Two articles in this issue address the clinical challenge of identifying patients with chronic kidney disease (CKD) who are at risk of progression to kidney failure. Peralta and colleagues Article report that compared with reliance on creatinine-based estimated glomerular filtration rate alone, a triple-marker approach that combined measurement of creatinine, cystatin C, and the urine albumin-to-creatinine ratio was associated with improved prediction of end-stage renal disease and all-cause mortality. In an analysis of demographic and clinical data from patients with CKD, Tangri and colleagues Article found that a model that included results of routine laboratory tests accurately predicted a progression to kidney failure. In an editorial, Tonelli and Manns Article discuss the clinical utility of new approaches to risk assessment among patients with CKD.
In an analysis of data from Medicare beneficiaries who underwent primary or revision total hip arthroplasty between 1991 and 2008, Cram and colleagues examined long-term trends in patient-related factors and a number of outcome measures. Among the authors' findings were that between 1991 and 2008, patient age and comorbidities increased, while hospital length of stay and rates of in-hospital mortality decreased; the proportion of patients discharged home decreased, the proportion discharged to skilled care increased, and 30-day all-cause readmission rates increased.
The use of whole-genome sequencing in the diagnosis of clinically challenging cancers is described in 2 articles in this issue. In the first article, Link and colleagues Article report the identification of a novel TP53 cancer susceptibility mutation in a woman who had early-onset breast and ovarian cancer and therapy-related acute myeloid leukemia, despite not having significant family history of cancer—a finding with important implications for her children. Welch and colleagues Article report results of whole-genome sequencing in a patient initially diagnosed and treated for acute myeloid leukemia and who was awaiting allogeneic stem cell transplant. Whole-genome sequencing performed on a sample of the patient's pretreatment bone marrow cells revealed a novel and cytogenetically invisible fusion oncogene [t(15;17)] associated with acute promyelocytic leukemia—which altered the patient's treatment plan and prognosis. In an editorial, Pasche and Absher Article discuss innovations in genetic testing and the promise of personalized medicine.
Clinical inertia has been described by Phillips and colleagues as a “failure of health care providers to initiate or intensify therapy when indicated.” In light of clinical trial data suggesting worse outcomes among patients receiving more intensive treatment for diabetes, hypertension, and dyslipidemia, Giugliano and Esposito present an alternate interpretation of clinical inertia, which posits that it may be a clinical safeguard or response to uncertainty in the midst of today's medication-intensive approach to disease management.
“Upon returning to his room with ice cream, I encountered a remarkably changed patient. . . . ‘Boy!’ he exclaimed. ‘I’ve waited so long for this!’” From “The Ice Cream Man.”
New findings indicate that measuring the rate of increase of a prostate-specific antigen level adds minimal benefit to traditional screening methods for prostate cancer.
Reforming the World Health Organization
Ethical enrollment of research participants
Integrating health services research and clinical practice
Join Lydia A. Bazzano, MD, PhD, Wednesday, May 18, from 2 to 3 PM eastern time to discuss antihypertensive treatment and secondary prevention of cardiovascular disease among those without hypertension. To register, go to http://www.ihi.org/AuthorintheRoom.
How would you manage a patient with a renal mass discovered with magnetic resonance imaging (MRI) that was not addressed clinically for several months? Go to www.jama.com to read the case, and submit your response, which may be selected for online publication. Submission deadline is May 1.
For your patients: Information about cognitive impairment and money management.
This Week in JAMA . JAMA. 2011;305(15):1511. doi:10.1001/jama.2011.479