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Among older adults, prediction of coronary heart disease (CHD) events using traditional risk factors is less accurate than for middle-aged adults. In a prospective population-based cohort of 2192 adults without preexisting cardiovascular disease and aged 70 to 79 years at baseline, Auer and colleagues examined whether baseline electrocardiographic (ECG) abnormalities or development of new and persistent ECG abnormalities were associated with an increased risk of incident CHD events. During a median 6.4 years' follow-up, the authors found that major and minor ECG abnormalities were associated with an increased risk of CHD and improved the prediction of CHD events beyond traditional cardiovascular disease risk factors. In an editorial, Greenland discusses whether a resting ECG should be a routine CHD risk assessment test for healthy asymptomatic adults.
Observational studies that compared losartan with other angiotensin II receptor blockers have suggested that losartan may be associated with increased mortality among patients with heart failure. In an analysis of Danish national registry data (1998-2008), Svanström and colleagues compared the risk of all-cause mortality among 4397 patients initiating losartan therapy and 2082 patients initiating candesartan therapy for heart failure. The authors found no increase in all-cause mortality risk associated with losartan use.
Proposals to cut US health care costs commonly focus on reductions in payment levels, benefit structures, and eligibility. Berwick and Hackbarth discuss potential health care cost savings associated with a systematic approach to reducing waste in 6 categories—failures of care delivery, failures of care coordination, overtreatment, administrative complexity, pricing failures, and fraud and abuse—which they estimate could result in a 20% reduction in total health care expenditures.
In this Rational Clinical Examination article, Nishijima and colleagues report results of a systematic review and data analysis to assess the precision and accuracy of symptoms, signs, laboratory tests, and bedside imaging studies to identify intra-abdominal injury in patients who had sustained blunt abdominal trauma. Twelve studies (10 757 patients) assessing clinical findings and 22 studies (12 089 patients) assessing bedside ultrasonography were included in the analyses. Among the authors' findings was that a positive bedside ultrasound examination had the highest accuracy of all individual findings, but a normal result did not exclude intra-abdominal injury. The authors suggest that combinations of clinical findings may be most useful to identify patients not requiring further evaluation.
A patient with a history of severe eczema presents with erythematous scaly patches on his face, chest, and back. Five days after initiating treatment with oral doxycycline and tacrolimus ointment, he develops painful vesicles in the same distribution. What would you do next?
High-resolution imaging methods may revive hospital autopsy procedures.
Should healthy men take statins?
ArticleArticle ONLINE POLL AND AUTHOR AUDIO INTERVIEW
Accountable care organizations and antitrust issues
“Experienced clinicians will efficiently follow the same diagnostic pathways to arrive at the same correct diagnoses. Or so I thought.” From “Subjective Case.”
Debut: Dueling Viewpoints
Dr Bauchner summarizes and comments on this week's issue. Go to http://audio.jamanetwork.com/jamaeditorsaudiosummary/pcast_041112.mp3.
How would you help Mr J, a 52-year-old with depressive symptoms who feels socially isolated? Read the case at www.jama.com. Submit your response by April 29 for possible online posting.
Join James T. Pacala, MD, MS, April 18 from 2 to 3 PM eastern time to discuss hearing deficits in older patients. To register, go to http://www.ihi.org/AuthorintheRoom.
Theme Issue on Comparative Effectiveness Research
For your patients: Information about pancreatitis.
This Week in JAMA. JAMA. 2012;307(14):1459. doi:10.1001/jama.2012.435