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In This Issue of Archives of Internal Medicine |

In This Issue of Archives of Internal Medicine FREE

Arch Intern Med. 2001;161(15):1809. doi:10.1001/archinte.161.15.1809.
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Despite a reduction in some low-yield diagnostic test usage (eg, neurologic testing) examined between 1994 and 1998, Pires et al show the approach to patients with syncope, including using specialty evaluations, had not changed much.

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Patients with congestive heart failure (CHF) may often have depression; this may confer worse outcomes. Jiang et al looked at incidence and outcomes of depression in hospitalized class II CHF patients. Of 374 patients screened, 13.9% had major depressive disorder; 16.5%, mild depression. Overall mortality was 7.9% at 3 months and 16.2% at 1 year. Major depression was associated with increased mortality at 3 months (OR, 2.5 vs no depression; P = .079) and 1 year (OR, 2.23; P = .038) and readmission at 3 months (OR, 1.90; P = .043) and 1 year (OR, 3.07; P = .005), independent of baseline risk factors. Major depression is common in hospitalized CHF patients and independently predicts a poor prognosis.

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By factor analysis of dietary information from the 1984 Nurses' Health Study food frequency questionnaire, Fung et al identified the "prudent" dietary pattern (PP), characterized by higher intakes of vegetables, poultry, and whole grains; and the "Western" pattern (WP), higher intakes of red meats, sweets and desserts, and refined grains. Women with higher PP scores smoked less, used more vitamin supplements, and drank more alcohol, the opposite of the WP women. Of 74 209 women followed up for 12 years, those without diagnosed cardiovascular disease, cancer, diabetes, or high cholesterol levels, 893 new cases of coronary heart disease (CHD) (259 fatal cardiac events, 634 nonfatal myocardial infarcts) were noted. Adjusting for age, smoking, and other CHD risk factors, those with top quintile PP scores had a relative risk (RR) of 0.65 (95% CI = 0.52-0.82) for CHD compared with those at the bottom quintile, ie, WP score group (RR, 1.45 [95% CI = 1.08-1.95]). Data results from the stratified analyses by body mass index, smoking status, and family history of CHD consistently showed that overall dietary patterns defined by factor analysis predict future risk of CHD in women.

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Erlinger et al found a strong inverse association of serum β-carotene with inflammation markers (C-reactive protein and white blood cell count) in never smokers, ex-smokers, and current smokers, suggesting that the relationship between serum β-carotene and disease risk may be confounded by inflammation. It provides a basis for reinterpreting previous findings of an association between low serum β-carotene levels and increased disease risk. For β-carotene and other nutrient levels, it seems unwise to interpret biomarker data as prima facie evidence of dietary intake without a fuller understanding of the physiologic processes involved.

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An 18-week one-on-one randomized trial was conducted to reduce excessive use of broad-spectrum antibiotics (BSAs). Done at a teaching hospital on the medical, oncology, and cardiology services, all orders for levofloxacin and ceftazidime were reviewed using a priori criteria. Those deemed probably unnecessary were flagged for inclusion. Intervention services physicians writing orders for BSAs got one-on-one education using standard scripts and materials. Over the 18 weeks, the likely unnecessary orders for the study drugs fell on the intervention but rose on the control services. There was no appreciable rise in length of stay, ICU transfers, readmission rates, or mortality. Academic detailing programs can be a practical means for improving BSA prescribing and quality in acute care settings.

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In a 1990s cohort of 19 501 subjects starting hypertension therapy in Saskatchewan, Canada, β-blockers were less commonly dispensed than angiotensin-converting enzyme inhibitors or calcium antagonists, particularly among younger patients, females, or diabetics. Patients seen by a cardiologist were more likely to be given antihypertensive therapy with a calcium antagonist. By the first year's end, two thirds of patients had stopped the initial drug regimen; during 7 years' follow-up, 89% of subjects underwent at least 1 therapeutic modification, not including dose adjustments. Such erratic drug use behaviors may lead to significant suboptimal hypertension control at the population level.

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