Yaramasu, Venkata, author

Yang, Yongheng, author

Sundaravadielu, S., author

Interview with Henry M. Blumberg, MD, author of Update on the Treatment of Tuberculosis and Latent Tuberculosis Infection, published in the June 8 issue of JAMA, the Journal of the American Medical Association. Summary Points: 1. Tuberculosis is a public health problem. The responsibility for prescribing an appropriate regimen and assuring that treatment is completed is assigned to the public health program or the treating physician, not the patient. 2. Directly observed therapy is recommended for all patients being treated for active TB, this will necessitate the need for greater collaboration between the treating physician and the public health department. 3. Initial therapy for newly diagnosed patients with tuberculosis consists of a 4-drug regimen including isoniazid, rifampin, pyrazinamide and ethambutol. 4. Testing for latent TB infection should be targeted at those who are at increased risk of progression to active TB. 5. Despite its limitations, the tuberculin skin test remains the most commonly used test for the diagnosis of latent TB infection; newer diagnostic tests for latent TB infection are on the horizon. 6. Active tuberculosis should be excluded before beginning treatment for latent tuberculosis infection. 7. Nine months of isoniazid is the preferred therapy for the treatment of latent TB infection.

Interview with Fangjun Zhou, PhD, MS and Rafael Harpaz, MD, MPH, authors of Impact of Varicella Vaccination on Health Care Utilization, published in the August 17 issue of JAMA, the Journal of the American Medical Association. Summary Points: 1. Varicella can be severe and at times life threatening, however, since the introduction of varicella vaccine in 1995, varicella hospitalizations have declined significantly, as have outpatient visits. 2. Herd immunity is protecting unvaccinated persons from varicella. Since varicella can be more severe in adults, it is particularly important that patients be screened for evidence of immunity to varicella and anyone susceptible be vaccinated, so that children and adolescents do not remain susceptible at adulthood. The federal government's Advisory Committee on Immunization Practices, or ACIP, provides new recommendations regarding screening patients for evidence of immunity to varicella and vaccinating those at risk of the disease. 3. The diagnosis of varicella has become challenging as rates have declined and since the disease is highly modified among those vaccinated. Laboratory testing will play an increasing role in diagnosis of varicella. 4. Providers should report varicella to the local health department so that public health authorities can act to control outbreaks and can monitor for development of problems in the vaccination program. Thanks to everyone who took part in Author in the Room on September 21. During the call, Dr. Rafael Harpaz mentioned that the CDC has some photo images of more attenuated forms of varicella. You can find these images at www.cdc.gov.

Interview with Charles N. Ford, MD, author of Evaluation and Management of Laryngopharyngeal Reflux, published in the September 28 issue of JAMA, the Journal of the American Medical Association. Summary points: 1. Differentiating between gastroesophageal reflux and laryngopharyngeal reflux. 2. Making and confirming laryngopharyngeal reflux diagnosis. 3. Resolution of laryngopharyngeal reflux findings may require aggressive and prolonged treatment.

Interview with David R. Flum, MD, MPH, author of Use of Early Mortality Among Medicare Beneficiaries Undergoing Bariatric Surgical Procedures, published in the October 19 issue of JAMA, the Journal of the American Medical Association. Summary Points: 1. Patients 65 years or older have a much higher risk of early death than younger patients after bariatric (obesity) surgery. 2. Already a high risk population, Medicare medically disabled patients have a higher risk of early death after bariatric (obesity) surgery is performed than previously reported. 3. Older patients of more experienced bariatric surgeons had a much lower risk of death than those older patients whose surgeons had less experience performing the surgery.

Interview with Matthew H. Samore, MD, author of Clinical Decision Support and Appropriateness of Antimicrobial Prescribing: A Randomized Trial, published in the November 9 issue of JAMA, the Journal of the American Medical Association. Summary points: 1. Repetitive use of a diagnostic and treatment algorithm to ingrain new prescribing habits was a valuable part of this practice change intervention. 2. Clinical decision support systems (CDSS) are feasibly implemented in practice settings that lack electronic medical records, including rural communities. 3. CDSS needs to be integrated with tools that save clinicians' time to be sustainable.

Interview with Sandra Dial, MD, MSc, author of Use of Gastric Acid Suppressive Agents and the Risk of Community Acquired Clostridium difficile Associated Disease, published in the December 21 issue of JAMA, the Journal of the American Medical Association. Summary Points: 1. Acid suppressive therapy use was associated with an increased risk of CDAD, with PPIs appearing to be associated with a higher risk than h2blockers. These agents, particularly PPIs, are being prescribed with increasing frequency to patients, including situations where the benefits may be small. 2. Although the rate is lower than in the hospital, CDAD is occurring in the community and is being diagnosed more frequently. 3. Prior antibiotic exposure appears to be less frequent in patients diagnosed in the community as compared to patients diagnosed in hospital.

Interview with Olga Jonasson, MD, author of Watchful Waiting vs Repair of Inguinal Hernia in Minimally Symptomatic Men, published in the January 18 issue of JAMA, the Journal of the American Medical Association. Summary Points: 1. Men, and men only, who have few if any symptoms from their inguinal hemia, can safely delay having it fixed. 2. When symptoms develop, especially if the symptoms worsen suddenly, they should visit a surgeon and request a repair. 3. If the hernia suddenly becomes incarcerated, painful, and signs of a bowel obstruction develop (vomiting, abdominal cramps), an operation should be done immediately. In 2006, even this emergency operation is safe and mortality rates are low.

Interview with Anna Taddio, PhD, author of Intravenous Morphine and Topical Tetracaine for Treatment of Pain in Preterm Neonates Undergoing Central Line Placement, published in the February 15 issue of JAMA, the Journal of the American Medical Association. Summary Points: 1. Infants feel pain during central line placement and this pain can be reduced with analgesics. 2. IV Morphine used alone or in combination with Tetracaine Gel is more effective than Tetracaine alone or no treatment. 3. IV Morphine and Tetracaine Gel are associated with expected side effects; IV Morphine causes mild respiratory depression and Tetracaine causes reddening discoloration of the skin.

Interview with Thomas Nolan, PhD, and Donald M. Berwick, MD, MPP, author of All-or-None Measurement Raises the Bar on Performance, published in the March 8 issue of JAMA, the Journal of the American Medical Association. Summary Points: 1. All or none measurement more closely reflects the interests and likely desires of patients than other approaches to measurement such as composite or item-by-item. 2. All or none measurement forces a system perspective. 3. All or none measurement offers a more sensitive scale for assessing improvements.

Interview with William Taylor, MD, author of A 71-Year-Old Woman Contemplating a Screening Colonoscopy, published in the March 8 issue of JAMA, the Journal of the American Medical Association. Summary Points: 1. Embedded in experts’ recommendations for colorectal cancer screening are nearly impossible demands on primary care clinicians to discuss the pros and cons of various modalities for screening with each patient and to assess risk even to the detail of learning the pathology of the biopsy of relatives’ colonoscopies (e.g., adenomatous vs. hyperplastic polyps). 2. The complex set of components involved in the decision to screen (or not) for colon cancer includes input from both the doctor (e.g., data about what might happen and how likely the possibilities are) and the patient (e.g., how the patient weighs the relative desirability of the various possible outcomes that result from the possible decisions). 3. The decision to undertake a preventive maneuver involves weighing the risks, cost, and inconvenience of an intervention now for a potential benefit in the future.

Interview with Christopher M. Callahan, MD, author of Effectiveness of Collaborative Care for Older Adults With Alzheimer Disease in Primary Care: A Randomized Controlled Trial, published in the May 10 issue of JAMA, the Journal of the American Medical Association. Summary Points: 1. Primary care practices have standard protocols to offer a patient with Alzheimer Disease and their caregivers. 2. The quality of care of many geriatric syndromes, including Alzheimer Disease, can be improved by implementing a collaborative care model. 3. Similarly to many geriatric syndromes, medication may be useful, but it is not enough. Medications are one part of a package of care.

Interview with Victor G. Vogel, MD, MHS, author of Effects of Tamoxifen vs Raloxifene on the Risk of Developing Invasive Breast Cancer and Other Disease Outcomes , published in the June 21 issue of JAMA, the Journal of the American Medical Association. Summary Points: 1. Raloxifene is as effective in reducing the risk of invasive breast cancer in postmenopausal women who are at increased risk of the disease. 2. The safety profile of raloxifene is more favorable than tamoxifen with fewer hysterectomies, uterine malignancies, serious thrombotic events, and cataracts. 3. Both physicians and patients are familiar with raloxifene and its use for preventing and treating osteoporosis, and there is a long experience with its use in healthy women.

Interview with David Gonzales, PhD, and Stephen Rennard, MD, authors of Helping Patients Stop Smoking: Varenicline vs Bupropion, published in the July 5 issue of JAMA, the Journal of the American Medical Association. Summary Points: 1. There is a new and novel pharmaceutical approach to treating nicotine addiction that helps smokers quit by specifically targeting nicotine receptors. 2. Efficacy for varenicline was three to four times that of placebo and twice that of bupropion at the end of 12 weeks of treatment, but abstinence rates in all groups declined after drug treatment ended. 3. The launch of a new smoking cessation medication will likely drive patient demand for smoking cessation services. Medical practices should be prepared to respond to this demand by having a clear, systematic approach to smoking cessation.

Interview with Harriet L. MacMillan, MD, MSc, FRCP(C), author of Approaches to Screening for Intimate Partner Violence in Health Care Settings: A Randomized Trial, published in the August 8 issue of JAMA, the Journal of the American Medical Association. Summary Points: 1. Even though we have long assumed that clinicians should ask patients directly about intimate partner violence, this study shows that self-complete methods for soliciting such information are preferred by women, and may be more efficient. 2. The prevalence rate for intimate partner violence differs by setting and population and varies significantly from approximately 4% to approximately 18%. 3. While this study provides evidence on the best methods to solicit information on intimate partner violence, it doesn't tell us if collecting this information improves outcomes for women exposed to such violence. A randomized controlled trial evaluating the effectiveness of screening women for intimate partner violence in health care settings is currently underway.

Interview with David Mark Spiro, MD, MPH, author of Wait-and-See Prescription for the Treatment of Acute Otitis, published in the September 13 issue of JAMA, the Journal of the American Medical Association. Summary Points: 1. Wait-and-See Prescription (WASP) is a viable approach to managing children with acute otitis media. Compared with the standard prescription group, the WASP group filled the antimicrobial prescription much less frequently and had equivalent clinical outcomes. 2. Within the WASP group, fever and ear pain were associated with filling the prescription demonstrating that parents are able to make appropriate care decisions when given clear guidance. 3. In the management of acute otitis media, important points for clinicians are first to make right diagnosis and then to provide sufficient analgesia. Adequate pain control allows parents to better manage their sick child and use antimicrobials judiciously while also reducing the risk of medical adverse effects and antibiotic resistance.

Interview with Dariush Mozaffarian, MD, DrPH, author of Fish Intake, Contaminants, and Human Health, published in the October 18 issue of JAMA, the Journal of the American Medical Association. Summary Points: 1. For the general population, the health benefits of fish intake far outweigh the risks. 2. Women of childbearing age, nursing mothers and young children should eat up to two servings of fish per week as the benefits of fish intake still outweigh the risks. 3. Given the magnitude of the benefits, physicians should regularly give dietary advice to patients for cardiovascular disease prevention.

Interview with Louise Walter, MD, author of PSA Screening Among Elderly Men With Limited Life Expectancies. Summary Points: 1. Most cancer screening guidelines do not recommend screening elderly persons in poor health who have limited life expectancies because the harms of screening (which occur immediately) outweigh the potential benefits (which occur many years in the future). 2. PSA screening rates among elderly men with limited life expectancies should be much lower than current practice to avoid harming these men with unnecessary tests and procedures. 3. Guidelines should be more explicit about how life expectancy is defined and provide tools to help clinicians identify men with poor prognoses who are most likely to be harmed by PSA screening, considering both age and the presence of severe disease.

Interview with Dennis Black, PhD, author of The Effects of Continuing or Stopping Alendronate after Five Years of Treatment: Results from the Fracture Intervention Trial Long-term Extension. Summary Points: 1. The long-term use of alendronate for up to 10 years is safe. 2. Those who discontinued treatment at 5 years lost bone mass compared with those who continued but the bone loss was only moderate. Rates of fracture were similar among those who continued vs those who discontinued except for clinical vertebral fractures which, although relatively uncommon, were higher in those who discontinued treatment. 3. Results suggest that after 5 years of alendronate, many women may discontinue therapy for up to 5 years. However, those at high risk of clinical vertebral fracture may benefit by continuing.

Interview with David Ganz, MD, MPH, author of The Rational Clinical Exam: Will My Patient Fall? Summary Points: 1. Screening for falls is as simple as asking the patient if she's fallen in the past year. For patients who have not fallen, ask about gait or balance problems (e.g. "Do you have a walking or balance problem?"). 2. Most older patients who have a history of falls in the past year, or a gait/balance problem, have at least a 50% chance of falling in the coming year. You may want to do a more thorough evaluation on these patients. 3. To make screening easy for new patients, add into your pre-visit questionnaire questions that ask about a history of falls and/or gait/balance problems. Or, have your office staff ask these questions routinely when patients are being checked in.

Interview with Paul M. Ridker, MD, MPH, author of Development and Validation of Improved Algorithms for the Assessment of Global Cardiovascular Risk in Women: The Reynolds Risk Score. Summary Points: 1. Half of all heart attacks and strokes occur among those with normal cholesterol levels and 15-20% occur among those with no major risk factors at all. 2. The major breakthroughs in understanding cardiovascular disease over the past decade include insights about inflammation and genetics. Each of these can easily be ascertained with either a simple blood test (hsCRP for inflammation) or a simple question about parental history of myocardial infarction. 3. By incorporating these 2 new measures into how we think about risk, a new risk tool was derived known as the "Reynolds Risk Score." 4. This is a win-win for everyone as it allows us to better target therapies, avoid toxicity, and improve overall prevention strategies for heart disease.

Interview with Peter B. Bach, MD, author of Computed Tomography Screening and Lung Cancer Outcomes. Summary Points: 1. Screening and other prevention approaches involve subjecting very large numbers of people to an intervention, with the expectation that a few will benefit, but most will not (as they would have never developed the condition anyway). 2. In general, screening for diseases such as cancer will uncover some reservoir of abnormalities that appear to be precursors to clinical disease but are not yet causing disease. 3. We really have no evidence to support screening for lung cancer right now with any technology. 4. We really should be advocating for our patients to help them understand why they shouldn't have this test until we know that it is more likely to hurt them or help them.

Interview with Steven R. Steinhubl, MD, author of Aspirin Dose for the Prevention of Cardiovascular Disease. Summary Points: 1. While aspirin is generally a safe drug and extremely effective, with more than 50 million US adults taking it every day for cardiovascular disease prevention, even a very small incidence of adverse effects can have major implications. Consistent with this, one study found that the most common medication leading to an adverse event requiring hospitalization was aspirin for cardiovascular disease prevention. 2. In terms of preventing heart attacks, strokes, or cardiovascular deaths, no clinical trial has identified an aspirin dose more efficacious than 75 to 81 mg daily. 3. Although there is no dose of aspirin that doesn't increase the risk of GI toxicity or bleeding, greater doses of aspirin are consistently associated with a greater risk. For example, in the United States alone, if everyone took 325 mg of aspirin daily instead of 81 mg, based on observational data, this could translate into nearly 1 million additional major bleeding complications a year.

Interview with Jan L. Brandes, MD, author of Sumatriptan-Naproxen for Acute Treatment of Migraine. Summary Points: 1. Evidence from two replicate randomized, double-blind, placebo-controlled trials showed sumatriptan-naproxen as a fixed dose combination was superior in treating an attack of migraine when compared with sumatriptan alone, naproxen alone, or placebo. 2. Most importantly, given that migraine attacks in adults are 4 to 72 hours in duration, the fixed-dose combination of sumatriptan-naproxen was significantly more effective than sumatriptan monotherapy or naproxen monotherapy in providing a 24-hour sustained pain-free response. 3. Patients using the fixed-dose combination therapy were less likely to use rescue medication or to have headache recurrence, and did not experience any increase in adverse effects using the combination.