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In This Issue of Archives of Internal Medicine |

In This Issue of Archives of Internal Medicine FREE

Arch Intern Med. 2004;164(7):696. doi:10.1001/archinte.164.7.696.
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The results of this population-based community study reveal marked decreases in length of stay for patients hospitalized with acute myocardial infarction over the last decade. Mean length of stay has decreased significantly from approximately 12 days in 1986-1988 to 6 days in 1997-1999. During this period, there was a 10-fold increase in the proportion of patients discharged home in less than 6 days. Even after adjusting for study year, age, comorbidities, myocardial infarction complications, and other potential prognostic confounders, no association between decreased length of stay and increased postdischarge mortality was observed.

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Appropriate management of dyslipidemia can significantly reduce cardiovascular morbidity and mortality. Niacin is unique in that it improves all lipoprotein abnormalities. It significantly reduces low-density lipoprotein cholesterol, triglycerides and lipoprotein(a) levels, while increasing high-density lipoprotein cholesterol level, making it ideal for a variety of dyslipidemias. Niacin may be used alone or in combination to improve lipid profile and reduce clinical events; however, tolerability issues have limited its wider use. Niacin is available in 3 formulations (immediate release, extended release, and long acting), and adverse effects are directly related to the specific formulation. This article reviews the use of niacin in a variety of dyslipidemias, the available niacin formulations, and provides guidance for improving patient tolerance and adherence.

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A systematic review by Schroeder et al of interventions to improve adherence to blood pressure–lowering medication concluded that simplification of dosing regimens appears to be effective in improving adherence and should be used as a first-line strategy, although there was little evidence of an effect on blood pressure. The evidence for motivational and more complex interventions was mixed. This review included 38 randomized controlled trials evaluating 58 different interventions. Included trials were heterogeneous and often of poor methodological quality, and more evidence from carefully designed randomized trials is needed.

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In a large, nationally representative sample of US short-stay, general hospital admissions, Smothers et al administered a survey interview that yielded a DSM-IV diagnosis of alcohol use disorder; 24% of current-drinking admissions qualified for the diagnosis. The authors then estimated the extent to which hospital records documented detection of alcohol abuse or dependence and other alcohol-related problems in admissions receiving an interview-based diagnosis. Smothers et al also estimated rates of inpatient alcohol intervention and referral for treatment. Record-documented diagnoses of alcohol-related problems were found in 40% to 42% of interview-diagnosed admissions. Inpatient intervention rate was estimated at 21% for interview-diagnosed admissions and treatment referral rate at 24%. These rates suggest that alcohol use disorder in inpatient general hospital admissions is underrecognized and undertreated.

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Preventable adverse drug events (ADEs), or medication errors leading to patient harm, frequently occur at the prescribing stage and are the most common cause of injury to hospitalized patients. The Institute of Medicine recommends that health care organizations implement proven medication safety processes, including computerized prescriber order entry (CPOE), to decrease medication errors and improve health care in America. In this study, Bobb et al found that prescribing errors, identified and averted by clinical staff pharmacists, are indeed common. The overall rate was 62.4 errors per 1000 medication orders, with about one third of errors potentially leading to patient harm had they not been changed by a pharmacist. Prescribing errors were rated by study investigators as preventable with CPOE 65% of the time overall, but only 30% of the time for those errors rated as potentially harmful. Many organizations are currently implementing these complex and expensive CPOE systems. Focusing decision support on prescribing errors with the greatest potential for patient harm and continued pharmacist involvement in the medication use process are vital for achieving maximum medication safety.

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