In This Issue of JAMA Internal Medicinedoi: 10.1001/jamainternmed.2013.63pmid: N/A
Evaluation of the Mobile Acute Care of the Elderly (MACE) Service The MACE service is a novel model of care designed to deliver specialized interdisciplinary care to hospitalized older adults to improve patient outcomes. To evaluate the impact of the MACE service, Hung et al conducted a prospective, matched cohort study of patients 75 years or older admitted to a tertiary hospital for an acute illness to either the MACE service or medicine service. Admission to the MACE service was associated with lower rates of adverse events (9.5% vs 17.0%), shorter hospital length of stay by 0.8 days, and better satisfaction. Influenza Vaccines: Time for a Rethink Doshi challenges the basic assumptions of officials and professional societies to treat influenza as a major public health threat for which the annual vaccine offers a safe and effective solution, showing that there is no good evidence that vaccines reduce serious complications of influenza. Promotional messages conflate “influenza” (disease caused by influenza viruses) with “flu” (a syndrome with many causes, of which influenza viruses appear to be a minor contributor). This lack of precision causes physicians and potential vaccine recipients to have unrealistic assumptions about the vaccine's potential benefit and impedes dissemination of the evidence on nonpharmaceutical interventions against respiratory diseases. Also, unexpected and serious adverse effects of influenza vaccines have occurred. The decisions surrounding influenza vaccines need to include a discussion of these risks and benefits. Effects of Creative Arts Therapies on Psychological Symptoms and Quality of Life in Patients With Cancer Puetz et al conducted a systematic review of randomized clinical trials to summarize the effect of exposure to creative arts therapies (CAT) on psychological symptoms and quality of life (QoL) among patients with cancer during treatment and follow-up. Twenty-seven investigations that included both randomization to either a CAT or control condition and a measure of anxiety, depression, pain, fatigue, and/or QoL were selected. Meta-regression analyses examined whether the effects varied according to patient characteristics and modifiable features of CAT and clinical settings. Findings indicated that exposure to CAT reduced anxiety, depression, and pain and increased QoL during cancer treatment; fatigue was not significantly reduced. Exposure to CAT only significantly reduced pain during follow-up. Effects of an Acute Care for Elders Unit on Costs and 30-Day Readmissions To assess the impact of the interdisciplinary Acute Care for Elders (ACE) model on costs, Flood et al conducted a retrospective cohort study of hospitalist patients 70 years or older spending the entirety of their hospitalization in either the ACE or usual care (UC) unit. Variable direct cost was chosen as the primary outcome because it represents the cost stemming directly from daily patient care. The authors found significantly reduced mean (SD) variable direct cost per patient for ACE compared with UC ($2109 [$1870] vs 2480 [$2113]; P = .009). Adjusted cost ratios revealed significant cost savings for patients with low (0.82; 95% CI, 0.72-0.94) and moderate (0.74; 95% CI, 0.62-0.89) case-mix index scores; care was cost neutral for patients with high case-mix index scores (1.13; 95% CI, 0.93-1.37). Significantly fewer ACE patients were readmitted within 30 days of discharge compared with UC (7.9% vs 12.8%; P = .02). Characteristics of Oncology Clinical Trials Hirsch et al performed a comprehensive, systematic analysis of oncology clinical trials registered with ClinicalTrials.gov between October 2007 and September 2010 to better understand the strengths and weaknesses of ongoing cancer research. Of 40 970 interventional studies registered during that time frame, 22% focused on oncology. Oncology trials were more likely to be single arm, open label, and nonrandomized compared with trials in other diseases. One-third of trials were conducted completely outside the United States, and there was only moderate correlation between the number of trials focused on a specific cancer type and the respective incidence or mortality. These and other results highlight the crucial need to better understand the trials being performed and to develop metrics with which to guide trial design to ensure that reliable, relevant data are generated to inform clinical care.
Wide-Complex Tachycardia in a Patient With Coronary Disease—Quiz CaseWilliams, Eric S.;Viswanathan, Mohan N.;Prutkin, Jordan M.
doi: 10.1001/jamainternmed.2013.109apmid: 23546529
A 55-year-old man with a history of hypercholesterolemia and symptomatic premature ventricular complexes treated with a β-blocker was admitted to an outside hospital with acute-onset left-sided chest pressure, palpitations, and lightheadedness. Paramedics at the scene obtained a 12-lead electrocardiogram (ECG) revealing a wide-complex tachycardia at 248 beats per minute (Figure 1), which self-terminated as the patient was being prepared for direct-current cardioversion. The patient was then treated with chewable aspirin and intravenous lidocaine. View LargeDownload Figure 1. In the emergency department he reported recurrent palpitations, and a repeated ECG showed atrial fibrillation with occasional wide QRS complexes that resembled the clinical tachycardia (Figure 2). Intravenous heparin sodium and amiodarone infusions were initiated. Cardiac biomarkers showed a mildly elevated level of troponin T (0.08 ng/mL [0.08 μg/L]). Transthoracic echocardiography showed mild global left ventricular dysfunction with an ejection fraction of 45%. Urgent cardiac catheterization revealed an 80% proximal lesion in the left anterior descending artery and a 90% right coronary artery lesion that were treated with the implantation of 2 everolimus-eluting stents. View LargeDownload Figure 2. The patient continued to have runs of wide-complex tachycardia after revascularization, and he was transferred to our facility for possible implantable cardioverter-defibrillator (ICD) with the diagnosis of sustained ventricular tachycardia (VT) in the setting of ischemic heart disease and a mildly depressed ejection fraction. Questions: What is the most likely diagnosis of the tachycardia seen in Figure 1? Should this patient receive an ICD? Answer
Wide-Complex Tachycardia in a Patient With Coronary Disease—Diagnosisdoi: 10.1001/jamainternmed.2013.109bpmid: N/A
ANALYSIS OF ECGs The differential diagnosis of wide-complex tachycardia includes VT, a supraventricular tachycardia (SVT) with aberrancy, a preexcited tachycardia with anterograde conduction occurring over an accessory pathway, ventricular pacing, or QRS widening owing to an antiarrhythmic drug or electrolyte effect. The QRS complexes in the 12-lead ECG in Figure 1 show an atypical right bundle branch block QRS morphology with a right-inferior axis. There is no obvious evidence of atrioventricular (AV) dissociation. The positively concordant QRS complexes, the atypical notched monophasic R wave in lead V1, and the clinical scenario of ischemic heart disease all favor VT as the diagnosis. Published criteria by Brugada et al1 and Verecki et al2,3 are useful in the diagnosis of wide-complex rhythms and also support a diagnosis of VT in this patient. Clinical course The patient continued to have short episodes of wide-complex tachycardia at our facility despite treatment with amiodarone and metoprolol tartrate. He was subsequently brought to the electrophysiology (EP) laboratory for a diagnostic EP study to determine the mechanism of the arrhythmia. He presented in sinus rhythm with a normal QRS complex. An EP catheter was advanced from the right femoral vein into the coronary sinus, which recorded electrical signals from the left atrium and ventricle along the mitral annulus. Pacing from this catheter stimulated the left atrium, and the QRS complex demonstrated a delta wave with QRS morphology identical to those of clinical tachycardia (Figure 3), indicating the presence of a left free wall accessory pathway. Owing to patient agitation in the laboratory, arrhythmia induction attempts were brief, and SVT, atrial fibrillation, and atrial flutter were not seen. Based on the hypothesis that the patient's clinical tachycardia was an accessory pathway–mediated SVT, the accessory pathway was successfully ablated, and at the conclusion of the study, there was no evidence of a delta wave and no inducible arrhythmias. The patient was discharged home the following day without an ICD. View LargeDownload Figure 3. A 12-lead electrocardiogram during left atrial pacing in the coronary sinus. The pacing stimulus artifact (stim) is marked with an arrow. A delta wave is noted (arrow), with QRS morphology identical to those of the clinical tachycardia. In sinus rhythm, since the sinus node is anatomically closer to the atrioventricular (AV) node than to the left-sided accessory pathway, conduction proceeds preferentially over the normal conduction system, and preexcitation is not demonstrated. By pacing the left atrium, anatomically closer to the accessory pathway than to the AV node, conduction occurs preferentially over the accessory pathway and the delta wave becomes apparent. Calipers denote the onset of the P wave, QRS complex, and T wave; ms indicates milliseconds. Comment The patient presented with presumed antidromic AV reciprocating tachycardia using a left free wall accessory pathway as the anterograde conducting limb and the AV node as the retrograde limb, which is a manifestation of the Wolff-Parkinson-White syndrome. Because anterograde ventricular activation in this case does not occur over the normal conduction system, ECG findings can mimic those of VT. In addition, the commonly used criteria to discern VT from SVT were not validated in patients with preexcited tachycardia.1,2 In one prospective study, the presence of AV dissociation or QRS morphology consistent with ventricular activation from apex to base favored VT over preexcited tachycardia with high specificity but low sensitivity.4 Left-sided free wall accessory pathways are more prevalent than right-sided pathways and are amenable to catheter ablation with 90% to 95% success rates.5 They are also less likely to manifest with a delta wave on ECG during normal sinus rhythm. This is because the sinus node is anatomically closer to the AV node than to a left-sided accessory pathway (Figure 4), so conduction occurs preferentially over the normal conduction system, and the baseline ECG can look normal without evidence of a delta wave. With left atrial pacing (via the coronary sinus) closer to the accessory pathway during the EP study, conduction preferentially occurred over the accessory pathway, and the delta wave became readily apparent (Figure 3). Indications for catheter ablation include the treatment of symptomatic accessory pathway-mediated tachycardias, the treatment of an accessory pathway in patients deemed high-risk for sudden death,6 or for patients in high-risk occupations, such as commercial vehicle operators or airline pilots.5 View LargeDownload Figure 4. Cartoon illustration of anterograde conduction during sinus rhythm in the presence of an accessory pathway (AP). The sinus node in the right atrium (RA) is anatomically closer to the atrioventricular node than an AP connection between the left atrium (LA) and left ventricle (LV). The right ventricle (RV) is also depicted. Following catheter ablation, the patient no longer had runs of wide-complex tachycardia or “premature ventricular complexes” on cardiac telemetry. In retrospect, the latter was likely intermittent preexcitation misdiagnosed as ventricular ectopy. For example, Figure 2 illustrates different conducted QRS morphology during atrial fibrillation, which represent varying degrees of fusion between AV nodal (narrow complex) and accessory pathway (wide complex) conduction. The QRS complexes at a faster heart rate on the right of the strip appear more preexcited, as the AV node has less time to “recover” from the faster beats owing to its normal decremental conduction properties. Since the rhythm was not VT, the patient did not require an ICD and was discharged on appropriate medication for the secondary prevention of coronary heart disease. At the 6-month follow-up, he had no palpitations, dizziness, or syncope. Return to Questions Take-home points Take-home points Most wide-complex tachycardias occurring in the setting of structural heart disease are ventricular tachycardia; however, the differential diagnosis also includes supraventricular tachycardia with aberrancy, ventricular pacing, or preexcited tachycardia (conduction over an accessory pathway). The various criteria established to distinguish ventricular from supraventricular tachycardia were not validated in patients with preexcited tachycardia. Left-sided accessory pathways are less likely than right-sided or septal accessory pathways to manifest with a delta wave on ECG during normal sinus rhythm owing to the anatomic distance of these pathways from the sinus node. Patients with recurrent arrhythmias despite medical therapy warrant an electrophysiologic study to define the arrhythmia mechanism and to perform a potential catheter ablation. Back to top Article Information Correspondence: Jordan M. Prutkin, MD, MHS, Division of Cardiology, Section of Cardiac Electrophysiology, University of Washington, 1959 Pacific St NE, PO Box 356422, Seattle, WA 98195 ([email protected]). Published Online: April 1, 2013. doi:10.1001/jamainternmed.2013.109 Conflict of Interest Disclosures: None reported. References 1. Brugada P, Brugada J, Mont L, Smeets J, Andries EW. A new approach to the differential diagnosis of a regular tachycardia with a wide QRS complex. Circulation. 1991;83(5):1649-16592022022PubMedGoogle ScholarCrossref 2. Vereckei A, Duray G, Szénási G, Altemose GT, Miller JM. Application of a new algorithm in the differential diagnosis of wide QRS complex tachycardia. Eur Heart J. 2007;28(5):589-60017272358PubMedGoogle ScholarCrossref 3. Vereckei A, Duray G, Szénási G, Altemose GT, Miller JM. New algorithm using only lead aVR for differential diagnosis of wide QRS complex tachycardia. Heart Rhythm. 2008;5(1):89-9818180024PubMedGoogle ScholarCrossref 4. Steurer G, Gürsoy S, Frey B, et al. The differential diagnosis on the electrocardiogram between ventricular tachycardia and preexcited tachycardia. Clin Cardiol. 1994;17(6):306-3088070148PubMedGoogle ScholarCrossref 5. Zipes DP, Haïssaguerre M. Catheter Ablation of Arrhythmias. 2nd ed. Armonk, NY: Futura; 2002 6. Klein GJ, Bashore TM, Sellers TD, Pritchett EL, Smith WM, Gallagher JJ. Ventricular fibrillation in the Wolff-Parkinson-White syndrome. N Engl J Med. 1979;301(20):1080-1085492252PubMedGoogle ScholarCrossref
Bizarre and Wide QRS After Liver Transplant—Quiz CaseJohnson, Colleen J.;Scheinman, Melvin A.;Turakhia, Mintu P.
doi: 10.1001/jamainternmed.2013.644apmid: 23609165
A 52-year-old woman 3 weeks status post orthotopic liver transplant was noted to have ST-segment elevation on telemetry. The posttransplant course had been complicated by acute rejection treated with increasing tacrolimus doses resulting in status epilepticus from tacrolimus toxicity. She was treated with intravenous fosphenytoin followed by progressively increasing doses of intravenous phenytoin. Fluconazole, vancomycin, and meropenem had also been started empirically owing to decreased immune function and low blood pressure. At the time of the electrocardiogram (Figure 1), the corrected phenytoin level was 26 μg/mL (normal range 10-20, μg/mL). View LargeDownload Figure 1. On physical examination, the patient was intubated, undergoing mechanical ventilation, and receiving continuous hemodialysis. The temperature was 37.4°C, and the blood pressure, 110/60 mm Hg. The heart rate ranged from 78 to 110 bpm. The serum troponin I and serum electrolyte levels were normal (sodium, 135 mEq/L; potassium, 3.4 mEq/L; creatinine, 1.1 mg/dL; ionized calcium, 3.92 mg/dL; and magnesium, 2.1 mEq/L). The serum albumin level was low (2.2 g/dL). Transthoracic echocardiography revealed normal biventricular size with mildly to moderately reduced left ventricular systolic function. Questions: What is the rhythm? What is the cause of the electrocardiographic (ECG) abnormality? Answer
Bizarre and Wide QRS After Liver Transplant—Diagnosisdoi: 10.1001/jamainternmed.2013.644bpmid: N/A
Ecg interpretation The ECG revealed a regular wide complex tachycardia at a rate of 104 bpm (Figure 1). P waves were evident in leads V2 and V3 with 1:1 atrioventricular association. There was no response to carotid sinus massage. The QRS complex had a broad slurred sinusoidal pattern such that there was difficulty separating depolarization (the QRS complex) from repolarization (the ST segment and T wave). Clinical course Phenytoin and fluconazole were discontinued, while hemodialysis was continued in the intensive care unit. The ECGs were repeated (Figure 2 and Figure 3), while corrected phenytoin levels declined. Forty-eight hours after discontinuation of phenytoin and fluconazole treatment, the patient's ECG returned to baseline. Cardiac troponin levels remained normal throughout this period. View LargeDownload Figure 2. View LargeDownload Figure 3. Discussion The differential diagnosis for wide complex tachycardias includes ventricular tachycardia (VT), supraventricular tachycardia (SVT) with aberrancy, and antidromic atrioventricular reentrant tachycardia (AVRT), in which conduction from the atria to the ventricles occurs via an accessory pathway, and retrograde conduction back to the atria occurs via the AV node. Although it may be tempting to rely on wide complex tachycardia algorithms such as the Brugada criteria,1 it is important to recognize the limitations of this approach for ECGs with very atypical or bizarre QRS complexes. These findings are often caused by electrolyte derangements and medications that can affect cardiac conduction. Wide or bizarre QRS complexes may also mimic ST elevation, which should prompt consideration of ischemia, particularly if ST elevation persists as the QRS abnormalities resolve. However, in this case, the bizarre QRS pattern was more diffuse and not consistent with a coronary distribution; troponin levels were also normal. In this case, the patient was on 2 medications that can severely affect cardiac conduction: phenytoin and fluconazole. Although both medications delay conduction in pacemaker cells, specialized conducting tissue, and cardiac myocytes, the QRS abnormalities are due to delayed intraventricular conduction. Phenytoin is a Class 1b antiarrhythmic agent and blocks the sodium ion channel in both neural and cardiac tissue. Although the phenytoin level was not dramatically increased in our patient, other factors can potentiate the effect of phenytoin. In the bloodstream, phenytoin is largely bound to proteins such as albumin, making it physiologically inactive. Therefore, the laboratory-measured serum concentration of phenytoin does not accurately reflect the physiologically active fraction of the drug in states of hypoalbuminemia such as hepatic or renal failure.2,3 Renal failure alone can double or triple the unbound fraction of phenytoin.2 In addition, phenytoin is metabolized by the cytochrome P450 system of which fluconazole is an potent inhibitor.4 Although the patient's total serum concentration of phenytoin was at a level consistent with only mild toxicity, the free fraction of phenytoin may have been considerably higher, given the hypoalbuminemia, hepatic and renal failure, and concomitant fluconazole administration. QRS complex widening from phenytoin toxicity is well established. However, the patient also had QT prolongation, best seen in Figures 2 and 3, which is not characteristic of sodium channel blockade. Cardiac repolarization, as manifested by the T wave, is primarily dependent on calcium and potassium ion channels. Phenytoin has also been shown to inhibit the cardiac potassium channels albeit to a much lesser degree than the sodium channel blockade.5 However, fluconazole, along with other azole antifungal agents, is a potent potassium channel blocker and has been shown to cause QT prolongation and torsades de pointes.6-8 With discontinuation of fluconazole and phenytoin treatment and continuation of hemodialysis, the ECG changes gradually resolved over the next 48 hours. Therefore, the most likely cause of the ECG changes was phenytoin and fluconazole toxicity, which together caused QRS widening and QT prolongation in our patient. Return to Questions Take-home points Take-home points Algorithms for the diagnosis of wide complex tachycardias were not developed for clinical settings such as metabolic derangements or drugs that interfere with cardiac conduction. Many drugs such as phenytoin and fluconazole affect cardiac conduction and can result in bizarre ECG manifestations with toxic levels. Serum levels of drugs may not accurately reflect toxic effects in the setting of polypharmacy and comorbid conditions such as renal or hepatic failure. Back to top Article Information Correspondence: Mintu P. Turakhia, MD, MAS, Palo Alto VA Health Care System, Stanford University, 3801 Miranda Ave, 111C, Palo Alto, CA 94304 ([email protected]). Published Online: April 22, 2013. doi:10.1001/jamainternmed.2013.644 Conflict of Interest Disclosures: None reported. Disclaimer: The content and opinions expressed herein are solely the responsibility of the authors and do not necessarily represent the views or policies of the Department of Veterans Affairs. References 1. Brugada P, Brugada J, Mont L, Smeets J, Andries EW. A new approach to the differential diagnosis of a regular tachycardia with a wide QRS complex. Circulation. 1991;83(5):1649-16592022022PubMedGoogle ScholarCrossref 2. von Winckelmann SL, Spriet I, Willems L. Therapeutic drug monitoring of phenytoin in critically ill patients. Pharmacotherapy. 2008;28(11):1391-140018956999PubMedGoogle ScholarCrossref 3. Chabolla DR, Wszolek ZK. Pharmacologic management of seizures in organ transplant. Neurology. 2006;67(12):(suppl 4) S34-S3817190920PubMedGoogle ScholarCrossref 4. Blum RA, Wilton JH, Hilligoss DM, et al. Effect of fluconazole on the disposition of phenytoin. Clin Pharmacol Ther. 1991;49(4):420-4252015731PubMedGoogle ScholarCrossref 5. Danielsson BR, Lansdell K, Patmore L, Tomson T. Phenytoin and phenobarbital inhibit human HERG potassium channels. Epilepsy Res. 2003;55(1-2):147-15712948624PubMedGoogle ScholarCrossref 6. Han S, Zhang Y, Chen Q, et al. Fluconazole inhibits hERG K(+) channel by direct block and disruption of protein trafficking. Eur J Pharmacol. 2011;650(1):138-14420951697PubMedGoogle ScholarCrossref 7. Wassmann S, Nickenig G, Böhm M. Long QT syndrome and torsade de pointes in a patient receiving fluconazole. Ann Intern Med. 1999;131(10):79710577320PubMedGoogle ScholarCrossref 8. Pham CP, de Feiter PW, van der Kuy PH, van Mook WN. Long QTc interval and torsade de pointes caused by fluconazole. Ann Pharmacother. 2006;40(7-8):1456-146116849620PubMedGoogle ScholarCrossref
Creative Arts Therapies Defined: Comment on “Effects of Creative Arts Therapies on Psychological Symptoms and Quality of Life in Patients with Cancer”Bradt, Joke;Goodill, Sheryl
doi: 10.1001/jamainternmed.2013.6145pmid: 23699880
A diagnosis of cancer and subsequent treatments may result in significant emotional, physical, and social suffering, placing cancer survivors at greater risk for mental health issues.1,2 Therefore, the care of cancer patients should incorporate services that help meet patients' psychological, social, and spiritual needs. Creative arts therapies (CATs), such as dance/movement, music, art, poetry, drama, and psychodrama, are increasingly used to aid in the care of cancer patients and in their recovery. The results of several systematic reviews, as referenced in the study by Puetz et al3 have reported small to moderate effects of music, art, and dance/movement therapies on a variety of psychological outcomes in cancer patients. The systematic review by Puetz and colleagues aims to expand the existing evidence base by identifying potential moderators of the efficacy of CATs during and after cancer treatment. The review included 27 randomized clinical trials (RCTs) that examined the effects of arts interventions (music, art, dance, and expressive writing) on psychological outcomes in 1576 cancer patients. The pooled estimates indicate that arts interventions significantly reduced anxiety, depression, and pain and improved the quality of life in cancer patients. The results indicate no evidence of an effect on fatigue. Moderator analyses suggest greater pain reductions during inpatient treatment and for homogeneous cancer groups. In addition, the authors report that anxiety reduction was greater for those studies “in which the arts intervention was administered by a non-CAT therapist compared with those delivered by a CAT therapist.”3 The continuum of care in arts in health care practices ranges from performances for patients by artists to focused individualized psychotherapeutic CAT interventions. We value and applaud the use of the arts and creative processes across this continuum because they enhance patient care and well-being. Research on the efficacy of these interventions, however, requires clarity about the nature of the interventions themselves. Unfortunately, the analysis by Puetz et al3 offers no operational definition of CATs. Instead, the authors use“creative arts therapies” as a generic term to reference true CATs and also arts interventions administered by non-CAT health care professionals or artist volunteers. This limitation compromises the analysis at its foundation: the understanding of the independent variable in the included studies. We offer the following definition of CATs, drawing on a number of authoritative sources.4-9 Creative arts therapies involve the implementation of an arts intervention by a trained, credentialed creative arts therapist; the presence of a systematic psychotherapeutic process; and the use of individualized treatment interventions. Thus, CATs use a wide range of arts experiences to address specific therapeutic issues identified individually for patients and always include patient assessment, treatment, and evaluation. Specialties include art therapy, music therapy, dance/movement therapy, drama therapy, psychodrama, poetry therapy, and expressive therapy. In contrast, arts interventions administered by volunteers or professionals in other health care disciplines typically follow a universally applied program of arts activities and, in the case of music interventions, are often limited to passive listening to music. Many studies in the review by Puetz et al3 indeed investigated the effects of listening to prerecorded music. In their moderator analysis, the authors distinguish studies that involved a monitoring therapist from those that did not. However, the definitions provided in Table 2 for the 2 levels of therapeutic monitoring (ie, therapist present vs no therapist present) are not congruent with the study's conclusion, namely, that greater anxiety benefits were found when the arts intervention was administered by a non-CAT therapist compared with those studies that used a CAT therapist. This conclusion suggests that a therapist (CAT or non-CAT) was present during the intervention session for all studies in this review. However, the authors elsewhere identify 18 of the 25 trials that included anxiety as an outcome as “no therapist” trials. This contradiction leaves the reader somewhat confused. Regardless of the authors' intended meaning, relying on the distinction of therapist present vs no therapist remains problematic when no definition of therapist is provided. The absence of such a definition further complicates the matter in that a provider may have been present but the report does not say if that provider was a certified creative arts therapist, another health care professional, or an artist volunteer. Furthermore, the authors did not provide information on which of the included studies were categorized as “therapist present” or “no therapist present.” This lack of transparency, in combination with the apparent definitional contradictions within the review, renders the findings based on that categorization potentially meaningless. We are excited to see yet another systematic review confirm the health benefits of arts interventions in cancer patients. We hope that this rapidly expanding evidence will inspire cancer patients to include the arts and/or CATs in their treatment regimen so that their psychosocial well-being can be safeguarded during the challenging treatment and recovery period. We recommend that future research teams conducting systematic reviews of CATs include a CAT specialist to improve construct validity and ensure that included studies have proper adherence to professional standards for the provision of CAT services. When systematic reviews include CATs and arts interventions delivered by non-CAT providers, the 2 forms of intervention must be clearly defined and categorized. This step will yield meaningful results that can better inform programming in health care environments. Back to top Article Information Correspondence: Dr Bradt, Department of Creative Arts Therapies, College of Nursing and Health Professions, Drexel University, Bellet Bldg, Room 1041, 1505 Race St, Philadelphia, PA 19102 ([email protected]). Published Online: May 13, 2013. doi:10.1001/jamainternmed.2013.6145 Conflict of Interest Disclosures: None reported. References 1. Norton TR, Manne SL, Rubin S, et al. Prevalence and predictors of psychological distress among women with ovarian cancer. J Clin Oncol. 2004;22(5):919-92614990648PubMedGoogle ScholarCrossref 2. Massie MJ. Prevalence of depression in patients with cancer. J Natl Cancer Inst Monogr. 2004;32(32):57-7115263042PubMedGoogle ScholarCrossref 3. Puetz TW, Morley CA, Herring MP. Effects of creative arts therapies on psychological symptoms and quality of life in patients with cancer [published online May 13, 2013]. JAMA Intern Med. 2013;173(11):960-969Google Scholar 4. American Art Therapy Association. American Art Therapy Association home page. http://www.arttherapy.org/. Accessed February 18, 2013 5. American Dance Therapy Association. American Dance Therapy Association home page. http://www.adta.org/. Accessed February 18, 2013 6. American Music Therapy Association. American Music Therapy Association home page. http://www.musictherapy.org. Accessed February 18, 2013 7. American Society of Group Psychotherapy and Psychodrama. American Society of Group Psychotherapy and Psychodrama home page. http://www.asgpp.org/. Accessed February 18, 2013 8. National Association for Poetry Therapy. National Association for Poetry Therapy home page. http://www.poetrytherapy.org/. Accessed February 18, 2013 9. North American Drama Therapy Association. North American Drama Therapy Association. http://www.nadt.org/. Accessed February 18, 2013