A cohort of 15 486 female never smokers aged 65 to 74 years and living with their surviving husbands in Hong Kong were followed up prospectively through linkage with the territory-wide tuberculosis notification registry and death registry for tuberculosis and death from 2000 to 2008. Passive exposure to secondhand tobacco smoke within the household was independently associated with the development of both active tuberculosis (hazard ratio, 1.49; 95% confidence interval, 1.01-2.19) and culture-confirmed tuberculosis (hazard ratio, 1.70; 95% confidence interval, 1.04-2.80), after controlling for potentially confounding background variables.
In this study, Glombiewski et al aimed to investigate the course of unspecific chest pain in primary care, with a focus on symptom persistence and health care utilization in Hessen, Germany. Of approximately 190 000 consecutive patients visiting their general practitioner between October 2005 and July 2006, 807 patients with unspecific chest pain were identified. The rate of persistent unspecific chest pain was 55.5%, and 10% showed inappropriate health care utilization. Most patients with persistent unspecific chest pain were referred to a cardiologist, and less than 2% were referred to mental health care specialists. The authors conclude that for most patients with unspecific chest pain, standard medical care does not offer sufficient help for symptom relief. One-tenth of patients with persistent chest pain underwent repeated diagnostic testing of no known clinical benefit. Psychological referrals are rarely used.
Low back pain is the most common musculoskeletal condition managed in primary care. Clinical practice guidelines recommend that the first line of care should be advice and simple analgesics and that referral for ancillary investigations is normally not required. This study compared the care provided during 3533 physician-patient encounters for new episodes of low back pain with evidence-based recommendations contained in clinical guidelines. The results indicate that most patients do not receive advice or paracetamol in the first instance of care. Instead, treatment consists of more complex and potentially harmful medications and investigations. The pattern of care provided to patients has not become more aligned to evidence-based recommendations over time.
Poor medication adherence limits the effectiveness of human immunodeficiency virus (HIV) treatments. This meta-analysis takes a new approach toward analyzing intervention effects by examining the active content of adherence support provided not only to the intervention but also to the control groups (the “usual” or “standard” care). The results showed that the effectiveness of intervention and standard care varied considerably between studies and could account for much of the variability in treatment success rates in control and intervention groups. Moreover, the effect sizes were best explained by the unique content of interventions compared with the standard care provided to control groups in study clinics. The main conclusions are that adherence care can be highly effective and determines HIV treatment success rates to a large extent; that HIV treatment effectiveness can be improved considerably if adherence support is optimized; and that meta-analyses of (behavior change) interventions should examine and control for variability in standard care delivered to controls.
To evaluate the impact of hyponatremia on patient outcomes, Wald et al examined all admissions to a tertiary care medical center in Boston, Massachusetts, between 2000 and 2007. After adjustment for key demographic and clinical factors, hyponatremia—whether present on admission, aggravated following hospitalization, or acquired during hospitalization— was associated with a higher risk of in-hospital mortality. In addition, hyponatremia was associated with a prolongation of hospitalization and a higher risk of discharge to a facility, suggesting that hyponatremia might also increase resource consumption. Trials are needed to determine whether strategies to prevent hyponatremia or reverse established hyponatremia improve patient outcomes.
Restrictive cubic spline depicting the unadjusted relationship between hospital admission serum sodium concentrations and in-hospital mortality.
In This Issue of Archives of Internal Medicine. Arch Intern Med. 2010;170(3):226. doi:10.1001/archinternmed.2009.531