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New guidelines from the American Gastroenterological Association on the management of incidental pancreatic cysts recommend less aggressive evaluation than previous recommendations from other groups. The guidelines are needed because the rapid growth in the number of sensitive imaging studies has led to a marked increase in incidental pancreatic cysts. This commentary discusses lessons extending beyond pancreatic cysts about how physicians should consider diagnostic testing and what types of recommendations merit their attention.
Topics: pancreas, incidental findings
Ideas and Opinions | 
Giulio R. Romeo, MD; and Martin J. Abrahamson, MD
Each year, the American Diabetes Association's Standards of Medical Care in Diabetes provide comprehensive clinical practice recommendations for diabetes care, based on the latest available evidence. This commentary highlights 3 topics in the Standards of relevance to nonendocrinologists who care for patients with diabetes: ethnic differences in diabetes risk with different body mass indices, blood pressure targets, and individualization of diabetes treatment goals.
Topics: diabetes mellitus, patient-centered care, diabetes mellitus, type 2
Clinical Guidelines | 
Michael L. LeFevre, MD, MSPH, on behalf of the U.S. Preventive Services Task Force*
Description:Update of the 2004 U.S. Preventive Services Task Force (USPSTF) recommendation on screening for thyroid disease. Methods:The USPSTF reviewed the evidence on the benefits and harms of screening for subclinical and “overt” thyroid dysfunction without clinically obvious symptoms, as well as the effects of treatment on intermediate and final health outcomes. Population:This recommendation applies to nonpregnant, asymptomatic adults. Recommendation:The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for thyroid dysfunction in nonpregnant, asymptomatic adults. (I statement)
Topics: thyroid diseases, thyrotropin, early diagnosis, hypothyroidism, hyperthyroidism
Topics: thyroid diseases
Editorials | 
Anne R. Cappola, MD, ScM; and David S. Cooper, MD
In this issue, the U.S. Preventive Services Task Force concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for thyroid dysfunction in nonpregnant asymptomatic adults. The editorialists stress the urgent need for data to provide guidance on screening for thyroid dysfunction to assist clinicians in making the best decisions for their patients.
Topics: therapeutics, stalemate, subclinical thyroid disease, thyroid diseases
Original Research | 
Michael M. Mohareb, MD; Feng Qiu, MSc; Warren J. Cantor, MD; Kori J. Kingsbury, MSN, MPA; Dennis T. Ko, MD, MSc; and Harindra C. Wijeysundera, MD, PhD
Background:The use of invasive coronary angiography in stable ischemic heart disease (IHD) varies widely. Objective:To validate the 2012 appropriate use criteria for diagnostic catheterization (AUC) by examining the relationship between the appropriateness of cardiac catheterization in patients with suspected stable IHD and the proportion of patients with obstructive coronary artery disease (CAD) and subsequent revascularization. Design:Population-based, observational, multicenter cohort study. Setting:The Cardiac Care Network, a registry of all patients having elective angiography at 18 hospitals in Ontario, Canada, between 1 October 2008 and 30 September 2011. Patients:Persons without prior coronary revascularization or myocardial infarction who had angiography for suspected stable CAD. Measurements:Appropriateness scores were ascertained by using data collected at the time of the index angiography and were categorized as appropriate, inappropriate, or uncertain. Results:Among the final cohort of 48 336 patients, 58.2% of angiographic studies were classified as appropriate, 10.8% were classified as inappropriate, and 31.0% were classified as uncertain. Overall, 45.5% of patients had obstructive CAD. In patients with appropriate indications for angiography, 52.9% had obstructive CAD, with 40.0% undergoing revascularization. In those with inappropriate indications, 30.9% had obstructive CAD and 18.9% underwent revascularization; in those with uncertain indications, 36.7% had obstructive CAD and 25.9% had revascularization. Although more patients with appropriate indications had obstructive CAD and underwent revascularization (P < 0.001), a substantial proportion of those with inappropriate or uncertain indications had important coronary disease. Limitation:Data were not available on whether symptoms were atypical. Conclusion:Despite the association between appropriateness category and obstructive CAD, this study raises concerns about the ability of the AUC to guide clinical decision making. Primary Funding Source:Canadian Institutes of Health Research.
Topics: angina pectoris, angiogram, coronary angiography, cardiovascular stress test, exercise stress test, diagnosis, diagnostic imaging, revascularization, appropriateness, appropriate use, echocardiography, myocardial ischemia, catheterization, hospitals, coronary arteriosclerosis
In this issue, Mohareb and colleagues sought to validate the 2012 appropriate use criteria (AUC) for diagnostic catheterization. The editorialists discuss the opportunities and challenges of applying AUC to large data sets and urge physicians to embrace the opportunity for self-regulation that AUC offer to ensure that they remain advocates for patients and stewards of the health system.
Topics: social control, informal, appropriate use, diagnosis, catheterization
Ideas and Opinions | 
Neal Halsey, MD; and Daniel Salmon, PhD, MPH
Only a small portion of the U.S. population is susceptible to measles. However, international travel, vaccine refusal or delay, and rare vaccine failures combined with high social contacts allow this highly infectious virus to infect susceptible individuals of all ages. The recent measles outbreak in Disneyland is reflective of the increase in recent years of the number of parents declining to vaccinate their children. In addition, although great progress has been made in controlling measles globally, it has recently rebounded in many countries. Eradication of measles is possible but will take time, ramped-up efforts to ensure that eligible U.S. children are vaccinated, and greater international collaboration.
Topics: measles
Original Research | 
Ali Rowhani-Rahbar, MD, MPH, PhD; Douglas Zatzick, MD; Jin Wang, PhD; Brianna M. Mills, MA; Joseph A. Simonetti, MD, MPH; Mary D. Fan, MPhil, JD; and Frederick P. Rivara, MD, MPH
Background:Risk for violent victimization or crime perpetration after firearm-related hospitalization (FRH) must be determined to inform the need for future interventions. Objective:To compare the risk for subsequent violent injury, death, or crime perpetration among patients with an FRH, those hospitalized for noninjury reasons, and the general population. Design:Retrospective cohort study. Setting:All hospitals in Washington. Patients:Patients with an FRH and a random sample of those with a non–injury-related hospitalization in 2006 to 2007 (index hospitalization). Measurements:Primary outcomes included subsequent FRH, firearm-related death, and the combined outcome of firearm- or violence-related arrest ascertained through 2011. Results:Among patients with an index FRH (n = 613), rates of subsequent FRH, firearm-related death, and firearm- or violence-related arrest were 329 (95% CI, 142 to 649), 100 (CI, 21 to 293), and 4221 (CI, 3352 to 5246) per 100 000 person-years, respectively. Compared with the general population, standardized incidence ratios among patients with an index FRH were 30.1 (CI, 14.9 to 61.0) for a subsequent FRH and 7.3 (CI, 2.4 to 22.9) for firearm-related death. In survival analyses that accounted for competing risks, patients with an index FRH were at greater risk for subsequent FRH (subhazard ratio [sHR], 21.2 [CI, 7.0 to 64.0]), firearm-related death (sHR, 4.3 [CI, 1.3 to 14.1]), and firearm- or violence-related arrest (sHR, 2.7 [CI, 2.0 to 3.5]) than those with a non–injury-related index hospitalization. Limitation:Lack of information on whether patients continued to reside in Washington during follow-up may have introduced outcome misclassification. Conclusion:Hospitalization for a firearm-related injury is associated with a heightened risk for subsequent violent victimization or crime perpetration. Further research at the intersection of clinical care, the criminal justice system, and public health to evaluate the effectiveness of interventions delivered to survivors of firearm-related injury is warranted. Primary Funding Source:Seattle City Council and University of Washington Royalty Research Fund.
Topics: crime, firearms, hospitalization
Medicine and Public Issues | 
Steven E. Weinberger, MD; David B. Hoyt, MD; Hal C. Lawrence III, MD; Saul Levin, MD, MPA; Douglas E. Henley, MD; Errol R. Alden, MD; Dean Wilkerson, JD, MBA; Georges C. Benjamin, MD; and William C. Hubbard, JD
Deaths and injuries related to firearms constitute a major public health problem in the United States. In response to firearm violence and other firearm-related injuries and deaths, an interdisciplinary, interprofessional group of leaders of 8 national health professional organizations and the American Bar Association, representing the official policy positions of their organizations, advocate a series of measures aimed at reducing the health and public health consequences of firearms. The specific recommendations include universal background checks of gun purchasers, elimination of physician “gag laws,” restricting the manufacture and sale of military-style assault weapons and large-capacity magazines for civilian use, and research to support strategies for reducing firearm-related injuries and deaths. The health professional organizations also advocate for improved access to mental health services and avoidance of stigmatization of persons with mental and substance use disorders through blanket reporting laws. The American Bar Association, acting through its Standing Committee on Gun Violence, confirms that none of these recommendations conflict with the Second Amendment or previous rulings of the U.S. Supreme Court.
Topics: firearms, health personnel, statutes and laws
Editorials | 
Darren B. Taichman, MD, PhD, Executive Deputy Editor; Christine Laine, MD, MPH, Editor in Chief, on behalf of the Annals editors
Includes: Supplemental Content
Health care professionals have been relatively silent on firearm-related harms compared with other public health crises. With the emergence of new research, the development of a national research agenda, and a united call for action from many physician professional organizations, the editors call on health care professionals to join in speaking up and demanding the resources and freedom to learn how to fix the public health crisis of firearm-related harms.
Topics: firearms
Original Research | 
Paul F. Pinsky, PhD; David S. Gierada, MD; William Black, MD; Reginald Munden, MD; Hrudaya Nath, MD; Denise Aberle, MD; and Ella Kazerooni, MD
Background:Lung cancer screening with low-dose computed tomography (LDCT) has been recommended, based primarily on the results of the National Lung Screening Trial (NLST). The American College of Radiology recently released Lung-RADS, a classification system for LDCT lung cancer screening. Objective:To retrospectively apply the Lung-RADS criteria to the NLST. Design:Secondary analysis of a group from a randomized trial. Setting:33 U.S. screening centers. Patients:Participants were randomly assigned to the LDCT group of the NLST, were aged 55 to 74 years, had at least a 30–pack-year history of smoking, and were current smokers or had quit within the past 15 years. Intervention:3 annual LDCT lung cancer screenings. Measurements:Lung-RADS classifications for LDCT screenings. Lung-RADS categories 1 to 2 constitute negative screening results, and categories 3 to 4 constitute positive results. Results:Of 26 722 LDCT group participants, 26 455 received a baseline screen; 48 671 screenings were done after baseline. At baseline, the false-positive result rate (1 minus the specificity rate) for Lung-RADS was 12.8% (95% CI, 12.4% to 13.2%) versus 26.6% (CI, 26.1% to 27.1%) for the NLST; after baseline, the false-positive result rate was 5.3% (CI, 5.1% to 5.5%) for Lung-RADS versus 21.8% (CI, 21.4% to 22.2%) for the NLST. Baseline sensitivity was 84.9% (CI, 80.8% to 89.0%) for Lung-RADS compared with 93.5% (CI, 90.7% to 96.3%) for the NLST, and sensitivity after baseline was 78.6% (CI, 74.6% to 82.6%) for Lung-RADS versus 93.8% (CI, 91.4% to 96.1%) for the NLST. Limitation:Lung-RADS criteria were applied retrospectively. Conclusion:Lung-RADS may substantially reduce the false-positive result rate; however, sensitivity is also decreased. The effect of using Lung-RADS criteria in clinical practice must be carefully studied. Primary Funding Source:National Institutes of Health.
Topics: lung, reactive airways dysfunction syndrome, nlst trial, false-positive results
Ideas and Opinions | 
Theodore G. Ganiats, MD
The chronic fatigue syndrome is often ignored or mismanaged by clinicians. The Institute of Medicine recently convened an expert committee to examine the evidence base for the condition, develop evidence-based clinical diagnostic criteria, and recommend whether new terminology should be adopted.
Topics: chronic fatigue syndrome, diagnosis
As the American College of Physicians celebrates its 100th anniversary in 2015, it is an appropriate time to reflect on the current challenges and opportunities that face internal medicine specialists and subspecialists, their patients, and American society. This commentary highlights 3 leading issues for internal medicine and for ACP as it enters its second century and strives to continue to meet the needs of internists and their patients.
Topics: internal medicine, job satisfaction, health care systems, health care cost containment, american college of physicians
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