De Vries et al conducted a randomized controlled trial in 217 persons 65 years and older, who visited an emergency department or their family physician after a fall. A geriatric assessment and intervention were aimed at reduction of fall risk factors. Within 1 year, 55 of the 106 intervention participants (52%) and 62 of the 111 usual care participants (56%) fell at least once. No significant treatment effect was demonstrated on either the time to first fall (hazard ratio, 0.96; 95% confidence interval [CI], 0.67-1.37) or the time to second fall (hazard ratio, 1.13; 95% CI, 0.71-1.80). The intervention had no effect on quality of life or on mobility parameters.
Most cases of acute gout arthritis are diagnosed in primary care and in a large number of patients without joint fluid analysis. Janssens et al developed a diagnostic rule for family physicians (FPs) to predict the presence of crystal-proven gout. The clinical gout diagnosis made by the participating FPs appeared moderately valid (positive predictive value, 0.64; negative predictive value, 0.87). The identification of monosodium urate crystals was used as the gold reference test. The presented rule, containing 7 easily ascertainable clinical variables including the serum urate level, showed a good diagnostic performance (areas under the receiver operating characteristic curve, 0.85; 95% CI, 0.81-0.90). It can help FPs to select patients with a high and low probability of gout and to restrict additional joint aspiration for monosodium urate crystals for those with remaining uncertainty about the diagnosis.
Smith et al validated a single-question screening test for drug use and drug use disorders in primary care. The question, “How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons?” (a response of ≥1 was considered a positive screening result) was 92.9% sensitive and 94.1% specific for the detection of past-year drug use and 100% sensitive and 73.5% specific for the detection of a drug use disorder. The accuracy was comparable to that of other longer screening instruments. These findings support the use of this brief screen in primary care settings, which should, in turn, facilitate the implementation of screening and brief intervention in these settings.
Knowledge of polyp prevalence and race, stratified by race and sex, is needed to make sound decisions regarding sex or race stratifications (if any) in colon cancer/polyp screening guidelines (either starting age or frequency of surveillance), especially in average-risk individuals. The American College of Gastroenterology recommends that African Americans begin screening 5 years earlier than whites, at the age of 45 years; there are no sex-stratified guidelines proposed by any of the societies. However, in this study of almost 4000 screening (or minimally symptomatic) individuals' first colonoscopy and their follow-up studies after polypectomy over a decade, men had a higher age-corrected prevalence (odds ratio, 1.67 [95% CI, 1.39-2.02]) and a nearly 3-fold increase in the likelihood of having multiple polyps. African American race was not predictive of polyp prevalence or incidence. Although pathological data were not available on all patients' polyps, proportionally, adenomas made up a similar proportion of all polyps in both races in a manual histopathologic review, so these predictors of polyps likely also hold true for adenomas. Screening with colonoscopy earlier and more often in African Americans, simply because cancer or cancer-related death is more common, might not be the best response.
Pneumonia is common among patients with advanced dementia; however, whether antimicrobial treatment improves survival or comfort is not well understood. This study uses data from a prospective cohort of 323 nursing home residents with advanced dementia to compare the mortality and comfort associated with antibiotic treatment for suspected pneumonia episodes. Residents experienced 225 suspected pneumonia episodes, which were treated with antimicrobials as follows: none, 8.9%; oral only, 55.1%; intramuscular, 15.6%; and intravenous (or hospitalization), 20.4%. After multivariable adjustment, all antimicrobial treatments improved survival after pneumonia compared with no treatment. However, residents receiving any form of antimicrobial treatment for pneumonia had worse comfort compared with untreated residents.
Survival after suspected pneumonia episode, by treatment.
In This Issue of Archives of Internal Medicine. Arch Intern Med. 2010;170(13):1098. doi:10.1001/archinternmed.2010.219