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In This Issue of Archives of Internal Medicine
May 14, 2012

In This Issue of Archives of Internal Medicine

Arch Intern Med. 2012;172(9):681. doi:10.1001/archinternmed.2011.942

The year 2012 marks the final year for physicians to receive maximum payments from the Medicare and Medicaid Electronic Health Records Incentive Programs. Last year more than 30 000 clinicians received payments for demonstrating stage 1 “meaningful use.” However, many still have questions regarding how to participate. This Special Article gives an overview of the program and the process by which clinicians may qualify to receive incentives for the effective use of health information technology to improve care.

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Growing antibiotic resistance warrants studying nonantibiotic prophylaxis for recurrent urinary tract infections (rUTIs). In a randomized noninferiority trial, Beerepoot et al compared prophylaxis with oral capsules with Lactobacillus rhamnosus GR-1 and Lactobacillus reuteri RC-14 to trimethoprim-sulfamethoxazole (480 mg) in 252 postmenopausal women with rUTIs. After 12 months of prophylaxis, the mean number of symptomatic UTIs was 2.9 in the trimethoprim-sulfamethoxazole group and 3.3 in the lactobacilli group. The between-treatment difference was outside the authors' noninferiority margin. On the contrary, trimethoprim-sulfamethoxazole prophylaxis resulted in high resistance rates to trimethoprim-sulfamethoxazole, trimethoprim, and amoxicillin in Escherichia coli from the commensal fecal flora, from urine of asymptomatic women, and among E coli causing a UTI. Resistance did not increase during lactobacilli administration. Due to the lack of collateral damage, lactobacilli may be an acceptable alternative for the prevention of rUTIs.

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In this meta-analysis of 14 randomized, double-blind, placebo-controlled trials, which involved a total of 20 485 patients with existing cardiovascular disease, supplementation with omega-3 fatty acids did not reduce either the risk of overall cardiovascular events (relative risk, 0.99; 95% CI, 0.89-1.09) or other specified events such as all-cause mortality, sudden cardiac death, myocardial infarction, congestive heart failure, and transient ischemic attack and stroke. There was a small reduction in cardiovascular death (relative risk, 0.91; 95% CI, 0.84-0.99), which disappeared when the authors excluded a study with major methodological problems. This study indicates that there is a lack of sufficient evidence of the secondary preventive effects of omega-3 supplements on cardiovascular disease.

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Over the past 13 years, Abbott Laboratories, the maker of branded fenofibrate, has produced several reformulations, which dominate the market even though generics have been available for almost a decade. This continued use of branded formulations imposes an annual cost of approximately $700 million on our health care system. Abbott Laboratories maintained this dominance, in part, through a complex switching strategy involving the sequential launch of branded reformulations of fenofibrate. Using the fenofibrate example, Downing et al describe how current policy allows pharmaceutical companies to maintain market share of branded medications without demonstrating the superiority of next-generation products.

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This multicenter real-life surveillance evaluated the effectiveness and safety of a procalcitonin (PCT) algorithm for antibiotic guidance in adults with community-acquired lower respiratory tract infections in 14 centers in Switzerland, France, and the United States. Compliance with the PCT algorithm was 68.2% and differed between diagnoses, treatment sites, prior algorithm experience, and countries. Antibiotic duration was significantly shorter if the PCT algorithm was followed compared with cases where the algorithm was overruled (5.9 vs 7.4 days; difference, −1.51 days; 95% CI, −2.04 to −0.98; <  .001). There was no increase in the risk of the combined adverse outcome end point within 30 days of follow-up when the PCT algorithm was followed regarding withholding antibiotics on hospital admission (adjusted odds ratio, 0.83; 95% CI, 0.44 to 1.55; =  .56) and regarding early cessation of antibiotics (adjusted odds ratio, 0.61; 95% CI, 0.36 to 1.04; =  .07). This study extends the evidence for PCT-guided antibiotic stewardship from randomized controlled trials to real-life settings.

Algorithm compliance.

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