Table of Contents

Identifying people at high risk for active tuberculosis after exposure to infected persons is important. Information about the ability of interferon-γ–release assays, such as enzyme-linked immunospot (ELISpot), to predict active tuberculosis is scant. The authors followed 908 Turkish children and adolescents with recent household exposure to tuberculosis. Eleven of 381 children with positive ELISpot results subsequently developed active tuberculosis, compared with 12 of 550 children with a positive tuberculin skin test. Compared with a negative ELISpot result, a positive result increases the risk for progressing to active tuberculosis by about 3-fold.

Mitral valve prolapse is more common in women than in men, but men more frequently undergo surgery for severe mitral regurgitation. Avierinos and colleagues sought to determine the reason for these sex-specific differences. Among 4461 women and 3768 men with mitral valve prolapse diagnosed on echocardiography, women had severe regurgitation less frequently. However, women with severe regurgitation were less likely to have surgery and had worse survival than men. Among patients who had surgery, survival did not differ between men and women.

Alcohol misuse may be a risk factor for failing to adhere to medication regimens. Bryson and colleagues found a graded, linear decrease in adherence to statins and hypertension medications with increasing levels of alcohol misuse among patients at 7 Veterans Affairs primary care clinics. At 1 year, the percentage of patients adherent to statins was lower in the 2 highest alcohol misuse groups than in nondrinkers. Similarly, the percentage of patients adherent to antihypertensive regimens was lower in the 3 highest alcohol misuse groups than in nondrinkers.

Howell and colleagues describe a quality-improvement partnership to reduce emergency department overcrowding and improve emergency department throughput. A hospitalist regularly visited the emergency department, assessed inpatient bed availability, and helped triage admitted patients to units with empty beds. The program was effective: Admitted patients spent less time in the emergency department (a decrease from 458 to 360 minutes), and the number of hours that the emergency department had to divert ambulances because of crowded conditions decreased by 6%.

Evaluation of claims that a new diagnostic test is better than the current gold-standard test is hindered by the lack of a perfect reference standard. This problem may be sidestepped by focusing on the clinical consequences of the decision rather than on estimation of accuracy. The authors describe the concept of an unbiased “fair umpire” test that is imperfect yet can discriminate between disease and nondisease cases. Within this framework, they discuss 3 principles to aid in judging the value of new tests.

Initiatives intended to reduce medical errors generally rely on recognizing and disclosing medical errors. Fear of a malpractice suit often leads to failure to disclose. Some state legislatures have enacted “apology laws” to encourage physicians to disclose medical errors. The authors characterize apology laws in the 50 U.S. states and the District of Columbia, review some of the important differences in these laws across states, and explore the potential impact of apology laws.

Under current U.S. law, the estate tax rate falls to zero on 1 January 2010. Mendenhall discusses concerns about this abrupt change in tax rate and the incentives it creates for persons who are nearing the end of life to stay alive until the tax rate drops.

As a physician becomes involved in a family member's care, conflict arises between personal and professional roles. The authors discuss illustrative cases and the risks and benefits of having a physician as a family member.

Although the medical profession frowns on physicians who tell patients about their own health problems (self-disclosure), the practice is probably common. The authors use simulated dialogue and draw on theory and evidence to discuss the effectiveness of physician self-disclosure and offer recommendations for improving or replacing self-disclosure.

In this issue, Bryson and colleagues report a direct, dose-related association between alcohol misuse and medication nonadherence for antihypertensives and statins but not oral hypoglycemics. This well-designed, nicely executed prospective study is a major step forward in understanding the relationship between substance abuse and medication nonadherence, and as many classic studies do, it raises more questions than it answers.

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