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Original Research | 17 May 2013 
Combination Therapy With Telaprevir for Chronic Hepatitis C Virus Genotype 1 Infection in Patients With HIV: A Randomized Trial
Mark S. Sulkowski, MD; Kenneth E. Sherman, MD, PhD; Douglas T. Dieterich, MD; Mohammad Bsharat, PhD; Lisa Mahnke, MD, PhD; Jürgen K. Rockstroh, MD; Shahin Gharakhanian, MD, DPH; Scott McCallister, MD; Joshua Henshaw, PhD; Pierre-Marie Girard, MD, PhD; Bambang Adiwijaya, PhD; Varun Garg, PhD; Raymond A. Rubin, MD; Nathalie Adda, MD; and Vincent Soriano, MD, PhD
Background:Telaprevir (TVR) plus peginterferon-α2a (PEG-IFN-α2a) and ribavirin substantially increases treatment efficacy for genotype 1 chronic hepatitis C virus (HCV) infection versus PEG-IFN-α2a–ribavirin alone. Its safety and efficacy in patients with HCV and HIV-1 are unknown. Objective:To assess the safety and efficacy of TVR plus PEG-IFN-α2a–ribavirin in patients with genotype 1 HCV and HIV-1 and evaluate pharmacokinetics of TVR and antiretrovirals during coadministration. Design:Phase 2a, randomized, double-blind, placebo-controlled study. (ClinicalTrials.gov: NCT00983853) Setting:16 international multicenter sites. Patients:62 patients with HCV genotype 1 and HIV-1 who were HCV treatment–naive and taking 0 or 1 of 2 antiretroviral regimens were randomly assigned to TVR plus PEG-IFN-α2a–ribavirin or placebo plus PEG-IFN-α2a–ribavirin for 12 weeks, plus 36 weeks of PEG-IFN-α2a–ribavirin. Measurements:HCV RNA concentrations. Results:Pruritus, headache, nausea, rash, and dizziness were higher with TVR plus PEG-IFN-α2a–ribavirin during the first 12 weeks. Serious adverse events occurred in 5% (2 in 38) of those receiving TVR plus PEG-IFN-α2a–ribavirin and 0% (0 in 22) of those receiving placebo plus PEG-IFN-α2a–ribavirin; the same number in both groups discontinued treatment due to adverse events. Sustained virologic response occurred in 74% (28 in 38) of patients receiving TVR plus PEG-IFN-α2a–ribavirin and 45% (10 in 22) of patients receiving placebo plus PEG-IFN-α2a–ribavirin. Rapid HCV suppression was seen with TVR plus PEG-IFN-α2a–ribavirin (68% [26 in 38 patients] vs. 0% [0 in 22 patients] undetectable HCV RNA levels by week 4). Two patients had on-treatment HCV breakthrough with TVR-resistant variants. Patients treated with antiretroviral drugs had no HIV breakthroughs; antiretroviral exposure was not substantially modified by TVR. Limitation:Small sample size and appreciable dropout rate. Conclusion:In patients with HCV and HIV-1, more adverse events occurred with TVR versus placebo plus PEG-IFN-α2a–ribavirin; these were similar in nature and severity to those in patients with HCV treated with TVR. With or without concomitant antiretrovirals, sustained virologic response rates were higher in patients treated with TVR versus placebo plus PEG-IFN-α2a–ribavirin. Primary Funding Source:Vertex Pharmaceuticals and Janssen Pharmaceuticals.
Topics: hiv, hepatitis c, chronic, hepatitis c rna, combined modality therapy, genotype, ribavirin, infection, viruses, hepatitis c virus, anti-retroviral agents, telaprevir
Ann Intern Med. Published online 17 May 2013 doi:10.7326/0003-4819-159-2-201307160-00654
Ideas and Opinions | 17 May 2013 
The New Crisis in Confidence in Psychiatric Diagnosis FREE
Allen Frances, MD
The American Psychiatric Association has released the long-awaited fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). This commentary notes that the DSM-5 “introduced several high-prevalence diagnoses at the fuzzy boundary with normality” and recommends that “physicians … use the DSM-5 cautiously, if at all.”
Topics: diagnosis, psychiatric
Ann Intern Med. Published online 17 May 2013 doi:10.7326/0003-4819-159-3-201308060-00655
Summaries for Patients | 14 May 2013 
Screening and Behavioral Counseling to Reduce Alcohol Misuse: U.S. Preventive Services Task Force Recommendation FREE
Topics: alcohol abuse, advisory committees, behavior therapy, prevention
Ann Intern Med. Published online 14 May 2013 doi:10.7326/0003-4819-159-3-201308060-00651
Clinical Guidelines | 14 May 2013 
Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse: U.S. Preventive Services Task Force Recommendation Statement FREE
Virginia A. Moyer, MD, MPH, on behalf of the U.S. Preventive Services Task Force*
Description:Update of the 2004 U.S. Preventive Services Task Force (USPSTF) recommendation statement on screening and behavioral counseling interventions in primary care to reduce alcohol misuse. Methods:The USPSTF reviewed new evidence on the effectiveness of screening for alcohol misuse for improving health outcomes, the accuracy of various screening approaches, the effectiveness of various behavioral counseling interventions for improving intermediate or long-term health outcomes, the harms of screening and behavioral counseling interventions, and influences from the health care system that promote or detract from effective screening and counseling interventions for alcohol misuse. Population:These recommendations apply to adolescents aged 12 to 17 years and adults aged 18 years or older. These recommendations do not apply to persons who are actively seeking evaluation or treatment for alcohol misuse. Recommendation:The USPSTF recommends that clinicians screen adults aged 18 years or older for alcohol misuse and provide persons engaged in risky or hazardous drinking with brief behavioral counseling interventions to reduce alcohol misuse. (Grade B recommendation) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening and behavioral counseling interventions in primary care settings to reduce alcohol misuse in adolescents. (I statement)
Topics: alcohol abuse, advisory committees, behavior therapy, primary health care, united states preventive services task force, prevention
Ann Intern Med. Published online 14 May 2013 doi:10.7326/0003-4819-159-3-201308060-00652
Ideas and Opinions | 14 May 2013 
Influenza A(H7N9): From Anxiety to Preparedness FREE
Andrew T. Pavia, MD
On 31 March 2013, Chinese public health authorities notified the World Health Organization of the isolation of influenza A(H7N9) virus from 3 critically ill adults. This avian influenza virus had never before been detected in humans, and its association with severe disease shocked experts. This commentary asks whether we should be concerned and whether we are fully prepared for a pandemic.
Topics: anxiety, influenza, influenzavirus a, influenza a virus, h7n9 subtype
Ann Intern Med. Published online 14 May 2013 doi:10.7326/0003-4819-159-3-201308060-00653
Editorials | 30 April 2013 
Bringing the End in Sight: Consensus Regarding HIV Screening Strategies FREE
Moupali Das, MD, MPH; and Paul Volberding, MD
The updated U.S. Preventive Services Task Force recommendations converge with those from the Centers for Disease Control and Prevention. The editorialists comment on the Task Force recommendations and see them as informing the roadmap to the elusive end to AIDS.
Topics: vision, hiv screen, consensus
Ann Intern Med. Published online 30 April 2013 doi:10.7326/0003-4819-159-1-201307020-00643
Clinical Guidelines | 30 April 2013 
Screening for HIV: U.S. Preventive Services Task Force Recommendation Statement FREE
Virginia A. Moyer, MD, MPH, on behalf of the U.S. Preventive Services Task Force*
Includes: Supplemental Content
Description:Update of the 2005 U.S. Preventive Services Task Force (USPSTF) recommendation statement on screening for HIV. Methods:The USPSTF reviewed new evidence on the effectiveness of treatments in HIV-infected persons with CD4 counts greater than 0.200 × 109 cells/L; effects of screening, counseling, and antiretroviral therapy (ART) use on risky behaviors and HIV transmission risk; and long-term cardiovascular harms of ART. Population:These recommendations apply to adolescents, adults, and pregnant women. Recommendation:The USPSTF recommends that clinicians screen adolescents and adults aged 15 to 65 years for HIV infection. Younger adolescents and older adults who are at increased risk should also be screened. (Grade A recommendation) The USPSTF recommends that clinicians screen all pregnant women for HIV, including those who present in labor who are untested and whose HIV status is unknown. (Grade A recommendation)
Topics: hiv, advisory committees, cd4 count determination procedure, hiv seropositivity, hiv infection, hiv screen, united states preventive services task force, prevention
Ann Intern Med. Published online 30 April 2013 doi:10.7326/0003-4819-159-1-201307020-00645
Summaries for Patients | 30 April 2013 
Screening for HIV: U.S. Preventive Services Task Force Recommendation Statement FREE
Topics: advisory committees, hiv screen, prevention
Ann Intern Med. Published online 30 April 2013 doi:10.7326/0003-4819-159-1-201307020-00647
Ideas and Opinions | 30 April 2013 
Marathon Day at Massachusetts General FREE
Alasdair Conn, MD
We thought it would be a normal Marathon Monday at Massachusetts General Hospital. The Boston Marathon is always held on the third Monday in April and is a public holiday—Patriots Day. The hospital normally expects to receive about 15 to 20 marathon runners with hyponatremia and dehydration, many more are treated at the medical tents along the route of the marathon. For many this is a day that Bostonians look forward to as the unofficial start of spring.
Topics: dehydration, disasters, explosions, hospitals, operating room, disasters and emergency preparedness
Ann Intern Med. Published online 30 April 2013 doi:10.7326/0003-4819-159-2-201307160-00648
Ideas and Opinions | 30 April 2013 
Boston Medicine, Before and After FREE
Deborah Cotton, MD, MPH, Deputy Editor
The Boston health care war had really stepped up at the end of winter. The hospitals were competing furiously for us to be their patients. Their ads boasted: “Individual Care/Global Impact,” “Human First,” “Exceptional Care Without Exception.” They told us we should choose them because they were big, because they were small, because they alone could transplant faces, because they knew our neighborhoods, because they performed true miracles every day. And then it was a Perfect Spring Day and the Marathon was in full swing. Many of the runners were nurses. Many of the runners were doctors. Many were EMTs and health policy experts and insurance executives and legislators and some were even hospital CEOs. When the finish line exploded, the nurses and doctors and EMTs all ran to help and we could not tell them apart if we tried.
Topics: care of intensive care unit patient, health policy, hospitals, insurance carriers, nurses, money
Ann Intern Med. Published online 30 April 2013 doi:10.7326/0003-4819-159-2-201307160-00650
Original Research | 23 April 2013 
Comparative Effectiveness of Multivessel Coronary Bypass Surgery and Multivessel Percutaneous Coronary Intervention: A Cohort Study
Mark A. Hlatky, MD; Derek B. Boothroyd, PhD; Laurence Baker, PhD; Dhruv S. Kazi, MD, MS; Matthew D. Solomon, MD, PhD; Tara I. Chang, MD, MS; David Shilane, PhD; and Alan S. Go, MD
Background:Randomized trials of coronary artery bypass graft (CABG) surgery and percutaneous coronary intervention (PCI) suggest that patient characteristics modify the effect of treatment on mortality. Objective:To assess whether clinical characteristics modify the comparative effectiveness of CABG versus PCI in an unselected, general patient population. Design:Observational treatment comparison using propensity score matching and Cox proportional hazards models. Setting:United States, 1992 to 2008. Patients:Medicare beneficiaries aged 66 years or older. Intervention:Multivessel CABG or multivessel PCI. Measurements:The CABG–PCI hazard ratio (HR) for all-cause mortality, with prespecified treatment-by-covariate interaction tests, and the absolute difference in life-years of survival in clinical subgroups after CABG or PCI, both over 5 years of follow-up. Results:Among 105 156 propensity score–matched patients, CABG was associated with lower mortality than PCI (HR, 0.92 [95% CI, 0.90 to 0.95]; P < 0.001). Association of CABG with lower mortality was significantly greater (interaction P values < = 0.002 for each interaction) among patients with diabetes (HR, 0.88), a history of tobacco use (HR, 0.82), heart failure (HR, 0.84), and peripheral arterial disease (HR, 0.85). The overall predicted difference in survival between CABG and PCI treatment over 5 years was 0.053 life-year (range, −0.017 to 0.579 life-years). Patients with diabetes, heart failure, peripheral arterial disease, or tobacco use had the largest predicted differences in survival after CABG, whereas those with none of these factors had slightly better survival after PCI. Limitation:Treatments were chosen by patients and physicians rather than randomly assigned. Conclusion:Multivessel CABG is associated with lower long-term mortality than multivessel PCI in the community setting. This association is substantially modified by patient characteristics, with improvement in survival concentrated among patients with diabetes, tobacco use, heart failure, or peripheral arterial disease. Primary Funding Source:National Heart, Lung, and Blood Institute.
Topics: percutaneous coronary intervention, coronary artery bypass surgery, comparative effectiveness research
Ann Intern Med. Published online 23 April 2013 doi:10.7326/0003-4819-158-10-201305210-00639
Summaries for Patients | 23 April 2013 
Comparing the Effectiveness of Coronary Artery Bypass Graft Surgery and Nonsurgical Catheter-Based Interventions for Coronary Artery Disease FREE
Topics: coronary artery bypass surgery, coronary arteriosclerosis, catheter device
Ann Intern Med. Published online 23 April 2013 doi:10.7326/0003-4819-158-10-201305210-00641
Reviews | 23 April 2013 
Screening for and Treatment of Suicide Risk Relevant to Primary Care: A Systematic Review for the U.S. Preventive Services Task Force FREE
Elizabeth O'Connor, PhD; Bradley N. Gaynes, MD, MPH; Brittany U. Burda, MPH; Clara Soh, MPA; and Evelyn P. Whitlock, MD, MPH
Background:In 2009, suicide accounted for 36 897 deaths in the United States. Purpose:To review the accuracy of screening instruments and the efficacy and safety of screening for and treatment of suicide risk in populations and settings relevant to primary care. Data Sources:Citations from MEDLINE, PsycINFO, the Cochrane Central Register of Controlled Trials, and CINAHL (2002 to 17 July 2012); gray literature; and a surveillance search of MEDLINE for additional screening trials (July to December 2012). Study Selection:Fair- or good-quality English-language studies that assessed the accuracy of screening instruments in primary care or similar populations and trials of suicide prevention interventions in primary or mental health care settings. Data Extraction:One investigator abstracted data; a second checked the abstraction. Two investigators rated study quality. Data Synthesis:Evidence was insufficient to determine the benefits of screening in primary care populations; very limited evidence identified no serious harms. Minimal evidence suggested that screening tools can identify some adults at increased risk for suicide in primary care, but accuracy was lower in studies of older adults. Minimal evidence limited to high-risk populations suggested poor performance of screening instruments in adolescents. Trial evidence showed that psychotherapy reduced suicide attempts in high-risk adults but not adolescents. Most trials were insufficiently powered to detect effects on deaths. Limitation:Treatment evidence was derived from high-risk rather than screen-detected populations. Evidence relevant to adolescents, older adults, and racial or ethnic minorities was limited. Conclusion:Primary care–feasible screening tools might help to identify some adults at increased risk for suicide but have limited ability to detect suicide risk in adolescents. Psychotherapy may reduce suicide attempts in some high-risk adults, but effective interventions for high-risk adolescents are not yet proven. Primary Funding Source:Agency for Healthcare Research and Quality.
Topics: advisory committees, primary health care, psychotherapy, suicide attempt, suicide, feeling suicidal, suicidal behavior, suicide precautions, elderly, prevention
Ann Intern Med. Published online 23 April 2013 doi:10.7326/0003-4819-158-10-201305210-00642
Updates | 11 April 2013 
Update in Hematology and Oncology: Evidence Published in 2012
Jennifer R. Eads, MD; Neal J. Meropol, MD; and Jerry L. Spivak, MD
This Update summarizes studies published in 2012 that the authors consider highly relevant to the practice of hematology and oncology.
Topics: aspirin, polycythemia vera, mutation, cancer, chemotherapy regimen, colorectal cancer, medical oncology, phlebotomy, thrombocytopenia, hematology, neoplasms, protein-tyrosine kinase inhibitor, vandetanib, ruxolitinib, ponatinib
Ann Intern Med. Published online 11 April 2013 doi:10.7326/0003-4819-158-10-201305210-00105
Updates | 11 April 2013 
Update in Endocrinology: Evidence Published in 2012
Janet A. Schlechte, MD
This Update summarizes studies published in 2012 that the authors consider highly relevant to the practice of endocrinology. Topics include diabetes mellitus, thyroid disease, and osteoporosis and fractures.
Topics: obesity, osteoporosis, metformin, diabetes mellitus, type 2, cancer, fracture, endocrinology, spinal fractures, vitamin d, women, radioactive iodine, zoledronic acid, insulin, glargine, human, glucose control, bariatric surgery, ablation
Ann Intern Med. Published online 11 April 2013 doi:10.7326/0003-4819-158-11-201306040-00106
Updates | 11 April 2013 
Update in Rheumatology: Evidence Published in 2012
Atul Deodhar, MD
This Update summarizes studies published in 2012 that the authors consider highly relevant to the practice of rheumatology. Topics include treatment of rheumatologic disease, pharmacoepidemiology, diagnostic testing, and new practice guidelines.
Topics: arthritis, gout, anti-inflammatory agents, non-steroidal, rheumatology, infection, guidelines, rituximab
Ann Intern Med. Published online 11 April 2013 doi:10.7326/0003-4819-158-12-201306180-00107
Updates | 11 April 2013 
Update in Women's Health: Evidence Published in 2012
Megan McNamara*, MD, MSc; and Judith M.E. Walsh*, MD, MPH
This Update summarizes studies published in 2012 that the authors consider highly relevant to the practice of women's health. Topics include reproductive health, menopause, prevention and screening, and osteoporosis and bone health.
Topics: osteoporosis, hormone replacement therapy, calcium, contraceptive methods, hip fractures, women's health, women, proton pump inhibitors, endocrine therapy, venous thromboembolism
Ann Intern Med. Published online 11 April 2013 doi:10.7326/0003-4819-159-1-201307020-00104
Updates | 11 April 2013 
Update in Hospital Medicine: Evidence Published in 2012
A. Scott Keller, MD, MS; Tamara E. Buechler, MD, MHA; and James S. Newman, MD
This Update summarizes studies published in 2012 that the authors consider highly relevant to the practice of hospital medicine. Topics include perioperative myocardial infarction, anticoagulation, inpatient care, and transfusion medicine.
Topics: warfarin, hemorrhage, hospitals, patient readmission, mortality, hospital care
Ann Intern Med. Published online 11 April 2013 doi:10.7326/0003-4819-159-2-201307160-00103
Clinical Guidelines | 9 April 2013 
Screening for Prostate Cancer: A Guidance Statement From the Clinical Guidelines Committee of the American College of Physicians FREE
Amir Qaseem, MD, PhD, MHA; Michael J. Barry, MD; Thomas D. Denberg, MD, PhD; Douglas K. Owens, MD, MS; Paul Shekelle, MD, PhD, for the Clinical Guidelines Committee of the American College of Physicians*
Description:Prostate cancer is an important health problem in men. It rarely causes death in men younger than 50 years; most deaths associated with it occur in men older than 75 years. The benefits of screening with the prostate-specific antigen (PSA) test are outweighed by the harms for most men. Prostate cancer never becomes clinically significant in a patient's lifetime in a considerable proportion of men with prostate cancer detected with the PSA test. They will receive no benefit and are subject to substantial harms from the treatment of prostate cancer. The American College of Physicians (ACP) developed this guidance statement for clinicians by assessing current prostate cancer screening guidelines developed by other organizations. ACP believes that it is more valuable to provide clinicians with a rigorous review of available guidelines rather than develop a new guideline on the same topic when several guidelines are available on a topic or when existing guidelines conflict. The purpose of this guidance statement is to critically review available guidelines to help guide internists and other clinicians in making decisions about screening for prostate cancer. The target patient population for this guidance statement is all adult men. Methods:This guidance statement is derived from an appraisal of available guidelines on screening for prostate cancer. Authors searched the National Guideline Clearinghouse to identify prostate cancer screening guidelines in the United States and selected 4 developed by the American College of Preventive Medicine, American Cancer Society, American Urological Association, and U.S. Preventive Services Task Force. The AGREE II (Appraisal of Guidelines, Research and Evaluation in Europe) instrument was used to evaluate the guidelines. Guidance Statement 1:ACP recommends that clinicians inform men between the age of 50 and 69 years about the limited potential benefits and substantial harms of screening for prostate cancer. ACP recommends that clinicians base the decision to screen for prostate cancer using the prostate-specific antigen test on the risk for prostate cancer, a discussion of the benefits and harms of screening, the patient's general health and life expectancy, and patient preferences. ACP recommends that clinicians should not screen for prostate cancer using the prostate-specific antigen test in patients who do not express a clear preference for screening. Guidance Statement 2:ACP recommends that clinicians should not screen for prostate cancer using the prostate-specific antigen test in average-risk men under the age of 50 years, men over the age of 69 years, or men with a life expectancy of less than 10 to 15 years.
Topics: prostate cancer, clinical practice guideline, prostate specific antigen measurement, prostate cancer screening, american college of physicians
Ann Intern Med. Published online 9 April 2013 doi:10.7326/0003-4819-158-10-201305210-00633
Summaries for Patients | 9 April 2013 
Screening for Prostate Cancer: A Guidance Statement From the Clinical Guidelines Committee of the American College of Physicians FREE
Topics: clinical practice guideline, prostate cancer screening, american college of physicians
Ann Intern Med. Published online 9 April 2013 doi:10.7326/0003-4819-158-10-201305210-00634
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Print ISSN: 0003-4819 | Online ISSN: 1539-3704

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