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News From The Annals Of Internal Medicine: 9 July 2013

1. finds to recommend for or against screening for

(USPSTF) found insufficient evidence to assess the balance of benefits and harms of screening for primary open-angle glaucoma (POAG) in adults. Glaucoma is an acquired degeneration of the optic nerve that is the second most common cause of blindness worldwide. Open-angle is the most common type of glaucoma where an increase in pressure on the optic nerve occurs slowly over time. The goal of potential screening programs is to identify and treat POAG before the development of . A panel of experts was commissioned to review evidence on the benefits and harms of glaucoma screening and treatment to inform the recommendation. The USPSTF reviewed more than 100 studies on the accuracy of various tests for glaucoma. Because of the methodological limitations, variability in study designs, and lack of a diagnostic standard for glaucoma, the Task Force was not able to make any conclusions about the overall accuracy of screening for glaucoma. No studies directly evaluated whether screening prevents visual field loss, , or worsening quality of life. There were no published studies on the harms of screening but several studies assessed the harms of treatment. The Task Force concluded that evidence on the accuracy of screening tests and the benefits of screening or treatment to delay or prevent or improve quality of life is inadequate to make a recommendation.

2. Two commentaries explore the physician’s role in preventing gun violence

Expert urges physicians to talk to elderly patients about guns

Geriatric persons are significantly more likely than younger people to suffer self-inflicted gunshot wounds, especially to the head. To safeguard geriatric people as well as the rest of the population, physician engagement is crucial. Physicians have a legal right to ask their patients about their access to guns. If a gun is present in the home, the physician should explore the possible effect of the patient’s physical and mental situation on the risk of firearm injury. Risk for injury is increased by a number of conditions disproportionately affecting the geriatric patient population, including dementia, delusions and memory disorders, depression, and visual and hearing impairments. The author writes that if a patient is found to have one of these impairments, the physician should work with the family members to “confront, supervise, or exhort the older adult to relinquish access to a firearm.” According to the author, physicians have a legally enforceable obligation to engage in firearms-related inquiries. Physicians who practice this type of care “will be practicing a form of positive defensive medicine.”

3. Physicians should put ‘compassion before fear’ when discussing mental illness and gun violence

Two mental health experts express concern about the way the media has portrayed the mentally ill as a greater part of the problem of gun violence and more dangerous than they actually are. The authors support the renewed calls for strong controls on firearm availability but believe that restricting access to guns for the mentally ill should not be the reason for stricter laws. Patients with a serious mental illness such as schizophrenia, bipolar disorder, or depression have a two- to four-fold increase in violence but represent just three to five percent of total violence. The authors argue that public health interventions to restrict firearm access among people with mental disorders may be ineffective and waste resources because it is not possible to predict which patients will become violent. They write that “undue focus on the mentally ill is discriminatory, stigmatizing, and might discourage people with treatable mental disorders from seeking treatment.” They call for better treatment for mentally ill patients, as treatment may help to reduce the small subset of violence attributable to mental illness. They authors also urge physicians to advocate for mental health treatment and to “put compassion before fear” when discussing violence.


American College of Physicians