Letters
Corresponding Author: Joslyn S. Kirby, MD, Penn State Milton S. Hershey Medical Center, Department of Dermatology, 500 University Dr, Hershey, PA 17033 ([email protected]). Conflict of Interest Disclosures: None reported. 1. Weisshaar E, Szepietowski JC, Darsow U, et al. European guideline on chronic pruritus. Acta Derm Venereol. 2012;92(5):563-581. 2. Yosipovitch G. Chronic pruritus: a paraneoplastic sign. Dermatol Ther. 2010;23 (6):590-596. 3. Fukuoka M, Miyachi Y, Ikoma A. Mechanically evoked itch in humans. Pain. 2013; 154(6):897-904. 4. Ishiuji Y, Coghill RC, Patel TS, Oshiro Y, Kraft RA, Yosipovitch G. Distinct patterns of brain activity evoked by histamine-induced itch reveal an association with itch intensity and disease severity in atopic dermatitis. Br J Dermatol. 2009;161(5):1072-1080. 5. Misery L, Alexandre S, Dutray S, et al. Functional itch disorder or psychogenic pruritus: suggested diagnosis criteria from the French psychodermatology group. Acta Derm Venereol. 2007;87(4):341-344. 6. Leader B, Carr CW, Chen SC. Pruritus epidemiology and quality of life. Handb Exp Pharmacol. 2015;226:15-38.
Shared Decision-Making for Cancer Screening: Visual Tools and a 4-Step Method To the Editor Caverly’s concerns for promoting shared decisionmaking and selecting the best candidates for lung cancer screening deserve comment.1 First, it is untrue that developing a shared decisionmaking tool is complex.1 Common sense pictographs that use absolute numbers with a consistent denominator (ie, /1000 screened), time frames, and visuals employing the same scale for information on gains and losses of the options have been shown to change and improve decision-making.2,3 Such pictographs for breast cancer screening are already implemented in the small country of Belgium.4 It is puzzling why national health care agencies from so many countries enduringly fail to do this job properly. Second, to address whether a shared decision requires many more tools, a simple 4-step method can be employed: (1) Indicate that all options are acceptable; (2) administer the information (as above); (3) promote active participation of the patient by the expression of his or her values; and (4) analyze if the patient is comfortable with the decision by rephrasing. Finally, blood tests might be a cost-effective means to select candidates for computed tomography in the near future.5 Alain Braillon, MD, PhD Susan Bewley, MD, FRCOG, MA Author Affiliations: Amiens University Hospital, 80000 Amiens, France (Braillon); Women's Health Academic Centre, St Thomas' Hospital, London, England (Bewley). Corresponding Author: Alain Braillon, MD, PhD, Amiens University Hospital, 80000 Amiens, France ([email protected]). Conflict of Interest Disclosures: None reported. Editorial Note: This letter was shown to the corresponding author of the original article, who declined to reply on behalf of the authors. 1. Caverly T. Selecting the best candidates for lung cancer screening. JAMA Intern Med. 2015;175(6):898-900. 2. Zikmund-Fisher BJ, Fagerlin A, Ubel PA. A demonstration of “less can be more” in risk graphics. Med Decis Making. 2010;30(6):661-671. 3. Johansson M, Brodersen J. Informed choice in screening needs more than information. Lancet. 2015;385(9978):1597-1599.
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4. Belgian Health Care Knowledge Center (KCE). Report 216 [Breast cancer screening: messages for an informed choice]. 2014. http://kce.fgov.be/fr /publication/report/d%C3%A9pistage-du-cancer-du-sein-messages-en -support-d%E2%80%99un-choix-inform%C3%A9#.VQa0tPmG_6J. Accessed April 13, 2015. 5. Montani F, Marzi MJ, Dezi F, et al. miR-Test: a blood test for lung cancer early detection. J Natl Cancer Inst. 2015;107(6):djv063.
Physical Activity and Successful Aging: Even a Little Is Good To the Editor Recently in JAMA Internal Medicine, two studies1,2 highlighted the need of vigorous-intensity and/or long durations of physical activity for older adults. However, this is hardly feasible. Less than 50% are able to achieve the recommended minimum of 150 minutes of moderate-intensity physical activity, 75 minutes of vigorous-intensity physical activity, or an equivalent combination of moderate and vigorous physical activity (MVPA) per week.3,4 In a cohort of 204 542 middleaged and older Australians followed over the course of 6.5 years (7435 deaths included), Gebel et al1 reported significant benefits of vigorous-intensity physical activity in reducing mortality. Thus, they encourage vigorous intensity in activity guidelines to maximize benefits of physical activity in older adults.1 Can we recommend running to older adults for whom brisk walking is too demanding? Arem et al2 pooled data from 6 studies (5 American, 1 Swedish), including 661 137 middle-aged and older adults with 14.2 follow-up years (116 686 deaths registered) and reported an optimal threshold between 3 to 5 times the physical activity recommendations.2 Can we recommend 150 min/d physical activity to older adults who are not able to achieve 150 min/wk? Recommendations in the United States for older adults are similar to those for middle-aged adults.3 The only adaptation to the potential limitations of older adults is when older adults cannot do 150 minutes of moderate-intensity activity a week, they should be as physically active as their abilities and conditions allow.3 Doing little is better than doing nothing. The prescription of physical activity for older adults needs to be clarified (ie, the dose of physical activity required). We think that focusing on the current guidelines or on the upper threshold of physical activity may mean that the benefits of low-dose MVPA are overlooked in older adults. We think that older adults should increase physical activities progressively in their daily lives rather than changing their daily habits dramatically by adhereing to current recommendations. Based on the dose-response relationship between physical activity and mortality, we demonstrated that among the different bouts of daily exercise, the end of the first 15 minutes of MVPA yielded the largest increase in benefits, tapering off for subsequent 15-minute increments.5 Fifteen minutes per day could be a reasonable target dose for older adults. Small increases in physical activity may enable some older adults to incorporate more moderate activity and get closer to the recommended 150 min/wk.3 David Hupin, MD, MSc Frédéric Roche, MD, PhD Pascal Edouard, MD, PhD
JAMA Internal Medicine November 2015 Volume 175, Number 11 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a AUSTRALIAN NATIONAL UNIVERSITY User on 11/03/2015
jamainternalmedicine.com
Corresponding Author: Joslyn S. Kirby, MD, Penn State Milton S. Hershey Medical Center, Department of Dermatology, 500 University Dr, Hershey, PA 17033 ([email protected]). Conflict of Interest Disclosures: None reported. 1. Weisshaar E, Szepietowski JC, Darsow U, et al. European guideline on chronic pruritus. Acta Derm Venereol. 2012;92(5):563-581. 2. Yosipovitch G. Chronic pruritus: a paraneoplastic sign. Dermatol Ther. 2010;23 (6):590-596. 3. Fukuoka M, Miyachi Y, Ikoma A. Mechanically evoked itch in humans. Pain. 2013; 154(6):897-904. 4. Ishiuji Y, Coghill RC, Patel TS, Oshiro Y, Kraft RA, Yosipovitch G. Distinct patterns of brain activity evoked by histamine-induced itch reveal an association with itch intensity and disease severity in atopic dermatitis. Br J Dermatol. 2009;161(5):1072-1080. 5. Misery L, Alexandre S, Dutray S, et al. Functional itch disorder or psychogenic pruritus: suggested diagnosis criteria from the French psychodermatology group. Acta Derm Venereol. 2007;87(4):341-344. 6. Leader B, Carr CW, Chen SC. Pruritus epidemiology and quality of life. Handb Exp Pharmacol. 2015;226:15-38.
Shared Decision-Making for Cancer Screening: Visual Tools and a 4-Step Method To the Editor Caverly’s concerns for promoting shared decisionmaking and selecting the best candidates for lung cancer screening deserve comment.1 First, it is untrue that developing a shared decisionmaking tool is complex.1 Common sense pictographs that use absolute numbers with a consistent denominator (ie, /1000 screened), time frames, and visuals employing the same scale for information on gains and losses of the options have been shown to change and improve decision-making.2,3 Such pictographs for breast cancer screening are already implemented in the small country of Belgium.4 It is puzzling why national health care agencies from so many countries enduringly fail to do this job properly. Second, to address whether a shared decision requires many more tools, a simple 4-step method can be employed: (1) Indicate that all options are acceptable; (2) administer the information (as above); (3) promote active participation of the patient by the expression of his or her values; and (4) analyze if the patient is comfortable with the decision by rephrasing. Finally, blood tests might be a cost-effective means to select candidates for computed tomography in the near future.5 Alain Braillon, MD, PhD Susan Bewley, MD, FRCOG, MA Author Affiliations: Amiens University Hospital, 80000 Amiens, France (Braillon); Women's Health Academic Centre, St Thomas' Hospital, London, England (Bewley). Corresponding Author: Alain Braillon, MD, PhD, Amiens University Hospital, 80000 Amiens, France ([email protected]). Conflict of Interest Disclosures: None reported. Editorial Note: This letter was shown to the corresponding author of the original article, who declined to reply on behalf of the authors. 1. Caverly T. Selecting the best candidates for lung cancer screening. JAMA Intern Med. 2015;175(6):898-900. 2. Zikmund-Fisher BJ, Fagerlin A, Ubel PA. A demonstration of “less can be more” in risk graphics. Med Decis Making. 2010;30(6):661-671. 3. Johansson M, Brodersen J. Informed choice in screening needs more than information. Lancet. 2015;385(9978):1597-1599.
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4. Belgian Health Care Knowledge Center (KCE). Report 216 [Breast cancer screening: messages for an informed choice]. 2014. http://kce.fgov.be/fr /publication/report/d%C3%A9pistage-du-cancer-du-sein-messages-en -support-d%E2%80%99un-choix-inform%C3%A9#.VQa0tPmG_6J. Accessed April 13, 2015. 5. Montani F, Marzi MJ, Dezi F, et al. miR-Test: a blood test for lung cancer early detection. J Natl Cancer Inst. 2015;107(6):djv063.
Physical Activity and Successful Aging: Even a Little Is Good To the Editor Recently in JAMA Internal Medicine, two studies1,2 highlighted the need of vigorous-intensity and/or long durations of physical activity for older adults. However, this is hardly feasible. Less than 50% are able to achieve the recommended minimum of 150 minutes of moderate-intensity physical activity, 75 minutes of vigorous-intensity physical activity, or an equivalent combination of moderate and vigorous physical activity (MVPA) per week.3,4 In a cohort of 204 542 middleaged and older Australians followed over the course of 6.5 years (7435 deaths included), Gebel et al1 reported significant benefits of vigorous-intensity physical activity in reducing mortality. Thus, they encourage vigorous intensity in activity guidelines to maximize benefits of physical activity in older adults.1 Can we recommend running to older adults for whom brisk walking is too demanding? Arem et al2 pooled data from 6 studies (5 American, 1 Swedish), including 661 137 middle-aged and older adults with 14.2 follow-up years (116 686 deaths registered) and reported an optimal threshold between 3 to 5 times the physical activity recommendations.2 Can we recommend 150 min/d physical activity to older adults who are not able to achieve 150 min/wk? Recommendations in the United States for older adults are similar to those for middle-aged adults.3 The only adaptation to the potential limitations of older adults is when older adults cannot do 150 minutes of moderate-intensity activity a week, they should be as physically active as their abilities and conditions allow.3 Doing little is better than doing nothing. The prescription of physical activity for older adults needs to be clarified (ie, the dose of physical activity required). We think that focusing on the current guidelines or on the upper threshold of physical activity may mean that the benefits of low-dose MVPA are overlooked in older adults. We think that older adults should increase physical activities progressively in their daily lives rather than changing their daily habits dramatically by adhereing to current recommendations. Based on the dose-response relationship between physical activity and mortality, we demonstrated that among the different bouts of daily exercise, the end of the first 15 minutes of MVPA yielded the largest increase in benefits, tapering off for subsequent 15-minute increments.5 Fifteen minutes per day could be a reasonable target dose for older adults. Small increases in physical activity may enable some older adults to incorporate more moderate activity and get closer to the recommended 150 min/wk.3 David Hupin, MD, MSc Frédéric Roche, MD, PhD Pascal Edouard, MD, PhD
JAMA Internal Medicine November 2015 Volume 175, Number 11 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a AUSTRALIAN NATIONAL UNIVERSITY User on 11/03/2015
jamainternalmedicine.com
