In This Issue of Archives of Internal Medicine

Leung et al performed a multicenter cohort study of 964 263 cases from nearly 300 hospitals using the America College of Surgeons–National Surgical Quality Improvement Program database to determine the association between preoperative hyponatremia and 30-day perioperative outcomes. The investigators found that patients with hyponatremia, compared with those with normal baseline sodium levels, had greater odds of perioperative death, and this association was present for all subgroups without exception. There were likewise increased odds of major coronary events, surgical site infections, and pneumonia. These findings suggest that hyponatremia, when detected preoperatively, should be considered a marker for perioperative complications.

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To quantify the short-term within-person variability of C-reactive protein (CRP) in a sample of the general population, Bower et al analyzed data from the 2001-2002 National Health and Nutrition Examination Survey. High-sensitivity CRP was measured in 541 participants at 2 time points. Significant short-term variation in CRP levels was observed, particularly at higher CRP values. Of those with an elevated CRP level at the first clinical examination, 32% had normal CRP values at the second clinical examination. These findings suggest that clinicians should consider routine repeated testing to confirm elevations when using CRP to inform treatment decisions.

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Fairlie et al examined visit rates and antibiotic prescribing patterns for adults with acute sinusitis in the United States. Using a nationally representative data set of ambulatory visits, the authors found that, between 2000 and 2009, there was a mean of 4.3 million outpatient visits per year. More than 80% of patients diagnosed as having acute sinusitis received an antibiotic, and fewer than 20% received amoxicillin, the recommended first-line treatment during the study period. Nearly 50% of patients diagnosed as having acute sinusitis received either a macrolide or a quinolone. Changes in prescribing behavior of health care providers for sinusitis are urgently needed to improve health care quality and stem the rising tide of antibiotic resistance in the United States.

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In a retrospective evaluation of 442 patients with warfarin-associated gastrointestinal tract (GI) bleeding, Witt et al showed that patients who resumed warfarin therapy following their hospitalization or emergency department visit were not at significantly higher risk for recurrent bleeding during the next 90 days, but those who did resume warfarin therapy (n = 260) had a lower risk for thrombosis and death. While no bleeding recurrences were fatal, 3 patients with atrial fibrillation had fatal strokes during warfarin discontinuation. For many patients surviving warfarin-associated GI bleeding, the benefits of resuming anticoagulant therapy will outweigh the risks.

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Using 2007-2009 Medicare Part D data, Zhang et al examined geographic and seasonal variations in antibiotic use. Substantial geographic and seasonal variation existed across regions, after adjusting for population characteristics including demographics, insurance status, and clinical characteristics. These differences could not be explained by differences in the prevalence of the underlying conditions. The South saw the highest antibiotic use, where 21.4% of patients per quarter used an antibiotic, compared with 17.4% in the West (P < .01), the lowest region. Regardless of region, the rate of antibiotic use was highest in the first quarter (20.9% in January-March) and lowest in the third quarter (16.9% July-September) (P < .01).

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