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Some have proposed that transplantation in the earlier stages of chronic liver disease would improve outcomes. The authors randomly assigned patients with Child–Pugh stage B alcoholic cirrhosis to immediate listing for transplantation or to standard care; 68% and 25%, respectively, received a liver transplant. Patients assigned to immediate listing had no survival benefit and more cases of extrahepatic cancer than patients in the standard care group who received an early transplant. The results support the current policy of giving the highest priority to the sickest patients.
The various immunochemical fecal occult blood tests (iFOBTs) use different antibodies against human blood components. The authors compared characteristics of 6 qualitative iFOBTs and 1 guaiac-based FOBT to identify adenomas in adults who had screening colonoscopy. Performance characteristics of the 6 iFOBTs varied widely: Sensitivity and specificity for detecting advanced adenomas ranged from 25% to 72% and 70% to 97%, respectively, compared with 9% and 96% for the guaiac test. Given these large ranges, choosing among available iFOBTs requires careful investigation.
Percutaneous coronary intervention (PCI) can cause contrast-induced nephropathy (CIN). Understanding the relationship among CIN, contrast volume, and patient characteristics could help to minimize this complication. Marenzi and coworkers found that 20% of 561 patients with ST-segment elevation myocardial infarction who had primary PCI developed CIN. Patients with CIN were more likely to die in the hospital. Higher contrast volume and a higher ratio of contrast used to the ideal dose (contrast ratio) were associated with CIN and in-hospital death.
Emergency department visits and rehospitalization are common after hospital discharge. Jack and colleagues demonstrated that a nurse discharge advocate and clinical pharmacist working together to coordinate hospital discharge, educate patients, and reconcile medications led to fewer follow-up emergency visits and less rehospitalization than usual care alone. A systematic approach to hospital discharges can reduce unnecessary health care utilization.
The USPSTF tries to provide reliable and accurate evidence-based recommendations to primary care clinicians. However, clinicians want more guidance when the evidence is insufficient to make a recommendation. This article describes the USPSTF plan to routinely report information in 4 domains pertinent to clinical decisions about prevention, discusses the rationale for selecting these domains, and provides examples of how to use the information to guide clinical decision making when the evidence is insufficient.
Many journal readers have difficulty understanding the rapidly evolving evidence on genetic associations. Inadequate reporting of results creates difficulty in evaluating the strengths and weaknesses of this evidence. The STrengthening the REporting of Genetic Association studies (STREGA) initiative modifies 12 of the 22 items in the Strengthening the Reporting of Observational Studies in Epidemiology Statement. The STREGA recommendations are intended to enhance the clarity of research reports, whatever the methods used for design, conduct, or analysis.
The U.S. Preventive Services Task Force (USPSTF) updates its 2001 recommendation statement on screening for skin cancer. The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for skin cancer by primary care clinicians or by patient skin self-examination (I statement).
To support the USPSTF recommendation statement in this issue, Wolff and colleagues systematically reviewed the evidence on the benefits and harms of screening for skin cancer in the general population. They found no new high-quality evidence on the benefit of screening for skin cancer with a whole-body examination by a physician. One fair-quality article provides limited but insufficient evidence that skin self-examination can reduce morbidity and mortality from melanoma. The evidence is too limited to estimate the benefits of screening for skin cancer in the general primary care population.
In this issue, Vanlemmens and colleagues report that patients with Child–Pugh stage B alcoholic cirrhosis who were immediately listed for liver transplantation were more likely than those assigned to standard care to undergo liver transplantation and develop extrahepatic cancer, and they may have had worse cancer-free survival. These findings confirm that liver transplantation does not offer a survival benefit in patients with intermediate-stage alcoholic cirrhosis. Faced with the disparity between demand for liver transplantation and donor organ supply, only disease severity as assessed by a validated system should drive priority for organ allocation.
This issue provides a clinical overview of chronic kidney disease, 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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