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In This Issue of Archives of Internal Medicine
Arch Intern Med. 2002;162:17.
Changing Patient Characteristics and the Effect on Mortality in Endocarditis
Limited data exist on recent demographic and microbiological changes
in infective endocarditis (IE) and the impact of these changes on patient
survival. Therefore, Cabell et al sought to identify changes in demographic
and microbiological characteristics in patients with endocarditis and to determine
relationships between changing characteristics and survival. Data were collected
from all patients with definite or possible IE at Duke University Medical
Center from 1993 to 1999. Among the 329 study patients, rates of hemodialysis
dependence, immune suppression, and Staphylococcus aureus infection increased during the study period, while rates of infection
due to viridans group streptococci decreased. Patients with S aureus IE had a higher 1-year mortality rate (43.9% vs 32.5%) that
persisted after adjustment for other illness severity characteristics. In
this study, Cabell et al found that the demographic and microbiological characteristics
of IE at their institution have changed over the past decade in ways that
suggest a link between medical practice and IE characteristics. S aureus has emerged as a dominant cause of IE and is an independent
predictor of mortality. These findings identify clinical settings that may
warrant closer surveillance and more aggressive measures in the identification
and prevention of endocarditis.
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Changing characteristics from 1993 to 1999 of 329 patients with infective
endocarditis.
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(SEE ARTICLE)
The Effect of Antidepressant Treatment on Chronic Back Pain: A Meta-analysis
Nine randomized controlled trials with 10 treatment arms and 504 patients
were included. Seven treatment arms included patients with major depression.
Two continuous outcomes (change in back pain severity and ability to perform
activities of daily living) were measured. Patients treated with antidepressants
were more likely to improve pain severity than those treated with placebo
(standardized mean difference, 0.41; 95% confidence interval, 0.22-0.61) but
not in activities of daily living (standardized mean difference, 0.24; 95%
confidence interval, 0.21-0.69). Patients treated with antidepressants experienced
greater adverse effects (22% vs 15%, P = .01). Antidepressants
are more effective than placebo in reducing pain severity but not functional
status in patients with chronic back pain.
(SEE ARTICLE)
Supplemental Oxygen Use in Ischemic Stroke Patients: Does Utilization
Correspond to Need for Oxygen Therapy?
There are no data to support the routine use of supplemental oxygen
in patients who have an ischemic stroke. More recently, supplemental oxygen
has been suggested to be potentially detrimental. The authors of this study
evaluated the extent of oxygen use in ischemic stroke and whether patients
receiving oxygen had indications for its use. Using a literature-based list
of criteria for supplemental oxygen use, only 45.6% of inpatient days that
patients were receiving oxygen were justified in an ischemic stroke population.
The findings from this study demonstrate that oxygen therapy is commonly given
to ischemic stroke patients without clear indication and that opportunities
exist for substantial resource conservation.
(SEE ARTICLE)
National Patterns in the Treatment of Urinary Tract Infections in Women
by Ambulatory Care Physicians
Trimethoprim-sulfamethoxazole has consistently been the recommended
drug of choice for uncomplicated urinary tract infections (UTIs) in women.
Using a national survey of practicing physicians from 1989 through 1998, Huang
and Stafford examined trends in the antibiotics prescribed for women (aged
18 to 75 years) diagnosed as having an uncomplicated UTI. The authors found
that the proportion of trimethoprim-sulfamethoxazole prescriptions declined
from 48% in 1989-1990 to 24% in 1997-1998. Conversely, fluoroquinolone use
increased (19% to 29%) as did nitrofurantoin prescribing (14% to 30%). In
the analysis of predictors of antibiotic choice, the authors found that among
primary care physicians, internists were the most likely to prescribe fluoroquinolones,
while obstetricians were the most likely to prescribe nitrofurantoin. Current
prescribing trends may increase antimicrobial resistance to multiple agents
and incur unnecessary health care costs. Further exploration of the reasons
for subspecialty variation in UTI may be a crucial first step to improving
antibiotic prescribing practices.
(SEE ARTICLE)
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