0
Basic View | Expanded View
Showing 1-20 of 29 Articles
Ideas and Opinions | 
Henry M. Wu, MD; Jessica K. Fairley, MD; James Steinberg, MD; and Phyllis Kozarsky, MD
Recommendations for evaluation of patients with possible Ebola virus disease have focused on hospital emergency departments and inpatient units as the loci of care. However, patients may instead present to ambulatory settings. The authors describe a dedicated travel clinic–based program for such evaluation that uses existing phone triage systems, provides assessment by infectious disease experts, and ensures appropriate isolation and infection control.
Ideas and Opinions | 
Mark G. Kortepeter, MD, MPH; Philip W. Smith, MD; Angela Hewlett, MD; and Theodore J. Cieslak, MD
Medical centers in the United States are coming to grips with the need to prepare for care of patients with Ebola virus disease. The authors of this commentary discuss the challenges of treating these patients in a conventional setting and call for a network of strategically located regional referral centers serving designated catchment areas.
Academia and the Profession | 
Kira L. Ryskina, MD; Deborah Korenstein, MD; Arlene Weissman, PhD; Philip Masters, MD; Patrick Alguire, MD; and Cynthia D. Smith, MD
Background:Although high-value care (HVC) that balances benefits of tests or treatments against potential harms and costs has been a recently emphasized competency for internal medicine (IM) residents, few tools to assess residents' knowledge of HVC are available. Objective:To describe the development and initial results of an HVC subscore of the Internal Medicine In-Training Examination (IM-ITE). Design:The HVC concepts were introduced to IM-ITE authors during question development. Three physicians independently reviewed each examination question for selection in the HVC subscore according to 6 HVC principles. The final subscore was determined by consensus. Data from the IM-ITE administered in October 2012 were analyzed at the program level. Setting:U.S. IM residency programs. Participants:362 U.S. IM residency programs with IM-ITE data for at least 10 residents. Measurements:Program-level performance on the HVC subscore was compared with performance on the overall IM-ITE, the Dartmouth Atlas hospital care intensity (HCI) index of the program's primary training hospital, and residents' attitudes about HVC assessed with a voluntary survey. Results:The HVC subscore comprised 38 questions, including 21 (55%) on managing conservatively when appropriate and 14 (37%) on identifying low-value care. Of the 362 U.S. IM programs in the sample, 41% were in a different quartile when ranked based on the HVC subscore compared with overall IM-ITE performance. Rankings by HVC subscore and HCI index were modestly inversely associated, with 30% of programs ranked in the same quartile based on both measures. Limitation:Knowledge of HVC assessed from examination vignettes may not reflect practice of HVC. Conclusion:Although the HVC subscore has face validity and can contribute to evaluation of residents' HVC knowledge, additional tools are needed to accurately measure residents' proficiency in HVC. Primary Funding Source:None.
Topics: internal medicine, internship and residency, medical residencies, hospital care, hospitals, self-report
Ideas and Opinions | 
Andrew Hantel, MD; and Christopher Olusola Olopade, MD, MPH
A World Health Organization advisory panel recently concluded that it is ethical to use experimental medications and vaccines that have not been formally approved or tested in humans to treat persons with Ebola in the current West African epidemic. The authors of this commentary urge the medical community to focus on implementing the current standard of care fairly while maintaining principled experimentation to provide a better future standard.
Topics: ethics, informed consent, ebola virus, disease outbreaks, ebola virus disease, vaccines, epidemic, experimental treatment, compassionate use, ebola vaccines, zmapp
Federal agencies proposing any significant regulatory action are required to evaluate the regulation's costs and benefits. The U.S. Food and Drug Administration (FDA) prepared an economic impact analysis of a proposed rule for graphic warning labels on tobacco products. This commentary discusses the analysis and finds fault with the FDA's decision to include the “lost pleasure” from tobacco use as a cost in economic impact analyses of tobacco regulations.
Topics: cost-benefit analysis, cigarettes, government regulations, tobacco
On 4 November 2014, California residents will vote on Proposition 46, which increases the cap on noneconomic damages in medical liability cases, mandates that physicians check the state's database on prescription drug history before prescribing certain controlled substances, and requires hospitals to perform drug and alcohol testing of physicians. This commentary discusses why the manner in which Prop 46 makes physician drug and alcohol testing law is cause for concern.
Topics: alcohol abuse, ethanol, california, mandatory testing, physician impairment, substance abuse detection, medical liability, screening test, prescribing behavior, controlled substance, hospitals, statutes and laws
In the Balance | 
Julius Cuong Pham, MD, PhD; and Peter J. Pronovost, MD, PhD
On 4 November 2014, California residents will vote on Proposition 46, which increases the cap on noneconomic damages in medical liability cases, mandates that physicians check the state's database on prescription drug history before prescribing certain controlled substances, and requires hospitals to perform drug and alcohol testing of physicians. This commentary argues that, if enacted, the initiative's unintended consequences will likely exceed its benefits.
Topics: alcohol abuse, ethanol, california, hospitals, mandatory testing, physician impairment, statutes and laws, medical liability, screening test, controlled substance, prescribing behavior, substance abuse detection
Ideas and Opinions | 
Stephanie R. Morain, MPH, PhD; Charles Flexner, MD; Nancy E. Kass, ScD; and Jeremy Sugarman, MD, MPH, MA
The Physician Payment Sunshine Act was intended to bring greater transparency to physician–industry relationships by establishing the Open Payments database. This commentary discusses areas where disclosure of payments related to research may be prone to misinterpretation.
Topics: health care financing administration, disclosure, drug costs, research funding, physician payments sunshine act, clinical research
Topics: chlamydia infection, gonococcal infection, neisseria gonorrhoeae, preventive health services, sexually transmitted diseases, chlamydia, women, screening, gonorrhea guidelines, infection risk
Clinical Guidelines | 
Michael L. LeFevre, MD, MSPH, on behalf of the U.S. Preventive Services Task Force*
Description:Update of previous U.S. Preventive Services Task Force (USPSTF) recommendations on screening for chlamydia (2007) and gonorrhea (2005). Methods:The USPSTF reviewed the evidence on screening for chlamydial and gonococcal infections in asymptomatic patients from studies published since its last reviews. The USPSTF also considered evidence from its previous recommendations and reviews. Population:This recommendation applies to all sexually active adolescents and adults, including pregnant women. Recommendations:The USPSTF recommends screening for chlamydia in sexually active females aged 24 years or younger and in older women who are at increased risk for infection. (B recommendation) The USPSTF recommends screening for gonorrhea in sexually active females aged 24 years or younger and in older women who are at increased risk for infection. (B recommendation) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for chlamydia and gonorrhea in men. (I statement)
Topics: chlamydia infection, gonococcal infection, sexually transmitted diseases, chlamydia, women, screening, gonorrhea guidelines, infection risk, neisseria gonorrhoeae, preventive health services
Reviews | 
Elizabeth A. O'Connor, PhD; Jennifer S. Lin, MD, MCR; Brittany U. Burda, MPH; Jillian T. Henderson, PhD; Emily S. Walsh, MPH; and Evelyn P. Whitlock, MD, MPH
Includes: Supplemental Content
Background:Sexually transmitted infections (STIs) are common and preventable. Purpose:To update a previous systematic review about the benefits and harms of sexual risk-reduction counseling to prevent STIs for the U.S. Preventive Services Task Force. Data Sources:Selected databases from January 2007 through October 2013, manual searches of references lists and grey literature, and studies from the previous review. Study Selection:English-language fair- or good-quality trials conducted in adolescents or adults. Data Extraction:One investigator abstracted data and a second checked the abstraction. Study quality was dual reviewed. Data Synthesis:31 trials were included: 16 were newly published (n = 56 110) and 15 (n = 14 214) were from the previous review. Most trials targeted persons at increased risk for STIs based on sociodemographic characteristics, risky sexual behavior, or history of an STI. High-intensity (>2 hours) interventions reduced STI incidence in adolescents (odds ratio, 0.38 [95% CI, 0.24 to 0.60]) and adults (odds ratio, 0.70 [CI, 0.56 to 0.87]). Lower-intensity interventions were generally not effective in adults but some approaches were promising. Although moderate-intensity interventions may be effective in adolescents, data were very sparse. Reported behavioral outcomes were heterogeneous and most likely to show a benefit with high-intensity interventions at 6 months or less. No consistent evidence was found that sexual risk-reduction counseling was harmful. Limitations:Low-risk populations and male adolescents were underrepresented. Reliability of self-reported behavioral outcomes was unknown. Conclusion:High-intensity counseling on sexual risk reduction can reduce STIs in primary care and related settings, especially in sexually active adolescents and in adults at increased risk for STIs. Primary Funding Source:Agency for Healthcare Research and Quality.
Topics: counseling, preventive health services, primary health care, sexually transmitted diseases, risk reduction, risk reduction counseling, infection risk
Reviews | 
Bernadette Zakher, MBBS; Amy G. Cantor, MD, MHS; Miranda Pappas, MA; Monica Daegas, BA; and Heidi D. Nelson, MD, MPH
Includes: Supplemental Content
Background:Previous research has supported screening for gonorrhea and chlamydia in asymptomatic, sexually active women (including pregnant women) who are younger than 25 years or at increased risk but not in other patient populations. Purpose:To update the 2005 and 2007 systematic reviews for the U.S. Preventive Services Task Force on screening for gonorrhea and chlamydia in men and women, including pregnant women and adolescents. Data Sources:MEDLINE (1 January 2004 to 13 June 2014), Cochrane databases (May 2014), and reference lists. Study Selection:English-language trials and observational studies about screening effectiveness, test accuracy, and screening harms. Data Extraction:Extracted study data were confirmed by a second investigator, and study quality and applicability were dual-rated using prespecified criteria. Data Synthesis:Screening a subset of asymptomatic young women for chlamydia in a good-quality trial did not significantly reduce the incidence of pelvic inflammatory disease over the following year (relative risk, 0.39 [95% CI, 0.14 to 1.08]); however, one previous trial reported a reduction. An observational study evaluating a risk prediction tool to identify persons with chlamydia in high-risk populations had low predictive ability and applicability. In 10 new studies of asymptomatic patients, nucleic acid amplification tests demonstrated sensitivity of 86% or greater and specificity of 97% or greater for diagnosing gonorrhea and chlamydia, regardless of specimen type or test. Limitations:There were few relevant studies of screening benefits and harms. Only screening tests and methods cleared by the U.S. Food and Drug Administration for current clinical practice were included to determine diagnostic accuracy. Conclusion:Chlamydia screening in young women may reduce the incidence of pelvic inflammatory disease. Nucleic acid amplification tests are accurate for diagnosing gonorrhea and chlamydia in asymptomatic persons. Primary Funding Source:Agency for Healthcare Research and Quality.
Topics: chlamydia infection, gonococcal infection, neisseria gonorrhoeae, sexually transmitted diseases, chlamydia, women, screening, gonorrhea guidelines, infection risk, preventive health services, screening test
Topics: counseling, preventive health services, sexually transmitted diseases, risk reduction, risk reduction counseling, infection risk
Clinical Guidelines | 
Michael L. LeFevre, MD, MSPH, on behalf of the U.S. Preventive Services Task Force*
Description:Update of the U.S. Preventive Services Task Force (USPSTF) 2008 recommendation on behavioral counseling interventions to prevent sexually transmitted infections (STIs). Methods:The USPSTF reviewed the evidence on behavioral counseling for sexual risk reduction in primary care, including interventions targeting risky sexual behaviors to prevent STIs (alone or in combination with other behaviors) in persons of any sexual orientation or level of reported sexual activity. Population:This recommendation applies to all sexually active adolescents and to adults who are at increased risk for acquiring or transmitting STIs. Recommendation:The USPSTF recommends intensive behavioral counseling for all sexually active adolescents and for adults who are at increased risk for STIs. (B recommendation)
Topics: preventive health services, sexually transmitted diseases, risk reduction counseling, infection risk, counseling, risk reduction
Ideas and Opinions | 
Davidson H. Hamer, MD; and Lin H. Chen, MD
Chikungunya fever is a debilitating but rarely fatal disease that is being seen with increasing frequency in travelers returning to the United States from affected regions. In addition, the mosquito vectors for this virus are widespread within U.S. borders. Clinicians thus must be aware of the presentation, diagnosis, and management of this emerging infection.
Topics: chikungunya fever, alphavirus, alphavirus infections, communicable diseases, emerging, culicidae, traveler
Ideas and Opinions | 
Alexander Isakov, MD, MPH; Aaron Jamison, EMT-P; Wade Miles, EMT-P; and Bruce Ribner, MD, MPH
Members of a clinical team describe how they carried out the safe transport of the first 2 American patients evacuated from West Africa during the current Ebola epidemic.
Topics: ebola virus, communicable diseases, decontamination, disinfection, health personnel, infectious disease prevention / control, emergency medical services transportation, personal protective equipment, emergency evacuation, ebola virus disease
Ideas and Opinions | 
Brooke K. Decker, MD; Jonathan E. Sevransky, MD, MHS; Kevin Barrett, RN; Richard T. Davey, MD; and Daniel S. Chertow, MD, MPH
To assist U.S. medical facilities with advanced management capabilities, a group of health care workers suggests policies and procedures for the critical care of patients with Ebola.
Topics: care of intensive care unit patient, ebola virus, decontamination, ebola virus disease, infectious disease prevention / control, nosocomial infection, infection prophylaxis
Original Research | 
Paul F. Pinsky, PhD; David S. Gierada, MD; William Hocking, MD; Edward F. Patz Jr., MD; and Barnett S. Kramer, MD, MPH
Background:The NLST (National Lung Screening Trial) showed reduced lung cancer mortality in high-risk participants (smoking history of ≥30 pack-years) aged 55 to 74 years who were randomly assigned to screening with low-dose computed tomography (LDCT) versus those assigned to chest radiography. An advisory panel recently expressed reservations about Medicare coverage of LDCT screening because of concerns about its performance in the Medicare-aged population, which accounted for only 25% of the NLST participants. Objective:To examine the results of the NLST LDCT group by age (Medicare-eligible vs. <65 years). Design:Secondary analysis of a group from a randomized trial (NCT00047385). Setting:33 U.S. screening centers. Patients:19 612 participants aged 55 to 64 years (under-65 cohort) and 7110 participants aged 65 to 74 years (65+ cohort) at randomization. Intervention:3 annual rounds of LDCT screening. Measurements:Demographics, smoking and medical history, screening examination adherence and results, diagnostic follow-up procedures and complications, lung cancer diagnoses, treatment, survival, and mortality. Results:The aggregate false-positive rate was higher in the 65+ cohort than in the under-65 cohort (27.7% vs. 22.0%; P < 0.001). Invasive diagnostic procedures after false-positive screening results were modestly more frequent in the older cohort (3.3% vs. 2.7%; P = 0.039). Complications from invasive procedures were low in both groups (9.8% in the under-65 cohort vs. 8.5% in the 65+ cohort). Prevalence and positive predictive value (PPV) were higher in the 65+ cohort (PPV, 4.9% vs. 3.0%). Resection rates for screen-detected cancer were similar (75.6% in the under-65 cohort vs. 73.2% in the 65+ cohort). Five-year all-cause survival was lower in the 65+ cohort (55.1% vs. 64.1%; P = 0.018). Limitation:The oldest screened patient was aged 76 years. Conclusion:NLST participants aged 65 years or older had a higher rate of false-positive screening results than those younger than 65 years but a higher cancer prevalence and PPV. Screen-detected cancer was treated similarly in the groups. Primary Funding Source:National Institutes of Health.
Topics: chest x-ray, lung cancer, chest ct, nlst, low-dose spiral ct, medicare
In this issue, Pinsky and colleagues present the results of their secondary analysis of data from the National Lung Screening Trial, in which they compared outcomes of screening with low-dose computed tomography between Medicare-eligible and younger participants. The editorialist discusses the findings and their implications for clinicians and policymakers.
Topics: lung cancer, elderly, lung cancer screening, nlst
Reviews | 
Carolyn J. Crandall, MD, MS; Sydne J. Newberry, PhD; Allison Diamant, MD, MSHS; Yee-Wei Lim, MD, PhD; Walid F. Gellad, MD, MPH; Marika J. Booth, MS; Aneesa Motala, BA; and Paul G. Shekelle, MD, PhD
Background:Osteoporosis is a major contributor to the propensity to fracture among older adults, and various pharmaceuticals are available to treat it. Purpose:To update a review about the benefits and harms of pharmacologic treatments used to prevent fractures in adults at risk. Data Sources:Multiple computerized databases were searched between 2 January 2005 and 4 March 2014 for English-language studies. Study Selection:Trials, observational studies, and systematic reviews. Data Extraction:Duplicate extraction and assessment of data about study characteristics, outcomes, and quality. Data Synthesis:From more than 52 000 titles screened, 294 articles were included in this update. There is high-strength evidence that bisphosphonates, denosumab, and teriparatide reduce fractures compared with placebo, with relative risk reductions from 0.40 to 0.60 for vertebral fractures and 0.60 to 0.80 for nonvertebral fractures. Raloxifene has been shown in placebo-controlled trials to reduce only vertebral fractures. Since 2007, there is a newly recognized adverse event of bisphosphonate use, atypical subtrochanteric femur fracture. Gastrointestinal side effects, hot flashes, thromboembolic events, and infections vary among drugs. Limitations:Few studies have directly compared drugs used to treat osteoporosis. Data in men are very sparse. Costs were not assessed. Conclusion:Good-quality evidence supports that several medications for bone density in osteoporotic range and/or preexisting hip or vertebral fracture reduce fracture risk. Side effects vary among drugs, and the comparative effectiveness of the drugs is unclear. Primary Funding Source:Agency for Healthcare Research and Quality and RAND Corporation.
Topics: osteoporosis, pharmacotherapy, fracture, teriparatide, comparative effectiveness research, osteoporotic fracture risk, adverse event, bisphosphonates, denosumab
Advertisement
Forgot your password?
Enter your username and email address. We'll send you a reminder to the email address on record.
(Required)
(Required)