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In This Issue of JAMA Internal Medicine
March 2014


JAMA Intern Med. 2014;174(3):313-315. doi:10.1001/jamainternmed.2013.10640

Epidemiologic evidence has led to the hypothesis that more intensive treatment strategies for controlling diabetes-related comorbidities such as hyperglycemia, hyperlipidemia, and hypertension would reduce clinical complications such as memory impairment. In a clinical trial of a subset of 2977 randomized persons with type 2 diabetes mellitus from the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial, Williamson and coauthors assessed whether (1) intensive systolic blood pressure treatment to a goal of 120 mm Hg vs a goal of 135 mm Hg or (2) adding a fibrate therapy for persons with well-controlled low-density lipoprotein cholesterol levels would reduce the rate of decline in cognitive function over a 40-month period. The results revealed no overall benefit for either treatment. Data from this same group of participants had already shown that intensive glycemia management was no better for cognitive function than a hemoglobin A1c goal of 7.5%. Dufouil and Brayne assess the clinical impact of the findings in an Invited Commentary.

Invited Commentary

Author Audio Interview

Clinical guidelines have been criticized for encouraging use of β-blockers in noncardiac surgery despite weak evidence. In a Danish nationwide cohort study, Andersson and coauthors examined the risk of major adverse cardiovascular events and all-cause mortality associated with β-blocker therapy among patients with ischemic heart disease undergoing noncardiac surgery. They found that the protective effects associated with β-blocker therapy were limited to patients with concomitant heart failure or recent myocardial infarction and that β-blocker therapy during noncardiac surgery might even be harmful to people with stable ischemic heart disease. In an Invited Commentary, Whelton and Bansal set the findings in context of earlier research.

Invited Commentary

Many people meditate to reduce psychological stress and stress-related health problems, but in prior reviews, it has been unclear whether the benefits of meditation programs stem from placebo effects. Goyal and coauthors conducted a systematic review and meta-analysis to evaluate 47 randomized trials that controlled for placebo effects. The authors found moderate evidence that mindfulness meditation programs improve anxiety, depression, and pain and found low evidence that they improve stress/distress and mental health-related quality of life. Goroll provides an Invited Commentary.

Invited Commentary

Continuing Medical Education, Author Audio Interview

Although hospitalized older adults are often unable to make their own medical decisions, little is known about the frequency of decision making by family members or other surrogate decision makers or about the outcomes of surrogate decision making and its implications for hospital care. Torke and coauthors conducted a prospective observational study in the internal medicine and medical intensive care unit services of 2 hospitals in 1 Midwest city to describe the scope of surrogate decision making and hospital course and outcomes for older adults. They found that 47.4% of older adults required at least some surrogate involvement. More than half required decisions about life-sustaining care (mostly addressing code status), and nearly half needed decisions about procedures and surgical procedures or discharge planning. Patients who required a surrogate experienced a more complex hospital course with greater use of ventilators, artificial nutrition, and greater length of stay. In an Invited Commentary, Schenker and Barnato call for increased attention to the mechanism of surrogate decision making.

Invited Commentary

The challenge presented by warfarin drug-drug interactions with antibiotics has been extensively cited, but available research has been unable to quantify the scope of this problem in a large, real-world warfarin population. Clark and coauthors conducted a retrospective, longitudinal cohort study of 12 000 patients comparing international normalized ratio (INR) effects among 3 distinct groups of prevalent warfarin users—those who (1) purchased an antibiotic, (2) had a medical visit for upper respiratory tract infection but received no antibiotic, and (3) purchased only a warfarin refill. The mean INR change was negligible in all 3 groups, but the risk of a follow-up INR of 5.0 or greater was higher in both the patients who purchased an antibiotic and had an upper respiratory tract infection compared with the patients who only refilled their warfarin. Antibiotics that interfere with warfarin metabolism posed a greater risk of a follow-up INR of 5.0 or greater than antibiotics thought to disrupt vitamin K synthesis or without a known interaction mechanism. Katz provides additional comment in an Editor’s Note.

Editor’s Note

Despite the significant need, there is little decision support available to help older women with decision making around mammography screening. Schonberg and coauthors aimed to develop and evaluate a mammography screening decision aid for women 75 years or older, designing the decision aid using international standards and considering older adults’ decision-making processes. When the decision aid was evaluated among 45 women aged 75 to 86 years recruited from a large academic primary care practice in Boston, Massachusetts, in a pretest/posttest trial, nearly all women found the decision aid helpful and would recommend it to a friend. Receipt of the decision aid led to improved knowledge of mammography risks and benefits and resulted in fewer older women intending to be screened, particularly those with a life expectancy of 9 years or less.

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