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Some cervical cancer screening programs test for human papillomavirus (HPV) only after abnormal Papanicolaou (Pap) test results, whereas others perform both tests routinely and repeat testing if either result is abnormal. Datta and colleagues did both tests in 9657 U.S. women undergoing routine cervical cancer screening. Surprisingly, 9% of women 30 years of age or older with a normal Pap test had high-risk HPV infection, which supports routine simultaneous HPV testing and cervical cytology in this group.
Kestenbaum and associates tested the hypothesis that early kidney dysfunction, as measured by serum cystatin C levels and urinary albumin excretion, predates hypertension in adults without clinically recognized kidney or cardiovascular disease. During a median follow-up of 3.1 years, 545 (19.7%) of 2767 adults age 45 to 84 years developed hypertension. Higher baseline levels of cystatin C—but not the spot baseline urine albumin–creatinine ratio—were associated with higher incidence of hypertension, independent of other risk factors. These population-based findings complement experimental work implicating early kidney damage in the pathogenesis of essential hypertension.
To test strategies for avoiding aspiration pneumonia in cognitively impaired elderly patients, Robbins and colleagues randomly assigned 515 patients age 50 years or older with dementia or Parkinson disease to drink liquids in a chin-down posture or to consume nectar-thick or honey-thick liquids. The cumulative incidence of pneumonia at 3 months was 9.8% in the chin-down posture group, 8.4% in the nectar-thick liquid group, and 15.0% in the honey-thick liquid group. The confidence bounds of the differences in these rates between groups were wide, and the study was inconclusive.
When assessing the evidence on which of several treatment options is the most effective, it is important to know which ones have been compared with other options and which have been compared with placebo. The authors expressed these relationships geometrically. These networks show graphically which treatments have not been compared head-to-head. Expressing a treatment comparison network geometrically can help to define the direction of future evaluative research.
Cancer chemotherapy can activate latent hepatitis B virus (HBV) infection. The authors studied whether preventive lamivudine reduces chemotherapy-induced HBV-related morbidity and mortality. The 14 reviewed studies included 2 randomized trials and 12 observational studies with 275 preventive lamivudine recipients and 475 control participants. Preventive lamivudine was associated with a much reduced rate of HBV reactivation. No patient in the preventive lamivudine group had HBV-related hepatic failure; 4 had HBV-related death. Lamivudine was well tolerated and seemed to have no adverse effects.
The authors contend that tobacco dependence is a chronic illness for which effective treatment should be given as long as necessary to achieve successful clinical outcomes. The optimal duration of tobacco dependence treatment is unknown, and some smokers may require extended courses before they can stop smoking. Therefore, clinicians should encourage smokers to use smoking cessation therapies for long periods, and insurance carriers should provide coverage for extended treatment.
The U.S. Preventive Services Task Force (USPSTF) weighed the benefits (prevention of ≥1 exacerbation and improvement in respiratory health status measures) and harms (time and effort required by both patients and the health care system, false-positive screening tests, and adverse effects of subsequent unnecessary therapy) of screening healthy adults for chronic obstructive pulmonary disease (COPD) with spirometry. The USPSTF recommends against using spirometry to screen adults for COPD.
To support the USPSTF recommendation in this issue, Lin and colleagues reviewed the evidence on screening for COPD by using spirometry. Spirometry has not been shown to independently improve smoking cessation rates, and hundreds of patients would need to undergo spirometry to defer 1 COPD exacerbation. Potential harms from screening include false-positive results and adverse effects from subsequent unnecessary therapy.
Should women undergo simultaneous human papillomavirus (HPV) testing and cytology for primary cervical cancer screening? In this issue, Datta and colleagues report that 9% of women age 30 years and older were HPV positive but had normal cervical cytology. Should the positive HPV test change the way we manage women with normal cytology? At this point, we lack evidence-based surveillance strategies for these women. Clinicians who choose to perform dual testing should do so only after discussing with the patient the potential benefits above and beyond those achieved with cytology alone and the uncertainties associated with this screening strategy.
This issue provides a clinical overview of dementia, focusing on prevention, diagnosis, treatment, practice improvement, and patient information. Readers can complete the accompanying CME quiz for 1.5 credits.
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