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In This Issue of Archives of Internal Medicine
Sep 10, 2012

In This Issue of Archives of Internal Medicine

Arch Intern Med. 2012;172(16):1200. doi:10.1001/archinternmed.2011.977

Given that critical care resource use accounts for nearly 1% of US gross domestic product, this study estimates what proportion of medical patients admitted from the emergency department or outpatient clinic in the Veterans Affairs Health Care System were triaged to the intensive care unit (ICU). The study also describes hospital variation in ICU admitting patterns after adjusting for 30-day predicted mortality on admission. Finally, the study describes the instability of hospital rankings based on ICU admitting patterns.

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Risk of acute myocardial infarction (AMI) following total hip or knee replacement was determined in this nationwide Danish retrospective cohort study. A total of 95 227 individuals undergoing total hip or knee replacement were identified. They were matched with 3 controls without hip or knee surgery. Risk of AMI was elevated during the first 2 weeks after total hip (adjusted hazard ratio, 25.5; 95% CI, 17.1-37.9) and knee replacement (adjusted. hazard ratio, 30.9; 95% CI, 11.1-85.5). The absolute 6-week risks were 0.51% for hip replacements and 0.21% for knee replacements. These findings support risk assessment of AMI shortly after total hip or knee replacement.

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Long-term use of the photosensitizing antihypertensive drugs, hydrochlorothiazide, combined hydrochlorothiazide-triamterene, and nifedipine was associated with increased risk of developing lip cancer in non-Hispanic whites. No association was noted for atenolol, which is not a photosensitizer. Findings for lisinopril were equivocal. Protecting the lips of fair-skinned patients from prolonged sun exposure should be considered in those taking these and other photosensitizing drugs.

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This study analyzed the effect of early syphilis on human immunodeficiency virus (HIV) markers. A total of 282 HIV-infected men who contracted syphilis during their follow-up were matched with 1233 syphilis-free HIV-infected men. Ninety percent were homosexuals and 85% were treated by combined antiretroviral therapy (cART). Time-specific changes in HIV-RNA levels and CD4 cell counts were found. Early syphilis was associated with a nearly 2-fold rise in the risk of viral load elevation in the months following diagnosis, even in patients receiving effective cART, and also with a moderate and transient fall in the CD4 cell count. This suggests that syphilis may increase the risk of HIV transmission, even in patients receiving antiretroviral therapy with controlled viral load, and call for continuing safe-sex promotion.

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The assessment of patients with symptoms suggestive of acute myocardial infarction (AMI) can be a diagnostic challenge and time-consuming, given the need for serial blood sampling for 6 to 9 hours. The recently developed high-sensitivity cardiac troponin T (hs-cTnT) assay can detect smaller amounts of cardiac troponin faster than former generations of cardiac troponin assays. Reichlin et al derived and validated an algorithm for the diagnosis of AMI in 872 patients with chest pain in the emergency department. Overall, the algorithm incorporating hs-cTnT baseline values and absolute changes within the first hour resulted in a definite diagnosis in 77% of unselected patients with acute chest pain within 1 hour. Sensitivity and negative predictive value for rule-out were 100%, and specificity and positive predictive value for rule-in were 97% and 84%, respectively, therefore allowing for a safe rule-out as well as an accurate rule-in of AMI within 1 hour. This novel strategy may obviate the need for prolonged monitoring and serial blood sampling in 3 of 4 patients.

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