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In This Issue of JAMA |

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JAMA. 2013;310(8):767-769. doi:10.1001/jama.2013.5273.
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In a randomized trial that enrolled 60 treatment-naive patients with hepatitis C virus (HCV) genotype 1 infection—including those with unfavorable treatment characteristics such as black race, genotype 1a, advanced liver fibrosis, and obesity—Osinusi and colleagues assessed the effect of treatment with sofosbuvir in combination with ribavirin on sustained virologic response—defined as an undetectable HCV viral load assessed 24 weeks after treatment completion. The authors report that a 24-week regimen of sofosbuvir and weight-based or low-dose ribavirin resulted in sustained viral response rates of 68% and 48%, respectively.

Difficulties identifying biliary anatomy during cholecystectomy can result in duct injury. To examine whether routine intraoperative cholangiography can prevent common duct injury during cholecystectomy, Sheffield and colleagues analyzed data from 92 932 Texas Medicare beneficiaries who underwent cholecystectomy in 2000-2009. Using instrumental variable analysis, with percentage of intraoperative cholangiography use by hospital and surgeon as the instrumental variables, the authors found no association between intraoperative cholangiography and common duct injury. In an Editorial, Bilimoria and colleagues discuss the use of instrumental variable analysis to address unmeasured confounding in analyses of observational data.

Related Editorial

Genetic factors predisposing to cardiovascular disease risk may be different in individuals with and without diabetes. In a genome-wide association analysis of samples from 5 prospective cohort studies, which in combination included 4188 individuals with type 2 diabetes—1517 of whom developed incident coronary heart disease (CHD)—Qi and colleagues identified a variant on chromosome 1q25 that is functionally related to glutamic acid metabolism and was consistently associated with CHD in persons with diabetes but not those without diabetes.

In a multipayer system, payment incentives implemented by one insurer in an accountable care organization (ACO) could—in theory—spillover and affect spending and the quality of care of another insurer’s enrollees served by the ACO. In an analysis of data from 1 761 325 Massachusetts Medicare beneficiaries, McWilliams and colleagues examined whether an Alternative Quality Contract—an early commercial ACO—was associated with changes in spending for Medicare beneficiaries who were not covered by the contractual arrangement. The authors report that compared with beneficiaries served by nonparticipating providers, spending was lower for Medicare beneficiaries served by 1 of the 11 provider organizations participating in the Alternative Quality Contract.

CLINICAL REVIEW & EDUCATION

Rotator cuff disease is the most common cause of shoulder pain. Hermans and colleagues performed a systematic review and meta-analysis to identify the most accurate clinical examination findings for rotator cuff disease. The authors identified 28 studies for analysis, all of which assessed specialist examination of referred patients. Among the authors’ findings were that a painful arc test and a positive external rotation resistance test result were the most accurate findings for detecting rotator cuff disease.

A 28-year-old previously healthy man had a 1-day history of persistent midepigastric and supraumbilical abdominal pain with occasional nausea. On examination he had bilateral lower abdominal tenderness and voluntary guarding to palpation. He was afebrile and had an elevated leukocyte count. A computed tomography scan was obtained. What would you do next?

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