In This Issue of Archives of Internal Medicine FREE

Of 4252 patients included in an 18-hospital multicenter prevalence study, 429 had nosocomial infection (10.1%). When patients from small, intermediate, and large hospitals were grouped for analysis, prevalence was 6.1%, 10.0%, and 10.9%, respectively (P<.001). Only adjustment for risk factors for nosocomial infection and comorbidity revealed that the relatively high nosocomial infection rates of larger institutions were related to unfavorable case-mix rather than to bed size. Unadjusted rates may lead to erroneous assumptions for health care prioritization.

Despite declines in blood lead levels over the past 20 years, lead exposure continues to be a public health concern. Studies have linked lead exposure with increased risk of diverse health outcomes. To evaluate the association of lead exposure and mortality in the United States, Lustberg and Silbergeld used the recently released mortality follow-up data for participants of the Second National Health and Nutrition Examination Survey, conducted from 1976 to 1980. After adjustment for potential confounders, individuals with blood lead levels of 20 to 29 µg/dL (15% of the adult population at the time) had 46% increased all-cause mortality (rate ratio [RR], 1.46; 95% confidence interval [CI], 1.14-1.86), 39% increased circulatory mortality (RR, 1.39; 95% CI, 1.01-1.91), and 68% increased cancer mortality (RR, 1.68; 95% CI, 1.02-2.78) compared with those with blood lead levels less than 10 µg/dL. In light of this finding, the authors strongly encourage efforts at lead abatement for the 1.7 million people in the United States with blood lead levels of 20 µg/dL or greater.

To evaluate the course of asthma during travel and identify travelers at risk for exacerbation, Golan et al prospectively evaluated 203 travelers with asthma using interviews, exercise testing, and spirometry. Asthma was frequently exacerbated during travel, with attacks reported by 43% of travelers, overall disease worsening by 20%, worse attacks ever by 18%, and life-threatening attacks by 5%. Demographics and allergy characteristics failed to predict an exacerbation, whereas frequent use of inhaled bronchodilators before travel and trekking during travel independently predicted attacks. These findings suggest that asthma is an important health problem that should not be ignored when providing pretravel consultation. Intensification of therapy and modification of travel plans are required to prevent asthma exacerbation during travel.

Obesity is a significant risk factor for diabetes and cardiovascular disease. Moderate weight reduction of 5% to 10% has been shown to improve cardiovascular risk profiles. Orlistat has been prescribed to promote weight loss, usually in conjunction with intense lifestyle modification and hypocaloric diet. It is not clear whether orlistat alone can cause significant weight reduction and hence improve insulin sensitivity and cardiovascular risk factors in patients with or without type 2 diabetes. A 6-month orlistat treatment without concomitant hypocaloric diet reduced body weight by about 3% to 5% in all subjects. Orlistat intervention significantly improved glycemic control, insulin sensitivity, and other cardiovascular risk factors. These results support the use of orlistat as an adjunct for management of obese subjects with or without diabetes.

Law and colleagues present estimates of the underlying risk of death after having had a myocardial infarction in the absence of treatment. These were determined from an analysis of 23 published studies (14 211 patients; 6676 deaths) conducted before 1980 (before modern effective treatments were available). Mortality after an infarct in the absence of treatment is high—5% a year after a first infarct and 10% a year after a subsequent infarct, persisting for many years and probably for the rest of a person's life. Identifying everyone who has had an infarct, even years previously, and ensuring that they receive effective preventive treatment, should be regarded as a medical priority.