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In This Issue of Archives of Internal Medicine
January 11, 2010

In This Issue of Archives of Internal Medicine

Arch Intern Med. 2010;170(1):5. doi:10.1001/archinternmed.2009.444
Rapid Response Teams

Chan et al examined the effect of rapid response teams on hospital rates of cardiopulmonary arrests and mortality through a systematic literature review and meta-analysis. While their use appears to have resulted in lower rates of cardiopulmonary arrests outside of the intensive care unit, the use of rapid response teams was not associated with lower hospital mortality in adults. In children, their use was associated with lower hospital mortality, but the findings were not robust to sensitivity analyses and the number of deaths prevented was out of proportion to reductions in cardiopulmonary arrest rates, raising questions about mechanisms of improvement. The authors conclude that, while rapid response teams have broad appeal, robust evidence to support their effectiveness in reducing hospital mortality—the primary reason for their development—remains lacking.

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Systematic Review of Guidelines on Cardiovascular Risk Assessment

In this study, guidelines for recommendations on cardiovascular risk assessment were critically appraised to guide selection of screening interventions for a cardiovascular health check. A review of 27 guidelines showed that only 16 provided information on conflicts of interest and 18 guidelines showed a considerable quality of development. Of these 18 guidelines, 20 recommendations were shown in detail. Disagreements were found on target populations, treatment thresholds, and screening tests in addition to the major cardiovascular risk factors. These disagreements can have important implications for allocation of preventive interventions. The authors conclude that physicians should select rigorously developed guidelines including sufficient information about possible conflicts of interest, which allows informed decision making on organizing their cardiovascular health checks.

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Detecting Acute HIV Infection Using 3 Different Screening Immunoassays and Nucleic Acid Amplification Testing for HIV RNA, 2006-2008

Identifying acute human immunodeficiency virus (HIV) infection (AHI) affords an important opportunity for HIV prevention because during this time individuals are highly infectious and are often unaware of their HIV status. Several studies have shown that AHI detection using pooled nucleic acid amplification testing (NAAT) after HIV-antibody screening is feasible in public health settings. Although the yield of pooled NAAT will ultimately depend on the sensitivity during seroconversion of the screening immunoassay used, all of the previous studies examined the yield of pooled NAAT after relatively insensitive immunoassays. In this study, Patel et al assessed the yield of pooled NAAT relative to first-, second-, and third-generation HIV-antibody screening assays. In addition, the authors examined the sensitivity of a fourth-generation antibody-antigen assay for AHI detection. Findings from this study support AHI screening with pooled NAAT after third-generation assays in areas of high HIV prevalence. However, when fourth-generation assays become available in the United States, it is less clear whether NAAT should play a role in AHI screening programs.

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Treatment Modification in HIV-Infected Individuals Starting Combination Antiretroviral Therapy Between 2005 and 2008

Adverse events to combination antiretroviral therapy (cART) against HIV infection are common reasons for treatment modification and poor adherence. In this study, Elzi et al investigated factors associated with early treatment modification due to drug toxic effects in 1318 antiretroviral-naive HIV-infected individuals participating in the Swiss HIV Cohort Study, who started cART between 2005 and 2008. Toxic effects remain a frequent reason for treatment modification. Also, the availability of different treatment options may trigger cART modification within the first weeks and months. However, it does not have an impact on treatment outcome. Close monitoring and management of adverse effects and drug-drug interactions are essential for the durability of cART.

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Unexplained Variation Across US Nursing Homes in Antipsychotic Prescribing Rates

Serious safety concerns related to the use of antipsychotics have not decreased the prescribing of these agents to nursing home (NH) residents. Chen et al assessed the extent to which resident clinical characteristics and institutional prescribing practice were associated with antipsychotic prescribing for a nationwide, cross-sectional population of 16 586 newly admitted NH residents in 2006 and found that more than 29% (n = 4818) of study residents received at least 1 antipsychotic medication in 2006. Of the antipsychotic medication users, 32% (n = 1545) had no identified clinical indication for this therapy. The authors conclude that the NH antipsychotic prescribing rate was independently associated with the use of antipsychotics in NH residents.

Use of antipsychotic medications in 2006.

Use of antipsychotic medications in 2006.

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