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In This Issue of Archives of Internal Medicine |

In This Issue of Archives of Internal Medicine FREE

Arch Intern Med. 2012;172(1):9. doi:10.1001/archinternmed.2011.608.
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COGNITIVE BEHAVIOR THERAPY, EXERCISE, OR BOTH FOR TREATING CHRONIC WIDESPREAD PAIN

Physical exercise and psychological therapies are recommended treatments for primary care patients with chronic widespread pain. In a randomized controlled trial, McBeth et al evaluated the efficacy of graded physical exercise, telephone-delivered cognitive behavioral therapy, or both interventions in predicting improvements in global health. Single interventions significantly improved outcome in up to 35% of patients. Receiving both interventions was associated with a small, but not substantially better, improvement in outcome compared with single interventions. Study results suggest significant improvements in outcome can be achieved.

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OVERTREATMENT OF ENTEROCOCCAL BACTERIURIA

Despite the propensity of Enterococcus to infect the urinary tract, little is known about how health care providers manage enterococci in the urine and the clinical outcomes of enterococcal bacteriuria. This retrospective study reviewed 339 episodes of enterococcal bacteriuria at 2 different hospitals. The current Infectious Diseases Society of America guidelines were applied to determine if episodes represented symptomatic urinary tract infection or asymptomatic bacteriuria and whether antibiotics were indicated or not. Health care providers inappropriately prescribed antibiotics in 33% of asymptomatic episodes and were 3.3 times (95% CI, 1.49-7.18 times) more likely to do so when pyuria was present. At the same time, subsequent distant infection with Enterococcus occurred in only 2% of all episodes of bacteriuria and after only 1% of asymptomatic episodes. Given the low incidence of infectious complications, efforts should be made to reduce the use of antibiotics for asymptomatic enteroccocal bacteriuria.

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MODEST PUBLIC HEALTH IMPACT OF NONTARGETED HUMAN IMMUNODEFICIENCY VIRUS SCREENING IN 29 EMERGENCY DEPARTMENTS

This study assessed the public health impact of nontargeted human immunodeficiency virus (HIV)–rapid test (RT) screening among emergency department (ED) patients in the metropolitan Paris region (11.7 million inhabitants), where half of France's new HIV cases are diagnosed annually. In 29 EDs HIV-RTs were performed on a 24-hour basis during a randomly assigned 6-week period for each ED; 12 754 patients were tested. Nontargeted screening identified only 18 new HIV diagnoses (0.14%; 95% CI, 0.08%-0.22%), often already at late stages, and most newly diagnosed patients belonged to a high-risk group. These results do not support the implementation of nontargeted HIV screening of the general population in EDs.

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BLOOD PRESSURE COMPONENTS AND END-STAGE RENAL DISEASE IN PERSONS WITH CHRONIC KIDNEY DISEASE

In this study, Peralta et al evaluated the association of blood pressure (BP) levels with risk for progression to end-stage renal disease (ESRD) among 16 000 persons with chronic kidney disease (CKD) participating in the Kidney Early Evaluation Program (KEEP). Higher systolic BP (SBP) was associated with higher ESRD risk, starting at SBP of 140 mm Hg or higher, and this risk was highest among persons with SBP of 150 mm Hg or higher compared with SBP of 130 mm Hg. Persons with SBP of 130 to 139 mm Hg had risk similar to persons with SBP lower than 130 mm Hg. Diastolic BP (DBP) of 90 mm Hg or higher was associated with higher ESRD risk compared with DBP of 60 to 74 mm Hg. More than 33% of participants had SBP of 150 mm Hg or higher or DBP of 90 mm Hg or higher, and this was mostly due to isolated systolic hypertension. The authors suggest that efforts to control BP among persons with CKD should focus on lowering SBP.

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PATIENT-CENTERED MEDICAL HOME CHARACTERISTICS AND STAFF MORALE IN SAFETY NET CLINICS

How does the patient-centered medical home (PCMH) affect health care provider and staff morale, satisfaction, and burnout? This study surveyed 391 health care providers and 382 clinical staff members in 65 safety net clinics across 5 states beginning to adopt the PCMH model. Respondents were asked about their perceptions of current PCMH characteristics in their own clinic as well as their morale, satisfaction, and burnout. Characteristics of PCMHs were combined into 5 separate domains (access and communication with patients, communication with other providers, tracking data, care management, and quality improvement) as well as a total PCMH score. Health care providers and staff who perceived more PCMH characteristics in their clinics were more likely to have higher morale but less provider freedom from burnout. Among the PCMH domains, quality improvement was particularly correlated with higher morale and satisfaction and lower burnout.

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Correlation of work environment score with PCMH scores at 65 clinics (work environment score vs quality improvement subscale score [r = 0.78]).

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Correlation of work environment score with PCMH scores at 65 clinics (work environment score vs quality improvement subscale score [r = 0.78]).

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