<?xml version="1.0" encoding="utf-8"?>
<recommendedContent xmlns="http://api.mspoke.com">
    <recommendedItem id="20100101_19_458"
                     title="Calcium Scoring Misses 20% of CAD Cases (CME/CE)"
                     score="0.01"
                     href="http://www.medpagetoday.com/Cardiology/AcuteCoronarySyndrome/tb/18387?impressionId=1265730996954"
                     
      &lt;p&gt;Contrary to guidelines, the absence of coronary artery calcium doesn&apos;t rule out coronary artery disease in symptomatic patients, researchers found in a new study.&lt;/p&gt;
&lt;p&gt;In a multicenter clinical trial, 19% of patients with a coronary calcium score of 0 had stenosis of at least 50% in one or more coronary artery segments, according to Carlos E. Rochitte, MD, of the University of S&amp;#227;o Paulo, Brazil, and colleagues.&lt;/p&gt;
&lt;p&gt;Likewise, 20% of vessels seen to be totally occluded on revascularization had no calcium on scans, they reported in the Feb. 16 &lt;em&gt; Journal of the American College of Cardiology&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;&quot;The absence of coronary calcification should not be used as a gatekeeper and should not prevent a symptomatic patient from undergoing angiography,&quot; the researchers wrote.&lt;/p&gt;
&lt;p&gt;Currently, American Heart Association/American College of Cardiology guidelines suggest that excluding measurable coronary calcium could serve as an effective filter for sending patients on to invasive testing or admitting them.&lt;/p&gt;
&lt;p&gt;One systematic review of 18 studies had indicated that a zero calcium score had a negative predictive value of 93% for stenosis and a positive predictive value of 68% in symptomatic patients.&lt;/p&gt;
&lt;p&gt;However, in Rochitte&apos;s trial  --  CORE64 (Coronary Evaluation Using Multi-Detector Spiral Computed Tomography Angiography Using 64 Detectors)  --  the negative predictive value of a coronary calcium score of 0 was 68%, while the positive predictive value was 81%.&lt;/p&gt;
&lt;p&gt;Overall sensitivity to predict the absence of significant (at least 50%) stenosis was 45%, while specificity was 91%.&lt;/p&gt;
&lt;p&gt;&quot;This apparent lack of predictive value of a calcium scan should be enough to give a clinician pause,&quot; Rita F. Redberg, MD, of the University of California San Francisco, wrote in an accompanying editorial.&lt;/p&gt;
&lt;p&gt;Whatever the reason for the discrepancy, neither the trial nor the review provided any information on how coronary calcium scans add incrementally to traditional predictors of coronary artery disease, such as clinical assessment and stress testing, she said. Nor would she rule out their use entirely for patients with chest pain.&lt;/p&gt;
&lt;p&gt;&quot;Given the significant &lt;a href=&quot;http://www.medpagetoday.com/Cardiology/AcuteCoronarySyndrome/12732&quot; mce_href=&quot;http://www.medpagetoday.com/Cardiology/AcuteCoronarySyndrome/12732&quot; target=&quot;_blank&quot;&gt;radiation risks&lt;/a&gt; of coronary artery calcium scans, however, clinicians must use extreme caution when ordering such scans,&quot; Redberg cautioned.&lt;/p&gt;
&lt;p&gt;The prospective &lt;a href=&quot;http://www.medpagetoday.com/Radiology/DiagnosticRadiology/11927&quot; mce_href=&quot;http://www.medpagetoday.com/Radiology/DiagnosticRadiology/11927&quot; target=&quot;_blank&quot;&gt;CORE64 study&lt;/a&gt; was originally designed to compare diagnostic performance of CT and invasive angiography in symptomatic patients with suspected coronary artery disease. But it also included a coronary calcium scan up to 30 days prior to conventional angiography.&lt;/p&gt;
&lt;p&gt;Of the 291 patients included in the calcium score analysis (73% male, mean age 59.3), 56% had at least 50% coronary stenosis by conventional angiography and 45% had at least 70% stenosis.&lt;/p&gt;
&lt;p&gt;Calcium score only weakly correlated with the highest degree of coronary stenosis found in a patient. Its ability to predict presence of significant lesions was &quot;moderate&quot; (area under the receiver-operating characteristic curve 0.77, &lt;em&gt;P&lt;/em&gt;&amp;lt;0.001).&lt;/p&gt;
&lt;p&gt;A non-zero score was associated with 8.1-fold likelihood of having at least 50% coronary stenosis (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.001) after adjusting for age, sex, hypertension, dyslipidemia, family history of premature heart disease, diabetes, race, and hospitalization.&lt;/p&gt;
&lt;p&gt;Among the 100 patients who went on to revascularization within 30 days of angiography, 13% had a coronary calcium score of 0, 25% had a score of 1 to 10, and 44% had a score over 10 (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.001 for trend).&lt;/p&gt;
&lt;p&gt;The fact that significant coronary artery disease occurred in the absence of calcification in almost 20% of patients should not be surprising, since coronary calcification is thought to occur late in the atherosclerotic process, while obstruction can occur earlier, Redberg asserted.&lt;/p&gt;
&lt;p&gt;The researchers also cautioned that the results would not apply to asymptomatic patients with intermediate risk for events, a group in which a score of 0 has been consistently shown to indicate low risk.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The study was supported by grants from Toshiba Medical Systems, the Doris Duke Charitable Foundation, the National Heart, Lung, and Blood Institute, the National Institute on Aging, and the Donald W. Reynolds Foundation.&lt;/p&gt;&lt;p&gt;Rochitte reported no conflicts of interest. Coauthors reported financial relationships with Toshiba Medical Systems, Bayer, Schering, GE Healthcare, Bracco, Bristol-Myers Squibb, sanofi-aventis, and Vital Images.&lt;/p&gt;&lt;p&gt;Redberg provided no information on conflicts of interest.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_457"
                     title="Long-Term Safety of Drug-Eluting Stents Affirmed (CME/CE)"
                     score="0.01"
                     href="http://www.medpagetoday.com/Cardiology/Atherosclerosis/tb/18374?impressionId=1265730996954"
                     
      &lt;p&gt;Using sirolimus-eluting stents for the treatment of in-stent restenosis appears safe and effective over four years of follow-up, a study of an Italian registry showed.&lt;/p&gt;
&lt;p&gt;Through four years, there were low rates of target lesion revascularization (11.1%) and stent thrombosis (2.8%), according to Francesco Liistro, MD, of San Donato Hospital in Arezzo, Italy, and colleagues.&lt;/p&gt;
&lt;p&gt;About one in 10 patients (9.8%) died, and 3.2% had a nonfatal myocardial infarction.&lt;/p&gt;
&lt;p&gt;Survival free from a major adverse cardiac event was 80.3% at the end of follow-up, the researchers reported in the Feb. 16 issue of the&lt;em&gt; Journal of the American College of Cardiology&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;Although drug-eluting stents have been shown to be safe and better than balloon angioplasty and vascular brachytherapy for in-stent restenosis in the short term, most previous studies have had limited follow-up.&lt;/p&gt;
&lt;p&gt;Reports of late stent thrombosis following implantation with drug-eluting stents have raised some concern about the long-term safety of these devices in unselected patient groups, according to Liistro and his colleagues.&lt;/p&gt;
&lt;p&gt;To explore the issue, the researchers turned to the Tuscany Registry of Unselected In-Stent Restenosis (TRUE), a prospective, two-center registry.&lt;/p&gt;
&lt;p&gt;All 244 patients included in the analysis underwent antiplatelet therapy with aspirin and either ticlopidine or clopidogrel (Plavix) for at least six months after the sirolimus-eluting stent was implanted.&lt;/p&gt;
&lt;p&gt;An earlier, nine-month analysis of this registry showed safety and effectiveness for the stent. This study confirmed the benefits through four years.&lt;/p&gt;
&lt;p&gt;Of 24 recorded deaths, 11 were from cardiac causes.&lt;/p&gt;
&lt;p&gt;Definite stent thrombosis occurred in five patients, four of whom had stopped taking clopidogrel more than a month before the event.&lt;/p&gt;
&lt;p&gt;Another two patients who were taking aspirin and clopidogrel had probable stent thrombosis.&lt;/p&gt;
&lt;p&gt;Patients who had diabetes were significantly more likely to have target lesion revascularization (OR 0.32, 95% CI 0.14 to 0.71) and major adverse cardiac events (OR 0.38, 95% CI 0.20 to 0.71) through four years.&lt;/p&gt;
&lt;p&gt;A left ventricular ejection fraction less than 50% was associated with higher odds of major adverse cardiac events (OR 0.32, 95% CI 0.13 to 0.80), as was creatinine greater than 1.5 mg/dL (OR 0.23, 95% CI 0.11 to 0.48).&lt;/p&gt;
&lt;p&gt;And patients with peripheral or carotid arterial disease were more likely to need target lesion revascularization (OR 0.35, 95% CI 0.14 to 0.88).&lt;/p&gt;
&lt;p&gt;The authors noted that the registry study was limited by the lack of valid control groups.&lt;/p&gt;
&lt;p&gt;In addition, in patients with a late occurrence of target lesion revascularization, the researchers could not determine whether a stenotic lesion inside the stented segment was a new atherosclerotic lesion or a restenosis.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The authors did not make any financial disclosures.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_456"
                     title="BLOG: Preempting End-of-Life Decisions"
                     score="0.01"
                     href="http://www.medpagetoday.com/Blogs/18382?impressionId=1265730996954"
                     
      &lt;blockquote&gt;&lt;i&gt;&amp;quot;I do not want my life to be prolonged if, to a reasonable degree of medical certainty, my situation is hopeless.&amp;quot;&lt;br&gt;
&amp;quot;I want my life to be prolonged as long as possible within the limits of generally accepted medical standards, even if this means that I might be kept alive on machines for years.&amp;quot;&lt;/i&gt;&lt;br&gt;
&lt;/blockquote&gt;Check one. That&apos;s one of the places where I&apos;m stalled on making my advance medical directive. &lt;br&gt;
&lt;br&gt;
It&apos;s not that I&apos;m in a hurry to die. All the talk and fear engendered by the so-called &amp;quot;&lt;a target=&quot;_blank&quot; href=&quot;http://www.medpagetoday.com/PrimaryCare/Geriatrics/15623&quot;&gt;death panels&lt;/a&gt;&amp;quot; during debate over healthcare reform last year didn&apos;t scare me.&lt;br&gt;
&lt;br&gt;
As someone who travels frequently for work and lives a distance from my relatives, it&apos;s important to me to make sure strangers aren&apos;t making one of the biggest decisions of my life -- under what circumstances I would want to live when all hope seems lost. I already carry a simpler copy in my wallet in case of an emergency to make sure my wishes are known. &lt;br&gt;
&lt;br&gt;
After being in Orlando for the American Heart Association meeting in November when it was announced that a &lt;a target=&quot;_blank&quot; href=&quot;http://www.medpagetoday.com/MeetingCoverage/AHA/17068&quot;&gt;leading cardiologist&lt;/a&gt; had been killed while jogging outside his hotel and remained a John Doe for some time, I always carry a form of identification and my emergency card even when I&apos;m out running. &lt;br&gt;
&lt;br&gt;
It&apos;s not morbid thinking to be prepared.  &lt;br&gt;
&lt;br&gt;
If I become incapacitated, emergency responders will know medication allergies and who I&apos;ve appointed as my agent to make healthcare decisions for me in such a circumstance. No scrambling through my cell phone for emergency contacts or searching for next of kin. &lt;br&gt;
&lt;br&gt;
However, making the end-of-life decisions is proving more difficult than anticipated. For me, the challenge is that the line between hopeless and salvageable has been increasingly blurred. Medical certainty just doesn&apos;t seem that sure.&lt;br&gt;
&lt;br&gt;
Late last year, news broke of a man who had been judged to be in a &lt;a target=&quot;_blank&quot; href=&quot;http://www.huffingtonpost.com/2009/11/23/rom-houben-man-in-coma-fo_n_367798.html&quot;&gt;vegetative state for 23 years&lt;/a&gt; but who was alert and unable to communicate the entire time. After decades of this frustrating existence, a PET scan determined that his brain activity was nearly normal and he was given special computer equipment to reestablish contact with the outside world.&lt;br&gt;
&lt;br&gt;
Then earlier this month, researchers reported that an unknown proportion of individuals in a persistent vegetative state may &lt;a target=&quot;_blank&quot; href=&quot;http://www.medpagetoday.com/Neurology/GeneralNeurology/18283&quot;&gt;retain some awareness&lt;/a&gt;. Functional MRI imaging combined with instructions to visualize one activity as a Yes and another as a No allowed limited communication with five out of 54 patients tested.&lt;br&gt;
&lt;br&gt;
What if I was not as hopeless a case as I appeared from the outside, would I want to prolong my life as long as possible in the hopes that someone would realize this? Would I be willing to go decades in that state? &lt;br&gt;
&lt;br&gt;
Either way, my family and friends would suffer; pulling life support even if I prespecified that was my wish couldn&apos;t be easy. My healthcare agent is aware of the responsibility she has accepted. We&apos;ve talked about it, but I haven&apos;t yet made the call, checked the box determining whether I would keep hope alive perpetually or throw in the towel. &lt;br&gt;
&lt;br&gt;
For now I&apos;ll just have to trust in the (perceived) invincibility of youth to stave off the decision a little longer. &lt;br&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_455"
                     title="Low Vitamin D Linked to Hip OA (CME/CE)"
                     score="0.01"
                     href="http://www.medpagetoday.com/Rheumatology/Arthritis/tb/18379?impressionId=1265730996954"
                     
      &lt;p&gt;Elderly men with low serum levels of vitamin D are at increased risk for developing hip osteoarthritis, a prospective cohort study found.&lt;/p&gt;
&lt;p&gt;Men whose levels of 25-hydroxyvitamin (OH)D were between 15.1 to 30 ng/mL had twice the likelihood of prevalent radiographic hip osteoarthritis than those whose levels were normal (OR 2.19, 95% CI 1.21 to 3.97), according to R. Krishna Chaganti, MD, of the University of California at San Francisco, and colleagues.&lt;/p&gt;
&lt;p&gt;Conversely, after adjusting for age, season at blood draw, and clinic site, higher vitamin D levels were associated with a lower prevalence of hip osteoarthritis (OR 1.39 per 1 SD decrease in 25(OH)D level, 95% CI 1.11 to 1.74), the researchers reported in the February issue of &lt;em&gt;Arthritis &amp;amp; Rheumatism&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;Because the role vitamin D may play in the pathogenesis and progression of osteoarthritis is unclear, Chaganti and colleagues analyzed data from the Osteoporotic Fractures in Men Study, which enrolled a large cohort of elderly men between 2000 and 2002 from six centers across the U.S.&lt;/p&gt;
&lt;p&gt;A total of 1,104 men whose mean age was 77.2 years had baseline measurements of serum vitamin D, and about 4.5 years later pelvic radiographs were obtained.&lt;/p&gt;
&lt;p&gt;Radiographs were scored to reflect joint space narrowing, osteophyte formation, cysts, subchondral sclerosis, and femoral head deformity.&lt;/p&gt;
&lt;p&gt;Vitamin D levels were categorized as deficiency (&amp;#8804;15 ng/mL), insufficiency (15.1 to 30 ng/mL), and sufficiency (&amp;gt;30 ng/mL).&lt;/p&gt;
&lt;p&gt;Mean vitamin D level was 23.38 ng/mL in men who had radiographic hip osteoarthritis, compared with 26.04 ng/mL in men without radiographic abnormalities (&lt;em&gt;P&lt;/em&gt;=0.0002).&lt;/p&gt;
&lt;p&gt;Men with hip osteoarthritis had a higher prevalence of both vitamin D insufficiency (77% versus 65%, &lt;em&gt;P&lt;/em&gt;=0.002) and deficiency (10.2% versus 7.5%, &lt;em&gt;P&lt;/em&gt;=0.012).&lt;/p&gt;
&lt;p&gt;Moreover, they had slower six-meter walking speed (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.0001) and reported more hip pain (&lt;em&gt;P&lt;/em&gt;=0.0001).&lt;/p&gt;
&lt;p&gt;Men who were vitamin D deficient also tended to have an increased likelihood of hip osteoarthritis (OR 1.99, 95% CI 0.83 to 4.74), but after adjustment in multivariate models, statistical significance was lost with this level of the vitamin.&lt;/p&gt;
&lt;p&gt;&quot;The association of low 25(OH)D levels with prevalent radiographic hip [osteoarthritis] underscores the potentially important role of vitamin D in the pathogenesis of [osteoarthritis]. Vitamin D metabolites have been found to be associated with the regulation of the Wnt pathway, products of which play important roles in the development and maintenance of bone and cartilage,&quot; the investigators explained.&lt;/p&gt;
&lt;p&gt;Furthermore, in vitro studies have suggested that serum levels of 25-hydroxyvitamin D&lt;sub&gt;3&lt;/sub&gt; can affect the ratio of RANKL to osteoprotegerin and thereby influence bone deterioration and repair.&lt;/p&gt;
&lt;p&gt;Previous investigations have yielded conflicting results. One study found that low levels of vitamin D were not associated with worsening of knee osteoarthritis, as reflected in loss of articular cartilage on MRI.&lt;/p&gt;
&lt;p&gt;Another study, however, linked knee osteoarthritis with low vitamin D levels, particularly in patients who also had decreased bone mineral density in the lumbar spine.&lt;/p&gt;
&lt;p&gt;&quot;Vitamin D influences the mineralization of bone matrix, and low serum levels of vitamin D may result in poorly mineralized bone that might alter forces across the joint and reduce joint deterioration,&quot; the authors suggested.&lt;/p&gt;
&lt;p&gt;On the other hand, low levels may interfere with chondrocyte metabolism and thereby increase degeneration.&lt;/p&gt;
&lt;p&gt;Further studies will be needed to more fully clarify the effects of the vitamin on the development and progression of osteoarthritis, the investigators cautioned.&lt;/p&gt;
&lt;p&gt;Strengths of the study include the large cohort of participants, careful classification of radiographic osteoarthritis, and reliance on the gold standard of vitamin D measurement, the 25(OH)D level.&lt;/p&gt;
&lt;p&gt;Limitations include the cross-sectional design, precluding the inference of causality, and the gap in time between measurement of serum vitamin D and radiography.&lt;/p&gt;
&lt;p&gt;The authors concluded that therapeutic interventions to increase vitamin D serum levels in the elderly &quot;are warranted,&quot; with the goal of improving skeletal health in this vulnerable age group.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The study was supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases, the National Institute on Aging, the National Center for Research Resources, and the NIH Roadmap for Medical Research.&lt;/p&gt;&lt;p&gt;The lead author was supported by a grant from the American College of Rheumatology Research and Education Foundation.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_454"
                     title="Glaucoma Meds Linked to Lower Mortality Risk (CME/CE)"
                     score="0.01"
                     href="http://www.medpagetoday.com/Ophthalmology/Glaucoma/tb/18371?impressionId=1265730996954"
                     
      For patients diagnosed with glaucoma, taking medications for the condition appears to improve survival, researchers found.&lt;br&gt;
&lt;br&gt;Patients with suspected or confirmed glaucoma were 74% less likely to die during a five-year period if they were prescribed any glaucoma medication (HR 0.26, 95% CI 0.16 to 0.40), according to Joshua Stein, MD, of the University of Michigan Kellogg Eye Center in Ann Arbor, and colleagues.&lt;br&gt;
&lt;br&gt;However, in an analysis of patients with suspected glaucoma only, the association was no longer significant (HR 1.19, 95% CI 0.43 to 3.27), the researchers reported in the February issue of the &lt;em&gt;Archives of Ophthalmology&lt;/em&gt;.&lt;br&gt;
&lt;br&gt;&quot;Additional studies need to be done to try to sort out exactly why the patients who have diagnosed glaucoma tend to have reduced mortality relative to the other patients who are not being treated,&quot; Stein told &lt;em&gt;MedPage Today&lt;/em&gt;, adding that changes in clinical management should not be made until this is sorted out.&lt;p&gt;&lt;/p&gt;
&lt;p&gt;Previous studies of glaucoma and mortality have yielded conflicting results. Few have examined the effect of glaucoma medications, which can be absorbed systemically and affect the body in ways that may confound such analyses.&lt;/p&gt;
&lt;p&gt;So Stein and his colleagues looked at data from a large managed care network involving 21,506 patients 40 and older with suspected or confirmed glaucoma.&lt;/p&gt;
&lt;p&gt;About half (50.5%) had suspected glaucoma and the rest had received a definite diagnosis, most commonly open-angle glaucoma (21.5%).&lt;/p&gt;
&lt;p&gt;Comorbidities were common: 52.7% of the patients had hypertension and 41.3% had diabetes.&lt;/p&gt;
&lt;p&gt;From 2003 through 2007, 28.1% of the patients filled a prescription for a glaucoma medication. The most frequently prescribed drugs were prostaglandin analogues (20.8%) and beta-antagonists (12.8%).&lt;/p&gt;
&lt;p&gt;More than a quarter (28%) were also prescribed oral beta-blockers.&lt;/p&gt;
&lt;p&gt;During the study, 1.1% of the patients died.&lt;/p&gt;
&lt;p&gt;The overall reduction in risk of death during the study held for both single agents  --  topical beta-antagonists (HR 0.40, 95% CI 0.18 to 0.86) and prostaglandin analogues (HR 0.27, 95% CI 0.14 to 0.52),&lt;strong&gt; &lt;/strong&gt;as well as for combinations of glaucoma medications.&lt;/p&gt;
&lt;p&gt;The mortality risk declined as the number of prescribed medications increased (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.001). The hazard ratios for one, two, and three or more medications were 0.29, 0.19, and 0.12, respectively.&lt;/p&gt;
&lt;p&gt;Among those with the most common diagnosis, open-angle glaucoma, the risk of dying during the study was reduced by a relative 77% for those prescribed at least one medication (HR 0.23, 95% CI 0.14 to 0.37).&lt;/p&gt;
&lt;p&gt;It is unclear why glaucoma medication use is associated with a lower mortality risk, but it is possible that topical medications absorbed systemically could affect blood pressure, heart rate, breathing, and kidney function, Stein said.&lt;/p&gt;
&lt;p&gt;&quot;But the fact that multiple different medication classes are showing this protective effect suggests to me that it may not necessarily be the medications themselves, but perhaps it&apos;s the types of patients who are receiving the medications,&quot; he said.&lt;/p&gt;
&lt;p&gt;The patients taking medication for glaucoma might be healthier than the untreated patients, he said.&lt;/p&gt;
&lt;p&gt;Those with more serious conditions might have to selectively choose which drugs they buy, and might purchase medications for more serious conditions than glaucoma.&lt;/p&gt;
&lt;p&gt;Also, physicians treating patients with more serious conditions might not focus on glaucoma, Stein said.&lt;/p&gt;
&lt;p&gt;A final possibility might be differences in the beneficiaries&apos; access to healthcare.&lt;/p&gt;
&lt;p&gt;The authors noted a number of limitations of the study: &lt;ul&gt; &lt;li&gt;The use of claims data, and not patient records, resulted in missing information on some important clinical variables&lt;strong&gt;,&lt;/strong&gt; such as smoking, body weight, blood pressure.&lt;/li&gt; &lt;li&gt;The results are not necessarily generalizable beyond the insured patients in this single, managed care network.&lt;/li&gt; &lt;li&gt;Death status could not be verified and cause of death could not be determined because of the use of de-identified data.&lt;/li&gt; &lt;li&gt;It is unclear whether patients actually took the prescribed medications.&lt;/li&gt; &lt;li&gt;The relationship between certain drug classes and mortality risk could not be determined because of low patient numbers.&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The authors did not make any financial disclosures.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
</recommendedContent>