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In This Issue of Archives of Internal Medicine
April 12, 2010

In This Issue of Archives of Internal Medicine

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Copyright 2010 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.2010

Arch Intern Med. 2010;170(7):582. doi:10.1001/archinternmed.2010.47
Dietary Glycemic Load and Index and Risk of Coronary Heart Disease in a Large Italian Cohort: The EPICOR Study

This study investigated the supposed link between coronary heart disease and a diet high in glycemic load (GL) and glycemic index (GI) in a large cohort of Italian men and women. It was found that high dietary GL, that is, a diet rich in carbohydrate from high GI foods, increased the risk of coronary heart disease in women but not in men. The role of dietary carbohydrate depended on type, with an increased risk for carbohydrates from high-GI foods but no association for carbohydrates from low-GI foods. The adverse effects of a high-glycemic diet in women may be mediated by sex-related differences in lipoprotein and glucose metabolism.

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Health Information Exchange

The American Recovery and Reinvestment Act of 2009 provides $36 billion dollars to promote electronic health records (EHRs) and the formation of regional centers that foster community-wide electronic health information exchange (HIE), with the ultimate goal of a nationwide health information network. This qualitative study explored the motivations, challenges, and strategies for overcoming barriers to HIE in 9 small Minnesota practices that are responding to state legislative mandates for all hospitals and health care providers to have interoperable EHRs by 2015. Key informants indicated that small practices do not generally have the means or motivation to fully participate in regional HIEs at this time; however, many are exchanging health data in piecemeal arrangements with stakeholders with whom they are not directly competing for patients. These findings highlight the importance of appropriate planning before EHR adoption and the need to make community-wide HIE a high priority in the planning process.

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Influenza Vaccination and Vitamin K Antagonist Treatment

In accordance with the conflicting results previously obtained in several small observational and mostly retrospective studies investigating the effects of influenza vaccination on plasma international normalized ratio (INR) in patients treated with vitamin K antagonists (VKAs), different guidelines on VKA management list influenza vaccination among either the potentiating or inhibiting drugs that interact with VKAs. The results of this double-blind, crossover, randomized study show that influenza vaccination causes no change in the INR values and in warfarin weekly doses, ruling out any major interaction between influenza vaccination and VKA therapy. No major bleeding or thrombotic events were recorded. Therefore, patients receiving stable, long-term VKA therapy may safely undergo influenza vaccination without routinely increasing the frequency of INR testing.

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Percentages of time spent in therapeutic range.

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Hemorrhage During Warfarin Therapy Associated With Cotrimoxazole and Other Urinary Tract Anti-infective Agents

Cotrimoxazole and some other antibiotics inhibit warfarin's metabolism and may be associated with a greater risk of hemorrhage in warfarin-treated patients. This study examined the risk of upper gastrointestinal (UGI) tract hemorrhage in older patients receiving warfarin and antibiotics commonly used to treat urinary tract infections. Fischer et al conducted a population-based, nested case-control study using Ontario health care databases of individuals 66 years or older continuously receiving warfarin therapy (n = 134 637). Cases were those hospitalized with UGI tract hemorrhage (n = 2151). Cases were nearly 4 times more likely than controls to have recently received cotrimoxazole (adjusted odds ratio, 3.84; 95% confidence interval, 2.33-6.33). Ciprofloxacin was associated with a smaller increased risk (adjusted odds ratio, 1.94; 95% confidence interval, 1.28-2.95), but no significant association was observed with amoxicillin, ampicillin, nitrofurantoin, or norfloxacin.

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Implantable Cardiac Device Procedures in Older Patients

Using data from a multihospital database spanning 2004 and 2005, Swindle et al identified 26 887 patients with heart failure who underwent an implantable cardiac device procedure; 17.5% were 80 years or older. Compared with younger patients, those 80 years or older were more likely to receive cardiac resynchronization therapy alone. In-hospital mortality increased from 0.7% in patients younger than 80 years to 1.2% among those aged between 80 and 85 years, and 2.2% in those older than 85 years (P < .001). Independent predictors of in-hospital mortality included age 80 years or older, elevated comorbidity score, inotrope use, and procedure-related complications. The authors conclude that although most device trials have excluded patients older than 80 years, more than one-sixth of implantable cardioverter defibrillator and cardiac resynchronization therapy devices are implanted in this age group. Advanced age is an independent predictor of in-hospital mortality following device implantation, suggesting that additional study is needed to define criteria for appropriate device use in elderly patients.

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