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Articles 
Rochelle P. Walensky, Christian Arbelaez, William M. Reichmann, Ron M. Walls, Jeffrey N. Katz, Brian L. Block, Matthew Dooley, Adam Hetland, Simeon Kimmel, Jessica D. Solomon, and Elena Losina Few studies have examined the performance characteristics of rapid oral HIV testing. Walensky and colleagues found that 39 of 849 adults who visited an urban emergency department had a reactive result on rapid oral HIV testing. Confirmatory tests showed that 26 of these 39 patients were not HIV-infected, a much higher rate of false-positive results than expected. Reactive results increased the odds of HIV infection 8-fold to 32-fold compared with the pretest odds. Rapid oral HIV testing can help identify patients with greater odds of HIV infection.
Kathryn L. Burgio, Stephen R. Kraus, Shawn Menefee, Diane Borello-France, Marlene Corton, Harry W. Johnson, Veronica Mallett, Peggy Norton, Mary P. FitzGerald, Kimberly J. Dandreo, Holly E. Richter, Thomas Rozanski, Michael Albo, Halina M. Zyczynski, Gary E. Lemack, Toby C. Chai, Salil Khandwala, Jan Baker, Linda Brubaker, Anne M. Stoddard, Patricia S. Goode, Betsy Nielsen-Omeis, Charles W. Nager, Kimberly Kenton, Sharon L. Tennstedt, John W. Kusek, T. Debuene Chang, Leroy M. Nyberg, William Steers for the Urinary Incontinence Treatment Network The authors sought to determine whether behavioral therapy would help women with urge urinary incontinence to stop drug therapy for this condition. In this multicenter trial, 307 women with urge-predominant incontinence were randomly assigned to receive 10 weeks of tolterodine plus behavioral training or tolterodine alone. Six months later, 41% of women in both groups reported a 70% or greater reduction in the frequency of incontinence episodes and did not require treatment. Even with behavioral therapy, short-term treatment does not provide sustainable improvement in urge urinary incontinence.
Andrew P. Wilper, Steffie Woolhandler, Karen E. Lasser, Danny McCormick, David H. Bor, and David U. Himmelstein Some claim that U.S. persons without health insurance do not typically have ongoing health care needs. Using data from the National Health and Nutrition Examination Survey, Wilper and associates estimate that more than 11 million working-age Americans without health insurance have cardiovascular disease, hypertension, diabetes, dyslipidemia, obstructive lung disease, or previous cancer. Chronically ill patients without insurance were less likely than those with coverage to visit a health professional and were more likely to identify an emergency department as their standard site of care.
Reviews
Madhukar Pai, Alice Zwerling, and Dick Menzies Tuberculin skin tests (TSTs) and interferon-
Perspectives
Andrew J. Vickers, Ethan Basch, and Michael W. Kattan Cut-points for defining a diagnosis have substantial limitations. Risk prediction, in which patient risk factors are combined into a single model and the results used in shared decision making about treatments, may offer an alternative to diagnosis. The authors compare the diagnostic and risk prediction approaches and attempt to identify for which types of medical problem each is best suited.
Clinical Guidelines
U.S. Preventive Services Task Force The U.S. Preventive Services Task Force (USPSTF) updates their 2002 recommendation statement on screening for prostate cancer. Current evidence is insufficient to assess the balance of benefits and harms of screening for prostate cancer in men younger than age 75 years (I statement). The Task Force does not recommend screening for prostate cancer in men age 75 years or older (grade D recommendation).
Kenneth Lin, Robert Lipsitz, Therese Miller, and Supriya Janakiraman To support the USPSTF recommendation in this issue, Lin and colleagues performed a systematic review to seek new evidence on the benefits and harms of screening asymptomatic men for prostate cancer. No good-quality randomized, controlled trials of screening for prostate cancer have been completed. In 1 cross-sectional and 2 prospective cohort studies of fair to good quality, false-positive prostate-specific antigen (PSA) results caused psychological adverse effects for up to 1 year after the test. The authors concluded that PSA screening is associated with psychological harms, and its potential benefits remain uncertain.
Editorials
Christopher D. Pilcher and C. Bradley Hare In this issue, Walensky and colleagues report one emergency department's experience with rapid oral HIV screening. Most of the positive test results were false positive; therefore, the authors cautioned against use of oral HIV testing and recommended tempering expectations about the accuracy of these tests in low-prevalence settings. Yet, early detection and treatment remains our best hope to stop the spread of HIV, and screening for HIV in acute care settings just might be the right strategy.
Marshall H. Chin The article by Wilper and colleagues in this issue tells us that chronic disease is rampant among uninsured persons. This editorial identifies opportunities for policy reforms and outlines what every practice, hospital, and health plan can do now to improve outcomes for vulnerable patients with chronic disease.
On Being a Doctor
Manoj Jain My wife and I had a game: I would say "I love you" on the phone to her, and she would reply giggling, "Me too." But somewhere along the way, things had changed. Action was required.
On Being a Patient
Steve Blevins Winter was raging throughout the Great Plains, and Oklahoma was reeling from the icy assault. We reveled in "ice stories," to which I contributed generously. But even the most provocative story would soon be eclipsed by a more intimate tale.
Letters Is There Enough Evidence to Support Use of N-Acetylcysteine in Contrast-Induced Nephropathy?
Denise A. Gonzales, Robert A. Star, Steven J. Kern, Charles Natanson, and Robert L. Danner Fever Increases the Risk for Cardiac Arrest in the Brugada Syndrome
Ahmad S. Amin, Paola G. Meregalli, Abdennasser Bardai, Arthur A.M. Wilde, and Hanno L. Tan A Case of Apical Ballooning Cardiomyopathy Associated with Duloxetine
Correction: Effectiveness of Drugs for Preventing Contrast-Induced Nephropathy
Correction: Reported Methodologic Quality and Discrepancies between Large and Small Randomized Trials in Meta-Analyses
Lise L. Gluud, Kristian Thorlund, Christian Gluud, Lesley Woods, Ross Harris, and Jonathan A.C. Sterne
Dawn S. Brezina and Paul Brezina
Eleni Linos
Cynthia Scott
This issue provides a clinical overview of gastroesophageal reflux disease, focusing on prevention, diagnosis, treatment, practice improvement, and patient information. Readers can complete the accompanying CME quiz for 1.5 credits. | ||||||||||||||||||||||||||||||||||||||||||||||||||
In this Issue
Articles
Previous Issue
–release assays (IGRAs) are used to detect latent tuberculosis. In an updated meta-analysis, now including 38 studies, Pai and colleagues found that both TST and IGRAs have high specificity (95%) for tuberculosis in populations not vaccinated with bacille Calmette–Guérin (BCG). In BCG-vaccinated populations, the specificity of IGRAs was as good as in BCG-naive populations and substantially higher than that of TSTs. Thus, IGRAs are preferred in BCG-vaccinated patients in whom latent tuberculosis is suspected. 