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In This Issue of JAMA Internal Medicine
January 2017


JAMA Intern Med. 2017;177(1):1-3. doi:10.1001/jamainternmed.2016.6124


In this randomized trial of 302 nursing home residents with advanced dementia, Hanson and colleagues tested the Goals of Care decision aid intervention and found that it was effective to improve quality of communication and palliative care treatment plans, and reduce hospitalization rates for nursing home residents with advanced dementia. Unroe and colleagues provide the Invited Commentary.

Invited Commentary

In this randomized clinical trial, Agar and colleagues assigned 247 adults with a palliative diagnosis and delirium to 1 of 3 groups if they were experiencing behavioral, communication, and/or perceptual delirium symptoms: dose-titrated risperidone, haloperidol, or placebo oral solution for 72 hours. Delirium symptoms were better controlled in the placebo group compared with either the haloperidol or risperidone groups. These data suggest that approaches that identify delirium early, treat underlying precipitant(s) if appropriate, and provide other evidence-based supportive measures provide better reduction in delirium symptoms associated with distress than the addition of an antipsychotic. Maust and Kales provide the Invited Commentary.

Invited Commentary

Continuing Medical Education

Humphreys and colleagues examined the effect of Florida’s “stand your ground” self-defense law on patterns of violent mortality over a 9-year period (2005-2014). The Florida law was the first to safeguard an individual’s right to protect themselves using lethal force when encountering perceived threats to health and safety. Humphreys and colleagues found that the implementation of the law coincided with an increase in homicide (24.4%) and firearm homicide (31.6%). Comparing these effects with trends in 4 control states, Humphreys and colleagues were unable to identify comparable effects. Further consideration is required of laws that encourage members of the public to discharge lethal force in public places. In Florida, this appears to have had a detrimental effect on health and safety.

Author Audio Interview

In this population-based study, Gomes and colleagues report the results of a time-series analysis evaluating the effect of the introduction of limits to reimbursement levels of blood glucose test strips (BGTS) by provincial drug funders in Ontario, Canada. In this study of over 800 000 individuals with diabetes, quantity limits for BGTS led to no changes in rates of emergency department visits for hypoglycemia, hyperglycemia, or mean glycated hemoglobin. These results remained consistent in a sensitivity analysis among high-volume users of BGTS and when stratified by type of diabetes therapy used by included patients.

In this study, Puttnam and colleagues performed a secondary analysis of the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) to test whether participants randomized to the thiazide-type diuretic chlorthalidone had lower risk of hip and pelvic fractures than participants randomized to the calcium channel blocker amlodipine or the angiotensin-converting-enzyme inhibitor lisinopril. During the in-trial period, 22 180 participants randomized to chlorthalidone had a statistically significant 21% lower risk of fractures versus amlodipine or lisinopril combined and a 25% significantly lower risk versus lisinopril. Over the in-trial and posttrial period, the cumulative incidence of fractures was 13% lower in participants assigned to chlorthalidone versus assignment to lisinopril or amlodipine combined and versus each medication separately. These findings provide evidence for the beneficial effect of thiazide-type diuretic therapy for reducing hip and pelvic fracture risk compared with other antihypertensive medications. Colón-Emeric and Lee provide the Invited Commentary.

Invited Commentary

In this observational study, Hickey and colleagues analyzed whether prosthetic aortic valve models display unexpected patterns in freedom from mortality or reintervention using routinely collected national registry data and record linkage. From 43 782 biological and 11 084 mechanical prostheses implanted over a 15-year period in England and Wales, with a median follow-up of 4.1 years, Hickey and colleagues identified 2 biological valves displaying increased hazards. Clinical registry data can be used to augment postmarket surveillance programs.

In the National Institutes of Health–AARP (formerly known as the American Association of Retired Persons) Diet and Health Study, Inoue-Choi and colleagues evaluated the association between lifelong, low-intensity cigarette smoking and mortality. Relative to never smoking, lifelong smoking of less than 1 or 1 to 10 cigarettes a day was associated with higher overall mortality, including deaths from lung cancer and cardiovascular disease. Former smokers who had previously smoked less than 1 or 1 to 10 cigarettes a day had progressively lower risks with younger age of cessation, providing further evidence for the health benefits of cessation for all smokers, regardless of how few cigarettes they smoke per day.

Clinical Review & Education

In this Special Communication, McCourt and colleagues reviewed the temporary firearm transfer laws of all 50 states and make recommendations for exceptions allowing temporary transfers of firearms without a background check. The presence of a firearm in the home is a substantial risk factor for suicide. As a result, physicians are encouraged to recommend temporary transfer of a firearm from the home for high-risk individuals. Eighteen states and the District of Columbia have laws requiring a background check prior to all firearm transfers. While an important means of making it harder for dangerous people to acquire guns, these laws may also act as an unintended obstacle to temporary transfer designed to reduce suicide risk.