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Ideas and Opinions | 
Katie Watson, JD; and Belinda Fu, MD
Effective communication in clinical care requires more than just understanding words. In this essay, the authors describe the potential of “medical improv” to help teach us to listen and communicate better.
Topics: professionalism
Original Research | 
Marian E. Betz, MD, MPH; Deborah Azrael, PhD; Catherine Barber, MPA; and Matthew Miller, MD, ScD
Includes: Supplemental Content
Background:Health care providers have been encouraged to discuss firearms with patients; whether patients view these discussions as appropriate is unclear. Objective:To estimate, in a national sample, the perceived appropriateness of provider discussions about firearms. Design:Probability-based online survey conducted in April 2015. Analyses used survey weights to generate nationally representative estimates. Setting:U.S. adults. Participants:3914 English-speaking adults (55% participation rate). Measurements:Participants were asked, “In general, would you think it is never, sometimes, usually, or always appropriate for physicians and other health professionals to talk to their patients about firearms?” Results:A majority (66% [95% CI, 63% to 69%]) of participants said that it is at least sometimes appropriate for providers to talk to patients about firearms. Specifically, 23% (CI, 20% to 25%) said that provider discussions about firearms were always appropriate, 14% (CI, 11% to 16%) said that they were usually appropriate, and 30% (CI, 27% to 33%) thought they were sometimes appropriate; 34% (CI, 31% to 37%) felt that such discussions were never appropriate. Views varied by firearm ownership: 54% (CI, 52% to 57%) of gun owners said that provider discussions are at least sometimes appropriate, compared with 67% (CI, 62% to 71%) of nonowners living with an owner and 70% (CI, 66% to 74%) of nonowners not living with an owner. Firearm owners who were more likely to think that firearm discussions are at least sometimes appropriate included those with children at home (62% [CI, 57% to 67%]), those who thought that having a gun at home increases suicide risk (75% [CI, 67% to 83%), and those who thought that provider discussions of seat belts are at least sometimes appropriate (73% [CI, 70% to 75%]). Limitations:The provider discussion question did not specify clinical context. Conclusion:Two thirds of non–firearm owners and over one half of firearm owners in the United States believe that health care provider discussions about firearms are at least sometimes appropriate. The observed heterogeneity underscores the need to better understand assumptions that may underlie these views, particularly among firearm owners. Primary Funding Source:Fund for a Safer Future and Joyce Foundation.
Topics: firearms, public opinion, veterans, health personnel
Original Research | 
Martial L. Ndeffo-Mbah, PhD; Alyssa S. Parpia, MPH; and Alison P. Galvani, PhD
Includes: Supplemental Content
Background:Because of the risk for Zika virus infection in the Americas and the links between infection and microcephaly, other serious neurologic conditions, and fetal death, health ministries across the region have advised women to delay pregnancy. However, the effectiveness of this policy in reducing prenatal Zika virus infection has yet to be quantified. Objective:To evaluate the effectiveness of pregnancy-delay policies on the incidence and prevalence of prenatal Zika virus infection. Design:Vector-borne Zika virus transmission model fitted to epidemiologic data from 2015 to 2016 on Zika virus infection in Colombia. Setting:Colombia, August 2015 to July 2017. Patients:Population of Colombia, stratified by sex, age, and pregnancy status. Intervention:Recommendations to delay pregnancy by 3, 6, 9, 12, or 24 months, at different levels of adherence. Measurements:Weekly and cumulative incidence of prenatal infections and microcephaly cases. Results:With 50% adherence to recommendations to delay pregnancy by 9 to 24 months, the cumulative incidence of prenatal Zika virus infections is likely to decrease by 17% to 44%, whereas recommendations to delay pregnancy by 6 or fewer months are likely to increase prenatal infections by 2% to 7%. This paradoxical exacerbation of prenatal Zika virus exposure is due to an elevated risk for pregnancies to shift toward the peak of the outbreak. Limitation:Sexual transmission was not explicitly accounted for in the model because of limited data but was implicitly subsumed within the overall transmission rate, which was calibrated to observed incidence. Conclusion:Pregnancy delays can have a substantial effect on reducing cases of microcephaly but risks exacerbating the Zika virus outbreak if the duration is not sufficient. Duration of the delay, population adherence, and the timing of initiation of the intervention must be carefully considered. Primary Funding Source:National Institutes of Health.
Topics: pregnancy, americas, prenatal care, zika virus disease, zika virus, microcephaly, colombia
Reviews | 
Meng-Yang Di, MD, PhD; Hao Liu, MD; Zu-Yao Yang, PhD; Peter A.L. Bonis, MD; Jin-Ling Tang, MD, PhD; and Joseph Lau, MD
Includes: Supplemental Content
Background:Acute pancreatitis (AP) varies in severity, prompting development of systems aimed at predicting prognosis to help guide therapy. Although several prediction approaches are available, their test characteristics and clinical utility are not completely understood. Purpose:To evaluate the test characteristics (prognostic accuracy, incremental predictive value) and clinical utility (effect on patient outcomes) of severity scores for predicting mortality in AP. Data Sources:Ovid MEDLINE and EMBASE (inception to 3 May 2016). Study Selection:Longitudinal studies, in any language, that evaluated the prognostic value of at least 1 clinical severity score in AP. Data Extraction:Dual data extraction and quality assessment. Data Synthesis:Of 4039 citations screened, 94 unique studies evaluating 18 scores in 53 547 patients met the inclusion criteria. All studies provided data on prognostic accuracy, whereas 6 provided data on incremental predictive values. Most scores demonstrated low prognostic accuracy. The Acute Physiology and Chronic Health Evaluation (APACHE) II score and the Ranson criteria were studied most extensively. The median sensitivity and specificity of APACHE II at a threshold of 7 were 100% (range, 68% to 100%) and 63% (range, 21% to 96%), respectively, and those of the Ranson criteria at a threshold of 2 were 90% (range, 0% to 100%) and 67% (range, 14% to 97%), respectively. Estimates of sensitivity were based on relatively few patients. Evidence was limited regarding the incremental predictive value of the scoring systems or their effect on patient outcomes. Limitation:Substantial clinical heterogeneity and inadequate methodological and reporting quality precluded a meta-analysis. Conclusion:The test characteristics and clinical utility of AP severity scores remain uncertain. Additional studies with improved methodological rigor are needed, and the development of new scoring systems may be justified. Primary Funding Source:Global Scholarship Programme for Research Excellence for 2014 to 2015, The Chinese University of Hong Kong.
Topics: mortality, prognosis, pancreatitis, acute, ranson's criteria score, patient-focused outcomes, apache ii score
Editorials | 
Chris E. Forsmark, MD; and Dhiraj Yadav, MD, MPH
In this issue, Lau and colleagues report a systematic review revealing that prognostic scoring systems for acute pancreatitis are of limited accuracy and value in predicting mortality. The editorialists discuss how simpler measures, such as hematocrit or blood urea nitrogen level, are as predictive as more complex scoring systems. They call for future research to determine better methods for identifying high-risk patients soon after or before they develop pancreatic injury, as well as therapies to mitigate disease severity.
Topics: pancreatitis, acute
Ideas and Opinions | 
Joseph A. Lewnard, MPhil; Gregg Gonsalves, MPhil; and Albert I. Ko, MD
Concerns have been raised over possible expansion of the Zika virus epidemic by infected travelers returning from the Brazil Olympic games. A modeling study was performed to assess this risk.
Original Research | 
Brian L. Sprague, PhD; Emily F. Conant, MD; Tracy Onega, PhD; Michael P. Garcia, MS; Elisabeth F. Beaber, PhD; Sally D. Herschorn, MD; Constance D. Lehman, MD, PhD; Anna N.A. Tosteson, ScD; Ronilda Lacson, MD, PhD; Mitchell D. Schnall, MD, PhD; Despina Kontos, PhD; Jennifer S. Haas, MD, MSc; Donald L. Weaver, MD; William E. Barlow, PhD, on behalf of the PROSPR Consortium
Background:About half of U.S. states currently have legislation requiring radiology facilities to disclose mammographic breast density information to women, often with language recommending discussion of supplemental screening options for women with dense breasts. Objective:To examine variation in breast density assessment across radiologists in clinical practice. Design:Cross-sectional and longitudinal analyses of prospectively collected observational data. Setting:30 radiology facilities within the 3 breast cancer screening research centers of the Population-based Research Optimizing Screening through Personalized Regimens (PROSPR) consortium. Participants:Radiologists who interpreted at least 500 screening mammograms during 2011 to 2013 (n = 83). Data on 216 783 screening mammograms from 145 123 women aged 40 to 89 years were included. Measurements:Mammographic breast density, as clinically recorded using the 4 Breast Imaging Reporting and Data System categories (heterogeneously dense and extremely dense categories were considered “dense” for analyses), and patient age, race, and body mass index (BMI). Results:Overall, 36.9% of mammograms were rated as showing dense breasts. Across radiologists, this percentage ranged from 6.3% to 84.5% (median, 38.7% [interquartile range, 28.9% to 50.9%]), with multivariable adjustment for patient characteristics having little effect (interquartile range, 29.9% to 50.8%). Examination of patient subgroups revealed that variation in density assessment across radiologists was pervasive in all but the most extreme patient age and BMI combinations. Among women with consecutive mammograms interpreted by different radiologists, 17.2% (5909 of 34 271) had discordant assessments of dense versus nondense status. Limitation:Quantitative measures of mammographic breast density were not available for comparison. Conclusion:There is wide variation in density assessment across radiologists that should be carefully considered by providers and policymakers when considering supplemental screening strategies. The likelihood of a woman being told she has dense breasts varies substantially according to which radiologist interprets her mammogram. Primary Funding Source:National Institutes of Health.
Topics: mammography, breast, breast density, radiologist
Original Research | 
William D. Leslie, MD, MSc; Sumit R. Majumdar, MD, MPH; Suzanne N. Morin, MD, MSc; and Lisa M. Lix, PhD
Background:Whether change in bone mineral density (BMD) is an accurate indicator of antifracture effect in clinical practice is unknown. Objective:To evaluate repeated BMD testing as an indicator of treatment-related fracture risk reduction. Design:Registry-based cohort study. Setting:Manitoba, Canada. Patients:6629 women aged 40 years or older initiating osteoporosis treatment with 2 consecutive dual-energy x-ray absorptiometry scans (mean interval, 4.5 years). Measurements:Change in BMD between the first and second dual-energy x-ray absorptiometry scans categorized as stable, detectable decrease, or detectable increase. Incident fractures were ascertained from health services data. Results:During a mean of 9.2 years, 910 (13.7%) women developed incident fractures, including 198 with hip fractures. After adjustment for baseline fracture probability, women with a detectable decrease in total hip BMD compared with stable BMD had an absolute increase of 2.9% (95% CI, 1.5% to 4.4%) and 5.5% (CI, 2.8% to 8.1%) in the 5- and 10-year cumulative incidence of any fracture, respectively. In contrast, risk for any fracture in women with a detectable increase in total hip BMD was 1.3% (CI, 0.4% to 2.2%) and 2.6% (CI, 0.7% to 4.5%) lower after 5 and 10 years, respectively. Consistent results were seen for change in femoral neck and lumbar spine BMD and across a range of subgroup analyses. Limitation:Lack of standardization in the BMD testing interval. Conclusion:Treatment-related increases in total hip BMD are associated with reduced fracture risk compared with stable BMD, whereas decreases in BMD are associated with greater risk for fractures. Monitoring BMD in clinical practice may help to identify women with a suboptimal response to osteoporosis treatment. Primary Funding Source:None.
Topics: osteoporosis, bone mineral density, fracture, hip region, hip joint, osteoporotic fracture risk, neck of femur
Reviews | 
Hanna E. Bloomfield, MD, MPH; Eva Koeller, BA; Nancy Greer, PhD; Roderick MacDonald, MS; Robert Kane, MD; and Timothy J. Wilt, MD, MPH
Includes: Supplemental Content
Background:Mediterranean diets may be healthier than typical Western diets. Purpose:To summarize the literature comparing a Mediterranean diet with unrestricted fat intake with other diets regarding their effects on health outcomes in adults. Data Sources:Ovid MEDLINE, CINAHL, and the Cochrane Library from 1990 through April 2016. Study Selection:Controlled trials of 100 or more persons followed for at least 1 year for mortality, cardiovascular, hypertension, diabetes, and adherence outcomes, as well as cohort studies for cancer outcomes. Data Extraction:Data extracted by 1 investigator was verified by another. Two reviewers assessed risk of bias and strength of evidence. Data Synthesis:Two primary prevention trials found no difference in all-cause mortality between diet groups. One large primary prevention trial found that a Mediterranean diet resulted in a lower incidence of major cardiovascular events (hazard ratio [HR], 0.71 [95% CI, 0.56 to 0.90]), breast cancer (HR, 0.43 [CI, 0.21 to 0.88]), and diabetes (HR, 0.70 [CI, 0.54 to 0.92]). Pooled analyses of primary prevention cohort studies showed that compared with the lowest quantile, the highest quantile of adherence to a Mediterranean diet was associated with a reduction in total cancer mortality (risk ratio [RR], 0.86 [CI, 0.82 to 0.91]; 13 studies) and in the incidence of total (RR, 0.96 [CI, 0.95 to 0.97]; 3 studies) and colorectal (RR, 0.91 [CI, 0.84 to 0.98; 9 studies]) cancer. Of 3 secondary prevention studies reporting cardiovascular outcomes, 1 found a lower risk for recurrent myocardial infarction and cardiovascular death with the Mediterranean diet. There was inconsistent, minimal, or no evidence pertaining to any other outcome, including adherence, hypertension, cognitive function, kidney disease, rheumatoid arthritis, and quality of life. Limitations:Few trials; medium risk-of-bias ratings for many studies; low or insufficient strength of evidence for outcomes; heterogeneous diet definitions and components. Conclusion:Limited evidence suggests that a Mediterranean diet with no restriction on fat intake may reduce the incidence of cardiovascular events, breast cancer, and type 2 diabetes mellitus but may not affect all-cause mortality. Primary Funding Source:Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, Quality Enhancement Research Initiative. (PROSPERO: CRD42015020262)
Topics: mediterranean diet, cancer, diet, diabetes mellitus, type 2, rheumatoid arthritis
Topics: mammography, breast density
Ideas and Opinions | 
Cheryl Bettigole, MD, MPH; and Thomas A. Farley, MD, MPH
On 16 June 2016, thirteen of Philadelphia's 17 City Council members voted “yes” on the city's sweetened drinks tax, making it the first large city to pass such a measure. This commentary discusses how the measure has the potential to change both an important behavioral determinant of health and the social determinants of health.
Topics: social determinants of health, alcoholic beverages
Original Research | 
Mohammed K. Ali, MBChB, MSc, MBA; Kavita Singh, MSc; Dimple Kondal, PhD; Raji Devarajan, MSc; Shivani A. Patel, MPH, PhD; Roopa Shivashankar, MD; Vamadevan S. Ajay, MPH, PhD; A.G. Unnikrishnan, MD, DM; V. Usha Menon, PhD; Premlata K. Varthakavi, MD, DNB; Vijay Viswanathan, MD, PhD; Mala Dharmalingam, MD, DM; Ganapati Bantwal, MD, DM; Rakesh Kumar Sahay, MD, DM; Muhammad Qamar Masood, MBBS; Rajesh Khadgawat, MD, DM; Ankush Desai, MD, DM; Bipin Sethi, MD, DM; Dorairaj Prabhakaran, MD, DM; K.M. Venkat Narayan, MD; Nikhil Tandon, MD, PhD, on behalf of the CARRS Trial Group
Background:Achievement of diabetes care goals is suboptimal globally. Diabetes-focused quality improvement (QI) is effective but remains untested in South Asia. Objective:To compare the effect of a multicomponent QI strategy versus usual care on cardiometabolic profiles in patients with poorly controlled diabetes. Design:Parallel, open-label, pragmatic randomized, controlled trial. (ClinicalTrials.gov: NCT01212328) Setting:Diabetes clinics in India and Pakistan. Patients:1146 patients (575 in the intervention group and 571 in the usual care group) with type 2 diabetes and poor cardiometabolic profiles (glycated hemoglobin [HbA1c] level ≥8% plus systolic blood pressure [BP] ≥140 mm Hg and/or low-density lipoprotein cholesterol [LDLc] level ≥130 mg/dL). Intervention:Multicomponent QI strategy comprising nonphysician care coordinators and decision-support electronic health records. Measurements:Proportions achieving HbA1c level less than 7% plus BP less than 130/80 mm Hg and/or LDLc level less than 100 mg/dL (primary outcome); mean risk factor reductions, health-related quality of life (HRQL), and treatment satisfaction (secondary outcomes). Results:Baseline characteristics were similar between groups. The median diabetes duration was 7.0 years; 6.8% and 39.4% of participants had preexisting cardiovascular and microvascular disease, respectively; the mean HbA1c level was 9.9%; the mean BP was 143.3/81.7 mm Hg; and the mean LDLc level was 122.4 mg/dL. Over a median of 28 months, a greater percentage of intervention participants achieved the primary outcome (18.2% vs. 8.1%; relative risk, 2.24 [95% CI, 1.71 to 2.92]). Compared with usual care, intervention participants achieved larger reductions in HbA1c level (−0.50% [CI, −0.69% to −0.32%]), systolic BP (−4.04 mm Hg [CI, −5.85 to −2.22 mm Hg]), diastolic BP (−2.03 mm Hg [CI, −3.00 to −1.05 mm Hg]), and LDLc level (−7.86 mg/dL [CI, −10.90 to −4.81 mg/dL]) and reported higher HRQL and treatment satisfaction. Limitation:Findings were confined to urban specialist diabetes clinics. Conclusion:Multicomponent QI improves achievement of diabetes care goals, even in resource-challenged clinics. Primary Funding Source:National Heart, Lung, and Blood Institute and UnitedHealth Group.
Original Research | 
Rana S. Hinman, BPhysio(Hons), PhD; Tim V. Wrigley, BSc(Hons), MSc; Ben R. Metcalf, BSc(Hons); Penny K. Campbell, BAppSci(FoodSci&Nutr); Kade L. Paterson, BAppSci(Hons), BPod, PhD; David J. Hunter, MBBS, PhD; Jessica Kasza, BSc(Hons), PhD; Andrew Forbes, BSc(Hons), MS, PhD; and Kim L. Bennell, BAppSci(Physio), PhD
Background:Appropriate footwear is recommended for self-management of knee osteoarthritis. Shoes that reduce harmful knee loads are available, but symptomatic effects are uncertain. Objective:To evaluate the efficacy of unloading shoes in alleviating knee osteoarthritis symptoms. Design:Participant- and assessor-blinded comparative effectiveness randomized, controlled trial. (Australian New Zealand Clinical Trials Registry: ACTRN12613000851763) Setting:Community. Participants:164 persons with medial knee osteoarthritis. Intervention:Walking shoes with triple-density, variable-stiffness midsoles and mild lateral-wedge insoles designed to unload the medial knee and worn daily (intervention) versus conventional walking shoes (comparator). Measurements:Primary outcomes were pain with walking (assessed on a numerical rating scale [NRS]) and physical function (Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC]) at 6 months. Secondary outcomes were knee pain and stiffness (WOMAC), average pain (NRS), intermittent and constant knee pain (Intermittent and Constant Osteoarthritis Pain questionnaire), quality of life (Assessment of Quality of Life instrument), physical activity (Physical Activity Scale for the Elderly), and global change in pain and function (Likert scales). Results:A total of 160 participants (98%) completed primary outcome measures at 6 months. Changes in pain (mean difference, 0.0 units [95% CI, −0.9 to 0.8 unit]) and function (mean difference, 0.3 unit [CI, −3.2 to 3.7 units]) did not differ between groups at 6 months, with both groups showing clinically relevant improvements in function and the intervention group showing clinically relevant improvements in pain. There were no differences in secondary outcomes. Pain was globally improved in 54% of participants, and function was globally improved in 44% to 48%. Unloading shoes were not associated with increased probability of improvement (odds ratios, 0.99 [CI, 0.53 to 1.86] for pain and 0.85 [CI, 0.45 to 1.61] for function). Limitation:Effects on joint structure were not evaluated. Conclusion:Shoes with modified midsoles to unload the medial knee conferred no additional benefit over conventional walking shoes. Both improved pain and function by clinically relevant amounts. Primary Funding Source:Australian National Health and Medical Research Council.
Summaries for Patients | 
Topics: osteoarthritis, knee, shoes
The authors believe that physicians who hold leadership positions in health care organizations, such as chairs of clinical departments, hospital chief executive officers, and deans of medical schools, should participate in direct patient care. They explain why in this essay.
Ideas and Opinions | 
Regina L. LaRocque, MD, MPH; and Edward T. Ryan, MD
Several mosquito-transmitted viral diseases, including dengue, chikungunya, and now Zika, have recently become substantial health threats in the Americas. Population-level actions, such as mosquito control, are essential to reduce the incidence of infection. This article discusses additional steps that individuals can take to reduce their personal risk for infection.
Editorials | 
Marian T. Hannan, DSc, MPH; Carol A. Oatis, PhD, PT; and Robert R. McLean, DSc, MPH
Guidelines recommend appropriate footwear for patients with knee osteoarthritis, but little evidence exists to inform shoe choice. Hinman and colleagues report a randomized trial that compared shoes designed to unload the knee versus new conventional shoes. The editorialists note that the fact that both groups improved similarly leads one to wonder whether readily available, new, supportive lace-up shoes should be the current evidence-based recommendation for appropriate footwear while we await future studies of knee biomechanics that might identify more effective interventions.
Original Research | 
Louise B. Oestergaard, MD; Mia N. Christiansen, MD; Michelle D. Schmiegelow, MD, PhD; Robert L. Skov, MD; Paal S. Andersen, PhD; Andreas Petersen, PhD; Kristian Aasbjerg, MD; Thomas A. Gerds, PhD; Per K. Andersen, PhD, DMSci; and Christian Torp-Pedersen, MD, DMSci
Includes: Supplemental Content
Background:A genetic predisposition to Staphylococcus aureus bacteremia has been demonstrated in animals, suggesting that genetic differences might influence susceptibility to S aureus in humans. Objective:To determine whether a history of S aureus bacteremia in first-degree relatives increases the rate of the disease, and whether this rate is affected by the type of family relationship (that is, parent or sibling) or by how the relative acquired the infection. Design:Register-based nationwide cohort study (1992 to 2011). Setting:Denmark. Participants:First-degree relatives (children or siblings) of patients previously hospitalized with S aureus bacteremia. Measurements:Poisson regression models were used to calculate standardized incidence ratios (SIRs) of S aureus bacteremia, with the incidence rate in the population as a reference. Results:34 774 individuals (the exposed cohort) with a first-degree relative (index case patient) previously hospitalized with S aureus bacteremia were followed up for a median of 7.8 years (interquartile range, 3.6 to 13.0). A higher rate of S aureus bacteremia was observed among these first-degree relatives (SIR, 2.49 [95% CI, 1.95 to 3.19]) than in the background population. The estimate was significantly higher if the index case patient was a sibling (SIR, 5.01 [CI, 3.30 to 7.62]) than a parent (SIR, 1.96 [CI, 1.45 to 2.67]; interaction P < 0.0001). No interaction was observed regarding the sex of the first-degree relative (interaction P for parents = 0.85; interaction P for siblings = 0.92). Stratifying by disease acquisition revealed the highest rates in individuals exposed to index case patients with non–hospital-acquired infection. Few were infected with genetically identical bacteremia isolates. Limitation:The rarity of the outcome limited the number of variables in the multiple regression analysis, and whether nonsignificant interactions were true or caused by insufficient statistical power remains uncertain. Conclusion:A significant familial clustering of S aureus bacteremia was found, with the greatest relative rate of disease observed in individuals exposed to siblings with a history of the disease. Primary Funding Source:The Danish Heart Foundation and the Christian Larsen and Judge Ellen Larsen Foundation.
Topics: staphylococcus aureus, bacteremia, first degree relative
Research and Reporting Methods | 
Douglas K. Owens, MD, MS; Evelyn P. Whitlock, MD, MPH; Jillian Henderson, PhD, MPH; Michael P. Pignone, MD, MPH; Alex H. Krist, MD, MPH; Kirsten Bibbins-Domingo, PhD, MD, MAS; Susan J. Curry, PhD; Karina W. Davidson, PhD, MASc; Mark Ebell, MD, MS; Matthew W. Gillman, MD, SM; David C. Grossman, MD, MPH; Alex R. Kemper, MD, MPH, MS; Ann E. Kurth, PhD, RN, MSN, MPH; Michael Maciosek, PhD; Albert L. Siu, MD, MSPH; Michael L. LeFevre, MD, MPH, on behalf of the U.S. Preventive Services Task Force
The U.S. Preventive Services Task Force (USPSTF) develops evidence-based recommendations about preventive care based on comprehensive systematic reviews of the best available evidence. Decision models provide a complementary, quantitative approach to support the USPSTF as it deliberates about the evidence and develops recommendations for clinical and policy use. This article describes the rationale for using modeling, an approach to selecting topics for modeling, and how modeling may inform recommendations about clinical preventive services. Decision modeling is useful when clinical questions remain about how to target an empirically established clinical preventive service at the individual or program level or when complex determinations of magnitude of net benefit, overall or among important subpopulations, are required. Before deciding whether to use decision modeling, the USPSTF assesses whether the benefits and harms of the preventive service have been established empirically, assesses whether there are key issues about applicability or implementation that modeling could address, and then defines the decision problem and key questions to address through modeling. Decision analyses conducted for the USPSTF are expected to follow best practices for modeling. For chosen topics, the USPSTF assesses the strengths and limitations of the systematically reviewed evidence and the modeling analyses and integrates the results of each to make preventive service recommendations.
Topics: evidence-based practice, rationale, lung cancer
Original Research | 
Gustaf Edgren, MD, PhD; Henrik Hjalgrim, MD, PhD, DrMedSci; Klaus Rostgaard, MSc; Paul Lambert, PhD; Agneta Wikman, MD, PhD; Rut Norda, MD, PhD; Kjell-Einar Titlestad, MD, PhD; Christian Erikstrup, MD, PhD; Henrik Ullum, MD, PhD; Mads Melbye, MD, DrMedSci; Michael P. Busch, MD, PhD; and Olof Nyrén, MD, PhD
Background:The aggregation of misfolded proteins in the brain occurs in several neurodegenerative disorders. Aberrant protein aggregation is inducible in rodents and primates by intracerebral inoculation. Possible transfusion transmission of neurodegenerative diseases has important public health implications. Objective:To investigate possible transfusion transmission of neurodegenerative disorders. Design:Retrospective cohort study. Setting:Nationwide registers of transfusions in Sweden and Denmark. Participants:1 465 845 patients who received transfusions between 1968 and 2012. Measurements:Multivariable Cox regression models were used to estimate hazard ratios for dementia of any type, Alzheimer disease, and Parkinson disease in patients receiving blood transfusions from donors who were later diagnosed with any of these diseases versus patients who received blood from healthy donors. Whether excess occurrence of neurodegenerative disease occurred among recipients of blood from a subset of donors was also investigated. As a positive control, transmission of chronic hepatitis before and after implementation of hepatitis C virus screening was assessed. Results:Among included patients, 2.9% received a transfusion from a donor diagnosed with one of the studied neurodegenerative diseases. No evidence of transmission of any of these diseases was found, regardless of approach. The hazard ratio for dementia in recipients of blood from donors with dementia versus recipients of blood from healthy donors was 1.04 (95% CI, 0.99 to 1.09). Corresponding estimates for Alzheimer disease and Parkinson disease were 0.99 (CI, 0.85 to 1.15) and 0.94 (CI, 0.78 to 1.14), respectively. Hepatitis transmission was detected before but not after implementation of hepatitis C virus screening. Limitation:Observational study design, underascertainment of the outcome, and possible insufficient statistical power. Conclusion:The data provide no evidence for the transmission of neurodegenerative diseases and suggest that if transmission does occur, it is rare. Primary Funding Source:Swedish Research Council, Swedish Heart-Lung Foundation, Swedish Society for Medical Research, and Danish Council for Independent Research.
Topics: blood transfusion, neurodegenerative disorders, transfusion, donors, parkinson disease, alzheimer's disease, follow-up, dementia
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