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In This Issue of JAMA Internal Medicine
September 2015

Highlights

JAMA Intern Med. 2015;175(9):1433-1435. doi:10.1001/jamainternmed.2014.5084
Research

The Mini-Mental State Examination (MMSE) is the proprietary instrument for dementia screening. Tsoi and colleagues performed a meta-analysis on 149 diagnostic studies with over 49 000 subjects to compare the diagnostic accuracy between the MMSE and 10 other screening tests. Results showed screening tests other than the MMSE were comparably effective, easier to perform, and available for little or no cost. These findings support the increasing use of other tests for dementia screening.

Invited Commentary

Cognitive behavioral therapy for insomnia (CBT-I) is the current gold standard nonpharmacological treatment for insomnia disorders. To examine the efficacy of CBT-I for insomnia comorbid with psychiatric and/or medical conditions, Wu and colleagues conducted a meta-analysis of 37 randomized clinical trials with an adult patient population meeting criteria for insomnia and a co-occurring condition and found medium to large improvements in sleep efficiency, sleep onset latency, wake after sleep onset, and sleep quality. There were also overall small improvements in comorbid outcomes, which were greater in psychiatric populations than in medical populations. Wu and colleagues concluded that CBT-I is effective for improving insomnia symptoms and sleep parameters for patients with comorbid insomnia.

Invited Commentary

In a prospective cohort study with a 2-year follow-up, Ageno and colleagues enrolled 604 patients with splanchnic vein thrombosis and assessed the incidence rates of major bleeding and thrombosis. Ageno and colleagues found annual rates of both outcomes exceeding 10% in patients with liver cirrhosis. In this population, anticoagulant treatment administered to well-selected patients appears safe and effective. In patients with solid or hematologic cancer and in patients with unprovoked events, the long-term risk of thrombosis appears to outweigh the risk of bleeding. In patients with transient risk factors, the risk of both outcomes is low.

Invited Commentary

The extent of mammography screening varies widely across counties in the United States, providing a natural opportunity to examine its relationships with breast cancer diagnoses, tumor size, and mortality. Harding and colleagues found that screening extent was strongly associated with breast cancer incidence but not mortality. While screening extent was associated with an increased diagnosis of small breast cancers, there was no concomitant decrease in the diagnosis of larger breast cancers or locally advanced and metastatic breast cancers. Together, these findings suggest widespread overdiagnosis.

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Invited Commentary

Author Audio Interview

Elderly patients share control-of-health information with family members or other informal caregivers to help meet changing needs. Patient portals can be helpful for viewing health information and communicating with clinicians, but few explicitly support caregiver roles. Crotty and colleagues conducted a study with older patients and family caregivers to best balance the needs of patients and their caregivers to better design portal access for proxies. Crotty and colleagues found that information sharing may lead to unintended consequences and that control over information is a dynamic process.

Invited Commentary

The National Lung Screening Trial demonstrated a reduction in lung cancer mortality among participants screened with low-dose computed tomography vs chest radiography. In February 2015, Medicare announced its decision to cover annual lung screening for patients with a significant smoking history. These guidelines promote smoking cessation treatment as an adjunct to screening, but the frequency and effectiveness of physician-delivered smoking cessation interventions following lung screening are unknown. Park and colleagues performed a matched case-control study of 3336 National Lung Screening Trial participants who were smokers at enrollment and prevalence of physician-delivered 5As (Ask, Advise, Assess, Assist, and Arrange follow-up) following lung screening. Associated smoking behavior changes were then examined.

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Invited Commentary

A concern about offering current smokers lung cancer screening is that it may be perceived as an alternative to quitting. Zeliadt and colleagues interviewed veterans who were offered screening during routine primary care visits as part of a rollout of a lung cancer screening program and found that nearly all patients offered screening believed they would benefit. Patients with no suspicious findings were eager to interpret the results as evidence that smoking was not causing them harm. When small nodules were identified that did not require immediate action, many patients described feeling that screening had caught their disease early and repeated imaging would continue to provide protection. These findings suggest that there are many ways screening can exacerbate cognitive biases and potentially lower motivation to quit smoking among long-term smokers.

Invited Commentary

Allopurinol is a conventional first-line drug used for treating hyperuricemia and gout. However, it has been associated with fatal hypersensitivity reactions in rare cases. In this nationwide population-based study of Taiwanese adults, Yang and colleagues found that the annual incidence of allopurinol hypersensitivity was 4.68 per 1000 new users and related death was 0.39 per 1000 new users. Female sex, high initial dose, age older than 60 years, and comorbid renal or cardiovascular disorders were all associated with increased risk, particularly among patients with asymptomatic hyperuricemia and either chronic kidney diseases or cardiovascular disorders.

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Editor’s Note

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