Table of Contents

The benefits of intensive lipid-lowering treatment for elderly persons with heart disease are largely unknown. In a secondary analysis of a randomized trial, Wenger and associates examined outcomes of 3809 adults age 65 years or older with coronary heart disease after 4.9 years of receiving atorvastatin, 80 mg/d or 10 mg/d. Patients achieved average low-density lipoprotein cholesterol levels of approximately 1.81 mmol/L (70 mg/dL) and 2.59 mmol/L (100 mg/dL), respectively. The absolute reduction in risk for serious cardiovascular events was 2% in patients who received 80 mg of atorvastatin relative to those who received 10 mg.

The mechanisms by which β-blockers prevent recurrent myocardial infarction are not clear. In a pooled analysis of individual patient data, Sipahi and coworkers examined changes in coronary atheroma volume as measured by serial intravascular ultrasonography in 4 randomized trials. The trials followed 1515 patients with coronary artery disease for 18 to 24 months. Atheroma volume decreased in patients who were receiving β-blockers but stayed the same in those not receiving β-blockers. β-Blockers appear to slow progression of coronary atherosclerosis.

Sarnak and colleagues asked whether cystatin C, iothalamate glomerular filtration rate (GFR), or creatinine better predicted mortality in chronic kidney disease. They examined long-term outcomes of 825 nondiabetic patients with chronic kidney disease who had participated in 2 trials of protein restriction. Abnormal baseline results on all 3 measures were associated with increased risk for kidney failure and all-cause mortality. The association with cardiovascular mortality was slightly stronger for cystatin C than for GFR or creatinine, indicating that cystatin C was as good as or better than creatinine and iothalamate GFR as a predictor of chronic kidney disease outcomes.

Hepatitis E virus (HEV) infection causes severe liver disease in pregnant women. In a case series of 220 pregnant women with jaundice and acute viral hepatitis, women with HEV infection died more often and had more obstetric complications and worse fetal outcomes than did women with other forms of viral hepatitis.

Physicians in intensive care units sometimes withdraw life support in incapacitated patients who lack surrogate decision makers and advance directives. How often such action is taken is unknown. This prospective study of 3011 critically ill adults in 7 geographically diverse intensive care units found that 5.5% of deaths occurred in patients who did not have surrogate decision makers and advance directives. Care teams made life-support decisions without formal review by the hospital or a judge for 30 of 37 such patients. Applicable policies varied widely across hospitals and states.

Counseling about diet and lifestyle modification are the principal weight loss strategies for obese or overweight people. The long-term weight change attributable to dietary counseling is unclear. The investigators performed a systematic review and meta-analysis of the evidence that dietary counseling changes body mass index more than usual care. Dietary counseling produced modest weight loss that diminished over time. Secondary analyses suggested that calorie restriction recommendations, frequency of support meetings, inclusion of exercise, and diabetes independently predict weight change.

Advance directives about the care of dying patients have had little effect. Many experts blame problems in completing and implementing advance directives, but the author suggests that the concept itself may be fundamentally flawed. Advance directives imply that health care providers can control future events. In fact, frequent, unexpected problems frustrate efforts to implement advance directives. Advance care planning should emphasize preparing patients and families to cope emotionally with future crises.

Current treatment end points for chronic hepatitis B include hepatitis B e antigen (HBeAg) seroconversion, reduction of hepatitis B virus (HBV) DNA levels to less than 105 copies/mL, and normalization of alanine aminotransferase (ALT) values. The authors state that these guidelines are not suitable for hepatitis B carriers who acquire infection in early life. They propose that treatment end points for these patients should be permanent suppression of HBV DNA to undetectable levels and reduction of ALT levels to less than 0.5 times the upper limit of normal.

In this issue, Lai and Yuen raise concern that existing guidelines for treatment of HBV infection are inappropriate for patients with perinatal HBV infection. They propose that patients with normal ALT levels who acquire infection early in life should also be treated, and that HBeAg-positive patients should continue treatment after HBeAg seroconversion. The editorialists put aspects of Lai and Yuen's proposal in the context of existing evidence.

This issue marks the beginning of the 80th year of publishing Annals of Internal Medicine. The Editors present a selective look forward at their strategy to keep the journal vital far into the future.

Shared decision making and cultural competence are inherently relativistic concepts. Two patient encounters illustrate the conflict of these important themes of general internal medicine and the challenge of chronic illness care.

This issue provides a clinical overview of irritable bowel syndrome, focusing on diagnosis, treatment, and practice improvement. Readers can complete the accompanying CME quiz for 1.5 credits.