In This Issue of Archives of Internal Medicine

The National Physicians Alliance (NPA) initiated a project that aimed to develop a list of the “Top 5” activities in family medicine, internal medicine, and pediatrics, where changes in practice could lead to higher quality care and better use of finite clinical resources. An ideal activity for the “Top 5” lists would be one that was common in primary care practice, that was strongly supported by the evidence, and that would lead to significant health benefits and reduce risks, harms, and costs. The initial lists were subjected to 2 rounds of field testing. The 255 physicians involved in the field testing were generally supportive of the lists.

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Procalcitonin appears to be an effective indicator of bacterial respiratory processes and thus may be useful for tailoring antibiotic therapies for these conditions in an effort to reduce unnecessary antibiotic exposure for patients and health care costs. Schuetz et al performed a systematic review of the design, efficacy, and safety of published randomized controlled trials that used clinical algorithms based on procalcitonin levels to guide decisions about antibiotic treatment. Fourteen trials were included, and no difference in mortality between procalcitonin guided treatment and control patients was found. There was a consistent reduction in antibiotic prescription and/or duration of therapy identified, mainly owing to lower prescription rates in low-acuity conditions and shorter duration of therapy in moderate- and high-acuity conditions. On the basis of the available evidence, the authors propose procalcitonin algorithms for low-, moderate-, and high-acuity patients as bases for future trials aiming at reducing antibiotic overconsumption.

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Previous studies demonstrated that lifestyle modification can prevent type 2 diabetes mellitus (T2DM) among those with impaired glucose tolerance, but similar beneficial results have not been proven among those with impaired fasting glucose (IFG). This randomized controlled trial investigated the efficacy of 3-year individual-based lifestyle intervention on T2DM incidence in the overweight Japanese with IFG. The adjusted hazard ratio in the frequent intervention group was 0.56 (95% confidence interval [CI], 0.36-0.87). In the post hoc subgroup analyses, the hazard ratio decreased to 0.41 (95% CI, 0.24-0.69) among those with impaired glucose tolerance at baseline, and to 0.24 (95% CI, 0.12-0.48) among those with a baseline hemoglobin A_1c (HbA_1c) level of 5.6% or more (Japan Diabetes Society method). Lifestyle modifications could prevent T2DM among those with IFG. In addition, identifying individuals with more deteriorated glycemic status by using HbA_1c or 75-g oral glucose tolerance test, especially HbA_1c, could enhance the efficacy.

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Timely referral to nephrologists of patients with progressive chronic kidney disease has long been recommended, yet little is known about actual patterns of such care. Winkelmayer and colleagues assembled a large cohort study of older patients with chronic kidney disease who initiated dialysis between 1996 and 2006 and who had at least 2 years of Medicare coverage prior to initiation of dialysis. They found sizeable improvements toward earlier nephrology consultation among these patients over time. Patients initiated dialysis with more preserved kidney function and less anemia in more recent years; however, corresponding reductions in adjusted 1-year mortality over the decade of study were small.

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Despite the lack of evidence of its benefits or risks, consumption of soy isoflavones by menopausal women has significantly increased after the Women's Health Initiative report of the health risks associated with hormone therapy. In a 2-year placebo-controlled randomized trial, Levis et al evaluated the efficacy of high-dose soy isoflavone tablets in preventing menopausal changes. The study enrolled women aged 45 to 60 years, within 5 years from menopause. The authors report no differences between treatment groups in spine and hip bone density, cholesterol levels, or thyroid function. Women consuming soy isoflavone tablets experienced more hot flashes and constipation than those receiving placebo. Given current trends in the use of soy isoflavone products, these findings may influence women's choices when considering alternatives to hormone therapy to address menopausal symptoms and bone loss.

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