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.

Interview with Bernard Cole, PhD, and Robert S. Sandler, MD, authors of Folic Acid for Prevention of Colorectal Adenomas. Summary Points: 1. Folic acid supplementation is not useful for preventing colorectal adenomas. 2. Folic acid supplementation may be harmful through increasing colorectal adenomas. 3. Practitioners and patients should wait for strong evidence before initiating therapies given the potential for waste and unintended adverse consequences.

Interview with Roy C. Ziegelstein, MD, author of Acute Emotional Stress and Cardiac Arrhythmias. Summary Points: 1. Episodes of emotional stress, especially when sudden, severe, and unexpected, may have significant adverse effects on the heart. 2. Acute emotional stress can increase sympathetic stimulation of the heart and can alter brain activity in a way that makes the heart more susceptible to rhythm disturbances. 3. Since episodes of emotional stress are almost inevitable in life, part of a healthy lifestyle is learning how to deal effectively with stress.

Interview with Douglas R. Lowy, MD, author of Effect of Human Papillomavirus 16/18 L1 Viruslike Particle Vaccine Among Young Women With Preexisting Infection. Summary Points: 1. The HPV vaccine has been shown to work very well in preventing new (incident) infection and disease caused by the HPV types targeted in the vaccine. 2. The JAMA study shows that HPV vaccination does not hasten clearance of existing (prevalent) infection with the HPV types targeted by the vaccine (HPV16 and 18). 3. It is most cost-effective to administer the vaccine before patients are exposed to HPV, because the vaccine is effective in preventing new infection but does not appear to be effective in treating established infection.

Interview with Romsai T. Boonyasai, MD, MPH, author of Effectiveness of Teaching Quality Improvement to Clinicians. Summary Points: 1. Quality Improvement (QI) curricula are often effective in improving learners plus or minus QI-related participation, attitudes, and knowledge. 2. QI curricula are less often associated with clinical improvements. 3. Clinical improvements occur more often when learners engage in multiple small cycles of change, and when they have individualized coaching in QI, access to their performance data, and access to pre-developed QI tools.

Interview with R. Monina Klevens, DDS, MPH, author of Invasive Methicillin-Resistant Staphylococcus aureus Infections in the United States. Summary Points: 1. The magnitude of MRSA infection is significant, demonstrating that it is a major healthcare and public health issue. 2. The majority of invasive MRSA infections are healthcare associated; hospitals and other healthcare facilities should make MRSA prevention a priority. 3. MRSA skin infections are common in the community and rarely become life threatening or invasive.

Interview with Dena M. Bravata, MD, MS, author of Using Pedometers to Increase Physical Activity and Improve Users' Health. Summary Points: 1. Pedometer users increase their physical activity. They walked 2000 steps per day more than people who do not use a pedometer. 2000 steps is equivalent to about 1 mile per day or about 100 calories per day. 2. Having a daily step goal is important for increasing physical activity with a pedometer. Pedometer users with any goal plus or minus either 10,000 steps per day or an individualized step goal plus or minus increase their physical activity whereas those pedometer users without a goal do not. 3. Pedometer users lose weight and lower their blood pressure. 4. Pedometer interventions that take place in the workplace are less likely to result in improvements in physical activity than interventions that took place in non-workplace settings. This is because the people who chose to participate in workplace interventions already had relatively high baseline physical activity which suggests that workplace interventions should target sedentary employees.

Interview with Ian G. Williamson, MD, author of Antibiotics and Topical Nasal Steroid for Treatment of Acute Maxillary Sinusitis. Summary Points: 1. Antibiotics are not so effective in the routine treatment of cases of acute sinusitis even when of probable bacterial origin, and should therefore be used more judiciously and with greater caution. 2. Expectations should not necessarily be for antibiotics but balanced risk assessments and symptom advice are still important. 3. Findings of lack of efficacy for antibiotics should drive a research agenda which aims to identify subgroups that might benefit from their use and/or other types of treatment.

Interview with Mark J. Pletcher, MD, MPH, author of Trends in Opioid Prescribing by Race/Ethnicity for Patients Seeking Care in US Emergency Departments. Summary Points: 1. Doctors appear to prescribe opioids less often to blacks and Hispanics/Latinos than they do to whites in the emergency department. 2. These differences do not appear to be explained by differences in type or severity of pain. To address these disparities, we would recommend: 1. Educating patients to make sure non-white patients expect good pain control and know how/when to ask for it. 2. Educating physicians and nurses about the existing disparities and the need to eliminate them, specifically addressing fears of prescription opioid abuse and other reasons physicians may withhold opioids. 3. Creating systems that minimize barriers to prescribing and monitor resolution of pain. 4. Monitoring quality of care by measuring resolution of pain and collecting and analyzing data by race/ethnicity.

Interview with Stephen M. Shortell, PhD, MBA, MPH, author of Improving Patient Safety by Taking Systems Seriously. Summary Points: 1. To make real progress in patient safety will require redesigning the underlying system of care such that healthcare professionals and institutions providing a continuum of services from prevention to hospice can address multiple conditions and episodes over time. A "culture of systems" must be established. 2. Competing priorities, professional autonomy, solo and small physician practices, disciplinary silos, miss-aligned financial incentives, and inadequate feedback about performance all undermine efforts to create safe healthcare systems. 3. A number of strategic, cultural, technical, and structural barriers need to be addressed to assure safer care. This includes the need for patient safety organizations to gather information across the continuum of care and provide both rapid feedback to practitioners and analyze trends over time.

Interview with Laura P. Svetky, MD, MHS, author of Comparison of Strategies for Sustaining Weight Loss: The Weight Loss Maintenance Randomized Controlled Trial. Summary Points: 1. Weight loss is feasible and long term weight loss is possible. 2. Ongoing personal contact and technology based interventions were effective but the overall benefits were small. 3. The role of clinicians is to reinforce the message that weight loss can prevent and treat multiple chronic conditions. Even small amounts of weight loss can lead to significant health benefits. 4. Our focus should be on long term healthy life style changes rather than dieting, which is by its very nature short term.

Interview with Barbara V. Howard, PhD, author of Effect of Lower Targets for Blood Pressure and LDL Cholesterol on Atherosclerosis in Diabetes: The SANDS Randomized Trial. Summary Points: 1. Both standard and aggressive targets for blood pressure and LDL cholesterol in individuals with diabetes can be achieved and are safe. 2. Aggressive targets were associated with regression in IMT and greater decrease in LV mass, but long term data are needed to determine if they will result in improvement in clinical events. 3. Aggressive targets for blood pressure and LDL cholesterol may be considered on an individual basis.

Interview with Wendie A. Berg, MD, PhD, author of Combined Screening With Ultrasound and Mammography vs Mammography Alone in Women at Elevated Risk of Breast Cancer. Summary Points: 1. Adding a single screening ultrasound examination to screening mammography in women at increased risk of breast cancer with at least heterogeneously dense breasts increases the cancer detection rate from 50% to 78%. 2. The risk of a biopsy for a benign lesion in our series was 1 in 40 for women undergoing mammography versus 1 in 10 for women undergoing mammography combined with ultrasound screening. 3. Using the standardized technique and interpretive criteria developed for this study, other radiologists and facilities with similar equipment and experience should expect similar results.

Interview with Sherita Hill Golden, MD, MHS, author of Examining a Bidirectional Association Between Depressive Symptoms and Diabetes. Summary Points: 1. People with symptoms of depression are more likely to engage in diabetes-producing health behaviors, including eating more, exercising less, and smoking more. As a consequence, they were more obese. 2. People with elevated symptoms of depression had a 42 percent increased risk of developing Type 2 diabetes over 3 years. This was partially explained by unhealthy behaviors. 3. People with treated Type 2 diabetes had a 52 percent increased risk of developing depressive symptoms over 3 years. This suggests that individuals with diabetes should be monitored for development of depression.

Interview with Beverly Beth Green, MD, MPH, author of Effectiveness of Home Blood Pressure Monitoring, Web Communication, and Pharmacist Care on Hypertension Control: The e-BP Randomized Controlled Trial. Summary Points: 1. If blood pressure (BP) control could be improved, many deaths from cardiovascular and renal disease could be prevented. 2. The Chronic Care Model was used to design an intervention that empowered patients to be more involved in their own care using home BP monitoring, a patient shared electronic medical record, and Web-based pharmacist assistance. 3. The group of patients that received BP monitors and training to use an existing patient website (with encouragement to send their BP numbers to their physician) had a modest decrease in systolic blood pressure, but BP control did not significantly improve. The group that received BP monitors, web training, and web-based pharmacy assistance had greater decreases in BP and were almost two times as likely to have controlled BP.

Interview with H. George Nurnberg, MD, author of Sildenafil Treatment of Women With Antidepressant-Associated Sexual Dysfunction: A Randomized Controlled Trial. Summary Points: 1. Emergent sexual dysfunction (SD) is a principal reason for a three-fold increased risk of non-adherence that leads to increased relapse, recurrence, and poor disease management outcomes. 2. Selective phosphodiesterase-type 5 inhibitors (PDE5Is), limited to studies in men, have demonstrated evidence based data to support broad based and clinically meaningful treatment efficacy. 3. In an intention-to-treat analysis, women treated with sildenafil showed significant improvement in adverse sexual effects compared with those taking placebo. 4. Evidence shows that selective phosphodiesterase type 5 inhibitors are effective in both sexes for patients who have been effectively treated for depression but need to continue on their medication to avoid relapse or recurrence.

Interview with Ingrid E. Nygaard, MD, MS, author of Symptomatic Pelvic Floor Disorders in Women. Summary Points: 1. The three primary pelvic floor disorders include urinary and fecal incontinence, and pelvic organ prolapse. 2. In a national population-based sample, nearly one-quarter of U.S. women reported at least one symptomatic pelvic floor disorder: overall, 15.7 percent experienced moderate to severe urinary incontinence, 9.0 percent experienced fecal incontinence at least monthly and 2.9 percent experienced symptomatic pelvic organ prolapse (a bulge in the vagina they could see or feel). 3. Older women, overweight and obese women and multiparous women were more likely to report a pelvic floor disorder.

Interview with Rita Redberg, MD, MSc, author of Stress Testing to Document Ischemia Prior to Elective PCI. Summary Points: 1. A majority (55.5% ) of Medicare patients with stable coronary artery disease who underwent an elective percutaneous coronary intervention (PCI) did not have a recommended stress test performed to document ischemia. 2. The rate of stress testing before elective PCI shows significant geographic variation, from a low of 22% in Fresno, CA to a high of 71% in Rochester, MN. 3. Patient characteristics (female sex, age of 85 years or older, and having co-existing illnesses) and physician characteristics (physicians who performed a higher volume of PCI procedures) were associated with lower rates of stress testing.

Interview with Brett D. Thombs, PhD, and Roy Ziegelstein, MD, authors of Depression Screening for Patients with Cardiovascular Disease. Summary Points: 1. Depression is a common and serious condition in patients with heart disease; therefore health care workers should inquire about symptoms of depression in their heart disease patients. 2. Our recent systematic review shows that there is not sufficient evidence at this time to call for routine screening for depression in patients with heart disease. 3. Additional research is needed to determine the optimal model(s) of care that will allow depression to be appropriately diagnosed and treated in patients with heart disease, particularly at times when these patients are being cared for primarily by heart disease experts rather than by experts in depression diagnosis and treatment.

Interview with David J.A. Jenkins, MD, PhD, author of Effect of a Low Glycemic Index or a High Cereal Fiber Diet on Type 2 Diabetes: A Randomized Trial. Summary Points: 1. Drugs such as the a–glucosidase inhibitor acarbose, which reduces the rate of digestion and absorption of carbohydrate and so flattens the post prandial glycemic response, have been shown to improve diabetes control, reduce the risk of developing hypertension, and lower the risk for cardiovascular disease. 2. Can a selection of more slowly digested carbohydrate foods achieve qualitatively similar benefits to drugs? Current data suggest that selection of diets containing low–glycemic intake foods have modest benefits in reducing glycated hemoglobin A1c even in patients with type 2 diabetes treated with 1 to 3 antihyperglycemic medications. 3. Foods with a low glycemic index include many traditional study foods such as dried peas, beans, lentils, intact-grain breads, pasta, oats, barley, parboiled rice, and temperate-climate fruits and berries. Low–glycemic index starchy foods are digested less readily in vitro. 4. Other effects include a tendency for higher high-density lipoprotein cholesterol levels, lower C-reactive protein values, and greater weight loss in the per-protocol completers, ie, those who completed the study with no change in medications.

Interview with Mary M. McDermott, MD, author of Treadmill Exercise and Resistance Training in Patients With Peripheral Arterial Disease With and Without Intermittent Claudication. Summary Points: 1. Supervised treadmill exercise improves walking performance for patients with peripheral arterial disease (PAD), whether or not the patient has classic symptoms of intermittent claudication. 2. Supervised lower extremity strength training improves quality of life, stair climbing ability, and treadmill walking performance for PAD patients with and without intermittent claudication. 3. Supervised treadmill walking exercise improves brachial arterial flow mediated dilation in patients with PAD, suggesting a global cardiovascular health benefit.

Interview with Steven A. Schroeder, MD, author of A 51-Year-Old Woman With Bipolar Disorder Who Wants to Quit Smoking. Summary Points: 1. Smoking is extremely common among persons with mental illness and exerts a huge toll in terms of morbidity and mortality. 2. We are now in the midst of a culture change. Formerly smoking was an integral part of the mental health culture and smoking cessation was not deemed pertinent. Now it is evolving into an important component of mental health and wellness. 3. Most smokers who have mental illness would like to quit. And many are able to do so, using the standard smoking cessation techniques used for the general population. There is still much more to know, but we know enough to encourage persons with mental illness to stop smoking and to provide them the tools to do so.

Interview with Michael K. Kearney, MD, author of Self-care of Physicians Caring for Patients at the End of Life. Summary Points: 1. Burnout and compassion fatigue are fundamentally different phenomena. Understanding the difference is helpful for effective intervention. 2. Investments in self-awareness and self-care are sound business strategies that can be expected to reduce staff turnover and increase patient satisfaction. 3. Mindfulness meditation and reflective writing have both been shown to increase self-awareness and self-care. They are among a number of strategies that can be built into clinical practice to prevent burnout and compassion fatigue.

Interview with Lisa A. Cooper, MD, author of A 41-Year-Old African American Man With Poorly Controlled Hypertension. Summary Points: 1. Cardiovascular disease accounts for 35% of the excess mortality in African Americans, in large part because of hypertension. 2. Racial disparities in physicians' clinical decision-making and in quality of care for cardiovascular disease have been documented extensively; studies also show racial differences in patient-physician communication, particularly when the patient and physician come from different racial backgrounds, and unconscious racial biases among physicians. 3. A categorical approach that lumps patients of particular cultural backgrounds into groups and outlines their characteristics values, customs and beliefs may lead to over-simplication and stereotyping. Instead, an understanding of broad cultural concepts and skills that emphasize a patient-centered approach are preferred. This approach takes into account the individual patients' explanatory model, illness agenda and behaviors, and social context, and attitudes and skills with regard to negotiating treatment. It also includes participatory behaviors such as asking open-ended questions, using reflective listening, and avoiding arguments in which one tries to change the patient's views. 4. Systematic reviews of interventions to improve patient adherence to treatments for hypertension show that simplifying dosing regimens is most effective; using motivational strategies such as home monitoring, small-group training, counseling by a nurse or other professional, and reminder calls for patients are somewhat effective; and patient education alone is not effective. Quality improvement strategies for hypertension management show team change interventions that include assignment of some responsibilities to a health professional other than the patient's physician (such as a nurse or pharmacist) are associated with the largest reductions in blood pressure. Improvement in patient-physician communication is linked to improved outcomes for mental health; more studies are needed that examine how patient-physician communication may improve hypertension control and other physiologic measures.

Interview with Peter H. Hwang, MD, author of A 51-Year-Old Woman With Acute Onset of Facial Pressure, Rhinorrhea, and Tooth Pain. Summary Points: 1. There are now published consensus guidelines for the diagnosis and treatment of acute rhinosinusitis. 2. Acute viral rhinosinusitis and acute bacterial rhinosinusitis can be difficult to distinguish in the first 10 days of symptoms. 3. Radiologic imaging is often "positive" in both viral and bacterial etiologies of acute sinusitis and therefore cannot be used to distinguish the two. 4. Oral antibiotics when prescribed appropriately confer a higher rate of partial or complete resolution of acute sinusitis symptoms compared to placebo. However, it should be noted that the spontaneous rate of resolution of acute bacterial rhinosinusitis may be as high as 40-60%. 5. Adjunctive therapies such as topical and oral decongestants may offer symptomatic relief but have not been proven to shorten the duration of illness.

Interview with Charles M. Morin, PhD, author of Cognitive-Behavior Therapy, Singly and Combined with Medication, for Persistent Insomnia. Summary Points: 1. Cognitive Behavioral Therapy (CBT) is an effective treatment for chronic insomnia and can help reduce medication treatment for this condition. 2. Clinicians can be successfully trained in CBT. 3. CBT works well alone for insomnia and while medication treatment may help early in the course of this condition, it has not advantages for long term use.

Interview with John P. Forman, MD, MSc, author of Diet and Lifestyle Risk Factors Associated With Incident Hypertension in Women. Summary Points: 1. At an individual level, combining healthy lifestyle factors may substantially reduce the risk of developing hypertension; according to the findings of the study, women who followed 6 healthy factors had nearly an 80% reduction in risk. 2. At a population level, a large fraction of all new cases of hypertension could hypothetically be prevented if all individuals in the population followed combinations of healthy lifestyle factors; according to the findings of the study, this fraction may is 78%. 3. Given that hypertension is a leading cause of preventable death in the population, and given that the majority of hypertension may be preventable through lifestyle modification, efforts should be intensified to improve lifestyle as a means of improving public health.

Interview with Thomas H. Gallagher, MD, author of A 62-Year-Old Woman With Skin Cancer Who Experienced Wrong-Site Surgery. Summary Points: 1. Errors and adverse events are common, and disclosure of these events to patients is recommended but often does not take place. 2. Physician fear of litigation inhibits disclosure, but so does physicians' lack of confidence in their communication skills and concern that disclosure might be harmful to the patient. 3. Important future developments in the field include linking disclosure with offers of compensation, and using performance improvement tools to enhance the disclosure process.

Interview with John Iskander, MD, author of Postlicensure Safety Surveillance for Quadrivalent Human Papillomavirus Recombinant Vaccine. Summary Points: 1. Since quadrivalent HPV vaccine was licensed in June 2006, more than 23 million doses have been administered nationally. 2. There were a total of 12,424 reports to the Vaccine Adverse Event Reporting System (VAERS) of adverse events following HPV vaccination through December 2008. The vast majority (94%) of adverse events reported to VAERS after receiving this vaccine have not been considered serious. The findings of this first published post-licensure safety review were generally not different from what is seen in safety reviews of other vaccines recommended for 9 to 26 year olds. 3. The most common events reported were syncope, local reactions at the site of immunization (pain and redness), dizziness, nausea, and headache.

Interview with Michael S. Krasner, MD, author of Association of an Educational Program in Mindful Communication With Burnout, Empathy, and Attitudes Among Primary Care Physicians. Summary Points: 1. Burnout is prevalent among physicians, and has untoward effects not only on the physicians themselves but also on the quality of the care they provide to their patients. 2. Mindful Communication training among a group of primary care physicians resulted in not only improvements in burnout and measures of well-being, but also improvements in markers of relationship-centered care to their patients. 3. Mindful Communication should be considered among a menu of continuing medical education opportunities available for physicians to enhance well-being, meaning, and interpersonal relationships in the practice of medicine.

Interview with Laura Esserman, MD, MBA, author of Rethinking Screening for Breast Cancer and Prostate Cancer. Summary Points: 1. The effectiveness of screening depends on the underlying biology of cancer. Routine mammographic screening works best for slow to moderate growth tumors, most common in women 50-74 and explains why the Preventive Services guidelines actually make sense. 2. There are ways that we can improve screening today. Trained mammographers find the most cancers and have the fewest false positives. Offering follow-up as an option for low risk mammographic lesions will decrease false positives. Screening the populations who benefit most will also avoid false positives and overdiagnosis in those who benefit less from screening. The prostate cancer risk calculator is a good tool to use to determine whether to do a biopsy. 3. We can and must do better. Mammography and PSA testing can detect very low risk cancers, and these cancers can be less aggressively treated. Tools are available to distinguish these low risk cancers. The most aggressive cancers often present between normal screens, so women with new masses, regardless of a recent normal mammogram should be evaluated. Men and women at high risk to develop breast and prostate cancer should consider prevention interventions. Future screening should be developed to reduce mortality from the highest risk cancers.

Interview with Hussein Hollands, MD, MSc, author of Acute-Onset Floaters and Flashes: Is This Patient at Risk for Retinal Detachment? Summary Points: 1. The most likely cause of acute onset monocular floaters or flashes is posterior vitreous detachment. If left untreated, vitreous detachment complicated by retinal tear can progress to vision-threatening retinal detachment. 2. A minimum approach to evaluating a patient with suspected posterior vitreous detachment should include a history of change in vision or curtain of darkness, measurement of visual acuity, and assessment of confrontational visual fields. 3. High-risk features for retinal tear in the setting of acute posterior vitreous detachment are subjective or objective visual acuity loss, monocular visual field loss (or curtain of darkness), and vitreous pigment or hemorrhage on slit-lamp examination. Patients with any of these clinical findings should be referred for same day ophthalmology assessment.

Interview with David Reuben, MD, author of Medical Care for the Final Years of Life. Summary Points: 1. When caring for older patients, the conventional evidence-based approach is modified by 3 important caveats: prognosis, insufficient evidence, and patient goals and preferences. 2. Conceptually, the care of older persons can be divided into 3 time frames: short term, which focuses on remediating the current problems; mid-range, focusing on preventive and foreseeable problems; and long-range, which focus on eventual decline and living arrangements. 3. Individual clinicians need to structure their practices to efficiently and comprehensively accommodate the diverse needs of elderly patients.

Interview with Frank Davidoff, MD, author of Heterogeneity Is Not Always Noise. Summary Points: 1. A clinical trial is a powerful tool for showing whether an intervention works, but the heterogeneity of trial participants means it may be a mistake to assume that the overall (or group) benefit of an intervention found in such a trial is the same for every participant. 2. The absolute benefit of an intervention is greater for trial participants-and for patients generally-whose baseline risk for a bad outcome is high than it is for those whose baseline risk is low. 3. A quality improvement program in any one organization is like an individual patient in the sense that it is highly complex, it is unstable (ie, changes over time), and its local circumstances are unique. It is thus hard-although not impossible-to judge whether a quality improvement program in any particular setting actually works and to know whether it would work elsewhere.

Interview with Mary E. Tinetti, MD, author of The Patient Who Falls. Summary Points: 1. Falls are common health events that cause discomfort and disability for older adults and stress for caregivers. Previous falls; strength, gait and balance impairments; and medications are the strongest risk factors for falling. 2. The most effective strategy for reducing the rate of falling in community-living older adults may be intervening on multiple risk factors including strengthening and balance exercises through physical therapy, medication reduction, environmental modifications to reduce fall hazards, cataract surgery. Vitamin D has strong evidence of benefit for preventing fractures among older men at risk and probably of preventing falls in all at risk older adults. 3. While challenges and barriers exist, fall prevention strategies can be incorporated into clinical practice.

Interview with Roger Chou, MD, author of Will This Patient Develop Persistent Disabling Low Back Pain? Summary Points: 1. A small proportion of patients with acute LBP go on to develop chronic LBP, these patients account for a very high proportion of costs, services, and suffering. 2. The most helpful items to predict persistent disabling low back pain are presence of maladaptive pain coping behaviors, nonorganic signs, functional impairment, general health status, and presence of psychiatric comorbidities. 3. Early identification of patients with these risk factors could help guide early use of psychological therapies and exercise therapy to reduce the likelihood that they will go on to develop chronic disabling low back pain.

Interview with David B. Carr, MD, author of The Older Adult Driver With Cognitive Impairment. Summary Points: 1. Know how to assess a cognitively impaired older driver in the office setting. 2. Know how and where to refer at-risk cognitively impaired older drivers. 3. Know how to counsel cognitively impaired older drivers in regards to driving retirement.

Interview with Kenneth J. Mukamal, MD, MPH, MA, author of A 42-Year-Old Man Considering Whether to Drink Alcohol for His Health. Summary Points:1. Careful alcohol histories are needed for all patients, particularly to identify binge drinking, which is frequent among moderate and especially younger drinkers. 2. Even moderate alcohol consumption has important and plausible health effects based on short-term trials and observational studies, including lower risk of heart disease presumably via higher HDL-cholesterol and higher risk of breast cancer (presumably via higher levels of estrone and DHEA sulfates). 3. Given these points, even controlled alcohol consumption is unlikely to benefit younger drinkers, but is a reasonable point of discussion for middle-aged and older adults, especially as a launching point for education about problem drinking and the potential risks and benefits of including alcohol as part of a healthy diet in older age.

Interview with Patricia S. Goode, MSN, MD, author of Incontinence in Older Women. Summary Points: 1. UI is very common in older women and should be in Review of System for ALL older women. 2. Initial behavioral therapy (pelvic floor muscle exercises, urge and stress strategies, caffeine avoidance) is easy to do and should be FIRST line treatment for older women with urge and stress urinary incontinence. 3. Modifiable Contributing Factors for urinary incontinence should be addressed before prescribing antimuscarinic medications and include: urinary tract infection, constipation, diabetes control, mobility impairment, sleep apnea, caffeine, timing of diuretics, over-sedation.

Interview with Matthew K. Wynia, MD, MPH, author of The Role of Professionalism and Self-regulation in Detecting Impaired or Incompetent Physicians. Summary Points: At the conclusion of this activity, participants will be able to: 1. Describe the frequency with which physicians report encountering other physician who may be impaired or incompetent. 2. Explain the 3 basic options available to policy-makers for regulating and ensuring the quality of medical practitioners. 3. Name at least 3 newer mechanisms by which the profession of medicine is enhancing its ability to self-regulate and detect physicians who are not providing high quality care.

Interview with Ralph Gonzales, MD, MSPH, author of Does This Coughing Adolescent or Adult Patient Have Pertussis? Summary Points: 1. When evaluating adolescents and adults with persistent cough illness, the presence of classic symptoms of pertussis (paroxysmal cough, whooping cough, post-tussive emesis) modestly increase the likelihood of pertussis, and their absence modestly decreases the likelihood of pertussis; but they are not strong enough to rule-in or rule-out disease. 2. Most patients in whom pertussis is suspected will not derive symptomatic benefit from antibiotic treatment because their illness duration is usually greater than 10 days. 3. Vigilant testing and treatment should be provided to adolescents and adults who have been exposed to a known case of pertussis, or have contact with individuals at high risk for serious complications of pertussis, ie, child care providers and teachers, health care workers, and patients who live or work with infants less than 6 months of age; unvaccinated children; or immunosuppressed individuals.

Interview with Michael A. Steinman, MD, author of Managing Medications in Clinically Complex Elders. Summary Points: 1. First, a systematic approach to approaching prescribing is essential. 2. Second, an essential first step is to know what the patient is actually taking right now, and to clarify what goals you are trying to achieve by prescribing drugs. 3. Third, it is critical to individualize care based on what benefits and harms a patient is actually experiencing from their drugs.

Interview with Julia Neily, RN, MS, MPH, author of Association Between Implementation of a Medical Team Training Program and Surgical Mortality. Summary Points: 1. Improved communication is associated with decreased surgical mortality. 2. Since there was a dose response relationship, this indicates that continuing follow up was related to better results. 3. Briefings and debriefings is more than a checklist, it is about the conversation.

Interview with Julia Howell Hayes, MD, author of Active Surveillance Compared With Initial Treatment for Men With Low-Risk Prostate Cancer: A Decision Analysis. Summary Points: 1. Active surveillance is a reasonable approach to consider for carefully selected 65-year-old men with low-risk clinically localized prostate cancer, providing improved quality of life even if associated with an increased risk of prostate cancer–specific death. 2. The results depend on patient preferences. 3. It is crucial that individual patients make this decision in conjunction with their physicians.

Interview with Steven J. Jacobsen, MD, PhD, author of Herpes Zoster Vaccine in Older Adults and the Risk of Subsequent Herpes Zoster Disease. Summary Points: 1. The findings suggest that the zoster vaccine is as effective in a community setting with its mixed population and routine clinical practices as was found in the controlled clinical trials. 2. To date, the uptake of the zoster vaccine has been modest due to a number of reasons, including weaknesses in the adult vaccine infrastructure, knowledge and beliefs of clinicians and patients, periodic supply shortfalls, as well as financial reasons. 3. Because zoster and its attendant neurologic complication of postherpetic neuralgia are common and serious among the elderly, it seems prudent to recommend zoster vaccine. The potential impact of vaccination on the burden of the disease in this population is significant.

Interview with Gabriela Schmajuk, MD, author of Receipt of Disease-Modifying Antirheumatic Drugs Among Patients With Rheumatoid Arthritis in Medicare Managed Care Plans. Summary Points: 1. One third of Medicare managed care patients diagnosed with rheumatoid arthritis are not receiving disease-modifying antirheumatic drugs. 2. There is variation in disease-modifying antirheumatic drug receipt based on "accidental factors": sociodemographics, geographic location, and health plan. 3. Because disease-modifying antirheumatic drug use is the main way to affect outcomes in rheumatoid arthritis, these patient groups and the physicians treating them are a reasonable target for quality improvement interventions.