Showing papers in "Annals of Internal Medicine in 2009"
TL;DR: PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) is introduced, an update of the QUOROM guidelines for reporting systematic reviews and meta-analyses.
Abstract: Moher and colleagues introduce PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses), an update of the QUOROM guidelines for reporting systematic reviews and meta-analyses. Us...
23,203 citations
TL;DR: The CKD-EPI creatinine equation is more accurate than the Modification of Diet in Renal Disease Study equation and could replace it for routine clinical use.
Abstract: The Modification of Diet in Renal Disease (MDRD) Study equation underestimates glomerular filtration rate (GFR) in patients with mild kidney disease. Levey and associates therefore developed and va...
18,691 citations
TL;DR: The updating of the QUOROM Statement is described, to ensure clear presentation of what was planned, done, and found in a systematic review, and the name of the reporting guidance was changed to PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses).
3,513 citations
Dartmouth College1, Cedars-Sinai Medical Center2, HealthPartners3, University of Missouri4, Icahn School of Medicine at Mount Sinai5, Georgia Regents University6, Arizona State University7, Baylor College of Medicine8, University of Massachusetts Medical School9, University of California, San Francisco10, University of Pennsylvania11, University of Minnesota12
TL;DR: The USPSTF concludes that the current evidence is insufficient to assess additional benefits and harms of either digital mammography or magnetic resonance imaging instead of film mammography as screening modalities for breast cancer.
Abstract: Description: Update of the 2002 U. S. Preventive Services Task Force (USPSTF) recommendation statement on screening for breast cancer in the general population. Methods: The USPSTF examined the evidence on the efficacy of 5 screening modalities in reducing mortality from breast cancer: film mammography, clinical breast examination, breast self-examination, digital mammography, and magnetic resonance imaging in order to update the 2002 recommendation. To accomplish this update, the USPSTF commissioned 2 studies: 1) a targeted systematic evidence review of 6 selected questions relating to benefits and harms of screening, and 2) a decision analysis that used population modeling techniques to compare the expected health outcomes and resource requirements of starting and ending mammography screening at different ages and using annual versus biennial screening intervals. Recommendations: The USPSTF recommends against routine screening mammography in women aged 40 to 49 years. The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take into account patient context, including the patient's values regarding specific benefits and harms. (Grade C recommendation) The USPSTF recommends biennial screening mammography for women between the ages of 50 and 74 years. (Grade B recommendation) The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of screening mammography in women 75 years or older. (I statement) The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of clinical breast examination beyond screening mammography in women 40 years or older. (I statement) The USPSTF recommends against clinicians teaching women how to perform breast self-examination. (Grade D recommendation) The USPSTF concludes that the current evidence is insufficient to assess additional benefits and harms of either digital mammography or magnetic resonance imaging instead of film mammography as screening modalities for breast cancer. (I statement)
1,405 citations
Journal Article•
TL;DR: This trial demonstrated that a nurse discharge advocate and clinical pharmacist working together to coordinate hospital discharge, educate patients, and reconcile medications led to fewer follow-up emergency visits and rehospitalizations than usual care alone.
Abstract: Emergency department visits and rehospitalization are common after hospital discharge. Jack and colleagues demonstrated that a nurse discharge advocate and clinical pharmacist working together to c...
1,392 citations
TL;DR: In this article, a randomized controlled trial was conducted to evaluate the clinical effect of implementing RED among patients admitted to a general medical service and found that a nurse discharge advocate and clinical pharmacist working together to coordinate hospital discharge, educate patients, and reconcile medications led to fewer follow-up emergency visits and rehospitalizations than usual care alone.
Abstract: One in 5 hospitalizations is complicated by postdischarge adverse events (1, 2), some of which may lead to preventable emergency department visits or readmissions. Despite this finding, hospital discharge procedures have not been standardized (3). In addition, the declining presence of primary care providers (PCPs) in hospitals has not been adequately accompanied by systems to ensure that patient data are transferred to subsequent caregivers (4, 5). For example, discharge summaries frequently lack critical data and are not sent to the PCP in a timely fashion (6, 7), resulting in outpatient clinicians being unaware of test results that were pending at discharge (8) and evaluations that were scheduled to be done after discharge not being completed (9). Similarly, patients are often left unprepared at discharge; many do not understand their discharge medications and cannot recall their chief diagnoses (10). With more than 32 million adult discharges in the United States each year (11), these deficiencies in the transition of care increase illness, unnecessary hospital utilization, and cost.
Some peridischarge interventions have shown a reduction in hospital readmission rates and cost (12-14), emergency department visits (15), and postdischarge adverse events (16), whereas some have shown little or no effect (17-20). Peridischarge interventions have also shown improved PCP follow-up and outpatient work-ups (21) and higher patient satisfaction (15). Most of these studies have focused on specific diagnoses (14, 22, 23) or highly selected populations, such as geriatric adults (12, 13, 19, 24). Some have focused on specific aspects of the discharge, such as increasing access to primary care follow-up (25), connecting with transitional nursing services (26), or improving patients′ ability to advocate for themselves after discharge (12). To date, no study has evaluated a standardized discharge intervention that includes patient education, comprehensive discharge planning, and postdischarge telephone reinforcement in a general medical population.
Context
Emergency department visits and rehospitalizations are common after hospital discharge.
Contribution
This trial demonstrated that a nurse discharge advocate and clinical pharmacist working together to coordinate hospital discharge, educate patients, and reconcile medications led to fewer follow-up emergency visits and rehospitalizations than usual care alone.
Caution
The trial was conducted at a single center, and not all eligible patients were enrolled.
Implication
A systematic approach to hospital discharges can reduce unnecessary health service use.
—The Editors
In 2004, we began an in-depth examination of hospital discharge, for which we designed a package of services to minimize discharge failures—a process called reengineered discharge (RED) (Table 1) (3, 27). We did a randomized, controlled trial to evaluate the clinical effect of implementing RED among patients admitted to a general medical service.
Table 1
Components of Reengineered Hospital Discharge
1,382 citations
TL;DR: The effect of screening colonoscopy on the death rate from colorectal cancer (CRC) is not known as mentioned in this paper, however, the authors used administrative claims data in Ontario, Canada, to match each person age 5...
Abstract: The effect of screening colonoscopy on the death rate from colorectal cancer (CRC) is not known. Baxter and colleagues used administrative claims data in Ontario, Canada, to match each person age 5...
1,155 citations
TL;DR: New studies and evidence gaps that were unresolved at the time of the 2002 USPSTF recommendation are focused on, including the effectiveness of mammography screening in decreasing breast cancer mortality among average-risk women aged 40 to 49 years and 70 years or older.
Abstract: To inform the USPSTF recommendations about breast cancer screening, Nelson and coworkers reviewed evidence on the effectiveness of mammography screening in decreasing breast cancer mortality among ...
1,149 citations
Agency for Healthcare Research and Quality1, Colorado Department of Public Health and Environment2, Arizona State University3, Cincinnati Children's Hospital Medical Center4, Dartmouth College5, Cedars-Sinai Medical Center6, Group Health Cooperative7, Regions Hospital8, University of Missouri9, Icahn School of Medicine at Mount Sinai10, Georgia Regents University11, Baylor College of Medicine12, University of Massachusetts Medical School13, University of California, San Francisco14, University of Pennsylvania15, University of Minnesota16
1,087 citations
TL;DR: Questions remain about which groups of patients benefit from therapy and at which point in the course of disease this therapy should be initiated, and limited rigorous evidence exists demonstrating the effect of these therapies on important long-term clinical outcomes.
Abstract: National Institutes of Health (NIH) consensus and stateof-the-science statements are prepared by independent panels of health professionals and public representatives on the basis of 1) the results of a systematic literature review prepared under contract with the Agency for Healthcare Research and Quality (AHRQ); 2) presentations by investigators working in areas relevant to the conference questions during a 2-day public session; 3) questions and statements from conference attendees during open discussion periods that are part of the public session; and 4) closed deliberations by the panel during the remainder of the second day and morning of the third. This statement is an independent report of the panel and is not a policy statement of the National Institutes of Health or the U.S. government. The statement reflects the panel’s assessment of medical knowledge available at the time the statement was written. Thus, it provides a “snapshot in time” of the state of knowledge on the conference topic. When reading the statement, keep in mind that new knowledge is inevitably accumulating through medical research. Hepatitis B is a major cause of liver disease worldwide, ranking as a substantial cause of cirrhosis and hepatocellular carcinoma. The development and use of a vaccine for hepatitis B virus (HBV) has resulted in a substantial decline in the number of new cases of acute hepatitis B among children, adolescents, and adults in the United States. However, this success has not yet been duplicated worldwide, and both acute and chronic HBV infection continue to represent important global health problems. Seven treatments are currently approved for adult patients with chronic HBV infection in the United States: interferon-, pegylated interferon-, lamivudine, adefovir dipivoxil, entecavir, telbivudine, and tenofovir disoproxil fumarate. Interferon- and lamivudine have been approved for children with HBV infection. Although available randomized, controlled trials (RCTs) show encouraging short-term results— demonstrating the favorable effect of these agents on such intermediate markers of disease as HBV DNA level, liver enzyme tests, and liver histology— limited rigorous evidence exists demonstrating the effect of these therapies on important long-term clinical outcomes, such as the development of hepatocellular carcinoma or a reduction in deaths. Questions therefore remain about which groups of patients benefit from therapy and at which point in the course of disease this therapy should be initiated.
816 citations
Journal Article•
TL;DR: In this article, the authors compared pulse cyclophosphamide with daily oral cyclophotonitrile (OC) for the treatment of generalized ANCA-associated vasculitis with renal involvement but not immediately life-threatening disease.
Abstract: BACKGROUND: Current therapies for antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis are limited by toxicity. OBJECTIVE: To compare pulse cyclophosphamide with daily oral cyclophosphamide for induction of remission. DESIGN: Randomized, controlled trial. Random assignments were computer-generated; allocation was concealed by faxing centralized treatment assignment to providers at the time of enrollment. Patients, investigators, and assessors of outcomes were not blinded to assignment. SETTING: 42 centers in 12 European countries. PATIENTS: 149 patients who had newly diagnosed generalized ANCA-associated vasculitis with renal involvement but not immediately life-threatening disease. INTERVENTION: Pulse cyclophosphamide, 15 mg/kg every 2 to 3 weeks (76 patients), or daily oral cyclophosphamide, 2 mg/kg per day (73 patients), plus prednisolone. MEASUREMENT: Time to remission (primary outcome); change in renal function, adverse events, and cumulative dose of cyclophosphamide (secondary outcomes). RESULTS: Groups did not differ in time to remission (hazard ratio, 1.098 [95% CI, 0.78 to 1.55]; P = 0.59) or proportion of patients who achieved remission at 9 months (88.1% vs. 87.7%). Thirteen patients in the pulse group and 6 in the daily oral group achieved remission by 9 months and subsequently had relapse. Absolute cumulative cyclophosphamide dose in the daily oral group was greater than that in the pulse group (15.9 g [interquartile range, 11 to 22.5 g] vs. 8.2 g [interquartile range, 5.95 to 10.55 g]; P < 0.001). The pulse group had a lower rate of leukopenia (hazard ratio, 0.41 [CI, 0.23 to 0.71]). LIMITATIONS: The study was not powered to detect a difference in relapse rates between the 2 groups. Duration of follow-up was limited. CONCLUSION: The pulse cyclophosphamide regimen induced remission of ANCA-associated vasculitis as well as the daily oral regimen at a reduced cumulative cyclophosphamide dose and caused fewer cases of leukopenia. PRIMARY FUNDING SOURCE: The European Union.
TL;DR: The net clinical benefit of warfarin anticoagulation is quantified as the estimated reduction in rate of thromboembolism, mainly ischemic stroke, minus 1.5 times the estimated increase in rates of intracranial hemorrhage attributable to warFarin therapy in standard stroke risk subgroups in the community-based cohort of patients in the ATRIA Study.
Abstract: Guidelines for prescribing anticoagulants in atrial fibrillation should balance treatment benefits and harms. Singer and colleagues calculated 6-year ischemic stroke rates (benefit) and intracrania...
Journal Article•
TL;DR: The hypothesis that a regimen of pulsed intermittent cyclophosphamide would be as effective but less toxic than daily oral cycloph phosphamide for inducing remission in patients with generalized ANCA-associated vasculitis with active glomerulonephritis was tested.
Abstract: Toxicity limits the use of cyclophosphamide for anti-neutrophil cytoplasmic antibody (ANCA)–associated vasculitis. In this comparison of pulse versus daily oral cyclophosphamide regimens, equal pro...
TL;DR: Stent placement with medical treatment had no clear effect on progression of impaired renal function but led to a small number of significant procedure-related complications, which favor a conservative approach to patients with ARAS.
Abstract: BACKGROUND: Little is known about the efficacy and safety of renal artery stenting in patients with atherosclerotic renal artery stenosis (ARAS) and impaired renal function. OBJECTIVE: To determine the efficacy and safety of stent placement in patients with ARAS and impaired renal function. DESIGN: Randomized clinical trial. Randomization was centralized and computer generated, and allocation was assigned by e-mail. Patients, providers, and persons who assessed outcomes were not blinded to treatment assignment. SETTING: 10 European medical centers. PARTICIPANTS: 140 patients with creatinine clearance less than 80 mL/min per 1.73 m(2) and ARAS of 50% or greater. INTERVENTION: Stent placement and medical treatment (64 patients) or medical treatment only (76 patients). Medical treatment consisted of antihypertensive treatment, a statin, and aspirin. MEASUREMENTS: The primary end point was a 20% or greater decrease in creatinine clearance. Secondary end points included safety and cardiovascular morbidity and mortality. RESULTS: Forty-six of 64 patients assigned to stent placement had the procedure. Ten of the 64 patients (16%) in the stent placement group and 16 patients (22%) in the medication group reached the primary end point (hazard ratio, 0.73 [95% CI, 0.33 to 1.61]). Serious complications occurred in the stent group, including 2 procedure-related deaths (3%), 1 late death secondary to an infected hematoma, and 1 patient who required dialysis secondary to cholesterol embolism. The groups did not differ for other secondary end points. LIMITATION: Many patients were falsely identified as having renal artery stenosis greater than 50% by noninvasive imaging and did not ultimately require stenting. CONCLUSION: Stent placement with medical treatment had no clear effect on progression of impaired renal function but led to a small number of significant procedure-related complications. The study findings favor a conservative approach to patients with ARAS, focused on cardiovascular risk factor management and avoiding stenting.
TL;DR: To inform the USPSTF recommendations about breast cancer screening, Mandelblatt and colleagues developed 6 models of breast cancer incidence and mortality in the United States and estimated benefit to patients.
Abstract: To inform the USPSTF recommendations about breast cancer screening, Mandelblatt and colleagues developed 6 models of breast cancer incidence and mortality in the United States and estimated benefit...
TL;DR: A systematic review and meta-analyses assessed the possible independent predictive ability of CRP level for incident CHD risk and recommended more aggressive risk reduction therapy in persons reclassified as high-risk and may consequently reduce incidentCHD events.
Abstract: To support the USPSTF recommendation statement in this issue, Buckley and colleagues systematically reviewed evidence on the use of CRP in assessing CHD risk in persons at intermediate risk based o...
TL;DR: This issue contains both this article, which is a commentary on the IOM committee report, and a perspective on better research methods for CER, which consisted of the elements of earlier definitions reduced to 2 sentences.
Abstract: The U.S. Congress asked the Institute of Medicine to elicit input from stakeholders on which research topics should have the highest priority for comparative effectiveness research (CER) funding an...
TL;DR: In this article, the authors demonstrate the use of reclassification measures and illustrate their performance for well-known cardiovascular risk predictors in a cohort of women and evaluate the potential of new models and markers to change risk strata and alter treatment decisions.
Abstract: Models for risk prediction are widely used in clinical practice to stratify risk and assign treatment strategies. The contribution of new biomarkers has largely been based on the area under the receiver-operating characteristic curve, but this measure can be insensitive to important changes in absolute risk. Methods based on risk stratification have recently been proposed to compare predictive models. Such methods include the reclassification calibration statistic, the net reclassification improvement, and the integrated discrimination improvement. This article demonstrates the use of reclassification measures and illustrates their performance for well-known cardiovascular risk predictors in a cohort of women. These measures are targeted at evaluating the potential of new models and markers to change risk strata and alter treatment decisions.
Colorado Department of Public Health and Environment1, Arizona State University2, Cincinnati Children's Hospital Medical Center3, Johns Hopkins University4, Cedars-Sinai Medical Center5, University of North Carolina at Chapel Hill6, HealthPartners7, University of Missouri8, University of Michigan9, Georgia Regents University10, Baylor College of Medicine11, University of Massachusetts Medical School12, University of California, San Francisco13, Icahn School of Medicine at Mount Sinai14, Merck & Co.15
TL;DR: Review of the literature since 2002, focusing on new evidence on the benefits and harms of aspirin for the primary prevention of cardiovascular disease, including myocardial infarction and stroke, concluded that evidence is insufficient to assess the balance of benefits and Harm in men and women 80 years or older.
Abstract: DESCRIPTION Update of the 2002 U.S. Preventive Services Task Force (USPSTF) recommendation about the use of aspirin for the prevention of coronary heart disease. METHODS Review of the literature since 2002, focusing on new evidence on the benefits and harms of aspirin for the primary prevention of cardiovascular disease, including myocardial infarction and stroke. The new evidence was reviewed and synthesized according to sex. RECOMMENDATIONS Encourage men age 45 to 79 years to use aspirin when the potential benefit of a reduction in myocardial infarctions outweighs the potential harm of an increase in gastrointestinal hemorrhage. (A recommendation) Encourage women age 55 to 79 years to use aspirin when the potential benefit of a reduction in ischemic strokes outweighs the potential harm of an increase in gastrointestinal hemorrhage. (A recommendation) Evidence is insufficient to assess the balance of benefits and harms of aspirin for cardiovascular disease prevention in men and women 80 years or older. (I statement) Do not encourage aspirin use for cardiovascular disease prevention in women younger than 55 years and in men younger than 45 years. (D recommendation).
TL;DR: A cluster randomized trial to test whether improved hand hygiene or surgical facemasks reduce the transmission of interpandemic influenza in households found that healthy family members started using these measures within 36 hours of symptom onset in an infected family member.
Abstract: Background Few data are available about the effectiveness of nonpharmaceutical interventions for preventing influenza virus transmission. Objective To investigate whether hand hygiene and use of facemasks prevents household transmission of influenza. Design Cluster randomized, controlled trial. Randomization was computer generated; allocation was concealed from treating physicians and clinics and implemented by study nurses at the time of the initial household visit. Participants and personnel administering the interventions were not blinded to group assignment. (ClinicalTrials.gov registration number: NCT00425893) Setting Households in Hong Kong. Patients 407 people presenting to outpatient clinics with influenza-like illness who were positive for influenza A or B virus by rapid testing (index patients) and 794 household members (contacts) in 259 households. Intervention Lifestyle education (control) (134 households), hand hygiene (136 households), or surgical facemasks plus hand hygiene (137 households) for all household members. Measurements Influenza virus infection in contacts, as confirmed by reverse-transcription polymerase chain reaction (RT-PCR) or diagnosed clinically after 7 days. Results Sixty (8%) contacts in the 259 households had RT-PCR-confirmed influenza virus infection in the 7 days after intervention. Hand hygiene with or without facemasks seemed to reduce influenza transmission, but the differences compared with the control group were not significant. In 154 households in which interventions were implemented within 36 hours of symptom onset in the index patient, transmission of RT-PCR-confirmed infection seemed reduced, an effect attributable to fewer infections among participants using facemasks plus hand hygiene (adjusted odds ratio, 0.33 [95% CI, 0.13 to 0.87]). Adherence to interventions varied. Limitation The delay from index patient symptom onset to intervention and variable adherence may have mitigated intervention effectiveness. Conclusion Hand hygiene and facemasks seemed to prevent household transmission of influenza virus when implemented within 36 hours of index patient symptom onset. These findings suggest that nonpharmaceutical interventions are important for mitigation of pandemic and interpandemic influenza. Primary funding source Centers for Disease Control and Prevention.
TL;DR: Most patients with Budd-Chiari syndrome have at least 1 thrombotic risk factor, and many have more than 1; myeloproliferative disorders are most common; one- and 2-year survival rates are good with contemporary management, which includes noninvasive therapies and invasive techniques.
Abstract: Darwish Murad and colleagues describe 163 patients with newly diagnosed hepatic venous outflow obstruction (the Budd–Chiari syndrome). Most of the patients had identifiable risk factors for clot, m...
Journal Article•
TL;DR: In some patients with pulmonary arterial hypertension, the addition of sildenafil to long-term intravenous epoprostenol therapy improves exercise capacity, hemodynamic measurements, time to clinical worsening, and quality of life, but not Borg dyspnea score.
TL;DR: Adverse workflow (time pressure and chaotic environments), low work control, and unfavorable organizational culture were strongly associated with low physician satisfaction, high stress, burnout, and intent to leave, and no associations were seen between adverse physician reactions and the quality of patient care.
Abstract: Linzer and colleagues assessed the relationship among adverse primary care work conditions, adverse physician reactions, and quality of patient care. Among 422 family practitioners and general inte...
TL;DR: The pathophysiology, epidemiology, clinical features, and management of statin-related myopathy are reviewed because even a small percentage of tens of millions of patients is a large number, and statin myopathy can adversely affect both quality of life and adherence to this potentially life-saving treatment.
Abstract: Statin-related myopathy is a clinically important cause of statin intolerance and discontinuation. The spectrum of statin-related myopathy ranges from common but clinically benign myalgia to rare but life-threatening rhabdomyolysis. Observational studies suggest that myalgia can occur in up to 10% of persons prescribed statins, whereas rhabdomyolysis continues to be rare. The mechanisms of statin-related myopathy are unclear. Options for managing statin myopathy include statin switching, particularly to fluvastatin or low-dose rosuvastatin; nondaily dosing regimens; nonstatin alternatives, such as ezetimibe and bile acid-binding resins; and coenzyme Q10 supplementation. Few of these strategies have high-quality evidence supporting them. Because statin-related myopathy will probably become more common with greater numbers of persons starting high-dose statin therapy and the increasing stringency of low-density lipoprotein cholesterol level targets, research to better identify patients at risk for statin myopathy and to evaluate management strategies for statin-related myopathy is warranted.
TL;DR: This meta-analysis examined whether -blocker dose or magnitude of heart rate reduction could account for the differences in treatment effects among heart failure -blockers trials.
Abstract: The reasons why β-blockade reduces mortality from heart failure remain elusive. In a review of 23 trials of β-blockade in heart failure, the authors sought to determine whether heart rate reduction...
TL;DR: The criteria a new risk factor must meet to be clinically useful for reclassifying intermediate-risk patients' risk for major CHD events are outlined and a series of systematic reviews were conducted to help the U.S. Preventive Services Task Force (USPSTF) determine which of 9 risk factors should be used to further stratify intermediate- risk patients.
Abstract: To support the USPSTF recommendation statement in this issue, Helfand and associates evaluated the clinical usefulness of 9 new risk factors for CHD. Available evidence varied among these factors. ...
TL;DR: Rates of cardiac and gastrointestinal events in 30-day rates were higher in colonoscopy patients, with advancing age and preexisting comorbid conditions, and after polypectomy.
Abstract: Complication rates of colonoscopy in older patients are not well established. Warren and colleagues measured 30-day cardiac and gastrointestinal event rates in a random sample of 53 220 Medicare be...
TL;DR: A recent prospective study of 203 patients showed that operative planning based on anatomical imaging alone would have inappropriately excluded 21.7% of patients from adrenalectomy and would have led to unnecessary sugery in 24.7%.
Abstract: Computed tomography (CT), magnetic resonance imaging (MRI), and adrenal vein sampling (AVS) are used to distinguish unilateral from bilateral aldosterone secretion so that primary aldosteronism can...
TL;DR: A meta-analysis of randomized, controlled trials to examine the effects ofintensive glucose control on CVD among patients with type 2 diabetes found that, compared with conventional control, intensive glucose control reduced the risk for cardiovascular disease but not for cardiovascular death or all-cause mortality, and increased risk for severe hypoglycemia.
Abstract: trol, intensive glucose control reduced the risk for cardiovascular disease (relative risk [RR], 0.90 [95% CI, 0.83 to 0.98]; risk difference per 1000 patients per 5 years [RD], 15 [CI, 24 to 5]) but not cardiovascular death (RR, 0.97 [CI, 0.76 to 1.24]; RD, 3 [CI, 14 to 7]) or all-cause mortality (RR, 0.98 [CI, 0.84 to 1.15]; RD, 4 [CI, 17 to 10]). Intensive glucose control increased the risk for severe hypoglycemia (RR, 2.03 [CI, 1.46 to 2.81]; RD, 39 [CI, 7 to 71]). As was seen in the overall analyses, pooled findings from the early and more recent trials showed that intensive glucose control reduced the risk for cardiovascular disease and increased the risk for severe hypoglycemia. Limitation: Summary rather than individual data were pooled across trials. Conclusion: Intensive glucose control reduced the risk for some cardiovascular disease outcomes (such as nonfatal myocardial infarction), did not reduce the risk for cardiovascular death or allcause mortality, and increased the risk for severe hypoglycemia.