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In This Issue of Archives of Internal Medicine
April 9, 2007

In This Issue of Archives of Internal Medicine

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Copyright 2007 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.2007

Arch Intern Med. 2007;167(7):625. doi:10.1001/archinte.167.7.625
Effect of Cocoa and Tea Intake on Blood Pressure

Habitual intake of cocoa and tea has been associated with a lower blood pressure (BP) in observational studies, but the clinical significance of this effect is uncertain. In this prospective meta-analysis, Taubert et al assessed the effect of cocoa or black and green tea administration on BP in randomized controlled trials. A pooled analysis of 5 randomized controlled trials (RCTs) of chocolate intake in 173 subjects with a median duration of 2 weeks revealed a significant reduction in systolic BP by −4.7 mm Hg (95% confidence interval, −7.6 to −1.8 mm Hg) and in diastolic BP by −2.8 mm Hg (95% confidence interval, −4.8 to −0.8 mm Hg) compared with the cocoa-free controls. An analysis of 5 RCTs of tea intake in 343 subjects with a median duration of 4 weeks revealed no significant changes in systolic or diastolic BP. These data suggest that cocoa, but not tea, may be considered part of dietary approaches to lower hypertension risk.

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Permanent Pacemaker and Implantable Cardioverter Defibrillator Infection

Infection of permanent pacemakers or implantable cardioverter-defibrillators is a devastating complication because of the need for device extraction and prolonged antimicrobial therapy. The incidence of cardiac device infection is not well understood but appears to be increasing over the past decade. In this issue, Uslan et al report the results of a retrospective cohort study of 1524 patients in Olmsted County, Minnesota, over 30 years. With over 7500 device-years of follow-up, they found that the incidence of device infection was 1.9 per 1000 device-years. The cumulative probability of device infection was higher among those with defibrillators compared with pacemakers. Of 22 cases of Staphylococcus aureus bloodstream infection, 12 (55%) had definite or possible cardiac device infection vs 3 (12%) of 25 cases of bloodstream infection due to gram-negative bacilli (P = .004).

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Physician Consideration of Patients' Out-of-Pocket Costs in Making Common Clinical Decisions

Pham et al analyzed national survey data on 6628 physicians to examine how frequently they report considering their insured patients' out-of-pocket expenses when prescribing drugs, selecting diagnostic tests, and choosing inpatient vs outpatient care settings. Of the physicians, 78% reported routinely considering out-of-pocket costs when prescribing drugs, 51.2% when selecting care settings, and 40.2% when selecting diagnostic tests. Primary care physicians were more likely than medical specialists to consider patients' costs in all 3 types of clinical decisions. Physicians working in large groups or health maintenance organizations were more likely to consider out-of-pocket costs in prescribing generic drugs, but those in solo and 2-person practices were more likely to do so in choosing tests and care settings. Cost-sharing arrangements targeting patients are likely to have limited effects in safely reducing health care spending because physicians do not routinely consider patients' out-of-pocket costs when making decisions regarding more expensive medical services.

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Older Age and the Response to and Tolerability of Antiretroviral Therapy

Silverberg et al conducted a retrospective cohort study within an integrated health care system of 5090 human immunodeficiency virus (HIV)-positive patients initiating highly active antiretroviral therapy (HAART), of whom 997 were 50 years or older. Patients were followed for up to 6 years after the initiation of HAART between 1995 and 2005. There were several key findings. First, older patients were more likely to achieve undetectable HIV RNA levels, a finding explained entirely by higher HAART adherence. Second, older patients had smaller increases in CD4 T-cell counts in the first year compared with younger patients but larger subsequent increases resulting in similar CD4 T-cell levels as younger patients at 3 years. Higher HAART adherence also explained immunological improvements in older patients. Finally, certain laboratory abnormalities were more frequent in older patients, including metabolic hematologic and renal adverse events.

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Albuminuria and Renal Function in Homozygous Sickle Cell Disease

Renal function was studied in subjects with sickle cell (SS) disease and in controls followed in a cohort study from birth. At age 18 to 23 years, subjects with SS disease had lower blood pressure and elevated glomerular filtration rate and effective renal plasma flow. The greater glomerular filtration rate and increased tubular secretion of creatinine combined to lower serum creatinine levels in patients with SS disease, giving an upper limit of the reference range of 0.90 mg/dL (80 μmol/L) in men and 0.77 mg/dL (68 μmol/L) in women.

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GFR indicates glomerular filtration rate; SS, sickle cell; and UL, upper limit.

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