In This Issue of Archives of Internal Medicine

To examine the effectiveness of a telephone-based counseling program rooted in motivational interviewing to improve medication adherence for osteoporosis, Solomon et al conducted a 1-year randomized controlled clinical trial in which all participants had been newly prescribed a medication for osteoporosis. Persons were randomized to either a program of telephone-based counseling using a motivational interviewing framework or a control group that received mailed educational materials. In an intention-to-treat analysis, median adherence was 49% in the intervention arm and 41% in the control arm (P = .07). There were no differences in self-reported fractures.

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This study aimed to determine the independent relationship of sitting time to all-cause mortality. Prospective questionnaire data from 222 497 individuals 45 years or older from the 45 and Up Study were linked to mortality data from the New South Wales Registry of Births, Deaths and Marriages (Australia). Participants sitting 8 to 11 h/d and those sitting 11 h/d or more were 15% and 40% more likely to die, respectively, than those who sat less than 4 h/d. The population-attributable fraction of sitting time suggested that sitting was responsible for 6.9% of deaths. The association between sitting and all-cause mortality appeared consistent across the sexes, age groups, body mass index categories, and physical activity levels and across healthy people compared with people with preexisting cardiovascular disease or diabetes. These findings suggest that prolonged sitting is a risk factor for all-cause mortality, independent of physical activity.

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Among 4930 patients in the EVENT (Evaluation of Drug Eluting Stents and Ischemic Events) registry with paired creatine kinase–MB fraction (CKMB) and troponin data obtained after percutaneous coronary intervention (PCI), myocardial infarction (MI) diagnosis was much more frequent with troponin than CKMB (24.3% vs 7.2%). While both biomarkers were associated with increased risk for 1-year all-cause mortality, the hazard ratio (HR) for 3-fold elevation of troponin (adjusted HR, 1.7; 95% CI, 1.1-2.5) was lower than for CKMB (adjusted HR, 2.5; 95% CI, 1.5-4.1) and only approached that of CKMB at a troponin threshold of 20 times the diagnostic level. The currently proposed troponin threshold of 3 times the 99th percentile of the upper reference limit for post-PCI MI classifies nearly one-quarter of patients with events, thus providing limited discrimination for detection of events with greater prognostic significance. A peak troponin value greater than 20 times the diagnostic level approximates the frequency and hazard for late death associated with CKMB values greater than 3 times the diagnostic level.

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Estimates of influenza vaccine effectiveness for older adults are largely from observational studies, which are susceptible to bias. Applying instrumental variable analysis, a method designed to control for unmeasured confounding, to linked health administrative databases in Ontario, Canada, Wong et al found influenza vaccination to be associated with reductions in the composite of pneumonia and influenza hospitalization and all-cause mortality during influenza season (adjusted odds ratio, 0.86; 95% CI, 0.79-0.92) but not mortality alone (adjusted odds ratio, 0.94; 95% CI, 0.84-1.03). Compared with standard regression modeling, instrumental variable analysis appears to produce less-biased estimates of influenza vaccine effectiveness.

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Stelfox et al followed 3000 hospitalized patients with sudden clinical deterioration resulting in evaluation by an intensive care unit (ICU) medical emergency team. As the number of available ICU beds decreased, patients were less likely to be admitted to an ICU and more likely to have their goals of care changed to not include ICU admission, although hospital mortality did not vary. These findings suggest that valid admission and discharge guidelines for ICUs may help to guide resource allocation when demand for resources exceeds supply.

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