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Urinary Tract Infection.
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Urinary Tract Infection.

Ann Intern Med. 2017 Oct 03;167(7):ITC49-ITC64

Authors: Gupta K, Grigoryan L, Trautner B

Urinary tract infections (UTIs) are common in both inpatient and outpatient settings. This article provides an evidence-based, clinically relevant overview of management of UTIs, including screening, diagnosis, treatment, and prevention. Conditions covered include acute cystitis (both uncomplicated and complicated), catheter-associated UTI, and asymptomatic bacteriuria in both women and men.

PMID: 28973215 [PubMed - indexed for MEDLINE]

Should We Screen This Patient for Carotid Artery Stenosis?: Grand Rounds Discussion From Beth Israel Deaconess Medical Center.
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Should We Screen This Patient for Carotid Artery Stenosis?: Grand Rounds Discussion From Beth Israel Deaconess Medical Center.

Ann Intern Med. 2017 Oct 03;167(7):484-492

Authors: Smetana GW, Schermerhorn M, Mukamal KJ

In July 2014, the U.S. Preventive Services Task Force (USPSTF) published a clinical guideline on screening for asymptomatic carotid artery stenosis. The guideline recommended against screening in asymptomatic adults, based primarily on the results of 3 large randomized trials (grade D recommendation). The principal screening test was carotid ultrasonography, and the intervention in the 3 trials was carotid endarterectomy for patients with stenosis exceeding 50% to 60%. In a meta-analysis, carotid endarterectomy reduced rates of 1) perioperative stroke, death, or subsequent ipsilateral stroke and 2) perioperative stroke, death, or any subsequent stroke. The corresponding absolute risk differences were -2.0% (95% CI, -3.3% to -0.7%) and -3.5% (CI, -5.1% to -1.8%), respectively. However, perioperative stroke and death were substantially less common among the 3 randomized trials than in contemporaneous cohort studies (1.9% vs. 3.3%). In addition to stroke or death in patients receiving carotid endarterectomy, a harm of screening included the risk for angiography prompted by abnormal results on carotid ultrasonography. In this article, 2 discussants address the risks and benefits of screening for carotid artery disease as well as how to apply the guideline to an individual patient who is deciding whether to be screened.

PMID: 28973212 [PubMed - indexed for MEDLINE]

Low-Dose Intravenous Immunoglobulin Treatment for Long-Standing Complex Regional Pain Syndrome: A Randomized Trial.
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Low-Dose Intravenous Immunoglobulin Treatment for Long-Standing Complex Regional Pain Syndrome: A Randomized Trial.

Ann Intern Med. 2017 Oct 03;167(7):476-483

Authors: Goebel A, Bisla J, Carganillo R, Frank B, Gupta R, Kelly J, McCabe C, Murphy C, Padfield N, Phillips C, Sanders M, Serpell M, Shenker N, Shoukrey K, Wyatt L, Ambler G

Background: Two small trials suggest that low-dose intravenous immunoglobulin (IVIg) may improve the symptoms of complex regional pain syndrome (CRPS), a rare posttraumatic pain condition.
Objective: To confirm the efficacy of low-dose IVIg compared with placebo in reducing pain during a 6-week period in adult patients who had CRPS from 1 to 5 years.
Design: 1:1 parallel, randomized, placebo-controlled, multicenter trial for 6 weeks, with an optional 6-week open extension. Patients were randomly assigned to 1 of 2 study groups between 27 August 2013 and 28 October 2015; the last patient completed follow-up on 21 March 2016. Patients, providers, researchers, and outcome assessors were blinded to treatment assignment. (ISRCTN42179756).
Setting: 7 secondary and tertiary care pain management centers in the United Kingdom.
Participants: 111 patients with moderate or severe CRPS of 1 to 5 years' duration.
Intervention: IVIg, 0.5 g/kg of body weight, or visually indistinguishable placebo of 0.1% albumin in saline on days 1 and 22 after randomization.
Measurements: The primary outcome was 24-hour average pain intensity, measured daily between days 6 and 42, on an 11-point (0- to 10-point) rating scale. Secondary outcomes were pain interference and quality of life.
Results: The primary analysis sample consisted of 108 eligible patients, 103 of whom had outcome data. Mean (average) pain scores were 6.9 points (SD, 1.5) for placebo and 7.2 points (SD, 1.3) for IVIg. The adjusted difference in means was 0.27 (95% CI, -0.25 to 0.80; P = 0.30), which excluded the prespecified, clinically important difference of -1.2. No statistically significant differences in secondary outcomes were found between the groups. In the open extension, 12 of the 67 patients (18%) who received 2 IVIg infusions had pain reduction of at least 2 points compared with their baseline score. Two patients in the blinded phase (1 in the placebo and 1 in the IVIg group) and 4 in the open IVIg phase had serious events.
Limitations: Results do not apply to patients who have had CRPS for less than 1 year or more than 5 years and do not extend to full-dose treatment (for example, 2 g/kg). The study was inadequately powered to detect subgroup effects.
Conclusion: Low-dose immunoglobulin treatment for 6 weeks was not effective in relieving pain in patients with moderate to severe CRPS of 1 to 5 years' duration.
Primary Funding Source: Medical Research Council/National Institute for Health Research Efficacy and Mechanism Evaluation Program, Pain Relief Foundation, and Biotest United Kingdom.

PMID: 28973211 [PubMed - indexed for MEDLINE]

Curing Hepatitis C Virus Infection: Best Practices From the U.S. Department of Veterans Affairs.
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Curing Hepatitis C Virus Infection: Best Practices From the U.S. Department of Veterans Affairs.

Ann Intern Med. 2017 Oct 03;167(7):499-504

Authors: Belperio PS, Chartier M, Ross DB, Alaigh P, Shulkin D

The U.S. Department of Veterans Affairs (VA) is the nation's largest care provider for hepatitis C virus (HCV)-infected patients and is uniquely suited to inform national efforts to eliminate HCV. An extensive array of delivery of services, policy guidance, outreach efforts, and funding has broadened the reach and capacity of the VA to deliver direct-acting antiviral (DAA) HCV therapy, supported by an infrastructure to effectively implement change and informed by extensive population health data analysis. The VA has treated more than 92 000 HCV-infected veterans since all-oral DAAs became available in January 2014, with cure rates exceeding 90%; only 51 000 veterans in VA care are known to remain potentially eligible for treatment. Key actions advancing the VA's aggressive treatment of HCV infection that are germane to non-VA settings include expansion of treatment capacity through the use of nonphysician providers, video telehealth, and electronic technologies; expansion of integrated care to address psychiatric and substance use comorbidities; and electronic data tools for patient tracking and outreach. A critical component of effective implementation has been building infrastructure through the creation of regional multidisciplinary HCV Innovation Teams, whose system redesign efforts have produced innovative HCV practice models addressing gaps in care while providing more efficient and effective HCV management for the populations they serve. Financing for HCV treatment and infrastructure resources coupled with reduced drug prices has been paramount to the VA's success in curing HCV infection. The VA is poised to share and extend best practices to other health care organizations and providers delivering HCV care, contributing to a concerted effort to reduce the overall burden of HCV infection.

PMID: 28973196 [PubMed - indexed for MEDLINE]

Treatment of Type 1 Diabetes: Synopsis of the 2017 American Diabetes Association Standards of Medical Care in Diabetes.
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Treatment of Type 1 Diabetes: Synopsis of the 2017 American Diabetes Association Standards of Medical Care in Diabetes.

Ann Intern Med. 2017 Oct 03;167(7):493-498

Authors: Chamberlain JJ, Kalyani RR, Leal S, Rhinehart AS, Shubrook JH, Skolnik N, Herman WH

Description: The American Diabetes Association (ADA) annually updates Standards of Medical Care in Diabetes to provide clinicians, patients, researchers, payers, and other interested parties with evidence-based recommendations for the diagnosis and management of patients with diabetes.
Methods: For the 2017 Standards of Care, the ADA Professional Practice Committee did MEDLINE searches from 1 January 2016 to November 2016 to add, clarify, or revise recommendations on the basis of new evidence. The committee rated the recommendations as A, B, or C, depending on the quality of evidence, or E for expert consensus or clinical experience. The Standards of Care were reviewed and approved by the Executive Committee of the ADA Board of Directors, which includes health care professionals, scientists, and laypersons. Feedback from the larger clinical community informed revisions.
Recommendation: This synopsis focuses on recommendations from the 2017 Standards of Care about monitoring and pharmacologic approaches to glycemic management for type 1 diabetes.

PMID: 28892816 [PubMed - indexed for MEDLINE]

Patterns of Sedentary Behavior and Mortality in U.S. Middle-Aged and Older Adults: A National Cohort Study.
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Patterns of Sedentary Behavior and Mortality in U.S. Middle-Aged and Older Adults: A National Cohort Study.

Ann Intern Med. 2017 Oct 03;167(7):465-475

Authors: Diaz KM, Howard VJ, Hutto B, Colabianchi N, Vena JE, Safford MM, Blair SN, Hooker SP

Background: Excessive sedentary time is ubiquitous in Western societies. Previous studies have relied on self-reporting to evaluate the total volume of sedentary time as a prognostic risk factor for mortality and have not examined whether the manner in which sedentary time is accrued (in short or long bouts) carries prognostic relevance.
Objective: To examine the association between objectively measured sedentary behavior (its total volume and accrual in prolonged, uninterrupted bouts) and all-cause mortality.
Design: Prospective cohort study.
Setting: Contiguous United States.
Participants: 7985 black and white adults aged 45 years or older.
Measurements: Sedentary time was measured using a hip-mounted accelerometer. Prolonged, uninterrupted sedentariness was expressed as mean sedentary bout length. Hazard ratios (HRs) were calculated comparing quartiles 2 through 4 to quartile 1 for each exposure (quartile cut points: 689.7, 746.5, and 799.4 min/d for total sedentary time; 7.7, 9.6, and 12.4 min/bout for sedentary bout duration) in models that included moderate to vigorous physical activity.
Results: Over a median follow-up of 4.0 years, 340 participants died. In multivariable-adjusted models, greater total sedentary time (HR, 1.22 [95% CI, 0.74 to 2.02]; HR, 1.61 [CI, 0.99 to 2.63]; and HR, 2.63 [CI, 1.60 to 4.30]; P for trend < 0.001) and longer sedentary bout duration (HR, 1.03 [CI, 0.67 to 1.60]; HR, 1.22 [CI, 0.80 to 1.85]; and HR, 1.96 [CI, 1.31 to 2.93]; P for trend < 0.001) were both associated with a higher risk for all-cause mortality. Evaluation of their joint association showed that participants classified as high for both sedentary characteristics (high sedentary time [≥12.5 h/d] and high bout duration [≥10 min/bout]) had the greatest risk for death.
Limitation: Participants may not be representative of the general U.S. population.
Conclusion: Both the total volume of sedentary time and its accrual in prolonged, uninterrupted bouts are associated with all-cause mortality, suggesting that physical activity guidelines should target reducing and interrupting sedentary time to reduce risk for death.
Primary Funding Source: National Institutes of Health.

PMID: 28892811 [PubMed - indexed for MEDLINE]

Reconciling the Effects of Screening on Prostate Cancer Mortality in the ERSPC and PLCO Trials.
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Reconciling the Effects of Screening on Prostate Cancer Mortality in the ERSPC and PLCO Trials.

Ann Intern Med. 2017 Oct 03;167(7):449-455

Authors: Tsodikov A, Gulati R, Heijnsdijk EAM, Pinsky PF, Moss SM, Qiu S, de Carvalho TM, Hugosson J, Berg CD, Auvinen A, Andriole GL, Roobol MJ, Crawford ED, Nelen V, Kwiatkowski M, Zappa M, Luján M, Villers A, Feuer EJ, de Koning HJ, Mariotto AB, Etzioni R

Background: The ERSPC (European Randomized Study of Screening for Prostate Cancer) found that screening reduced prostate cancer mortality, but the PLCO (Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial) found no reduction.
Objective: To evaluate whether effects of screening on prostate cancer mortality relative to no screening differed between the ERSPC and PLCO.
Design: Cox regression of prostate cancer death in each trial group, adjusted for age and trial. Extended analyses accounted for increased incidence due to screening and diagnostic work-up in each group via mean lead times (MLTs), which were estimated empirically and using analytic or microsimulation models.
Setting: Randomized controlled trials in Europe and the United States.
Participants: Men aged 55 to 69 (ERSPC) or 55 to 74 (PLCO) years at randomization.
Intervention: Prostate cancer screening.
Measurements: Prostate cancer incidence and survival from randomization; prostate cancer incidence in the United States before screening began.
Results: Estimated MLTs were similar in the ERSPC and PLCO intervention groups but were longer in the PLCO control group than the ERSPC control group. Extended analyses found no evidence that effects of screening differed between trials (P = 0.37 to 0.47 [range across MLT estimation approaches]) but strong evidence that benefit increased with MLT (P = 0.0027 to 0.0032). Screening was estimated to confer a 7% to 9% reduction in the risk for prostate cancer death per year of MLT. This translated into estimates of 25% to 31% and 27% to 32% lower risk for prostate cancer death with screening as performed in the ERSPC and PLCO intervention groups, respectively, compared with no screening.
Limitation: The MLT is a simple metric of screening and diagnostic work-up.
Conclusion: After differences in implementation and settings are accounted for, the ERSPC and PLCO provide compatible evidence that screening reduces prostate cancer mortality.
Primary Funding Source: National Cancer Institute.

PMID: 28869989 [PubMed - indexed for MEDLINE]

Accuracy of Cardiovascular Risk Prediction Varies by Neighborhood Socioeconomic Position: A Retrospective Cohort Study.
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Accuracy of Cardiovascular Risk Prediction Varies by Neighborhood Socioeconomic Position: A Retrospective Cohort Study.

Ann Intern Med. 2017 Oct 03;167(7):456-464

Authors: Dalton JE, Perzynski AT, Zidar DA, Rothberg MB, Coulton CJ, Milinovich AT, Einstadter D, Karichu JK, Dawson NV

Background: Inequality in health outcomes in relation to Americans' socioeconomic position is rising.
Objective: First, to evaluate the spatial relationship between neighborhood disadvantage and major atherosclerotic cardiovascular disease (ASCVD)-related events; second, to evaluate the relative extent to which neighborhood disadvantage and physiologic risk account for neighborhood-level variation in ASCVD event rates.
Design: Observational cohort analysis of geocoded longitudinal electronic health records.
Setting: A single academic health center and surrounding neighborhoods in northeastern Ohio.
Patients: 109 793 patients from the Cleveland Clinic Health System (CCHS) who had an outpatient lipid panel drawn between 2007 and 2010. The date of the first qualifying lipid panel served as the study baseline.
Measurements: Time from baseline to the first occurrence of a major ASCVD event (myocardial infarction, stroke, or cardiovascular death) within 5 years, modeled as a function of a locally derived neighborhood disadvantage index (NDI) and the predicted 5-year ASCVD event rate from the Pooled Cohort Equations Risk Model (PCERM) of the American College of Cardiology and American Heart Association. Outcome data were censored if no CCHS encounters occurred for 2 consecutive years or when state death data were no longer available (that is, from 2014 onward).
Results: The PCERM systematically underpredicted ASCVD event risk among patients from disadvantaged communities. Model discrimination was poorer among these patients (concordance index [C], 0.70 [95% CI, 0.67 to 0.74]) than those from the most affluent communities (C, 0.80 [CI, 0.78 to 0.81]). The NDI alone accounted for 32.0% of census tract-level variation in ASCVD event rates, compared with 10.0% accounted for by the PCERM.
Limitations: Patients from affluent communities were overrepresented. Outcomes of patients who received treatment for cardiovascular disease at Cleveland Clinic were assumed to be independent of whether the patients came from a disadvantaged or an affluent neighborhood.
Conclusion: Neighborhood disadvantage may be a powerful regulator of ASCVD event risk. In addition to supplemental risk models and clinical screening criteria, population-based solutions are needed to ameliorate the deleterious effects of neighborhood disadvantage on health outcomes.
Primary Funding Source: The Clinical and Translational Science Collaborative of Cleveland and National Institutes of Health.

PMID: 28847012 [PubMed - indexed for MEDLINE]