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In This Issue of JAMA Internal Medicine
July 2014


JAMA Intern Med. 2014;174(7):1017-1018. doi:10.1001/jamainternmed.2013.10660

Guidelines recommend both dietary control and statin use to treat high blood cholesterol level, but the recent time trend of food intake among statin users is unknown. Sugiyama and coauthors investigated whether the temporal trend of dietary intake differs by statin use among US adults using National Health and Nutrition Examination Survey data from 1999 through 2010. In 1999-2000, caloric intake was 179 kcal/d less for statin users than for nonusers, but by 2009-2010, owing to a 9.6% increase of caloric intake among statin users and a 1.9% decrease among nonusers, caloric intake no longer differed by statin use. Dietary recommendations may need to be reemphasized for statin users. An Editor’s Note from Redberg gives clinical context to the findings.

Editor’s Note

Serotonin-norepinephrine reuptake inhibitors are understood to be less effective than estrogen in treating hot flashes and night sweats, but these medications have not been simultaneously evaluated in one clinical trial to date. Joffe and coauthors conducted a 3-arm, 8-week randomized clinical trial comparing the efficacy of first-line low-dose hormonal therapy (estradiol, 0.5-mg/d orally) and a serotonin-norepinephrine reuptake inhibitor agent (venlafaxine extended release, 75 mg/d) against placebo for the treatment of vasomotor symptoms (VMS) in 339 perimenopausal and postmenopausal women. Compared with baseline, mean VMS frequency decreased by 53% with estradiol, 48% with venlafaxine, and 29% with placebo. Estradiol reduced VMS by 2.3 (95% CI, 3.1-4.7) more per day than placebo (P < .001), and venlafaxine by 1.8 (95% CI, 0.8-2.7) more per day than placebo (P = .005). No baseline demographic, menopause, or symptom profile characteristic predicted differential response to estradiol or venlafaxine.

Using 2010-2011 Medicare claims and accountable care organization (ACO) physician rosters, Schwartz and coauthors measured 3 related constructs relevant to ACOs’ incentives and their capacity to manage care: stability of assignment from 2010 to 2011; leakage of outpatient care; and contract penetration. Of 524 246 beneficiaries hypothetically assigned to 1 of 145 ACOs in 2010 or 2011, 66.0% were consistently assigned in both years. Unstable assignment was more common among beneficiaries with fewer conditions and office visits but also among those in several high-cost categories, including the highest decile of per-beneficiary spending. Among ACO-assigned beneficiaries, leakage of primary care office visits was minimal, but leakage of specialty visits was substantial, particularly among higher-cost patients. These baseline care patterns among beneficiaries served by ACOs suggest distinct challenges in achieving organizational accountability in Medicare. In an Editor’s Note, Katz and coauthors explain the findings in the context of the Less Is More initiative.

Editor’s Note

Continuing Medical Education

It is unknown whether resveratrol levels achieved with diet are associated with inflammation, cancer, cardiovascular disease, and mortality in humans. In a prospective cohort study of 783 community-dwelling adults 65 years and older living in the Chianti region of Tuscany, Italy, over 9 years of follow-up, Semba and coauthors found that higher dietary intake and urinary levels of resveratrol was not associated with longer life or lower risk of chronic diseases than those with low dietary intake or urinary levels of resveratrol.

The promise of advance care planning rests on the untested assumption that patients’ preferences for future treatments are relatively stable over time. To test this premise, Auriemma and coauthors conducted a systematic review and meta-analysis of studies of the stability of patients’ preferences for treatments near the end of life. They found that most patients’ preferences were stable over time, particularly for patients who were most ill and who had engaged in advance care planning. However, the large variability among studies in the methods used and results obtained suggests the need for both caution in assuming that prior preferences are applicable to current decisions and for future longitudinal research conducted in real-world settings. In an Invited Commentary, Schenker and coauthors consider the current state of advanced care planning.

Invited Commentary

Early hospital readmissions are a common and costly occurrence, and a variety of interventions have been tested to reduce their frequency. In a systematic review and meta-analysis of 47 randomized trials, Leppin and coauthors sought to synthesize the evidence for discharge interventions in reducing early readmissions and explore intervention characteristics most predictive of their varying effects. They found that, overall, discharge interventions are effective at reducing early readmissions but that more effective interventions assessed and enhanced patient and caregiver capacity for postdischarge care.

Measurement of a random urine sample for albumin concentration (UAC) costs less than measuring albumin to creatinine ratio (ACR), but its accuracy might be affected by hydration status. However, the additional creatinine measurement for ACR brings in extra variations across patients and laboratories. In a systematic review and meta-analysis, Wu and coauthors summarize the published information on the diagnostic performance of UAC and ACR for screening the patients with diabetes. They found that UAC, which has high sensitivity and specificity, is comparable to ACR for detection of microalbuminuria in random urine samples among patients with diabetes, when a urine albumin excretion rate of 30 to 300 mg/d in 24-hour timed urine collection is used as the gold standard.

Beaudoin and coauthors investigated an outbreak of severe group A Streptococcus (GAS) infections associated with outpatient liposuction procedures at 2 unregulated cosmetic surgery facilities. Four confirmed and 9 suspected cases, including 1 death, were identified (overall attack rate, 20% [13 of 66]). All confirmed case patients had necrotizing fasciitis and required surgical debridement. Procedures linked to illness were performed by 2 health care workers who were colonized with a GAS strain that was indistinguishable from case patient isolates. Substandard infection control practices were identified. In an Invited Commentary, Morgan and Harris explore the gap in oversight of outpatient cosmetic surgery facilities and call for appropriate infection control practices and consistent patient protections.

Invited Commentary, Continuing Medical Education