Table of Contents

November 17, 2009; 151 (10)

Articles

  • Roy and colleagues developed a program to guide diagnosis of pulmonary embolism for use on a mobile, handheld device. The investigators randomly assigned 20 emergency departments in France to activation of either the decision-support system on the devices or posters and pocket cards that showed diagnostic strategies. The device-based program improved appropriate testing of patients with suspected pulmonary embolism more than paper guidelines alone.

  • In this trial, 636 patients with hypertension were randomly assigned to receive usual care; a telephone-delivered, nurse-administered behavioral self-management intervention; home blood pressure self-monitoring; or both of the latter 2 interventions. Compared with usual care, the adjusted improvement in the proportion of patients with blood pressure control at 24 months was 4.3% for the behavioral intervention group, 7.6% for the blood pressure monitoring group, and 11.0% for the combined intervention group. The combined intervention improved blood pressure control and systolic and diastolic blood pressures more than usual care.

  • Lettieri and coworkers assessed whether a short course of eszopiclone therapy improves long-term adherence to continuous positive airway pressure (CPAP). They randomly assigned 160 adults with severe obstructive sleep apnea to eszopiclone or placebo for the first 14 nights of CPAP, and measured patients' adherence to CPAP weekly for 24 weeks. Patients receiving eszopiclone were less likely to discontinue CPAP and also used CPAP more nights and longer per night than did patients receiving placebo.

Review

  • Nelson and colleagues reviewed trials and observational studies to summarize the benefits and harms of tamoxifen citrate, raloxifene, and tibolone in reducing the risk for primary breast cancer in women. Tamoxifen, raloxifene, and tibolone each reduced risk for invasive breast cancer more than placebo. Tamoxifen and raloxifene reduced risk for estrogen receptor–positive but not estrogen receptor–negative breast cancer or death. All drugs reduced fracture risks but increased risk for thromboembolic events (tamoxifen and raloxifene), endometrial cancer (tamoxifen), or strokes (tibolone).

Clinical Guidelines

  • This U.S. Preventive Services Task Force (USPSTF) update recommends biennial screening mammography for women aged 50 to 74 years (grade B recommendation). The USPSTF recommends against routine screening mammography in women aged 40 to 49 years (grade C recommendation) and against clinicians teaching women how to perform breast self-examination (grade D recommendation). Finally, the USPSTF found that evidence is insufficient to assess screening mammography in women aged 75 years or older, clinical breast examination beyond screening mammography in women aged 40 years or older, and either digital mammography or magnetic resonance imaging instead of film mammography as screening modalities (I statements).

  • To inform the USPSTF recommendations about breast cancer screening, Nelson and coworkers reviewed evidence on the effectiveness of mammography screening in decreasing breast cancer mortality among average-risk women, the effectiveness of clinical breast examination and breast self-examination, and the harms of screening. They found that mammography screening reduced breast cancer mortality for women aged 39 to 69 years, but data for older women were insufficient. They also found that false-positive results and additional imaging tests were common, particularly among younger women. No benefit has been shown for clinical breast examination or breast self-examination.

  • To inform the USPSTF recommendations about breast cancer screening, Mandelblatt and colleagues developed 6 models of breast cancer incidence and mortality in the United States and estimated benefits and harms across 20 mammography screening strategies. The models showed that biennial screening achieves most of the benefit of annual screening with less harm. Decisions about the best screening strategy depend on program and individual objectives and the weight placed on benefits, harms, and resource considerations.

Editorials

  • In this issue, Roy and colleagues studied the use of a handheld clinical decision-support system to improve the diagnosis of pulmonary embolism in 20 French emergency departments. Handheld computers could provide a key resource that improves access to decision-support tools and leads to better management decisions. Roy and colleagues' work represents a promising start toward this essential goal.

  • Widespread use of screening mammography has been the mainstay of breast cancer prevention in the United States for the past 25 years. In this issue, the USPSTF has made major changes to its recommendations on breast cancer screening. Three accompanying articles summarize benefits and harms of screening, model different screening strategies, and review medications that reduce risk for breast cancer. The recommendations and new information should compel clinicians to examine whether current prevention practices in the United States are consistent with the best available evidence.

Letters

Ad Libitum

Medical Notices

Summaries for Patients

ACP Journal Club