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In This Issue of JAMA Internal Medicine
September 2014


JAMA Intern Med. 2014;174(9):1425-1427. doi:10.1001/jamainternmed.2013.10670

The effect of strict blood pressure (BP) control on clinical outcomes in patients with chronic kidney disease is unclear. In a retrospective cohort study of 77 765 patients, Kovesdy and coauthors measured the effect of systolic BP on all-cause mortality. Their findings suggested an association between stricter systolic BP control and higher all-cause mortality in patients with chronic kidney disease.

Low-risk prostate cancer is unlikely to cause symptoms or affect survival if left untreated; however, most older men diagnosed as having low-risk prostate cancer receive up-front treatment with prostatectomy or radiation therapy. In a population-based cohort study, Hoffman and coauthors evaluated the impact of 2145 physicians on the management of low-risk prostate cancer in 12 068 patients with observation vs up-front treatment. The variance in observation vs up-front treatment attributable to the diagnosing urologist was twice the variance attributable to measured patient characteristics such as age, comorbidity, and prostate-specific antigen level. Men diagnosed as having low-risk prostate cancer by urologists who treated prostate cancer were more likely to receive up-front treatment and, when treated, were more likely to receive a treatment that their diagnosing urologist used to treat non–low-risk disease.

Related Article

Primary androgen-deprivation therapy (ADT) is widely used to treat localized prostate cancer, although data supporting this practice are very limited. Lu-Yao and coauthors performed a population-based cohort study to assess the impact of primary ADT on cancer-specific and overall survival in men with localized (T1/T2) prostate cancer. Using data from 66 717 Medicare patients 66 years or older collected by the Surveillance, Epidemiology, and End Results (SEER) Program, the analysis compared results in the top tertile of ADT use with the bottom tertile of ADT use. With a median follow-up of 110 months, primary ADT was not associated with improved 15-year cancer-specific or overall survival for men with either moderately or poorly differentiated cancers. Trinh and Schrag set the findings in clinical context in an Invited Commentary.

Invited Commentary, Related Article

Continuing Medical Education

As payers move towards bundled payments, understanding sources of payment variation—including use of medical consultants—is important. In an observational retrospective cohort study, Chen and coauthors measured the number of inpatient medical consults for fee-for-service Medicare patients undergoing colectomy or total hip replacement (THR) between January 1, 2007, and December 31, 2010, at US acute care hospitals. They found wide variation across hospitals (interquartile range [IQR], 50%-91% for colectomy; IQR, 36%-90% for THR). Variation in use of medical consultations was greater for colectomy patients without complications (IQR, 47%-79%) compared with those with complications (IQR, 90%-95%); results stratified by complications were similar for THR. In an Invited Commentary, Sharma describes the challenges of standardizing medical consults.

Invited Commentary, Continuing Medical Education

Author Audio Interview

In a prospective, point-prevalence study, Devlin and coauthors assessed the frequency of omissions of clinically significant overnight issues during morning handover and identified factors that influence whether handover of these issues occurs. By directly observing 26 morning sign-in rounds at 2 tertiary-care academic medical centers, they discovered that the on-call trainee omitted 40% (95% CI, 32%-48%) of clinically significant issues during morning handover and did not document any information in the patient’s medical record for 86% (95% CI, 80%-92%). On-call residents who structured their morning handover by “running the list” patient by patient were significantly more likely to hand over clinically significant overnight issues to the daytime team. In an accompanying Perspective, Katz highlights the clinical significance of this study.

Related Article

Results from the landmark Ezetimibe and Simvastatin in Hypercholesterolemia Enhances Atherosclerosis Regression (ENHANCE) trial were announced in January 2008, demonstrating that ezetimibe use lowered cholesterol levels but did not slow the progression of atherosclerosis. Ross and coauthors examined the association of this announcement with national patterns of ezetimibe prescribing among a national sample of adults continuously enrolled in a large US pharmacy benefit manager from 2007 to 2010. Within this group, 29% obtained at least 1 prescription for a lipid-lowering agent, of whom 18% were prescribed ezetimibe and 95% another lipid-lowering agent, predominantly statins. Ezetimibe use peaked prior to announcement of the results of the ENHANCE trial, although nearly 2% continued to use ezetimibe afterwards, particularly as monotherapy in contrast to concomitant use with other lipid-lowering agents. Announcement of the ENHANCE trial was associated with significantly fewer ezetimibe therapy initiations and significantly more ezetimibe therapy discontinuations, particularly of ezetimibe monotherapy.

Clinical guidelines regarding the use of catheter-directed thrombolysis (CDT) in the treatment of acute proximal lower extremity or caval deep vein thrombosis (DVT) are conflicting. In a nationwide observational study of US adults from the Nationwide Inpatient Sample database, Bashir and coauthors evaluated trends in CDT utilization as a treatment modality for DVT and performed a propensity score–matched comparative safety analysis between patients treated with anticoagulation alone vs those treated with CDT plus anticoagulation. They found that in spite of low initial rates of CDT utilization, its use increased steadily from 2005 to 2010. In addition, compared with anticoagulation alone, CDT plus anticoagulation was associated with higher morbidity and resource utilization without any significant difference in mortality.

Clinical Review & Education

Researchers conducting randomized clinical trials may find themselves subject to legal subpoenas for interim data. When a subpoena demands premature disclosure of unblinded data, there is potential for damage to the scientific integrity and reputation of the ongoing trial. Kernan and coauthors describe general issues raised by subpoenas for trial data and the particular case of a 2012 subpoena served on investigators from Yale University. Mello and Cohen provide an Invited Commentary.

Invited Commentary

Author Audio Interview