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Articles 
Henry L.Y. Chan, E. Jenny Heathcote, Patrick Marcellin, Ching-Lung Lai, Mong Cho, Young M. Moon, You-Chen Chao, Robert P. Myers, Gerald Y. Minuk, Lennox Jeffers, William Sievert, Natalie Bzowej, George Harb, Ralf Kaiser, Xin-Jian Qiao, Nathaniel A. Brown and the 018 Study Group The best way to suppress viral replication in chronic hepatitis B remains an open question. In this 52-week open-label trial, 135 adults with hepatitis B e antigen–positive chronic hepatitis were randomly assigned to telbuvidine or adefovir for 52 weeks, or adefovir for 24 weeks followed by telbivudine for 28 weeks. At 52 weeks, the reduction in viral load was similar in the telbivudine-only and adefovir-to- telbivudine groups and greater than that in the adefovir-only group.
Daniel S. Budnitz, Nadine Shehab, Scott R. Kegler, and Chesley L. Richards Data from a national surveillance study of adverse drug events and a national outpatient survey indicate that U.S. adults age 65 years or older have more than 175 000 emergency department visits for adverse drug events yearly. Drugs that should never be prescribed accounted for 3.6% of these visits, whereas 3 commonly indicated drugs—warfarin, insulin, and digoxin—accounted for more than one third of them. Strategies to decrease adverse drug events among older adults should focus on these 3 drugs.
James D. Douketis, Chu Shu Gu, Sam Schulman, Angelo Ghirarduzzi, Vittorio Pengo, and Paolo Prandoni The decision to discontinue anticoagulation for venous thromboembolism (VTE) depends in part on the risk for a fatal recurrence after stopping. In cohorts from 2 source studies that monitored 2052 patients for an average of 5 years after discontinuing anticoagulation for a first episode of VTE, the annual risk for any fatal pulmonary embolism was 0.43 event per 100 patient-years, and the risk for definite or probable fatal recurrent VTE was 0.17 event per 100 patient-years. Decision makers must take these rates into account if they decide to stop anticoagulant therapy.
Academia and Clinic
Eric G. Campbell, Susan Regan, Russell L. Gruen, Timothy G. Ferris, Sowmya R. Rao, Paul D. Cleary, and David Blumenthal In a survey of physicians in 6 specialties, most of the 1662 responders agreed with statements in the Charter for Professionalism about principles of fair distribution of finite resources, improving access to care and quality of care, managing conflicts of interest, and professional self-regulation. However, self-reported adherence to the norms of professional behavior falls short of ideal.
Updates
Lowell E. Schnipper This Update features 10 articles published in 2006. Topics include lung, gastroesophageal, breast, and gynecologic cancer, and leukemia.
Perspectives
Michael Klompas and Richard Platt Legislators, payers, and quality-of-care advocates are considering whether to require hospitals to report ventilator-associated pneumonia rates as a way to evaluate quality of care. Accurate diagnosis of ventilator-associated pneumonia, however, is notoriously difficult, and the current surveillance definition requires considerable subjective judgment. Ventilator-associated pneumonia should not be a component of compulsory reporting initiatives until we develop and validate objective outcome measures that meaningfully reflect quality of care for ventilated patients.
Position Papers
Lois Snyder, Richard L. Neubauer for the American College of Physicians Ethics, Professionalism and Human Rights Committee This position paper of the American College of Physicians focuses on potential pitfalls of pay-for-performance programs. Incentives for good performance on specific elements of a condition may lead physicians to neglectother elements of care for complex patients or to discharge such patients from their practice. "Playing to the measures" is another risk. The primary focus of the quality movement should be on the patient, not on "paying for" or "performance" assessment based on limited measures.
Clinical Guidelines
U.S. Preventive Services Task Force A targeted literature search sought new evidence on the direct benefits and harms of screening, and on the harms of treating screen-detected or mild to moderate hypertension. The U.S. Preventive Services Task Force (USPSTF) found no new substantial evidence that would lead it to change its 2003 recommendation. It therefore reaffirms its recommendation that clinicians screen for high blood pressure in adults age 18 years or older.
Tracy Wolff and Therese Miller This evidence update supports the USPSTF recommendation on screening for high blood pressure. The only new evidence was about the harms of treatment of early hypertension: Although pharmacologic therapy is associated with common side effects, serious adverse events are uncommon.
Editorials
Jordan J. Feld and Marc G. Ghany In this issue, Chan and colleagues tested telbivudine alone, adefovir alone, and adefovir followed by telbivudine in 135 hepatitis B e antigen–positive patients. Their 24-week results more accurately reflect an initial treatment response compared with their 52-week results, and rates of sustained response and loss of hepatitis B surface antigen (HBsAg) remain poor. New drugs aimed at novel antiviral targets are needed to achieve HBsAg loss and successfully prevent and manage resistance.
Harold C. Sox The medieval European craft guilds are the antecedents of today's professions. As a commentary on the article by Campbell and colleagues in this issue, the Editor argues that, like the guilds, the medical profession exists in a 3-way relationship with government and business. The parable of the guilds teaches us that community institutions must adapt or wither.
On Being a Doctor
Adrienne E. Shapiro One month into medical school, I arrived in the ultrasonography suite to join my preceptor for the afternoon. I fought to hide my dismay that my first patient would be a moving image on a screen. So much for learning about the doctor–patient relationship, I thought.
Letters Risks of Intravenous Immunoglobulin in Sepsis Affect Trial Design
Alexis F. Turgeon, Dean A. Fergusson, D. William Cameron, Paul C. Hébert, Lauralyn McIntyre, and Alan A. Tinmouth—RESPONSE The Declining Number and Variety of Procedures Done by General Internists
Strategies for Timely and Effective Hospice Discussions: End-Stage Renal Disease
Pharmacogenetics of Efavirenz: Adherence and Virologic Outcomes
Correction: Update in General Internal Medicine
Peter Katona
Lin A. Brown
Thomas S. Metkus, Jr
Jason David Eubanks
This issue provides a clinical overview of heart failure, 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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