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This Week in JAMA
June 4, 2008

This Week in JAMA

JAMA. 2008;299(21):2475. doi:10.1001/jama.299.21.2475

Colorectal cancer in a first-degree relative increases one's personal risk of the disease, but the relationship of family history to cancer recurrence and survival is uncertain. Chan and colleagues Article assessed disease-free survival, recurrence-free survival, and overall survival in a prospective study of patients with stage III colon cancer who were enrolled in a randomized trial of adjuvant chemotherapy. The authors found that among patients with stage III disease and receiving adjuvant chemotherapy, a family history of colorectal cancer was associated with a significant reduction in cancer recurrence and death. In an editorial, Pasche Article discusses the molecular genetics of colorectal cancer.

Low levels of high-density lipoprotein cholesterol (HDL-C) are associated with an increased risk of ischemic heart disease, but whether this is a causal effect is not clear. In analyses of data from 2 general population studies and 1 case-control study of ischemic heart disease in Copenhagen, Denmark, Frikke-Schmidt and colleagues assessed whether low levels of HDL-C concentration caused by inherited loss of function mutations in the ABCA1 gene are associated with an increased risk of ischemic heart disease. In comparisons with noncarriers of the mutations, the authors found no association between low levels of HDL-C due to heterozygosity for the mutations and increased ischemic heart disease risk.

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Symptomatic heart failure is associated with a median life expectancy of less than 5 years. Whether patients with heart failure understand their prognosis is not clear. Allen and colleagues Article interviewed 122 ambulatory patients with heart failure to assess patients' expectations of survival and compared these with life expectancies calculated using a validated disease-specific model. The authors found that a majority of patients substantially overestimated their remaining life span compared with model-based predictions (median, 13.0 years vs 10.0 years, respectively). In an editorial, Yancy Article discusses the accuracy of tools to predict prognosis in chronic heart failure and considers the benefits and risks of sharing this information with patients.

Randomized clinical trials (RCTs) of diabetes interventions often examine physiological or laboratory outcomes rather than patient-important outcomes, such as death and quality of life (morbidity, pain, function). To determine the extent to which ongoing and future RCTs in diabetes will ascertain patient-important outcomes, Gandhi and colleagues searched 3 RCT registries in November 2007, identified phase 2 through 4 RCTs actively enrolling patients, and randomly sampled 50% for review. Of the 436 trials reviewed, the authors found that only 18% of ongoing RCTs in diabetes have outcomes that patients consider important as primary end points.

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Mrs T has type 2 diabetes, chronic hypertension, and a history of gastric bypass surgery, and she is contemplating pregnancy. Coustan discusses the management of diabetes prior to and during pregnancy and discusses the risks and benefits of preconception gastric bypass surgery for a woman with type 2 diabetes.

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“[A]s my friend Bonnie taught me, carrying this metaphor to every affected individual can be counterproductive, inappropriate, even destructive.” From “Waging Peace in the War on Cancer.”

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Congress has passed the Genetic Information Nondiscrimination Act, which bans insurers and employers from using genetic information to determine health coverage and to make hiring, firing, and other employment-related decisions.

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Presidential health and the public's need to know

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Legal barriers to health system reform

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Join Wendie Berg, MD, PhD, June 18 from 2 to 3 PM eastern time to discuss screening women at high risk of breast cancer with mammography plus ultrasound vs mammography alone. To register, go to http://www.ihi.org/AuthorintheRoom.

Dr DeAngelis summarizes and comments on this week's issue. Go to http://jama.ama-assn.org/misc/audiocommentary.dtl.

How would you manage a 70-year-old man with severe coronary and peripheral artery disease who presents with acute-onset slurred speech and left facial droop? Go to www.jama.com, read the case, and submit your response, which may be selected for online publication. Submission deadline is June 25.

For your patients: Information about pregnancy and diabetes.

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