Uncertainty surrounds many medical decisions. Decision aids can facilitate patient participation in making these decisions, but these tools remain underused in clinical practice. Little is known about the value of formal patient decision aids compared with credible publicly available Web sites. Frosch et al conducted a randomized controlled trial comparing dedicated decision support interventions for men considering prostate cancer screening with publicly available Web sites from the Centers for Disease Control and Prevention and American Cancer Society. Participants who reviewed a dedicated decision aid had significantly better knowledge about prostate cancer screening and were less likely to request a prostate-specific antigen test than men who accessed public Web sites.
See page 357
Rheumatoid arthritis is a severe inflammatory polyarthritis requiring chronic treatment with disease-modifying antirheumatic drugs. Concerns are increasing regarding the influence of rheumatoid arthritis therapy on the risk of hematological malignant neoplasms. Bernatsky et al used a case-control design nested within a cohort of 23 810 patients with rheumatoid arthritis, assembled from administrative databases covering the population of Quebec, Canada. Adjusting for clinical variables and concomitant medications, the authors used conditional logistic regression to examine potential associations between disease-modifying antirheumatic drug exposures and hematological malignancy risk. Adjusted estimates suggested that hematological cancer risk was most elevated after exposure to cyclophosphamide.
See page 378
The use of activated vitamin D analogues in dialysis patients has been associated with lower mortality, but it is unclear if such a benefit is present in patients with chronic kidney disease who are not yet receiving dialysis. In this study, Kovesdy et al examined the association between treatment with calcitriol and all-cause mortality, the composite of mortality and end-stage renal disease (ESRD), and ESRD separately in 520 patients with moderate and advanced chronic kidney disease. Treatment with calcitriol was associated with significantly lower mortality, lower composite of mortality and ESRD, and a trend toward lower ESRD incidence.
See page 397
The goal of this study was to describe antimicrobial use among a cohort of 214 residents with advanced dementia. A total of 142 residents (66.4%) with advanced dementia received at least 1 course of antimicrobials during a mean 322 days of follow-up. Quinolones and third-generation cephalosporins were the most commonly prescribed antimicrobials. Among 99 decedents, 42 (42.4%) received antimicrobials during the 2 weeks prior to death, of which 41.7% of courses were administered via the parenteral route. There is substantial exposure to antimicrobials among persons with advanced dementia, especially during the 2 weeks prior to death. The implications of this practice from the perspective of the individual treatment burden near the end of life and its contribution to the emergence of antimicrobial resistance in the nursing home setting need further evaluation.
Ensrud et al conducted a prospective study among older women in the Study of Osteoporotic Fractures (SOF) to compare the predictive validity of a simple frailty index (components of weight loss, inability to rise from a chair 5 times without using the arms, and poor energy [SOF index]) easily assessed in a clinical practice setting with that of the more complex frailty index derived from the Cardiovascular Health Study (components of unintentional weight loss, low grip strength, poor energy, slow walking speed, and low physical activity [CHS index]). The authors found that increasing evidence of frailty as defined by either the SOF or CHS index was similarly associated with an increased risk of adverse outcomes. Area under the curve and −2 log likelihood statistic comparisons revealed no differences between models with the SOF index vs models with the CHS index in discriminating falls, disability, nonspine fracture, hip fracture, or death. The authors concluded that the simple SOF index predicted risk of these adverse outcomes as well as the more complex CHS index and may provide a useful definition of frailty to identify high-risk older women in clinical practice.
Age-adjusted receiver operating characteristic curves for prediction of recurrent falls with the SOF and CHS frailty indexes.
See page 382
In This Issue of Archives of Internal Medicine. Arch Intern Med. 2008;168(4):346. doi:10.1001/archinternmed.2007.112