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In This Issue of JAMA Internal Medicine
February 2015


JAMA Intern Med. 2015;175(2):153. doi:10.1001/jamainternmed.2014.5049


Several recent spontaneous reports have signaled a possible association between tramadol, a popular opioid analgesic, and hypoglycemia. In the first population-based study to assess this risk, Fournier and colleagues used a cohort of 333 996 patients initiating tramadol or codeine therapy from the United Kingdom Clinical Practice Research Datalink. Compared with codeine, the initiation of tramadol therapy was associated with an increased risk of hospitalized hypoglycemia. This finding remained consistent in several secondary and sensitivity analyses. Nelson and Juurlink provide an Invited Commentary.

Invited Commentary, Related Article

Author Audio Interview

Most cardiac arrest patients receiving emergency medical services are provided prehospital advanced life support (ALS); however, supporting evidence for ALS over basic life support (BLS) is limited. In an observational cohort study, Sanghavi and coauthors used Medicare claims from 2009 to 2011 of patients from nonrural counties who experienced out-of-hospital cardiac arrest to compare health outcomes after ALS and BLS. Survival to 90 days and up to 2 years was significantly higher for BLS than ALS patients. Neurological performance was also significantly better among BLS patients. Current prehospital care guidelines should consider prioritizing the principles of BLS, including rapid transport. Callaham provides an Invited Commentary.

Invited Commentary, Continuing Medical Education

In a study of patients with ST-elevation myocardial infarction requiring interhospital transfer, Vora and colleagues examined the association of estimated drive time with reperfusion strategy selection via either primary percutaneous coronary intervention (pPCI) or fibrinolysis. They report that when estimated drive time exceeds 30 minutes, only 42.6% of patients transferred for primary PCI achieved first-door-to-balloon time of 120 minutes or less, but only 52.7% of eligible patients with an estimated drive time of more than 60 minutes received fibrinolysis. The authors conclude that neither fibrinolysis nor pPCI is being used optimally to achieve guideline-recommended reperfusion targets in the United States and that in eligible patients unable to receive timely pPCI, fibrinolysis followed by early transfer may be an option if the benefits of timely reperfusion outweigh bleeding risk. Claeys provides an Invited Commentary.

Invited Commentary

Tobacco use in the United States has declined, but socioeconomic disparities in smoking prevalence and tobacco-related disease remain. In a randomized clinical trial, Haas and coauthors demonstrate that interactive voice response (IVR)-facilitated outreach that linked disadvantaged smokers who had recently seen a primary care clinician to a program that included (1) telephone-based motivational counseling, (2) 6 weeks of free nicotine replacement (NRT) therapy, (3) access to community-based referrals to address sociocontextual mediators of tobacco use, and (4) integration of this program with an individual’s care team through the electronic health record was effective compared with “usual care.” Proactive IVR-facilitated treatment outreach in addition to counseling and NRT is effective for treating smokers of low socioeconomic status. Joseph and Fu provide an Invited Commentary.

Invited Commentary

To evaluate radiation dose responses on the prevalence of thyroid nodules in atomic bomb survivors exposed in childhood, in a survey study, Imaizumi and colleagues investigated between 2007 and 2011 Hiroshima and Nagasaki atomic bomb survivors who were younger than 10 years at exposure. The prevalence of thyroid nodules was significantly associated with thyroid radiation dose. However, radiation exposure was not associated with thyroid nodules smaller than 10 mm in diameter.

Although hospital physician staffing and composition may be affected by annual scientific meetings, patient outcomes and treatment patterns during meeting dates are unknown. Jena and colleagues analyzed differences in 30-day mortality and treatment utilization among patients admitted with acute myocardial infarction, heart failure, or cardiac arrest during dates of national cardiology conferences compared with identical nonmeeting days in the 3 weeks before and after conferences. The authors found that high-risk patients with heart failure and cardiac arrest hospitalized in teaching hospitals had lower 30-day mortality when admitted during dates of national cardiology meetings. High-risk patients with acute myocardial infarction admitted to teaching hospitals during meetings were less likely to receive percutaneous coronary intervention, without any mortality effect. Redberg provides an Editor’s Note.

Editor’s Note

Tenofovir disoproxil fumarate use has been associated with decline in the estimated glomerular filtration rate (eGFR) when used as part of antiretroviral treatment by human immunodeficiency virus type 1 (HIV-1)–infected persons, but limited data are available for risk when used as preexposure prophylaxis (PrEP) for HIV-1 prevention. In a large randomized clinical trial, Mugwanya and colleagues investigated whether daily oral tenofovir disoproxil fumarate–based PrEP resulted in glomerular renal dysfunction among 4696 African HIV-1 uninfected adult men and women. Use of PrEP was associated with a modest but statistically significant decrease in eGFR, which was nonprogressive for up to 36 months of study follow-up and was not accompanied by a significant increase in the likelihood of a clinically relevant change in eGFR. Katz provides an Invited Commentary.

Invited Commentary

Increasing access to care may be insufficient to improve the health of patients with diabetes mellitus and unmet basic needs. Berkowitz and colleagues evaluated several potentially modifiable material need insecurities and their relationship with diabetes control and the use of health care resources. On the basis of prior work, they hypothesized that difficulty paying for food and medications would be associated with poor diabetes control and greater use of health care resources even when accounting for other material need insecurities. The authors found that, despite near universal health care access, patients with material need insecurities have worse diabetes control and higher care utilization.