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In This Issue of JAMA Internal Medicine
May 2016


JAMA Intern Med. 2016;176(5):579-581. doi:10.1001/jamainternmed.2015.4876

Launay and colleagues conducted an open-label, multicenter, 1:1:1 parallel group trial in France where 437 adults with hepatitis B (HBV) seronegative human immunodeficiency virus 1 (HIV-1) with CD4 cell counts of more than 200 cells/μL, were randomly assigned to receive 3 intramuscular standard dose (20 μg) injections of recombinant HBV vaccine at weeks 0, 4, and 24 (IM20 × 3 group, n = 145); 4 intramuscular double dose (40 μg) injections at weeks 0, 4, 8, and 24 (IM40 × 4 group, n = 148); or 4 intradermal low dose (4 μg) injections at weeks 0, 4, 8, and 24 (ID4 × 4 group, n = 144). The percentage of responders at month 42 was 41% in the IM40 × 4 group and 44% in the ID4 × 4 group. The duration of response was longer in the IM40 × 4 group than in the IM20 × 3 group but did not differ between the ID4 × 4 group and the IM20 × 3 group. The 4 intramuscular double dose vaccine regimens improved long-term immune response in adults with HIV-1.

In this study, Schulman-Marcus and colleagues performed a descriptive analysis of 194 444 stable patients who had a coronary angiogram prior to noncardiac surgery in the National Cardiovascular Data Registry CathPCI Registry from 2009 to 2014. They found that a majority of patients undergoing diagnostic catheterization were site-reported as asymptomatic. Obstructive coronary artery disease was found in about half the patients, and treatment recommendations for this cohort were split between medical or conservative therapy and revascularization. Of patients who received percutaneous coronary intervention, drug-eluting stents were used in less than half. Findings highlight management dilemmas in this population and the need for better evidence-based guidelines and practices.


Miner and colleagues assessed the responses of smartphone-based conversational agents (eg, Apple’s Siri) to questions related to mental health, interpersonal violence, and physical health. Responses were recorded and classified from 68 phones with 4 conversational agents based on ability to recognize a crisis, respond with respect, and refer to an appropriate helpline. Although all 4 conversational agents are capable of recognizing health crises, it was noticed that none of these agents referred to a helpline when users expressed concerns about depression or domestic violence. Only 2 conversational agents referred users to a suicide prevention helpline and only 1 referred to a rape helpline. Conversational agents hold potential to deliver effective responses to health crises that could trigger timely interventions, but at present their responses are suboptimal.

Editor’s Note

Schoenfeld and colleagues conducted an audit study using standardized patients to assess the quality of care provided by companies that offer virtual visits for common acute illnesses. A statistically significant variation was found in guideline adherence among virtual visits companies and by condition but not by mode of communication (videoconference versus telephone versus webchat). This study provides, to date, the first evaluation in the quality of care by companies that offer virtual visits for management of common acute illnesses.

Invited Commentary

Considerable efforts have been undertaken to relate single nutrients with bone health. To this point, results are inconsistent. At the same time, suboptimal single nutrient intake does not occur in isolation, but rather reflects a poor diet quality. In a large US prospective cohort study that included 90 014 postmenopausal women, Haring and colleagues found that higher diet quality based on a Mediterranean diet was associated with a lower risk for hip fractures. These results support that following a healthy dietary pattern may play a role to maintain bone health for postmenopausal women.

Invited Commentary

Tang and colleagues conducted a cross-sectional study to identify clinician factors associated with prostate-specific antigen (PSA) screening in older veterans with limited life expectancy. Of the 826 286 veterans 65 years and older eligible for PSA screening in 2011, 56% of older veterans received PSA screening. This included 39% of the 203 717 men with limited life expectancy. After adjusting for patient demographics, higher PSA screening in patients with limited life expectancy was associated with having a clinician who was an older male and was no longer in training.

Continuing Medical Education

Cross-sectional studies in the United States and Europe have found higher smoking prevalence among unemployed jobseekers relative to employed workers. Prochaska and colleagues conducted a 2-group prospective observational study that sought to examine differences over 12-months’ time in re-employment by smoking status. Participants were 131 daily smokers and 120 nonsmokers, all unemployed jobseekers recruited from employment service settings in the San Francisco Bay Area. At 12-months follow-up, 55.6% of nonsmokers compared with 26.6% of smokers were re-employed. Among those re-employed at 1 year, the average hourly wage was $5 higher for nonsmokers than smokers. Smokers had a lower likelihood of re-employment at 1 year and were paid significantly less than nonsmokers when re-employed. Treatment of tobacco use in unemployment service settings is worth testing for increasing re-employment success and financial well-being.

Editor’s Note

In this qualitative interview study of 28 participants, Schoenborn and colleagues explore the perspectives of primary care practitioners on long-term prognosis in their care of older adults. The primary care practitioners report considering long-term prognosis in a number of clinical scenarios in the care of older adults but balanced the prognosis consideration against various other factors in decision-making. Patient age was found to modulate how prognosis affects participant decision-making. The participants assessed prognosis based on clinical experience rather than using validated tools and often considered prognosis without explicitly discussing it with patients, disagreeing on whether and when prognosis needed to be explicitly discussed. The participants identified numerous barriers to incorporating prognosis in the care of older adults. Despite clinical recommendations to increasingly incorporate patient long-term prognosis in a number of clinical decisions that have long lag time to benefit, primary care practitioners encounter a number of barriers and ambiguities in the implementation of these recommendations.

Invited Commentary