In This Issue of Archives of Internal Medicine FREE

Within the last several years, public reporting of standardized measures of hospital quality has become an important component of quality improvement activities at national and local levels. Landon et al linked performance data submitted to either the Hospital Quality Alliance or the Joint Commission on Accreditation of Healthcare Organizations for the first half of 2004 to American Hospital Association data on hospital characteristics and examined the associations between hospital characteristics and quality care. Patients are more likely to receive high-quality care in not-for-profit hospitals and hospitals with high registered nurse staffing ratios and more investment in technology.

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Elevated cardiac troponin levels are frequently observed among critically ill patients in the intensive care unit (ICU), but the interpretation and clinical significance of this finding is uncertain. In this systematic review, Lim et al evaluated 23 observational studies involving 4492 critically ill patients. Among those studies reporting the frequency of elevated troponin level, a median of 43% of critically ill patients had an elevated troponin measurement during their ICU stay. An elevated troponin measurement was associated with an increased risk of death in an adjusted analysis, with an odds ratio of 2.5 (95% confidence interval [CI], 1.9-3.4). Elevated troponin level was also associated with an increased length of ICU stay of 3.0 days (95% CI, 1.0-5.1 days). These findings suggest that elevated troponin level is common among critically ill patient and contributes to increased morbidity and mortality.

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Bone loss often accompanies weight loss induced by caloric restriction (CR), but whether bone loss accompanies similar weight loss induced by exercise is unknown. Forty-eight adults were randomly assigned to 1 of 3 groups: CR, regular exercise (EX), or healthy lifestyle control (HL). After 1 year, body weight decreased by approximately 9% in the CR and EX groups, whereas body weight did not change in the HL group. The decrease in body weight in the CR group was accompanied by significant decreases in bone mineral density (BMD) at the lumbar spine, total hip, intertrochanter, and femoral neck regions. The changes in BMD at the total hip and intertrochanter were significantly different from the corresponding changes in the HL group. Despite weight loss, the EX group did not demonstrate a decrease in BMD at any site. These data suggest that EX should be an important component of a weight-loss program to offset adverse effects of CR on bone.

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C-reactive protein (CRP) is a sensitive marker of inflammation in a variety of diseases, particularly in rheumatoid arthritis (RA). This study examines whether CRP levels are associated with increased risk of developing RA in healthy women. Study participants were from the Women's Health Study, a completed randomized trial of aspirin and vitamin E in cardiovascular disease and cancer prevention, begun in 1992. After 9.9 years of follow-up, 398 women reported a new diagnosis of RA, of which 90 cases were confirmed. In analyses adjusting for the risk factors, age, body mass index, and smoking, there was no increased risk of developing RA when measuring CRP at a single point in time. On whether CRP levels predicted incident RA within 4, from 5 to 8, or more than 9 years of CRP measurement, no significant associations for any period were found. In conclusion, a single CRP level did not predict increased risk of RA. Furthermore, CRP measurement closer to the time of diagnosis was not predictive. The consistency of this effect throughout different periods from diagnosis suggests that CRP does not have a large effect in predicting incident RA.

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This prospective cohort study including a large number of patients with stable coronary heart disease demonstrates that increased N-terminal pro–B-natriuretic peptide (NT-proBNP) levels are strongly and independently associated with recurrent cardiovascular disease events and show a superior predictive utility when directly compared with markers of renal function and inflammation.

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