Annals of Internal Medicine - recientes
Real-Time Use of Artificial Intelligence in Identification of Diminutive Polyps During Colonoscopy A Prospective Study18/9/2018
Mori Y, Kudo S, Misawa M, et al.
Background:Computer-aided diagnosis (CAD) for colonoscopy may help endoscopists distinguish neoplastic polyps (adenomas) requiring resection from nonneoplastic polyps not requiring resection, potentially reducing cost.
Objective:To evaluate the performance of real-time CAD with endocytoscopes (×520 ultramagnifying colonoscopes providing microvascular and cellular visualization of colorectal polyps after application of the narrow-band imaging [NBI] and methylene blue staining modes, respectively).
Design:Single-group, open-label, prospective study. (UMIN [University hospital Medical Information Network] Clinical Trial Registry: UMIN000027360).
Participants:791 consecutive patients undergoing colonoscopy and 23 endoscopists.
Intervention:Real-time use of CAD during colonoscopy.
Measurements:CAD-predicted pathology (neoplastic or nonneoplastic) of detected diminutive polyps (≤5 mm) on the basis of real-time outputs compared with pathologic diagnosis of the resected specimen (gold standard). The primary end point was whether CAD with the stained mode produced a negative predictive value (NPV) of 90% or greater for identifying diminutive rectosigmoid adenomas, the threshold required to “diagnose-and-leave” nonneoplastic polyps. Best- and worst-case scenarios assumed that polyps lacking either CAD diagnosis or pathology were true- or false-positive or true- or false-negative, respectively.
Results:Overall, 466 diminutive (including 250 rectosigmoid) polyps from 325 patients were assessed by CAD, with a pathologic prediction rate of 98.1% (457 of 466). The NPVs of CAD for diminutive rectosigmoid adenomas were 96.4% (95% CI, 91.8% to 98.8%) (best-case scenario) and 93.7% (CI, 88.3% to 97.1%) (worst-case scenario) with stained mode and 96.5% (CI, 92.1% to 98.9%) (best-case scenario) and 95.2% (CI, 90.3% to 98.0%) (worst-case scenario) with NBI.
Limitation:Two thirds of the colonoscopies were conducted by experts who had each experienced more than 200 endocytoscopies; 186 polyps not assessed by CAD were excluded.
Conclusion:Real-time CAD can achieve the performance level required for a diagnose-and-leave strategy for diminutive, nonneoplastic rectosigmoid polyps.
Primary Funding Source:Japan Society for the Promotion of Science.
Opioid Prescribing in the United States Before and After the Centers for Disease Control and Prevention's 2016 Opioid Guideline18/9/2018
Bohnert AB, Guy GP, Jr., Losby JL.
Background:In response to adverse outcomes from prescription opioids, the Centers for Disease Control and Prevention (CDC) released the Guideline for Prescribing Opioids for Chronic Pain in March 2016.
Objective:To test the hypothesis that the CDC guideline release corresponded to declines in specific opioid prescribing practices.
Design:Interrupted time series analysis of monthly prescribing measures from the IQVIA transactional data warehouse and Real-World Data Longitudinal Prescriptions population-level estimates based on retail pharmacy data. Population size was determined by U.S. Census monthly estimates.
Setting:United States, 2012 to 2017.
Patients:Persons prescribed opioid analgesics.
Measurements:Outcomes included opioid dosage, days supplied, overlapping benzodiazepine prescriptions, and the overall rate of prescribing.
Results:The rate of high-dosage prescriptions (≥90 morphine equivalent milligrams per day) was 683 per 100 000 persons in January 2012 and declined by 3.56 (95% CI, −3.79 to −3.32) per month before March 2016 and by 8.00 (CI, −8.69 to −7.31) afterward. Likewise, the percentage of patients with overlapping opioid and benzodiazepine prescriptions was 21.04% in January 2012 and declined by 0.02% (CI, −0.04% to −0.01%) per month before the CDC guideline release and by 0.08% (CI, −0.08% to −0.07%) per month afterward. The overall opioid prescribing rate was 6577 per 100 000 persons in January 2012 and declined by 23.48 (CI, −26.18 to −20.78) each month before the guideline release and by 56.74 (CI, −65.96 to −47.53) per month afterward.
Limitation:No control population; inability to determine the appropriateness of opioid prescribing.
Conclusion:Several opioid prescribing practices were decreasing before the CDC guideline, but the time of its release was associated with a greater decline. Guidelines may be effective in changing prescribing practices.
Primary Funding Source:CDC.
HIV Viral Suppression Trends Over Time Among HIV-Infected Patients Receiving Care in the United States, 1997 to 2015 A Cohort Study18/9/2018
Nance RM, Delaney J, Simoni JM, et al.
Background:Because HIV viral suppression is essential for optimal outcomes and prevention efforts, understanding trends and predictors is imperative to inform public health policy.
Objective:To evaluate viral suppression trends in people living with HIV (PLWH), including the relationship of associated factors, such as demographic characteristics and integrase strand transfer inhibitor (ISTI) use.
Design:Longitudinal observational cohort study.
Setting:8 HIV clinics across the United States.
Participants:PLWH receiving clinical care.
Measurements:To understand trends in viral suppression (≤400 copies/mL), annual viral suppression rates from 1997 to 2015 were determined. Analyses were repeated with tests limited to 1 random test per person per year and using inverse probability of censoring weights to address loss to follow-up. Joint longitudinal and survival models and linear mixed models of PLWH receiving antiretroviral therapy (ART) were used to examine associations between viral suppression or continuous viral load (VL) levels and demographic factors, substance use, adherence, and ISTI use.
Results:Viral suppression increased from 32% in 1997 to 86% in 2015 on the basis of all tests among 31 930 PLWH. In adjusted analyses, being older (odds ratio [OR], 0.76 per decade [95% CI, 0.74 to 0.78]) and using an ISTI-based regimen (OR, 0.54 [CI, 0.51 to 0.57]) were associated with lower odds of having a detectable VL, and black race was associated with higher odds (OR, 1.68 [CI, 1.57 to 1.80]) (P < 0.001 for each). Similar patterns were seen with continuous VL levels; when analyses were limited to 2010 to 2015; and with adjustment for adherence, substance use, or depression.
Limitation:Results are limited to PLWH receiving clinical care.
Conclusion:HIV viral suppression rates have improved dramatically across the United States, which is likely partially attributable to improved ART, including ISTI-based regimens. However, disparities among younger and black PLWH merit attention.
Primary Funding Source:National Institutes of Health.
Association Between Publication Characteristics and Treatment Effect Estimates A Meta-epidemiologic Study18/9/2018
Dechartres A, Atal I, Riveros C, et al.
Background:Evidence about the effect on meta-analysis results of including unpublished trials or those published in languages other than English is unclear or discordant.
Purpose:To compare treatment effects between published and unpublished randomized controlled trials (RCTs) and between trials published in English and other languages using a meta-epidemiologic approach.
Data Sources:Cochrane reviews published between March 2011 and January 2017 and trial references cited in the reviews.
Study Selection:RCTs included in meta-analyses of 3 or more trials with a binary efficacy outcome.
Data Extraction:Trial characteristics were extracted by original review authors. A single reviewer assessed publication status and language, with quality assurance by another investigator.
Data Synthesis:Among 5659 RCTs included in 698 meta-analyses, 5303 (93.7%) were published in journal articles and 356 (6.3%) were unpublished. Of journal articles, 92.6% (4910 of 5303) were published in English and 7.4% (393 of 5303) in another language. Treatment effects were larger in published than unpublished trials (combined ratio of odds ratios [ROR] for 174 meta-analyses, 0.90 [95% CI, 0.82 to 0.98]; I2 = 19.3%; τ2 = 0.0492). Treatment effects were also larger for trials published in a language other than English than in English (combined ROR for 147 meta-analyses, 0.86 [CI, 0.78 to 0.95]; I2 = 0%; τ2 = 0.0000).
Limitation:Reliance on the primary reference cited by review authors as the record of interest.
Conclusion:In meta-analyses, treatment effects were larger in published than unpublished trials and, for published trials, in those published in a language other than English than in English.
Primary Funding Source:Cochrane France.
Medicines for Treatment Intensification in Type 2 Diabetes and Type of Insulin in Type 1 and Type 2 Diabetes in Low-Resource Settings: Synopsis of the World Health Organization Guidelines on Second- and Third-Line Medicines and Type of Insulin for the Control of Blood Glucose Levels in Nonpregnant Adults With Diabetes Mellitus18/9/2018
Roglic G, Norris SL.
Description:The World Health Organization developed these guidelines to provide guidance on selection of medicines for treatment intensification in type 2 diabetes and on use of insulin (human or analogue) in type 1 and 2 diabetes. The target audience includes clinicians, policymakers, national diabetes program managers, and medicine procurement officers. The target population is adults with type 1 or 2 diabetes in low-resource settings in low- or high-income countries. The guidelines also apply to disadvantaged populations in high-income countries.
Methods:The recommendations were formulated by a 12-member guideline development group and are based on high-quality systematic reviews identified via a search of several bibliographic databases from 1 January 2007 to 1 March 2017. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) system was used to assess the quality of the evidence and the strength of the recommendations. The guideline was peer-reviewed by 6 external reviewers.
Recommendation 1:Give a sulfonylurea to patients with type 2 diabetes who do not achieve glycemic control with metformin alone or who have contraindications to metformin (strong recommendation, moderate-quality evidence).
Recommendation 2:Introduce human insulin treatment to patients with type 2 diabetes who do not achieve glycemic control with metformin and/or a sulfonylurea (strong recommendation, very-low-quality evidence).
Recommendation 3:If insulin is unsuitable, a dipeptidyl peptidase-4 (DPP-4) inhibitor, a sodium–glucose cotransporter-2 (SGLT-2) inhibitor, or a thiazolidinedione (TZD) may be added (weak recommendation, very-low-quality evidence).
Recommendation 4:Use human insulin to manage blood glucose in adults with type 1 diabetes and in adults with type 2 diabetes for whom insulin is indicated (strong recommendation, low-quality evidence).
Recommendation 5:Consider long-acting insulin analogues to manage blood glucose in adults with type 1 or type 2 diabetes who have frequent severe hypoglycemia with human insulin (weak recommendation, moderate-quality evidence for severe hypoglycemia).
World Health Organization Guidelines on Medicines for Diabetes Treatment Intensification: Commentary From the American College of Physicians High Value Care Committee18/9/2018
Humphrey LL, Kansagara D, Qaseem A, et al.
This commentary from the American College of Physicians High Value Care Committee discusses the World Health Organization guideline on managing diabetes mellitus, the nuances of clinical decision making in the face of limited evidence and resources, and the implications of the guideline for clinicians in the United States.
Pencina MJ, Rockhold FW, D'Agostino RB, Sr..
Experts and regulators have called for methods used in traditional trials to be adapted to “real-world” settings. This article describes 3 promising approaches that meld rigorous methodology with real-world data.
Genao I, Gelman J.
Since 1991, federal law has required that an employment practice be discarded if a plaintiff can show that the practice has a disparate impact based on race and the employer is unable to demonstrate that it is job-related and consistent with business necessity. This commentary discusses why the principle behind this law implies that we should stop using MCAT scores to decide who enters medical school.
Bretthauer M, Kalager M, Weinberg DS.
On 30 May 2018, the American Cancer Society (ACS) released updated guidelines for colorectal cancer (CRC) screening. Whereas nearly all previous guidelines recommended screening beginning at age 50 years, the ACS recommended that an additional 22 million Americans aged 45 to 49 years also participate in CRC screening. This commentary discusses concerns about the evidence behind and implications of the ACS recommendation.
Geisinger Health System received considerable attention in May 2018 when it announced that DNA sequencing would become a routine part of its clinical care. This commentary discusses why identifying persons with genetic risk and effectively mitigating that risk is a worthy goal and emphasizes that the timing of the introduction of genetic data into routine clinical care is contingent on further demonstrations of clinical utility and proven implementation models.
Holme Ø, Aabakken L.
Mori and colleagues reported promising findings from a study using computer-aided diagnosis to characterize colonic polyps. The editorialists discuss these results and what is needed before such technology can be incorporated into routine colorectal cancer screening practice.
Marston HD, Dieffenbach CW, Fauci AS.
In 2014, the Joint United Nations Programme on HIV/AIDS challenged all countries to diagnose 90% of HIV infections within their borders, provide antiretroviral therapy to 90% of diagnosed persons, and achieve viral suppression in 90% of treated patients. As of 2015, only 51% of people living with HIV in the United States had achieved viral suppression. This editorial discusses Nance and colleagues' study, which brings us closer to understanding the viral suppression gap, as well as strategies to close it.
The Importance of Reporting Biases in Patient Care: Can We Trust the Evidence From Either Individual Studies or Systematic Reviews?18/9/2018
Dickersin K, Qureshi R.
Dechartres and colleagues' examination of the association between publication characteristics and treatment effect estimates suggests that reporting biases are threatening our understanding of the truth in clinical evidence. The editorialists discuss the findings and propose strategies to increase the certainty that the body of evidence on which we base health-related decisions is correct.
Do we have to kill ourselves to help others live?
Rediger K, Miles D.
Thorn BE, Campbell LC, Van Dyke BP, et al.
Xirasagar S, de Groen PC.
Kahi CJ, Pohl H, Myers LJ, et al.
John D, George T.
Soshi M, Tokuda Y.
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