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In This Issue of Archives of Internal Medicine
May 22, 2006

In This Issue of Archives of Internal Medicine

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Copyright 2006 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.2006

Arch Intern Med. 2006;166(10):1061. doi:10.1001/archinte.166.10.1061
Management of Urinary Incontinence in Medicare Managed Care Beneficiaries

Urinary incontinence among seniors remains underreported by patients and underdiagnosed and treated by clinicians. Data from the 2004 Medicare Health Outcomes Survey show that 37.3% of seniors reported urinary incontinence within the last 6 months and that urinary incontinence problems were strongly associated with lower self-reported health. Yet only 55.5% of those with urinary incontinence problems reported discussing these problems during their recent visit to a physician or health care provider. Only 56.5% of patients received treatment, and the treatment rate was lower for older individuals (eg, 46.3% for those aged 90-94 years) or those with poor self-reported health status (50.5%).

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Cost-effectiveness of B-Type Natriuretic Peptide Testing in Patients With Acute Dyspnea

The long-term cost-effectiveness of B-type natriuretic peptide (BNP) guidance was estimated in the randomized B-Type Natriuretic Peptide for Acute Shortness of Breath Evaluation (BASEL) study, in which a diagnostic strategy involving the measurement of BNP levels (225 patients) was compared with assessment in a standard manner (227 patients). Nonparametric bootstrapping was used to estimate the distribution of incremental costs and effects on the cost-effectiveness plane during 180 days of follow-up. An analysis of incremental 180-day cost-effectiveness showed that BNP guidance resulted in lower mortality and lower cost in 80.6%, in higher mortality and lower cost in 19.3%, and in higher or lower mortality and higher cost in both in less than 0.1%. Results were robust to changes in most variables but sensitive to changes in rehospitalization with BNP guidance.

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Lowering the Threshold for Discussions of Domestic Violence

Rhodes et al conducted a randomized controlled trial with female patients at 2 socioeconomically diverse emergency departments. Randomization was to a computer-based health risk assessment that prompted health care providers to domestic violence and other health risks or to “usual care.” Visits for all enrolled patients were audiotaped to determine the effect of computer screening on rates of provider-patient discussion of domestic violence. While there were important intrasite differences, the authors conclude that it is likely that low-cost interventions that allow patients the opportunity to self-disclose can be used to improve detection of domestic violence.

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Performance-Based Physical Function and Future Dementia in Older People

This population-based longitudinal study, involving 2288 participants older than 65 years without dementia at baseline, investigated whether physical function was associated with incident dementia and Alzheimer disease (AD). Over the 6 years of follow-up, 319 participants developed dementia (221 had AD). The age-specific incidence rate of dementia was 53.1 per 1000 person-years for participants who scored 10 points or lower on the 16-point performance-based physical function test at baseline compared with 17.4 per 1000 person-years for those who scored higher than 10 points. A decrease in the baseline physical function test scores was associated with an increased risk for dementia, an increased risk for AD, and an increased rate of decline in cognitive function during the 6-year follow-up. The findings suggest that poor physical function may precede the onset of dementia and AD, and higher levels of physical function may be associated with a delayed onset.

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Safety of High Doses of Influenza Vaccine and Effect on Antibody Responses in Elderly Persons

Annual epidemics of influenza are associated with over 50 000 deaths and nearly 300 000 hospitalizations in the United States; most of these occur among persons older than 65 years. Immunization with inactivated influenza vaccine reduces the frequencies of these severe outcomes, but improved vaccines are needed to overcome age-related decline in antibody responses. Keitel et al assessed clinical and serological responses following immunization of ambulatory elderly subjects with standard or high-dose vaccines containing 2 to 4 times the amount of antigen present in licensed vaccines. High-dosage vaccines were well tolerated and elicited significantly higher antibody responses compared with the standard dosage. The authors conclude that the improved immunogenicity of high-dose vaccine should lead to enhanced protection against influenza.

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Percentage of participants with a serum hemagglutination inhibition antibody titer of 32 or greater after immunization for each vaccine dose group.

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