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In This Issue of Archives of Internal Medicine
Arch Intern Med. 2009;169(5):428.
The Natural History of Insomnia
This longitudinal study examined the natural course of insomnia (ie, the extent to which it is likely to persist or remit) for a 3-year period in 388 adults (mean age, 44.8 years; 61% female) who presented either insomnia symptoms or an insomnia disorder at the baseline assessment. Participants completed a yearly assessment of their sleep patterns at 4 time points (at baseline and at 1, 2, and 3 years). The results showed that 74% of the sample reported insomnia that persisted for at least a 1-year period, and 46% had insomnia persisting for the entire 3-year study period. The remission rate was 54%, but half of those (27%) who went into remission eventually relapsed. Insomnia was more likely to be long-term among women, older adults, and those with more severe sleep difficulties at baseline. These findings indicate that insomnia is very often a chronic condition; the main implication is that health practitioners should attend to this complaint and not assume that it will resolve spontaneously with time.
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Abandonment at the End of Life From Patient, Caregiver, Nurse, and Physician Perspectives
Surveys have shown that patients and families sometimes feel abandoned by their physicians near the end of life. In this study, researchers interviewed patients with incurable cancer and advanced chronic obstructive pulmonary disease, their family members, and their physicians prospectively during a 6-month period. Before death, patient and family worries about abandonment centered on loss of continuity with their physician. At the time of death and after, feelings of abandonment resulted from lack of closure with the physician. The professional value of nonabandonment consists of 2 different elements: providing continuity and facilitating closure of the patient-physician relationship.
(SEE ARTICLE)
Clinical Presentation, Etiology, and Outcome of Infective Endocarditis in the 21st Century
Infective endocarditis remains an incompletely understood disease with high morbidity and mortality. Textbook descriptions of the clinical and epidemiologic features of infective endocarditis are still largely based on data obtained from several decades ago. Murdoch et al present the findings from a prospective cohort study of 2781 adults with definite infective endocarditis admitted to 58 hospitals in 25 countries from 2000 to 2005. Most (77%) patients presented early in the disease course, with few of the classic clinical hallmarks of infective endocarditis. Recent health care exposure was found in one-quarter of the patients, and Staphylococcus aureus was the most common pathogen (31%). Surgical therapy was common (48%), and in-hospital mortality remained high (18%). Multivariable analysis provided evidence that early surgery was associated with decreased risk of in-hospital death (odds ratio, 0.61; 95% confidence interval, 0.44-0.83).
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Long-term Benefit of High-Density Lipoprotein Cholesterol–Raising Therapy With Bezafibrate
Data regarding the long-term effects of high-density lipoprotein cholesterol (HDL-C) level–raising therapies are limited. Goldenberg et al evaluate the long-term (16-year) mortality risk of 3026 patients with coronary heart disease enrolled in the Bezafibrate Infarction Prevention (BIP) trial. The authors demonstrate that the patients who were allocated to bezafibrate therapy during the original 6.2-year course of the BIP trial experienced an 11% reduction (P = .06) in the risk of 16-year mortality compared with the placebo-allocated patients. This long-term survival benefit was shown to be related to a pronounced 22% (P = .008) reduction in the risk of death among patients who exhibited an upper tertile HDL-C response (>8 mg/dL) to treatment with the study drug. These findings suggest that HDL-C raising therapy with bezafibrate has important long-term clinical implications that may extend for many years after termination of active treatment with the drug.
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Glucose Normalization and Outcomes in Patients With Acute Myocardial Infarction
Whether glucose normalization after admission is associated with improved survival in patients with acute myocardial infarction (AMI) and whether insulin therapy is associated with a mortality benefit in AMI beyond its associated glucose level–lowering effect are subjects of debate. Kosiborod et al studied 7820 hyperglycemic patients with AMI treated between January 2000 and December 2005 in 40 US hospitals. Multivariable logistic regression models and propensity-matching methods were used to examine whether lower glucose values after hospital admission are independently associated with better in-hospital survival and to compare mortality in patients who did and did not receive insulin. The authors found that lower mean glucose level after admission was associated with better survival; the nature of this association was similar regardless of whether patients received insulin. Postadmission glucose level, but not insulin therapy per se, was an important predictor of patient outcomes.
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Figure. Mortality among insulin-treated vs non–insulin-treated patients after propensity matching.
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(SEE ARTICLE)
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