Annals of Internal Medicine - recientes
Percutaneous Ablation Versus Partial and Radical Nephrectomy for T1a Renal Cancer A Population-Based Analysis17/7/2018
Talenfeld AD, Gennarelli RL, Elkin EB, et al.
Background:Stage T1a renal cell carcinoma (RCC) (tumors <4 cm) is usually curable. Nephron-sparing partial nephrectomy (PN) has replaced radical nephrectomy (RN) as the standard of care for these tumors. Radical nephrectomy remains the first alternative treatment option, whereas percutaneous ablation (PA), a newer, nonsurgical treatment, is recommended less strongly because of the relative paucity of comparative PA data.
Objective:To compare PA, PN, and RN outcomes.
Design:Observational cohort analysis using inverse probability of treatment–weighted propensity scores.
Setting:Population-based SEER (Surveillance, Epidemiology, and End Results) cancer registry data linked to Medicare claims.
Patients:Persons aged 66 years or older who received treatment for T1a RCC between 2006 and 2011.
Interventions:PA versus PN and RN.
Measurements:RCC-specific and overall survival, 30- and 365-day postintervention complications.
Results:4310 patients were followed for a median of 52 months for overall survival and 42 months for RCC-specific survival. After PA versus PN, the 5-year RCC-specific survival rate was 95% (95% CI, 93% to 98%) versus 98% (CI, 96% to 99%); after PA versus RN, 96% (CI, 94% to 98%) versus 95% (CI, 93% to 96%). After PA versus PN, the 5-year overall survival rate was 77% (CI, 74% to 81%) versus 86% (CI, 84% to 88%); after PA versus RN, 74% (CI, 71% to 78%) versus 75% (CI, 73% to 77%). Cumulative rates of renal insufficiency 31 to 365 days after PA, PN, and RN were 11% (CI, 8% to 14%), 9% (CI, 8% to 10%), and 18% (CI, 17% to 20%), respectively. Rates of nonurologic complications within 30 days after PA, PN, and RN were 6% (CI, 4% to 9%), 29% (CI, 27% to 30%), and 30% (CI, 28% to 32%), respectively. Ten percent of patients in the PN group had intraoperative conversion to RN. Seven percent of patients in the PA group received additional PA within 1 year of treatment.
Limitations:Analysis of observational data may have been affected by residual confounding by provider or from selection bias toward younger, healthier patients in the PN group. Findings from this older study population are probably less applicable to younger patients. Use of SEER–Medicare linked files prevented analysis of patients who received treatment after 2011, possibly reducing generalizability to the newest PA, PN, and RN techniques.
Conclusion:For well-selected older adults with T1a RCC, PA may result in oncologic outcomes similar to those of RN, but with less long-term renal insufficiency and markedly fewer periprocedural complications. Compared with PN, PA may be associated with slightly shorter RCC-specific survival but fewer periprocedural complications.
Primary Funding Source:Association of University Radiologists GE Radiology Research Academic Fellowship and Society of Interventional Radiology Foundation.
Clinicians' Perspectives on Providing Emergency-Only Hemodialysis to Undocumented Immigrants A Qualitative Study17/7/2018
Cervantes L, Richardson S, Raghavan R, et al.
Background:In the United States, nearly half of undocumented immigrants with end-stage kidney disease receive hemodialysis only when they are evaluated in an emergency department and are found to have life-threatening renal failure (“emergency-only hemodialysis” [EOHD]). These patients experience psychosocial distress and much higher mortality than patients receiving regularly scheduled hemodialysis, but little is known about how providing EOHD affects the clinicians involved.
Objective:To understand clinicians' experiences providing EOHD.
Design:Qualitative study using semistructured interviews.
Setting:A safety-net hospital in Denver, Colorado, and a safety-net system in Houston, Texas.
Participants:Fifty interdisciplinary clinicians experienced in providing EOHD.
Measurements:Interviews were analyzed using thematic analysis. Outcomes included themes and subthemes.
Results:Four themes and 13 subthemes (in parentheses) were identified: 1) drivers of professional burnout (emotional exhaustion from witnessing needless suffering and high mortality, jeopardizing patient trust, detaching from patients, perceived lack of control over EOHD criteria, and physical exhaustion from overextending to bridge care), 2) moral distress from propagating injustice (altered care based on nonmedical factors, focus on volume at the expense of quality, and need to game the system), 3) confusing and perverse financial incentives (wasting resources, confusing financial incentives, and concerns about sustainability), and 4) inspiration toward advocacy (deriving inspiration from patients and strengthened altruism).
Limitation:Whether the findings apply to other settings is unknown, and social desirability response bias might have reduced reporting of negative perceptions and experiences.
Conclusion:Clinicians in safety-net settings who provide EOHD to undocumented patients describe experiencing moral distress and being driven toward professional burnout. The burden of EOHD on clinicians should inform discussions of systemic approaches to support provision of adequate care based on medical need.
Primary Funding Source:Robert Wood Johnson Foundation and Doris Duke Charitable Foundation.
Association of Viral Suppression With Lower AIDS-Defining and Non–AIDS-Defining Cancer Incidence in HIV-Infected Veterans A Prospective Cohort Study17/7/2018
Park LS, Tate JP, Sigel K, et al.
Background:Viral suppression is a primary marker of HIV treatment success. Persons with HIV are at increased risk for AIDS-defining cancer (ADC) and several types of non–AIDS-defining cancer (NADC), some of which are caused by oncogenic viruses.
Objective:To determine whether viral suppression is associated with decreased cancer risk.
Setting:Department of Veterans Affairs.
Participants:HIV-positive veterans (n = 42 441) and demographically matched uninfected veterans (n = 104 712) from 1999 to 2015.
Measurements:Standardized cancer incidence rates and Poisson regression rate ratios (RRs; HIV-positive vs. uninfected persons) by viral suppression status (unsuppressed: person-time with HIV RNA levels ≥500 copies/mL; early suppression: initial 2 years with HIV RNA levels <500 copies/mL; long-term suppression: person-time after early suppression with HIV RNA levels <500 copies/mL).
Results:Cancer incidence for HIV-positive versus uninfected persons was highest for unsuppressed persons (RR, 2.35 [95% CI, 2.19 to 2.51]), lower among persons with early suppression (RR, 1.99 [CI, 1.87 to 2.12]), and lowest among persons with long-term suppression (RR, 1.52 [CI, 1.44 to 1.61]). This trend was strongest for ADC (unsuppressed: RR, 22.73 [CI, 19.01 to 27.19]; early suppression: RR, 9.48 [CI, 7.78 to 11.55]; long-term suppression: RR, 2.22 [CI, 1.69 to 2.93]), much weaker for NADC caused by viruses (unsuppressed: RR, 3.82 [CI, 3.24 to 4.49]; early suppression: RR, 3.42 [CI, 2.95 to 3.97]; long-term suppression: RR, 3.17 [CI, 2.78 to 3.62]), and absent for NADC not caused by viruses.
Limitation:Lower viral suppression thresholds, duration of long-term suppression, and effects of CD4+ and CD8+ T-cell counts were not thoroughly evaluated.
Conclusion:Antiretroviral therapy resulting in long-term viral suppression may contribute to cancer prevention, to a greater degree for ADC than for NADC. Patients with long-term viral suppression still had excess cancer risk.
Primary Funding Source:National Cancer Institute and National Institute on Alcohol Abuse and Alcoholism of the National Institutes of Health.
Associations Between American Board of Internal Medicine Maintenance of Certification Status and Performance on a Set of Healthcare Effectiveness Data and Information Set (HEDIS) Process Measures17/7/2018
Gray B, Vandergrift J, Landon B, et al.
Background:The value of the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program has been questioned as a marker of physician quality.
Objective:To assess whether physician MOC status is associated with performance on selected Healthcare Effectiveness Data and Information Set (HEDIS) process measures.
Design:Annual comparisons of HEDIS process measures among physicians who did or did not maintain certification 20 years after initial certification.
Participants:1260 general internists who were initially certified in 1991 and provided care for 85 931 Medicare patients between 2009 and 2012.
Measurements:Annual percentage of a physician's Medicare patients meeting each of 5 HEDIS annual or biennial standards and a composite indicating meeting all 3 HEDIS diabetes standards.
Results:Among the 1260 physicians, 786 maintained their certification from 1991 to 2012 and 474 did not. The mean annual percentage of HEDIS-eligible diabetic patients who completed semiannual hemoglobin A1c testing was 58.4% among physicians who maintained certification and 54.4% among those who did not (regression-adjusted difference, 4.2 percentage points [95% CI, 2.0 to 6.5 percentage points]; P < 0.001). Diabetic patients of physicians who maintained certification more frequently met the annual standard for low-density lipoprotein (LDL) cholesterol measurement (83.1% vs. 80.5%; regression-adjusted difference, 2.3 percentage points [CI, 0.6 to 4.1 percentage points]; P = 0.008) and all 3 diabetic standards (46.0% vs. 41.6%; regression-adjusted difference, 3.1 percentage points [CI, 0.5 to 5.7 percentage points]; P = 0.019). The regression-adjusted difference in biennial eye examinations was statistically insignificant (P = 0.112). Measures for LDL cholesterol testing in patients with coronary heart disease and biennial mammography were also met more frequently among physicians who maintained certification (79.4% vs. 77.4% and 72.0% vs. 67.8%, respectively), with regression-adjusted differences of 1.7 percentage points (CI, 0.2 to 3.3 percentage points; P = 0.032) and 4.6 percentage points (CI, 2.9 to 6.3 percentage points; P < 0.001), respectively.
Limitation:Potential confounding by unobserved patient, physician, and practice characteristics; inability to determine clinical significance of observed differences.
Conclusion:Maintaining certification was positively associated with physician performance scores on a set of HEDIS process measures.
Primary Funding Source:American Board of Internal Medicine.
Ghasemiesfe M, Ravi D, Vali M, et al.
Background:The health effects of smoking marijuana are not well-understood.
Purpose:To examine the association between marijuana use and respiratory symptoms, pulmonary function, and obstructive lung disease among adolescents and adults.
Data Sources:PubMed, Embase, PsycINFO, MEDLINE, and the Cochrane Library from 1 January 1973 to 30 April 2018.
Study Selection:Observational and interventional studies published in English that reported pulmonary outcomes of adolescents and adults who used marijuana.
Data Extraction:Four reviewers independently extracted study characteristics and assessed risk of bias. Three reviewers assessed strength of evidence. Studies of similar design with low or moderate risk of bias and sufficient data were pooled.
Data Synthesis:Twenty-two studies were included. A pooled analysis of 2 prospective studies showed that marijuana use was associated with an increased risk for cough (risk ratio [RR], 2.04 [95% CI, 1.02 to 4.06]) and sputum production (RR, 3.84 [CI, 1.62 to 9.07]). Pooled analysis of cross-sectional studies (1 low and 3 moderate risk of bias) showed that marijuana use was associated with cough (RR, 4.37 [CI, 1.71 to 11.19]), sputum production (RR, 3.40 [CI, 1.99 to 5.79]), wheezing (RR, 2.83 [CI, 1.89 to 4.23]), and dyspnea (RR, 1.56 [CI, 1.33 to 1.83]). Data on pulmonary function and obstructive lung disease were insufficient.
Limitation:Few studies were at low risk of bias, marijuana exposure was limited in the population studied, cohorts were young overall, assessment of marijuana exposure was not uniform, and study designs varied.
Conclusion:Low-strength evidence suggests that smoking marijuana is associated with cough, sputum production, and wheezing. Evidence on the association between marijuana use and obstructive lung disease and pulmonary function is insufficient.
Primary Funding Source:None. (PROSPERO: CRD42017059224)
Clonal Hematopoiesis Confers Predisposition to Both Cardiovascular Disease and Cancer: A Newly Recognized Link Between Two Major Killers17/7/2018
Ebert BL, Libby P.
The presence of a somatic mutation associated with hematologic cancer in the peripheral blood at a variant allele frequency of at least 2% in the absence of hematologic cancer defines clonal hematopoiesis of indeterminate potential (CHIP). This commentary discusses CHIP's potential in cardiovascular risk assessment and as a biomarker for response to interventions to reduce cardiovascular risk.
A Novel Strategy for Increasing Access to Treatment for Hepatitis C Virus Infection for Medicaid Beneficiaries17/7/2018
Sood N, Ung D, Shankar A, et al.
This commentary proposes a novel strategy for increasing access to treatment for hepatitis C virus infection for Medicaid beneficiaries. It posits a drug purchasing strategy that encourages competition among manufacturers that could save money for states and vastly expand treatment.
McMahon LF, Jr., Chopra V.
News that the CEOs of Amazon, Berkshire Hathaway, and JPMorgan Chase are coming together to combat high health care costs has been met with anticipation and skepticism. This commentary speculates on how these business giants might apply a Six Sigma approach to achieve the cost containment that has so far eluded the U.S. health care system.
The study by Cervantes and colleagues is the first to provide empirical evidence about the effects of EOHD on professionalism. The editorialist discusses the findings, draws parallels between providing standard dialysis to undocumented immigrants and providing universal health coverage to U.S. citizens, and proposes an approach to address the problem of EOHD.
Gray and colleagues report that Maintenance of Certification is correlated with small improvements in performance on several Healthcare Effectiveness Data and Information Set (HEDIS) metrics. The editorialist discusses these findings, the most disturbing of which is the overall low rates at which HEDIS standards were met and the minimally better performance among physicians who maintained certification.
For a month and a half, the letter sat on my couch as spring pushed life out onto trees. There was always a reason not to open it.
Chang AR, Luo JZ, Ho K, et al.
Kiryluk K, Groopman E, Rasouly H, et al.
Use of Immune Checkpoint Inhibitors in the Treatment of Patients With Cancer and Preexisting Autoimmune Disease17/7/2018
Oshima Y, Hagino N, Hara M, et al.
Use of Immune Checkpoint Inhibitors in the Treatment of Patients With Cancer and Preexisting Autoimmune Disease17/7/2018
Abdel-Wahab N, Shah M, Lopez-Olivo MA, et al.
Zanetti R, Sacchetto L, Rosso S.
Welch H, Brawley OW.
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