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In a 2012 survey of 3897 randomly selected US physicians to assess physicians’ perceived
roles and responsibilities in addressing health care costs, Tilburt and colleagues found that the
responding physicians accepted some responsibility to address health costs, but they were more
likely to assign major cost-reduction responsibility to other groups including, insurers, trial
lawyers, hospitals and health systems, pharmaceutical and device manufacturers, and patients. The
respondents expressed general agreement with several quality initiatives to reduce costs but
reported less enthusiasm for cost-containment involving changes in payment models, such as
eliminating fee-for-service payment. In an Editorial, Emanuel and Steinmetz discuss why physicians
must take the lead in controlling health care costs.
Racial disparities in breast cancer survival are recognized but poorly understood. In an analysis
of population-based data from more than 29 000 Medicare beneficiaries diagnosed with breast
cancer between 1991 and 2005 (7373 black women and 3 sets of 7375 white women matched on
demographics, patient and tumor presentation characteristics, and treatment), Silber and colleagues
found that differences in 5-year survival appear primarily related to presentation characteristics
rather than differences in subsequent treatment. In an Editorial, Mandelblatt and colleagues discuss
factors contributing to racial differences in breast cancer care and outcomes.
In 2013, a kidney transplant recipient with no known relevant exposures died of rabies 18 months
after the transplant. Vora and colleagues investigated the case and found that in retrospect the
donor’s clinical presentation was consistent with rabies. Raccoon rabies virus was detected in
archived brain tissue from the donor, and gene sequencing confirmed transplant as the route of
transmission to the decedent. Three additional organ recipients were asymptomatic and without rabies
virus–specific antibodies. In an Editorial, Kaul discusses donor-derived central nervous
system infections in organ recipients.
Kidney stone disease is common, and some reports suggest an association with systemic diseases,
including cardiovascular disease. To investigate the association between a history of kidney stones
and the risk of coronary heart disease, Ferraro and colleagues analyzed data from 3 large
prospective cohort studies that involved a total of 242 105 participants, 19 678 of whom
had a history of kidney stones. The authors report that during 24 years of follow-up in men and 18
years in women, 16 838 incident cases of coronary heart disease occurred. In analyses adjusted
for potential confounders, the authors found that a history of kidney stones was associated with a
modest increased risk of coronary heart disease in women but not men.
Ms T is a 60-year-old woman whose husband died 9 months after being diagnosed with stage IV
esophageal cancer. She and her husband had no children and they were inseparable through 28 years of
marriage. In the 16 months since his death, Ms T has found it very hard to resume her daily life;
she feels lost, and her grief is profound. In this Clinical Crossroads article, Simon summarizes
findings from a systematic review of the literature on complicated grief, including associated risk
factors, identification and clinical assessment, differential diagnosis, and treatment
Continuing Medical Education
A patient with a 3-year history of chest pain and odynophagia reports recent exacerbation of
symptoms and significant weight loss. Esophageal manometry reveals high swallowing pressures. A
barium swallow was diagnostic. What would you do next?
Highlights. JAMA. 2013;310(4):341-343. doi:10.1001/jama.2013.5222