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Annals of Internal Medicine - recientes

Racial and Ethnic Disparities in Interval Colorectal Cancer Incidence A Population-Based Cohort Study
20/6/2017
Fedewa SA, Flanders W, Ward KC, et al.
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Background:
Interval colorectal cancer (CRC) accounts for 3% to 8% of all cases of CRC in the United States. Data on interval CRC by race/ethnicity are scant.
Objective:
To examine whether risk for interval CRC among Medicare patients differs by race/ethnicity and whether this potential variation is accounted for by differences in the quality of colonoscopy, as measured by physicians' polyp detection rate (PDR).
Design:
Population-based cohort study.
Setting:
Medicare program.
Participants:
Patients aged 66 to 75 years who received colonoscopy between 2002 and 2011 and were followed through 2013.
Measurements:
Kaplan–Meier curves and adjusted Cox models were used to estimate cumulative probabilities and hazard ratios (HRs) of interval CRC, defined as a CRC diagnosis 6 to 59 months after colonoscopy.
Results:
There were 2735 cases of interval CRC identified over 235 146 person-years of follow-up. A higher proportion of black persons (52.8%) than white persons (46.2%) received colonoscopy from physicians with a lower PDR. This rate was significantly associated with interval CRC risk. The probability of interval CRC by the end of follow-up was 7.1% in black persons and 5.8% in white persons. Compared with white persons, black persons had significantly higher risk for interval CRC (HR, 1.31 [95% CI, 1.13 to 1.51]); the disparity was more pronounced for cancer of the rectum (HR, 1.70 [CI, 1.25 to 2.31]) and distal colon (HR, 1.45 [CI, 1.00 to 2.11]) than for cancer of the proximal colon (HR, 1.17 [CI, 0.96 to 1.42]). Adjustment for PDR did not alter HRs by race/ethnicity, but differences between black persons and white persons were greater among physicians with higher PDRs.
Limitation:
Colonoscopy and polypectomy were identified by using billing codes.
Conclusion:
Among elderly Medicare enrollees, the risk for interval CRC was higher in black persons than in white persons; the difference was more pronounced for cancer of the distal colon and rectum and for physicians with higher PDRs.
Primary Funding Source:
American Cancer Society.

Extracranial Carotid Disease and Effect of Intra-arterial Treatment in Patients With Proximal Anterior Circulation Stroke in MR CLEAN
20/6/2017
Berkhemer OA, Borst J, Kappelhof M, et al.
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Background:
The presence of extracranial carotid disease (ECD) is associated with less favorable clinical outcomes in patients with acute ischemic stroke caused by intracranial proximal occlusion. Acute intra-arterial treatment (IAT) in the setting of extracranial and intracranial lesions is considered challenging, and whether it yields improved outcomes remains uncertain.
Objective:
To examine whether the presence of ECD modified the effect of IAT for intracranial proximal anterior circulation occlusion.
Design:
Prespecified subgroup analysis of a randomized clinical trial of endovascular treatment for acute ischemic stroke in the Netherlands. (Trial registrations: NTR1804 [Netherlands Trial Register] and ISRCTN10888758)
Setting:
16 hospitals in the Netherlands.
Patients:
Acute ischemic stroke caused by proximal intracranial arterial occlusion of the anterior circulation. Extracranial carotid disease was defined as cervical internal carotid artery stenosis (>50%) or occlusion.
Intervention:
IAT treatment versus no IAT.
Measurements:
The primary outcome was functional outcome, as measured by the modified Rankin Scale at 90 days and reported as adjusted common odds ratio (acOR) for a shift in direction of a better outcome. Multivariable ordinal logistic regression analysis with an interaction term was used to estimate treatment effect modification by ECD.
Results:
The overall acOR was 1.67 (95% CI, 1.21 to 2.30) in favor of the intervention. The acOR was 3.1 (CI, 1.7 to 5.8) in the prespecified subgroup of patients with ECD versus 1.3 (CI, 0.9 to 1.9) in patients presenting without ECD. Both acORs are in favor of the intervention (P for interaction = 0.07).
Limitation:
The study was not powered for subgroup analysis.
Conclusion:
Intra-arterial treatment may be at least as effective in patients with ECD as in those without ECD, and it should not be withheld in these complex patients with acute ischemic stroke.
Primary Funding Source:
Dutch Heart Foundation, AngioCare BV, Medtronic/Covidien/EV3, MEDAC Gmbh/LAMEPRO, Penumbra, Stryker, and Top Medical/Concentric.

Prevalence of Elevated Cardiovascular Risks in Young Adults: A Cross-sectional Analysis of National Health and Nutrition Examination Surveys
20/6/2017
Patel KK, Taksler GB, Hu B, et al.
ver resumen
Background:
The 2013 cholesterol management guidelines from the American College of Cardiology and American Heart Association (ACC/AHA) recommend lipid screening in all adults older than 20 years to identify those at increased risk for atherosclerotic cardiovascular disease (ASCVD). Statins may be considered for patients with elevated 10-year risk (>5%) or a low-density lipoprotein cholesterol (LDL-C) level of 4.92 mmol/L (190 mg/dL) or greater.
Objective:
To describe the prevalence of elevated ASCVD risk among nondiabetic adults younger than 50 years.
Design:
Cross-sectional.
Setting:
NHANES (National Health and Nutrition Examination Survey), 1999 to 2000 through 2011 to 2012.
Participants:
Adults aged 30 to 49 years without known ASCVD or diabetes.
Measurements:
10-year ASCVD risk was estimated by using the 2013 ACC/AHA ASCVD risk calculator. Participants were subdivided by age, sex, and history of smoking and hypertension. The percentages of adults in each subgroup with a 10-year ASCVD risk greater than 5% and of those with an LDL-C level of 4.92 mmol/L (190 mg/dL) or greater were estimated. Low-prevalence subgroups were defined as those in which a greater than 1% prevalence of elevated cardiovascular risk could be ruled out (that is, the upper 95% confidence bound for prevalence was ≤1%).
Results:
Overall, 9608 NHANES participants representing 67.9 million adults were included, with approximately half (47.12%, representing 32 million adults) in low-prevalence subgroups. In the absence of smoking or hypertension, 0.09% (95% CI, 0.02% to 0.35%) of adult men younger than 40 years and 0.04% (CI, 0.0% to 0.26%) of adult women younger than 50 years had an elevated risk. Among other subgroups, 0% to 75.9% of participants had an increased risk. Overall, 2.9% (CI, 2.3% to 3.5%) had an LDL-C level of 4.92 mmol/L (190 mg/dL) or greater.
Limitation:
No information was available regarding cardiovascular outcomes.
Conclusion:
In the absence of risk factors, the prevalence of increased ASCVD risk is low among women younger than 50 and men younger than 40 years.
Primary Funding Source:
None.

Early Versus Delayed Feeding in Patients With Acute Pancreatitis A Systematic Review
20/6/2017
Vaughn VM, Shuster D, Rogers MM, et al.
ver resumen
Background:
Acute pancreatitis is among the most common and costly reasons for hospitalization in the United States. Bowel rest, pain control, and intravenous fluids are the cornerstones of treatment, but early feeding might also be beneficial.
Purpose:
To compare length of hospital stay, mortality, and readmission in adults hospitalized with pancreatitis who received early versus delayed feeding.
Data Sources:
MEDLINE via Ovid, EMBASE, the Cochrane Library, CINAHL, and Web of Science through January 2017.
Study Selection:
Two authors independently reviewed and selected studies if they were randomized clinical trials, included adults hospitalized with acute pancreatitis, and compared early versus delayed feeding (≤48 vs. >48 hours after hospitalization).
Data Extraction:
Two investigators independently extracted study data and rated risk of bias using the Cochrane Collaboration tool.
Data Synthesis:
Eleven randomized trials (8 peer-reviewed publications, 3 abstract-only presentations) that included 948 patients were eligible. Seven trials (3 with low risk of bias) enrolled patients with mild to moderate pancreatitis. Four trials (1 with low risk of bias) included patients with predicted severe pancreatitis. Routes used for early feeding included oral (4 studies), nasogastric (2 studies), nasojejunal (4 studies), and oral or nasoenteric (1 study). Among patients with mild to moderate pancreatitis, early feeding was associated with reduced length of stay in 4 of 7 studies (including 2 of 3 with low risk of bias). Other outcomes were heterogeneous and variably reported, but no study showed an increase in adverse events with early feeding. Among patients with severe pancreatitis, limited evidence revealed no statistically significant difference in outcomes between early and delayed feeding.
Limitation:
Heterogeneity of feeding protocols and outcomes, scant data, and unclear or high risk of bias in several studies.
Conclusion:
Limited data suggest that early feeding in patients with acute pancreatitis does not seem to increase adverse events and, for patients with mild to moderate pancreatitis, may reduce length of hospital stay.
Primary Funding Source:
None. (PROSPERO: CRD42015016193)

Data Escrow and Clinical Trial Transparency
20/6/2017
Krumholz HM, Kim J.
ver resumen
The logistics of data-sharing are complicated. This commentary proposes data escrow as a mechanism in which researchers deposit data with a neutral third party that safeguards the data to facilitate sharing agreements.

A National Strategy for the Elimination of Viral Hepatitis Emphasizes Prevention, Screening, and Universal Treatment of Hepatitis C
20/6/2017
Buckley GJ, Strom BL.
ver resumen
This commentary describes the consensus report from the National Academies of Sciences, Engineering, and Medicine that proposes an innovative strategy to eliminate hepatitis B and C as public health problems in the United States.

Toward Optimal Control of Hepatitis C Virus Infection in Persons With Substance Use Disorders
20/6/2017
Talal AH, Thomas DL, Reynolds JL, et al.
ver resumen
New direct-acting antiviral drugs for hepatitis C virus (HCV) infection are as effective in persons with substance use disorders as in others with this condition, but eradication rates among this population are low. This commentary discusses the gaps that must be addressed to eliminate HCV infection in this population.

March for Science
20/6/2017
Weinberg C.
ver resumen
This commentary from a co-chair of the March for Science organizing committee discusses the crisis that the scientific community is facing today and why the defense of science is necessary.

Cholesterol Evaluation in Young Adults: Absence of Clinical Trial Evidence Is Not a Reason to Delay Screening
20/6/2017
Ridker P, Cook NR.
ver resumen
The editorialists discuss the limitations of Patel and colleagues' study, which estimated the prevalence of elevated atherosclerotic risk among nondiabetic adults younger than 50 years. They also discuss why the primary prevention of cardiovascular disease should include early-life evaluation of low-density lipoprotein cholesterol, not a delayed approach.

Acute Pancreatitis: How Soon Should We Feed Patients?
20/6/2017
Roberts KM, Conwell D.
ver resumen
Vaughn and colleagues report a systematic review of early versus delayed enteral nutrition. The editorialists discuss the results, why they should be interpreted with caution, and the evidence gaps in defining when and how to best feed patients with acute pancreatitis.

Alternative Facts Have No Place in Science
20/6/2017
Laine C, Taichman DB.
ver resumen
On 22 April 2017, science supporters took to the streets in the first March for Science. Progress toward improved health may be impaired when the politicization of science interferes with the pursuit of knowledge or the use of what has been learned. The authors decry such an approach and explain why it is imperative that we stand up for science.

Rock Bottom
20/6/2017
Muller D.
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Moral Dilemma in the ER
20/6/2017
Al-Shamsi M.
ver resumen

Travel-Associated Zika Virus Disease
20/6/2017
Liuzzi G, Castilletti C, Vairo F, et al.
ver resumen

Travel-Associated Zika Virus Disease
20/6/2017
Hamer DH, Chen LH, Libman M, et al.
ver resumen

Heterogeneity in Treatment Effects
20/6/2017
Matthews RJ.
ver resumen

Heterogeneity in Treatment Effects
20/6/2017
Davidoff F.
ver resumen

Brain-Type Natriuretic Peptide and Amino-Terminal Pro–Brain-Type Natriuretic Peptide Discharge Thresholds for Acute Decompensated Heart Failure
20/6/2017
Nusbaum NJ.
ver resumen

Brain-Type Natriuretic Peptide and Amino-Terminal Pro–Brain-Type Natriuretic Peptide Discharge Thresholds for Acute Decompensated Heart Failure
20/6/2017
McQuade CN, Umscheid CA.
ver resumen

Correction: In the Clinic: Atrial Fibrillation
20/6/2017
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