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Breastfeeding and allergies: time for a change in paradigm?.

Page: 539DOI: 10.1097/MCI.0b013e32831dae43Authors: Duncan, Joanne M; Sears, Malcolm R

New aspects in allergic contact dermatitis.

Page: 547DOI: 10.1097/MCI.0b013e32831dae50Authors: Mortz, Charlotte Gotthard; Andersen, Klaus Ejner

Contemporary approaches to the identification of athletes at risk for sudden cardiac death.

Page: 552DOI: 10.1097/MCI.0b013e32831daee4Authors: Drezner, Jonathan A

How to break the vicious circle of antibiotic resistances?.

Page: 560DOI: 10.1097/MCI.0b013e32831dabd1Authors: Leone, Marc; Martin, Claude

Benefits of high-protein weight loss diets: enough evidence for practice?.

Page: 566DOI: 10.1097/MCI.0b013e32831daebdAuthors: Brehm, Bonnie J a; D'Alessio, David A b

Chronic pancreatitis.

Page: 572DOI: 10.1097/MCI.0b013e32831daddaAuthors: Conwell, Darwin L; Banks, Peter A

Heparin-induced thrombocytopenia: some working hypotheses on pathogenesis, diagnostic strategies and treatment.

Page: 577DOI: 10.1097/MCI.0b013e32831dae94Authors: Alberio, Lorenzo

Long-term prognosis after deep venous thrombosis.

Page: 586DOI: 10.1097/MCI.0b013e32831daea9Authors: Shbaklo, Hadia a; Kahn, Susan R a,b

New advances in Clostridium difficile infection: changing epidemiology, diagnosis, treatment and control.

Page: 591DOI: 10.1097/MCI.0b013e32831daed2Authors: DuPont, Herbert L a,b,c; Garey, Kevin b,c,d; Caeiro, Juan-Pablo b,c; Jiang, Zhi-Dong a

Elevations in serum creatinine with RAAS blockade: why isn't it a sign of kidney injury?.

Page: 599DOI: 10.1097/MCI.0b013e32831daeffAuthors: Ryan, Michael J a; Tuttle, Katherine R a,b

Renin inhibition: should it supplant ACE inhibitors and ARBS in high risk patients?.

Page: 606DOI: 10.1097/MCI.0b013e32831daf11Authors: Gaddam, Krishna K; Oparil, Suzanne

Diabetic polyneuropathy: an update.

Page: 613DOI: 10.1097/MCI.0b013e32831dae0bAuthors: Zochodne, Douglas W

Drug-induced myopathies.

Page: 620DOI: 10.1097/MCI.0b013e32831dae1cAuthors: Klopstock, Thomas

Evolving epidemiology of malignancies in HIV.

Page: 626DOI: 10.1097/MCI.0b013e32831dae71Authors: Bonnet, Fabrice a,b,c; Chene, Genevieve a,b

Vaccines against cervical cancer.

Page: 633DOI: 10.1097/MCI.0b013e32831dae88Authors: Rogers, Linda J; Eva, Lois J; Luesley, David Michael

Effectiveness and cost effectiveness of thrombolysis in patients with acute pulmonary embolism.

Page: 638DOI: 10.1097/MCI.0b013e32831dad76Authors: Zamanian, Roham T a,b; Gould, Michael K a,c

Update on biologics in juvenile idiopathic arthritis.

Page: 643DOI: 10.1097/MCI.0b013e32831dae32Authors: Ilowite, Norman T

Correction: probiotics for ulcerative colitis.

Correction: probiotics for ulcerative colitis. Ann Intern Med. 2010 Feb 2;152(3):200 Authors: PMID: 20124250 [PubMed - in process]

Correction: screening for breast cancer.

Correction: screening for breast cancer. Ann Intern Med. 2010 Feb 2;152(3):199-200 Authors: PMID: 20124249 [PubMed - in process]

Stent placement in patients with atherosclerotic renal artery stenosis and impaired renal function.

Stent placement in patients with atherosclerotic renal artery stenosis and impaired renal function. Ann Intern Med. 2010 Feb 2;152(3):198 Authors: Bax L, Mali WP, Beutler JJ PMID: 20124248 [PubMed - in process]

Colored sweat caused by pseudochromhidrosis.

Colored sweat caused by pseudochromhidrosis. Ann Intern Med. 2010 Feb 2;152(3):198-9 Authors: Panagoulias GS, St Basagiannis C, Tentolouris N, Stavropoulou E, Karnesis L PMID: 20124247 [PubMed - in process]

Stent placement in patients with atherosclerotic renal artery stenosis and impaired renal function.

Stent placement in patients with atherosclerotic renal artery stenosis and impaired renal function. Ann Intern Med. 2010 Feb 2;152(3):197 Authors: Mann SJ, Sos TA PMID: 20124246 [PubMed - in process]

Stent placement in patients with atherosclerotic renal artery stenosis and impaired renal function.

Stent placement in patients with atherosclerotic renal artery stenosis and impaired renal function. Ann Intern Med. 2010 Feb 2;152(3):197-8 Authors: Jovin IS, Topaz O PMID: 20124245 [PubMed - in process]

Reclassification Calculations for Persons With Incomplete Follow-up.

Reclassification Calculations for Persons With Incomplete Follow-up. Ann Intern Med. 2010 Feb 2;152(3):196-7 Authors: Cook NR, Ridker PM PMID: 20124244 [PubMed - in process]

Reclassification Calculations for Persons With Incomplete Follow-up.

Reclassification Calculations for Persons With Incomplete Follow-up. Ann Intern Med. 2010 Feb 2;152(3):195-6 Authors: Steyerberg EW, Pencina MJ PMID: 20124243 [PubMed - in process]

Determining the benefits of the new york city trans fat ban.

Determining the benefits of the new york city trans fat ban. Ann Intern Med. 2010 Feb 2;152(3):194 Authors: Ross GL PMID: 20124242 [PubMed - in process]

Determining the benefits of the new york city trans fat ban.

Determining the benefits of the new york city trans fat ban. Ann Intern Med. 2010 Feb 2;152(3):194 Authors: Satin M PMID: 20124241 [PubMed - in process]

Determining the benefits of the new york city trans fat ban.

Determining the benefits of the new york city trans fat ban. Ann Intern Med. 2010 Feb 2;152(3):194-5 Authors: Angell SY, Silver LD, Goldstein GP PMID: 20124240 [PubMed - in process]

Quite by chance.

Quite by chance. Ann Intern Med. 2010 Feb 2;152(3):192-3 Authors: Stillman M PMID: 20124239 [PubMed - in process]

Southern hospitality.

Southern hospitality. Ann Intern Med. 2010 Feb 2;152(3):190-1 Authors: Manning KD PMID: 20124238 [PubMed - in process]

Intravenous immunoglobulin to fight complex regional pain syndromes: hopes and doubts.

Intravenous immunoglobulin to fight complex regional pain syndromes: hopes and doubts. Ann Intern Med. 2010 Feb 2;152(3):188-9 Authors: Birklein F, Sommer C PMID: 20124237 [PubMed - in process]

Asymptomatic Postoperative Pericardial Effusions: Against the Routine Use of Anti-inflammatory Drug Therapy.

Asymptomatic Postoperative Pericardial Effusions: Against the Routine Use of Anti-inflammatory Drug Therapy. Ann Intern Med. 2010 Feb 2;152(3):186-7 Authors: Imazio M PMID: 20124236 [PubMed - in process]

Lessons That Patient-Centered Medical Homes Can Learn From the Mistakes of HMOs.

Lessons That Patient-Centered Medical Homes Can Learn From the Mistakes of HMOs. Ann Intern Med. 2010 Feb 2;152(3):182-5 Authors: Mirabito AM, Berry LL Patient-centered medical homes (PCMHs) have been endorsed by primary and specialty care medical associations, payers, and patient groups as an innovative structure for transforming health care delivery. The cornerstone principle of the PCMH is the primary care physician's coordination of a patient's use of health care services, including visits to specialists, to improve effectiveness and efficiency. This principle aligns with the vision behind the creation of HMOs, managed care organizations that were once embraced by physicians, patients, and policy analysts but have since lost much of their luster. Many patients and physicians rejected HMOs as too restrictive, objecting particularly to the concept of gatekeeping. This article reviews the HMO experience and identifies lessons applicable to PCMHs that build on the strengths of HMOs while avoiding their mistakes. PMID: 20124235 [PubMed - in process]

Is computed tomographic colonography being held to a higher standard?

Is computed tomographic colonography being held to a higher standard? Ann Intern Med. 2010 Feb 2;152(3):178-81 Authors: Garg S, Ahnen DJ Recent guidelines for colorectal cancer screening have reached different conclusions on whether computed tomographic colonography (CTC) is an acceptable screening option, and the Centers for Medicare & Medicaid Services recently decided not to cover CTC screening. The rationale against recommending or covering CTC screening includes concerns about radiation exposure, false-negative rates for small polyps, the discovery of extracolonic findings, variability in performance, a lack of targeted studies, a higher adenoma rate in the Medicare-eligible age group, and an absence of evidence that covering CTC would increase overall screening rates. Similar concerns can be raised for other recommended and covered colon cancer screening tests, but it seems that CTC is being held to a new and higher standard. PMID: 20124234 [PubMed - in process]

Meta-analysis: Noninvasive Coronary Angiography Using Computed Tomography Versus Magnetic Resonance Imaging.

Meta-analysis: Noninvasive Coronary Angiography Using Computed Tomography Versus Magnetic Resonance Imaging. Ann Intern Med. 2010 Feb 2;152(3):167-77 Authors: Schuetz GM, Zacharopoulou NM, Schlattmann P, Dewey M Background: Two imaging techniques, multislice computed tomography (CT) and magnetic resonance imaging (MRI), have evolved for noninvasive coronary angiography. Purpose: To compare CT and MRI for ruling out clinically significant coronary artery disease (CAD) in adults with suspected or known CAD. Data Sources: MEDLINE, EMBASE, and ISI Web of Science searches from inception through 2 June 2009 and bibliographies of reviews. Study Selection: Prospective English- or German-language studies that compared CT or MRI with conventional coronary angiography in all patients and included sufficient data for compilation of 2 x 2 tables. Data Extraction: 2 investigators independently extracted patient and study characteristics; differences were resolved by consensus. Data Synthesis: 89 and 20 studies (comprising 7516 and 989 patients) assessed CT and MRI, respectively. Bivariate analysis of data yielded a mean sensitivity and specificity of 97.2% (95% CI, 96.2% to 98.0%) and 87.4% (CI, 84.5% to 89.8%) for CT and 87.1% (CI, 83.0% to 90.3%) and 70.3% (CI, 58.8% to 79.7%) for MRI. In studies that included only patients with suspected CAD, sensitivity and specificity of CT were 97.6% (CI, 96.1% to 98.5%) and 89.2% (CI, 86.0% to 91.8%). Covariate analysis yielded a significantly higher sensitivity for CT scanners with more than 16 rows (98.1% [CI, 97.0% to 99.0%]; P < 0.050) than for older-generation scanners (95.6% [CI, 94.0% to 97.0%]). Heart rates less than 60 beats/min during CT yielded significantly better values for sensitivity than did higher heart rates (P < 0.001). Limitations: Few studies investigated coronary angiography with MRI. Only 5 studies were direct head-to-head comparisons of CT and MRI. Covariate analyses explained only part of the observed heterogeneity. Conclusion: For ruling out CAD, CT is more accurate than MRI. Scanners with more than 16 rows improve sensitivity, as do slowed heart rates. Primary Funding Source: None. PMID: 20124233 [PubMed - in process]

Narrative review: fibrotic diseases: cellular and molecular mechanisms and novel therapies.

Narrative review: fibrotic diseases: cellular and molecular mechanisms and novel therapies. Ann Intern Med. 2010 Feb 2;152(3):159-66 Authors: Rosenbloom J, Castro SV, Jimenez SA Abnormal and exaggerated deposition of extracellular matrix is the hallmark of many fibrotic diseases, including systemic sclerosis and pulmonary, liver, and kidney fibrosis. The spectrum of affected organs, the usually progressive nature of the fibrotic process, the large number of affected persons, and the absence of effective treatment pose an enormous challenge when treating fibrotic diseases. Delineation of the central role of transforming growth factor-beta (TGF-beta) and identification of the specific cellular receptors, kinases, and other mediators involved in the fibrotic process have provided a sound basis for development of effective therapies. The inhibition of signaling pathways activated by TGF-beta represents a novel therapeutic approach for the fibrotic disorders. One of these TGF-beta pathways results in the activation of the nonreceptor tyrosine kinase cellular Abelson (c-Abl), and c-Abl inhibitors, including imatinib mesylate, diminishing the fibrogenic effects of TGF-beta. Thus, recently acquired basic knowledge about the pathogenesis of the fibrotic process has enabled the development of novel therapeutic agents capable of modifying the deleterious effects of the fibrotic diseases. PMID: 20124232 [PubMed - in process]

Intravenous immunoglobulin treatment of the complex regional pain syndrome: a randomized trial.

Intravenous immunoglobulin treatment of the complex regional pain syndrome: a randomized trial. Ann Intern Med. 2010 Feb 2;152(3):152-8 Authors: Goebel A, Baranowski A, Maurer K, Ghiai A, McCabe C, Ambler G Background: Treatment of long-standing complex regional pain syndrome (CRPS) is empirical and often of limited efficacy. Preliminary data suggest that the immune system is involved in sustaining this condition and that treatment with low-dose intravenous immunoglobulin (IVIG) may substantially reduce pain in some patients. Objective: To evaluate the efficacy of IVIG in patients with longstanding CRPS under randomized, controlled conditions. Design: A randomized, double-blind, placebo-controlled crossover trial. (National Research Registry number: N0263177713; International Standard Randomised Controlled Trial Number Registry: 63918259) Setting: University College London Hospitals Pain Management Centre. Patients: Persons who had pain intensity greater than 4 on an 11-point (0 to 10) numerical rating scale and had CRPS for 6 to 30 months that was refractory to standard treatment. Intervention: IVIG, 0.5 g/kg, and normal saline in separate treatments, divided by a washout period of at least 28 days. Measurements: The primary outcome was pain intensity 6 to 19 days after the initial treatment and the crossover treatment. Results: 13 eligible participants were randomly assigned between November 2005 and May 2008; 12 completed the trial. The average pain intensity was 1.55 units lower after IVIG treatment than after saline (95% CI, 1.29 to 1.82; P < 0.001). In 3 patients, pain intensity after IVIG was less than after saline by 50% or more. No serious adverse reactions were reported. Limitation: The trial was small, and recruitment bias and chance variation could have influenced results and their interpretation. Conclusion: IVIG, 0.5 g/kg, can reduce pain in refractory CRPS. Studies are required to determine the best immunoglobulin dose, the duration of effect, and when repeated treatments are needed. Primary Funding Source: Association of Anaesthetists of Great Britain and Ireland, University College London Hospitals Charity, and CSL-Behring. PMID: 20124231 [PubMed - in process]

Effectiveness of extended-duration transdermal nicotine therapy: a randomized trial.

Effectiveness of extended-duration transdermal nicotine therapy: a randomized trial. Ann Intern Med. 2010 Feb 2;152(3):144-51 Authors: Schnoll RA, Patterson F, Wileyto EP, Heitjan DF, Shields AE, Asch DA, Lerman C Background: Tobacco dependence is a chronic, relapsing condition that may require extended treatment. Objective: To assess whether extended-duration transdermal nicotine therapy increases abstinence from tobacco more than standard-duration therapy in adult smokers. Design: Parallel randomized, placebo-controlled trial from September 2004 to February 2008. Participants and all research personnel except the database manager were blinded to randomization. (ClinicalTrials.gov registration number: NCT00364156) Setting: Academic center. Participants: 568 adult smokers. Intervention: In an unstratified small block-randomization scheme, participants were randomly assigned to standard therapy (Nicoderm CQ [GlaxoSmithKline, Research Triangle Park, North Carolina], 21 mg, for 8 weeks and placebo for 16 weeks) or extended therapy (Nicoderm CQ, 21 mg, for 24 weeks). Measurements: The primary outcome was biochemically confirmed point-prevalence abstinence at weeks 24 and 52. Secondary outcomes were continuous and prolonged abstinence, lapse and recovery events, cost per additional quitter, and side effects and adherence. Results: At week 24, extended therapy produced higher rates of point-prevalence abstinence (31.6% vs. 20.3%; odds ratio, 1.81 [95% CI, 1.23 to 2.66]; P = 0.002), prolonged abstinence (41.5% vs. 26.9%; odds ratio, 1.97 [CI, 1.38 to 2.82]; P = 0.001), and continuous abstinence (19.2% vs. 12.6%; odds ratio, 1.64 [CI, 1.04 to 2.60]; P = 0.032) versus standard therapy. Extended therapy reduced the risk for lapse (hazard ratio, 0.77 [CI, 0.63 to 0.95]; P = 0.013) and increased the chances of recovery from lapses (hazard ratio, 1.47 [CI, 1.17 to 1.84]; P = 0.001). Time to relapse was slower with extended versus standard therapy (hazard ratio, 0.50 [CI, 0.35 to 0.73]; P < 0.001). At week 52, extended therapy produced higher quit rates for prolonged abstinence only (P = 0.027). No differences in side effects and adverse events between groups were found at the extended-treatment assessment. Limitation: The generalizability of the findings may be limited because participants were smokers without medical comorbid conditions who were seeking treatment, and differences in adherence across treatment groups were detected. Conclusion: Transdermal nicotine for 24 weeks increased biochemically confirmed point-prevalence abstinence and continuous abstinence at week 24, reduced the risk for smoking lapses, and increased the likelihood of recovery to abstinence after a lapse compared with 8 weeks of transdermal nicotine therapy. Primary Funding Source: National Institutes of Health. PMID: 20124230 [PubMed - in process]

Nonsteroidal Anti-inflammatory Drug Treatment for Postoperative Pericardial Effusion: A Multicenter Randomized, Double-Blind Trial.

Nonsteroidal Anti-inflammatory Drug Treatment for Postoperative Pericardial Effusion: A Multicenter Randomized, Double-Blind Trial. Ann Intern Med. 2010 Feb 2;152(3):137-143 Authors: Meurin P, Tabet JY, Thabut G, Cristofini P, Farrokhi T, Fischbach M, Pierre B, Driss AB, Renaud N, Iliou MC, Weber H, Background: The incidence of asymptomatic pericardial effusion is high after cardiac surgery. Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely prescribed in this setting, but no study has assessed their efficacy. Objective: To assess whether the NSAID diclofenac is effective in reducing postoperative pericardial effusion volume. Design: Multicenter randomized, double-blind, placebo-controlled study. (Clinical trials.gov registration number: NCT00247052) Setting: 5 postoperative cardiac rehabilitation centers. Patients: 196 patients at high risk for tamponade because of moderate to large persistent pericardial effusion (grade 2, 3, or 4 on a scale of 0 to 4, as measured by echocardiography) more than 7 days after cardiac surgery. Intervention: Random assignment at each site in blocks of 4 to diclofenac, 50 mg, or placebo twice daily for 14 days. Measurements: The main end point was change in effusion grade after 14 days of treatment. Secondary end points included frequency of late cardiac tamponade. Results: The initial mean pericardial effusion grade was 2.58 (SD, 0.73) for the placebo group and 2.75 (SD, 0.81) for the diclofenac group. The 2 groups showed similar mean decreases from baseline after treatment (-1.08 grades [SD, 1.20] for the placebo group vs. -1.36 (SD, 1.25) for the diclofenac group). The mean difference between groups was -0.28 grade (95% CI, -0.63 to 0.06 grade; P = 0.105). Eleven cases of late cardiac tamponade occurred in the placebo group and 9 in the diclofenac group (P = 0.64). These differences persisted after adjustment for grade of pericardial effusion at baseline, treatment site, and type of surgery. Limitation: The sample was not large enough to find small beneficial effects of diclofenac or assess the cardiovascular tolerance of diclofenac. Conclusion: In patients with pericardial effusion after cardiac surgery, diclofenac neither reduced the size of the effusions nor prevented late cardiac tamponade. Primary Funding Source: French Society of Cardiology. PMID: 20124229 [PubMed - as supplied by publisher]

Gout.

Gout. Ann Intern Med. 2010 Feb 2;152(3):ITC21 Authors: Wilson JF This issue provides a clinical overview of gout focusing on prevention, diagnosis, treatment, practice improvement, and patient information. Readers can complete the accompanying CME quiz for 1.5 credits. Only ACP members and individual subscribers can access the electronic features of In the Clinic. Non-subscribers who wish to access this issue of In the Clinic can elect "Pay for View." Subscribers can receive 1.5 category 1 CME credits by completing the CME quiz that accompanies this issue of In the Clinic. The content of In the Clinic is drawn from the clinical information and education resources of the American College of Physicians (ACP), including PIER (Physicians' Information and Education Resource) and MKSAP (Medical Knowledge and Self Assessment Program). Annals of Internal Medicine editors develop In the Clinic from these primary sources in collaboration with the ACP's Medical Education and Publishing division and with assistance of science writers and physician writers. Editorial consultants from PIER and MKSAP provide expert review of the content. Readers who are interested in these primary resources for more detail can consult www.acponline.org, http://pier.acponline.org, and other resources referenced within each issue of In the Clinic. PMID: 20124228 [PubMed - in process]

Intravenous immunoglobulin treatment of the complex regional pain syndrome.

Intravenous immunoglobulin treatment of the complex regional pain syndrome. Ann Intern Med. 2010 Feb 2;152(3):I48 Authors: PMID: 20124227 [PubMed - in process]

Extended nicotine treatment for long-term smokers.

Extended nicotine treatment for long-term smokers. Ann Intern Med. 2010 Feb 2;152(3):I38 Authors: PMID: 20124226 [PubMed - in process]

Treating Postoperative Pericardial Effusion With Nonsteroidal Anti-inflammatory Drug Therapy.

Treating Postoperative Pericardial Effusion With Nonsteroidal Anti-inflammatory Drug Therapy. Ann Intern Med. 2010 Feb 2;152(3):I32 Authors: PMID: 20124225 [PubMed - in process]

About This Journal [About This Journal]

In This Issue of Archives of Internal Medicine [In This Issue of Archives of Internal Medicine]

Providing Patients With Global Cardiovascular Risk Information: Is Knowledge Power? [Editorial]

The Effect of Giving Global Coronary Risk Information to Adults: A Systematic Review [Review Article]

Background Global coronary heart disease (CHD) risk estimation (ie, a quantitative estimate of a patient's chances of CHD calculated by combining risk factors in an empirical equation) is recommended as a starting point for primary prevention efforts in all US adults. Whether it improves outcomes is currently unknown. Methods To assess the effect of providing global CHD risk information to adults, we performed a systematic evidence review. We searched MEDLINE for the years 1980 to 2008, Psych Info, CINAHL, and the Cochrane Database and included English-language articles that met prespecified inclusion criteria. Two reviewers independently reviewed titles, abstracts, and articles for inclusion and assessed study quality. Results We identified 20 articles, reporting on 18 unique fair or good quality studies (including 14 randomized controlled studies). These showed that global CHD risk information alone or with accompanying education increased the accuracy of perceived risk and probably increased intent to start therapy. Studies with repeated risk information or risk information and repeated doses of counseling showed small significant reductions in predicted CHD risk (absolute differences, –0.2% to –2% over 10 years in studies using risk estimates derived from Framingham equations). Studies providing global risk information at only 1 point in time seemed ineffective. Conclusions Global CHD risk information seems to improve the accuracy of risk perception and may increase intent to initiate CHD prevention among individuals at moderate to high risk. The effect of global risk presentation on more distal outcomes is less clear and seems to be related to the intensity of accompanying interventions.

Standard Care Impact on Effects of Highly Active Antiretroviral Therapy Adherence Interventions: A Meta-analysis of Randomized Controlled Trials [Review Article]

Background Poor adherence to medication limits the effectiveness of treatment for human immunodeficiency virus. Systematic reviews can identify practical and effective interventions. Meta-analyses that control for variability in standard care provided to control groups may produce more accurate estimates of intervention effects. Methods To examine whether viral load and adherence success rates could be accurately explained by the active content of highly active antiretroviral therapy (HAART) adherence interventions when controlling for variability in care delivered to controls, databases were searched for randomized controlled trials of HAART adherence interventions published from 1996 to January 2009. A total of 1342 records were retrieved, and 52 articles were examined in detail. Directly observed therapy and interventions targeting specific patient groups (ie, psychiatric or addicted patients, patients <18 years) were excluded, yielding a final sample of 31 trials. Two coders independently retrieved study details. Authors were contacted to complete missing data. Results Twenty studies were included in the analyses. The content of adherence care provided to control and intervention groups predicted viral load and adherence success rates in both conditions (P < .001 for all comparisons), with an estimated impact of optimal adherence care of 55 percentage points. After controlling for variability in care provided to controls, the capacity of the interventions accurately predicted viral load and adherence effect sizes (R2 = 0.78, P = .02; R2 = 0.28, P < .01). Although interventions were generally beneficial, their effectiveness reduced noticeably with increasing levels of standard care. Conclusions Intervention and control patients were exposed to effective adherence care. Future meta-analyses of (behavior change) interventions should control for variability in care delivered to active controls. Clinical practice may be best served by implementing current best practice.

The Course of Nonspecific Chest Pain in Primary Care: Symptom Persistence and Health Care Usage [Original Investigation]

Background Nonspecific chest pain is common in primary care, yet knowledge is sparse about its course and outcome and how they relate to optimum health care usage. We investigated the following observations: (1) many patients who present with nonspecific chest pain in primary care show symptom persistence for 6 months, (2) many patients with nonspecific chest pain showed signs of overinvestigation, and (3) many patients with chronic chest pain were referred to mental health specialists. Methods We conducted a prospective, general physician–based cohort study with 6-week and 6-month follow-ups in 74 primary care offices in Hessen, Germany. Of approximately 190 000 consecutive patients who visited their general physicians from October 1, 2005, to July 31, 2006, 807 patients with nonspecific chest pain were identified by an expert committee (delayed-type reference standard). The dropout rate was 2.7%. Main outcome measures were persistent chest pain at a 6-month follow-up visit and health care usage at 6 months. Results The rate of persistent chest pain was 55.5%. A total of 10.7% of patients had inappropriate health care usage, defined as 2 or more visits to a cardiologist or 3 or more cardiac diagnostic investigations. Most patients with persistent nonspecific chest pain were referred to a cardiologist, and less than 2% were referred to mental health specialists. Conclusions For most patients with nonspecific chest pain, standard medical care does not offer sufficient help for symptom relief. One-tenth of patients with persistent chest pain underwent additional diagnostic testing of no known clinical benefit. Psychological referrals were rarely given.

Acute Selenium Toxicity Associated With a Dietary Supplement [Original Investigation]

Background Selenium is an element necessary for normal cellular function, but it can have toxic effects at high doses. We investigated an outbreak of acute selenium poisoning. Methods A case was defined as the onset of symptoms of selenium toxicity in a person within 2 weeks after ingesting a dietary supplement manufactured by "Company A," purchased after January 1, 2008. We conducted case finding, administered initial and 90-day follow-up questionnaires to affected persons, and obtained laboratory data where available. Results The source of the outbreak was identified as a liquid dietary supplement that contained 200 times the labeled concentration of selenium. Of 201 cases identified in 10 states, 1 person was hospitalized. The median estimated dose of selenium consumed was 41 749 µg/d (recommended dietary allowance is 55 µg/d). Frequently reported symptoms included diarrhea (78%), fatigue (75%), hair loss (72%), joint pain (70%), nail discoloration or brittleness (61%), and nausea (58%). Symptoms persisting 90 days or longer included fingernail discoloration and loss (52%), fatigue (35%), and hair loss (29%). The mean initial serum selenium concentration of 8 patients was 751 µg/L (reference range, ≤125 µg/L). The mean initial urine selenium concentration of 7 patients was 166 µg/24 h (reference range, ≤55 µg/24 h). Conclusions Toxic concentrations of selenium in a liquid dietary supplement resulted in a widespread outbreak. Had the manufacturers been held to standards used in the pharmaceutical industry, it may have been prevented.

The Dietary Supplement Health and Education Act: Time for a Reassessment: Comment on "Acute Selenium Toxicity Associated With a Dietary Supplement" [Invited Commentary]

Failure of Automated Telephone Outreach With Speech Recognition to Improve Colorectal Cancer Screening: A Randomized Controlled Trial [Original Investigation]

Background Automated telephone outreach with speech recognition (ATO-SR) is used extensively by health plans. Whether ATO-SR can increase rates of colorectal cancer (CRC) screening is unknown. Methods We randomly allocated 40 000 health plan members to ATO-SR and 40 000 to usual care, of whom 10 432 and 10 506 in the intervention and usual care groups, respectively, had not been previously screened and were therefore eligible for analysis. The intervention was a single interactive outreach call using speech recognition to engage participants in conversation about the importance of CRC screening and options for and barriers to screening. The intervention directed participants to contact their primary care provider to schedule screening. The primary end point was any CRC screening in the year following intervention. Colonoscopy in the year following intervention was a secondary outcome. Results The incidence of any CRC screening was 30.6% in the intervention group and 30.4% in the usual care group (P = .76). After adjustment for available covariates, there remained no intervention effect (adjusted odds ratio [OR], 1.01; 95% confidence interval [CI], 0.94-1.07). A total of 21.4% of members in the intervention group and 20.3% in the usual care group underwent colonoscopy (P = .04). In multivariate analysis, there was a small intervention effect on colonoscopy (OR, 1.08; 95% CI, 1.00-1.16). Conclusions This study showed that ATO-SR failed to improve rates of CRC screening. Future studies should examine approaches that combine efforts to target patients and their health care providers to overcome the barriers to CRC screening. Trial Registration clinicaltrials.gov Identifier: NCT00792285

Low Back Pain and Best Practice Care: A Survey of General Practice Physicians [Original Investigation]

Background Acute low back pain (LBP) is primarily managed in general practice. We aimed to describe the usual care provided by general practitioners (GPs) and to compare this with recommendations of best practice in international evidence-based guidelines for the management of acute LBP. Methods Care provided in 3533 patient visits to GPs for a new episode of LBP was mapped to key recommendations in treatment guidelines. The proportion of patient encounters in which care arranged by a GP aligned with these key recommendations was determined for the period 2005 through 2008 and separately for the period before the release of the local guideline in 2004 (2001-2004). Results Although guidelines discourage the use of imaging, over one-quarter of patients were referred for imaging. Guidelines recommend that initial care should focus on advice and simple analgesics, yet only 20.5% and 17.7% of patients received these treatments, respectively. Instead, the analgesics provided were typically nonsteroidal anti-inflammatory drugs (37.4%) and opioids (19.6%). This pattern of care was the same in the periods before and after the release of the local guideline. Conclusions The usual care provided by GPs for LBP does not match the care endorsed in international evidence-based guidelines and may not provide the best outcomes for patients. This situation has not improved over time. The unendorsed care may contribute to the high costs of managing LBP, and some aspects of the care provided carry a higher risk of adverse effects.

Adherence, Not Just for Patients: Comment on "Low Back Pain and Best Practice Care" [Invited Commentary]

Impact of Health Disparities Collaboratives on Racial/Ethnic and Insurance Disparities in US Community Health Centers [Original Investigation]

Background The Health Resources and Services Administration Health Disparities Collaboratives (HDCs) were developed to improve care for chronic medical conditions in community health centers (CHCs). Methods We examined whether HDCs reduced disparities in quality by race/ethnicity or insurance status in CHCs nationally. We performed a controlled preintervention/postintervention study of 44 CHCs participating in HDCs for asthma, diabetes mellitus, or hypertension and 20 "external" control CHCs that had not participated. Each intervention center also served as an "internal" control for another condition. For each condition, we created an overall quality score, defined disparities in care as the differences in care between racial/ethnic groups and insurance groups, and examined changes in disparity through a series of hierarchical models using a 3-way interaction term among period, patient characteristics of interest, and treatment group. Results Overall, HDCs had little effect on disparities in composite measures for asthma, diabetes, and hypertension. For asthma care, collaborative centers had a baseline Hispanic-white disparity of 6.5%, which changed to a higher quality of recommended care for Hispanic patients over white patients by 0.8%, resulting in a significantly reduced Hispanic-white disparity compared with the change in disparity seen in external controls (P = .04). There were no other improvements in racial/ethnic or insurance disparities for any other conditions. Conclusions Although HDCs are known to improve quality of care in CHCs, they had minimal effect on racial/ethnic and insurance disparities. In addition to targeting improvement in overall quality, future initiatives should include activities aimed at disparity reduction as an outcome.

Passive Smoking and Tuberculosis [Original Investigation]

Background Increasing evidence has incriminated active smoking as a causal factor for tuberculosis (TB). However, the effect of secondhand tobacco smoke exposure on TB has not been similarly elucidated. Methods A cohort of 15 486 female never-smokers aged 65 to 74 years and living with their surviving husband were enrolled at 18 Elderly Health Centers in Hong Kong from 2000 to 2003 and followed up prospectively through linkage with the territory-wide TB notification registry and death registry for TB and death until December 31, 2008, using an identity card number as a unique identifier. The relationship between passive smoking and the development of TB was assessed with adjustment for other baseline characteristics. Results Passive exposure to secondhand tobacco smoke in the household was independently associated with obstructive lung disease (odds [OR], 1.43; 95% confidence interval [CI], 1.16-1.77) and diabetes mellitus (OR, 1.13; 95% CI, 1.02-1.26) at baseline and with the development of both active TB (hazard ratio [HR], 1.49; 95% CI, 1.01-2.19) and culture-confirmed TB (HR, 1.70; 95% CI, 1.04-2.80) on prospective follow-up after potentially confounding background variables were controlled for. Passive smoking accounted for 13.7% of active TB and for 18.5% of culture-positive TB in this cohort. Conclusions Similar to active smoking, passive exposure to secondhand tobacco smoke in the household also predisposes to the development of TB. Increased emphasis should therefore be put on tobacco control in national TB programs.

Secondhand Smoke and Infectious Disease in Adults: A Global Women's Health Concern: Comment on "Passive Smoking and Tuberculosis" [Invited Commentary]

Impact of Hospital-Associated Hyponatremia on Selected Outcomes [Original Investigation]

Background Hyponatremia is the most common electrolyte disorder encountered in hospitalized patients. Methods We evaluated whether hospital-associated hyponatremia has an independent effect on all-cause mortality, hospital length of stay (LOS), and patient disposition. This cohort study included all adult hospitalizations at an academic medical center occurring between 2000-2007 for which an admission serum sodium concentration ([Na+]) was available (N = 53 236). We examined community-acquired hyponatremia (admission serum [Na+], <138 mEq/L [to convert to millimoles per liter, multiply by 1.0]), hospital-aggravated hyponatremia (community-acquired hyponatremia complicated by worsening in serum [Na+]), and hospital-acquired hyponatremia (nadir serum [Na+], <138 mEq/L with a normal admission serum [Na+]). The independent associations of these hyponatremic presentations with in-hospital mortality, LOS, and patient disposition were evaluated using generalized estimating equations adjusted for age, sex, race, admission service, and Deyo-Charlson Comorbidity Index score. Results Community-acquired hyponatremia occurred in 37.9% of hospitalizations and was associated with adjusted odds ratios (ORs) of 1.52 (95% confidence interval [CI], 1.36-1.69) for in-hospital mortality and 1.12 (95% CI, 1.08-1.17) for discharge to a short- or long-term care facility and a 14% (95% CI, 11%-16%) adjusted increase in LOS. Hospital-acquired hyponatremia developed in 38.2% of hospitalizations longer than 1 day in which initial serum [Na+] was 138 to 142 mEq/L. Hospital-acquired hyponatremia was associated with adjusted ORs of 1.66 (95% CI, 1.39-1.98) for in-hospital mortality and 1.64 (95% CI, 1.55-1.74) for discharge to a facility and a 64% (95% CI, 60%-68%) adjusted increase in LOS. The strength of these associations tended to increase with hyponatremia severity. Conclusions Hospital-associated hyponatremia is a common occurrence. All forms of hyponatremia are independently associated with in-hospital mortality and heightened resource consumption.

Ventricular Tachycardia After Ingestion of Ayurveda Herbal Antidiarrheal Medication Containing Aconitum [Clinical Observation]

Ayurveda is an East Indian tradition involving the treatment of medical ailments through the use of herbal medications. A previously asymptomatic 62-year-old man with a history of hypertension and stable coronary artery disease developed paresthesias and fascicular and ventricular tachycardia after ingestion of an Ayurveda bowel regimen containing substrates from the Aconitum species, which is a known neurotoxin and cardiotoxin. Findings of electrophysiologic study and cardiac magnetic resonance imaging were within normal limits, pointing to the ingestion of Aconitum as the most likely source of his arrhythmia.

The Evidence Chasm [Editor's Correspondence]

Procedure Training--Is It Time for a Change? [Editor's Correspondence]

The Need for More Accurate Terminology in Discussing End-of-Life Options [Editor's Correspondence]

Breastfeeding and allergies: time for a change in paradigm?.

Page: 539DOI: 10.1097/MCI.0b013e32831dae43Authors: Duncan, Joanne M; Sears, Malcolm R

New aspects in allergic contact dermatitis.

Page: 547DOI: 10.1097/MCI.0b013e32831dae50Authors: Mortz, Charlotte Gotthard; Andersen, Klaus Ejner

Contemporary approaches to the identification of athletes at risk for sudden cardiac death.

Page: 552DOI: 10.1097/MCI.0b013e32831daee4Authors: Drezner, Jonathan A

How to break the vicious circle of antibiotic resistances?.

Page: 560DOI: 10.1097/MCI.0b013e32831dabd1Authors: Leone, Marc; Martin, Claude

Benefits of high-protein weight loss diets: enough evidence for practice?.

Page: 566DOI: 10.1097/MCI.0b013e32831daebdAuthors: Brehm, Bonnie J a; D'Alessio, David A b

Chronic pancreatitis.

Page: 572DOI: 10.1097/MCI.0b013e32831daddaAuthors: Conwell, Darwin L; Banks, Peter A

Heparin-induced thrombocytopenia: some working hypotheses on pathogenesis, diagnostic strategies and treatment.

Page: 577DOI: 10.1097/MCI.0b013e32831dae94Authors: Alberio, Lorenzo

Long-term prognosis after deep venous thrombosis.

Page: 586DOI: 10.1097/MCI.0b013e32831daea9Authors: Shbaklo, Hadia a; Kahn, Susan R a,b

New advances in Clostridium difficile infection: changing epidemiology, diagnosis, treatment and control.

Page: 591DOI: 10.1097/MCI.0b013e32831daed2Authors: DuPont, Herbert L a,b,c; Garey, Kevin b,c,d; Caeiro, Juan-Pablo b,c; Jiang, Zhi-Dong a

Elevations in serum creatinine with RAAS blockade: why isn't it a sign of kidney injury?.

Page: 599DOI: 10.1097/MCI.0b013e32831daeffAuthors: Ryan, Michael J a; Tuttle, Katherine R a,b

Renin inhibition: should it supplant ACE inhibitors and ARBS in high risk patients?.

Page: 606DOI: 10.1097/MCI.0b013e32831daf11Authors: Gaddam, Krishna K; Oparil, Suzanne

Diabetic polyneuropathy: an update.

Page: 613DOI: 10.1097/MCI.0b013e32831dae0bAuthors: Zochodne, Douglas W

Drug-induced myopathies.

Page: 620DOI: 10.1097/MCI.0b013e32831dae1cAuthors: Klopstock, Thomas

Evolving epidemiology of malignancies in HIV.

Page: 626DOI: 10.1097/MCI.0b013e32831dae71Authors: Bonnet, Fabrice a,b,c; Chene, Genevieve a,b

Vaccines against cervical cancer.

Page: 633DOI: 10.1097/MCI.0b013e32831dae88Authors: Rogers, Linda J; Eva, Lois J; Luesley, David Michael

Effectiveness and cost effectiveness of thrombolysis in patients with acute pulmonary embolism.

Page: 638DOI: 10.1097/MCI.0b013e32831dad76Authors: Zamanian, Roham T a,b; Gould, Michael K a,c

Update on biologics in juvenile idiopathic arthritis.

Page: 643DOI: 10.1097/MCI.0b013e32831dae32Authors: Ilowite, Norman T