Copyright 2008 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.2008
Dracup et al surveyed the level of knowledge about ischemic heart disease and self-perceived risk for a future acute myocardial infarction (AMI) in 3522 patients with documented ischemic heart disease. Higher knowledge level about AMI symptoms and appropriate response were significantly related to female sex, younger age, higher education, participation in cardiac rehabilitation, and receiving care by a cardiologist rather than an internist or general practitioner. Clinical history (eg, AMI or cardiac surgery) was not a significant predictor of knowledge. Patients who had coronary artery bypass surgery considered themselves to be at lower risk for a future AMI compared with individuals of the same age with no history of cardiac disease. Patients require continued reinforcement about the nature of cardiac symptoms, the benefits of early treatment, and their risk status.
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Clinicians have generally avoided prescribing corticosteroids for active infection because of their known immunosuppressive effects and concern about long-term complications. In this review, McGee and Hirschmann analyze the published randomized, double-blind trials comparing corticosteroids and placebo in infections. They distinguish 5 possible outcomes: treatment with corticosteroids may improve patient survival (group 1 infections), reduce long-term disability (group 2 infections), relieve symptoms (group 3 infections), have uncertain effects (group 4 infections), or be harmful (group 5 infections). Overall, the authors conclude that corticosteroids are safe and do not delay microbiologic recovery, although courses longer than 3 weeks should be withheld from patients with concomitant human immunodeficiency virus infection and low CD4 cell counts.
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Biopharmaceuticals are often singularly effective but can be very expensive. In developing policies for use of these agents, managed care organizations frequently require that the treating physician try a more thoroughly tested, less expensive agent first. This policy, known as “stepped care,” has met with resistance from patient advocacy organizations. In this article, Kravitz et al use a cost-minimization analysis to argue that N-of-1 trials (single patient examinations in which the “blinded” patient receives a randomized sequence of treatments) may reduce costs compared with open access, while providing more precise information on individual treatment response.
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Treatment patterns for androgen deficiency were estimated in a population-based random sample of 1486 community-dwelling men. Untreated androgen deficiency was defined using total and free testosterone thresholds (< 300 ng/dL and < 5 ng/dL, respectively) and symptoms, whereas a treated case was defined as anyone receiving testosterone therapy. The authors found that under their assumptions, the majority of men (87.8%) were not receiving treatment despite apparently adequate access to care.
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Edelson et al used a cardiopulmonary resuscitation–sensing monitor and defibrillator with audiovisual feedback to measure the performance of resident resuscitation teams during actual in-hospital cardiac arrests and instituted an educational program of performance debriefing based on these data. Using this program, the investigators found a significant improvement in rescuer knowledge of resuscitation guidelines as well as resuscitation performance, when compared with a historical control. These improvements corresponded to a significant increase in the number of successful resuscitations during the intervention period.
Sample performance debriefing presentation slide. A 20-second defibrillator tracing used in a postevent debriefing illustrates shallow chest compressions, failure to respond to audio prompts to “compress deeper,” and hyperventilation. Each ventilation is marked with an arrow, and each audio prompt is marked with an asterisk.
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In This Issue of Archives of Internal Medicine. Arch Intern Med. 2008;168(10):1026. doi:10.1001/archinte.168.10.1026