer, MBBS; Mary Y. Qian, MBBS; Joseph S. Doyle, PhD; Shantha M. W. Rajaratnam, PhD; and David Cunnington, MBBS
Includes: Supplemental Content
Background:Because psychological approaches are likely to produce sustained benefits without the risk for tolerance or adverse effects associated with pharmacologic approaches, cognitive behavioral therapy for insomnia (CBT-i) is now commonly recommended as first-line treatment for chronic insomnia. Purpose:To determine the efficacy of CBT-i on diary measures of overnight sleep in adults with chronic insomnia. Data Sources:Searches of MEDLINE, EMBASE, PsycINFO, CINAHL, the Cochrane Library, and PubMed Clinical Queries from inception to 31 March 2015, supplemented with manual screening. Study Selection: Randomized, controlled trials assessing the efficacy of face-to-face, multimodal CBT-i compared with inactive comparators on overnight sleep in adults with chronic insomnia, with studies of insomnia comorbid with medical, sleep, or psychiatric disorders excluded. Data Extraction:Study characteristics, quality, and data were assessed independently by 2 reviewers. Main outcome measures were sleep onset latency (SOL), wake after sleep onset (WASO), total sleep time (TST), and sleep efficiency (SE%). Data Synthesis:Among 292 citations and 91 full-text articles reviewed, 20 studies (1162 participants [64% female; mean age, 56 years]) were included. Approaches to CBT-i incorporated at least 3 of the following: cognitive therapy, stimulus control, sleep restriction, sleep hygiene, and relaxation. At the posttreatment time point, SOL improved by 19.03 (95% CI, 14.12 to 23.93) minutes, WASO improved by 26.00 (CI, 15.48 to 36.52) minutes, TST improved by 7.61 (CI, −0.51 to 15.74) minutes, and SE% improved by 9.91% (CI, 8.09% to 11.73%), and changes seemed to be sustained at later time points. No adverse outcomes were reported. Limitation:Our narrow inclusion criteria limited applicability to patients with comorbid insomnia and other sleep problems, and the accuracy of estimates at later time points was less clear. Conclusion:CBT-i is an effective treatment for adults with chronic insomnia, with clinically meaningful effect sizes. Primary Funding Source:None. (PROSPERO: CRD42012002863)
Topics: insomnia, chronic, cognitive-behavioral therapy, sleep, insomnia
Forgot your password?
Enter your username and email address. We'll send you a reminder to the email address on record.