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In This Issue of JAMA Internal Medicine
January 2014


JAMA Intern Med. 2014;174(1):1-3. doi:10.1001/jamainternmed.2013.10630


Overweight and obesity likely cause ischemic heart disease (IHD); however, whether coexisting metabolic syndrome is a necessary condition is unknown. Thomsen and Nordestgaard tested this hypothesis in 71 527 individuals from the Copenhagen General Population Study. During a median of 4 years of follow-up, they recorded 634 incident myocardial infarction and 1781 incident IHD events, finding that overweight and obesity were associated with increased risk of myocardial infarction and IHD independent of the presence or absence of metabolic syndrome. Jackson and Stampfer set the findings in context for clinicians and patients in an Invited Commentary.

Invited Commentary

Lifestyle changes after acute coronary syndrome reduce cardiovascular risk but are difficult for patients to achieve. In a 2-arm, parallel-group, multicenter randomized clinical trial, Cohen and coauthors sought to determine whether a nurse/dietician-led cardiovascular risk factor education program would improve risk factor reduction over the longer term after an acute coronary syndrome. They found no significant difference between the groups at 12 months for the primary outcome (smoking cessation, physical activity ≥3 hours per week, ≥5% reduction in waist circumference, or ≥4% reduction in weight). In an Invited Commentary, Fihn discusses cardiovascular risk factor interventions in the context of health care reform.

Invited Commentary

Patients with chest pain represent a high health care burden; it may be possible to identify a patient group with a low short-term risk of adverse cardiac events who are suitable for early discharge. In a randomized parallel-group trial of 542 patients, Than and coauthors compared an experimental pathway using the ADAPT (A 2-hour Accelerated Diagnostic Protocol to Assess patients with chest Pain symptoms using contemporary Troponins as the only biomarker) accelerated diagnostic protocol with a standard-care pathway, finding that using the accelerated diagnostic protocol in the experimental pathway almost doubled the proportion of patients with chest pain discharged early. Rahko considers the structural challenges for addressing the burden of low-risk cardiac chest pain in the emergency department in an Invited Commentary.

Invited Commentary

Hospital CEOs can shape the priorities and performance of their organizations, and the degree to which their compensation is based on their hospitals’ quality performance is not well known. In a retrospective observational study, Joynt and coauthors sought to characterize CEO compensation and examine its relationship with quality metrics. They studied 2681 private, nonprofit US hospitals, overseen by 1877 CEOs, finding that the CEOs in the sample had a mean compensation of $595 781 in 2009. CEO pay was associated with the number of hospital beds overseen ($550 for each additional bed), teaching status ($425 078 more at major teaching vs nonteaching hospitals), and urban location. They found no association between CEO pay and hospitals’ performance on process quality, mortality rates, readmission rates, or measures of community benefit. In an Invited Commentary, Browner addresses the findings from the perspective of a hospital CEO.

Invited Commentary

Alcohol dependence is a major burden for medicine, and available medications are rarely used. In a randomized clinical trial with 3-arms (placebo, 900-mg dose, and 1800-mg dose), Mason and coauthors showed that gabapentin, a widely prescribed generic calcium channel/GABA (γ-aminobutyric acid)-modulating drug, significantly improved drinking outcomes relative to placebo in outpatients with alcohol dependence. Relative to placebo, patients treated with gabapentin, 1800 mg, were more than twice as likely to have no heavy drinking (number needed to treat [NNT], 5) and more than 4-times more likely to be entirely abstinent (NNT, 8) over the 12-week study. Nunes discusses the challenges of treating alcohol dependence in an Invited Commentary.

Invited Commentary

Continuing Medical Education

Little is known about patients who undergo cardiovascular implantable electronic device (CIED) deactivation. In a study of 150 patients (median age, 79 years; 67% male) who underwent CIED deactivation at a tertiary medical center, Buchhalter and coauthors found that nearly all (99%) patients had poor or terminal prognoses. A majority (79%) of patients underwent deactivation of tachycardia therapies only (to avoid implantable cardioverter-defibrillator shocks); only 6 pacemaker-dependent patients (4%) underwent device deactivation. Approximately half of the deactivation requests (51%) were made by surrogates. Although more than half of the patients (57%) had advance directives, only 1 mentioned the device in his directive. In Invited Commentaries, Matlock and Mandrola discuss the findings from a clinician’s perspective, while Butler and Puri consider the implications for patients and families.

Invited Commentaries 1 and 2

Author Audio Interview

To inform the public debate about clinical testing standards for Food and Drug Administration (FDA) approval, Moore and Furberg examined all new drugs approved in 2008 under current law and policy and followed them for 4 years. The 24 drugs included 10 outpatient drugs, 10 inpatient drugs, and 4 diagnostic tests. The 8 therapeutic drugs deemed innovative enough for expedited FDA review were tested for efficacy in a median of 104 patients receiving the active drug, compared with a median of 580 patients for 12 standard review drugs. Safety questions unanswered at the time of approval were reflected in requirements for 85 postmarketing studies, of which 30% had been completed by early 2013 and 9% had been submitted. Carpenter evaluates the trustworthiness of expedited approval in an Invited Commentary.

Invited Commentary

To address the absence of data on national patterns of breast magnetic resonance imaging (MRI) use in community practice, Wernli and coauthors evaluate the use of breast MRI in women aged 18 to 79 years from 2005 through 2009. They found improvements in appropriate use of breast MRI, with fewer examinations performed for further evaluation of abnormal mammograms and symptomatic patients and more breast MRI performed for high-risk screening. In an Invited Commentary, Hwang and Bedrosian discuss the clinical implications of this study and the study by Stout and coauthors.

Invited Commentary

Author Video Interview