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In This Issue of Archives of Internal Medicine
September 22, 2008

In This Issue of Archives of Internal Medicine

Arch Intern Med. 2008;168(17):1842. doi:10.1001/archinte.168.17.1842
Chronic Immune Stimulation and Subsequent Waldenström Macroglobulinemia

Koshiol et al assessed the risk of Waldenström macroglobulinemia (WM) associated with chronic immune stimulatory conditions for 361 WM cases in a cohort of more than 4 million hospitalized US veterans. In this largest investigation of WM risk factors to date, Koshiol et al found a 2- to 3-fold elevated risk of WM among persons with a personal history of autoimmune diseases with autoantibodies and notably elevated risks for hepatitis, human immunodeficiency virus, and rickettsiosis. These findings provide novel insights into the still unknown etiology of WM.

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Calorie Restriction and Bone Health in Young, Overweight Individuals

Based on studies in animals, interventions of calorie restriction are promoted as a means of increasing longevity, yet this regimen in humans could lead to bone loss and fracture and therefore have an impact on quality of life. Redman et al conducted a 6-month study of calorie restriction in nonobese humans not only to assess changes in biomarkers of longevity but also to determine if calorie restriction is associated with changes in bone mass and/or bone turnover markers in young adults. The authors observed that a moderate calorie restriction (25%) with or without exercise that preserves calcium intake leads to large changes in body composition without significant bone loss in young adults. The authors conclude that longer studies with assessments of bone architecture are essential to future studies of calorie restriction to confirm that calorie restriction, nutrient-dense diets have no deleterious effect on bone health.

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Community Infections Caused by Extended-Spectrum β-Lactamase–Producing Escherichia coli

Community-acquired infections caused by extended-spectrum β-lactamase–producing Escherichia coli are increasing worldwide; this is a matter of concern because these organisms are frequently multidrug resistant. In this study, risk factors for such infections were investigated using a multicenter case-control design. Multivariate analysis selected previous receipt of aminopenicillins, cephalosporins, and fluoroquinolones as independent risk factors, among others. Observational analysis suggests that fosfomycin tromethamine might be the preferred therapy for uncomplicated cystitis and that amoxicillin–clavulanate potassium is an alternative for susceptible isolates.

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Cost-effectiveness of HIV Monitoring Strategies in Resource-Limited Settings

Bendavid et al examined the effectiveness and cost-effectiveness of monitoring human immunodeficiency virus (HIV)-infected individuals with CD4 cell counts and viral load in southern Africa. The authors found that at a treatment initiation threshold of 200/μL, monitoring CD4 cell counts to determine the timing of antiretroviral therapy was associated with a gain of over 6 months of life expectancy and lifetime cost savings of $464 per person. Starting antiretroviral therapy at a higher threshold of 350/μL was associated with an additional 5.3-month gain in life expectancy. Viral load monitoring was also effective but was associated with substantial costs. The authors conclude that monitoring CD4 cell counts in southern Africa is an efficient strategy that may save costs, while the cost-effectiveness of viral load monitoring depends on test price and rates of treatment failure.

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Trade-offs in Cervical Cancer Prevention

To inform clinical decision making in the context of current and emerging screening guidelines, Stout et al used a computer simulation model to assess benefits and potential harms for cervical cancer screening strategies using cytologic and human papillomavirus (HPV) DNA testing. They found expected colposcopy referrals differed 3- to 5-fold across screening strategy despite similar rates of cervical intraepithelial neoplasia (CIN) type 2 or 3 detection. Referrals were highest with combination cytologic and HPV DNA testing and lowest with HPV DNA testing followed by cytologic triage. Regardless of strategy, more than 95% of screening tests prompting diagnostic workup were in women with no serious abnormalities. The use of cytologic testing–based strategies in younger women would minimize diagnostic workups as well as HPV-positive results on the initial screening test. Because women vary in the relative values they place on benefits and risks from screening, providing comparative information for women and their physicians may help in choosing among several acceptable screening strategies.

Expected screening outcomes and lifetime risk.

Expected screening outcomes and lifetime risk.

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