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In This Issue of Archives of Internal Medicine
May 26, 2003

In This Issue of Archives of Internal Medicine

Arch Intern Med. 2003;163(10):1129. doi:10.1001/archinte.163.10.1129

In-Hospital Mortality Following Acute Exacerbations of Chronic Obstructive Pulmonary Disease

Acute exacerbations of chronic obstructive pulmonary disease (COPD) are a frequent cause of hospitalization in the United States. Previous studies of selected populations of patients with COPD have estimated in-hospital mortality to range from 4% to 30%. Patil and colleagues performed a cross-sectional study utilizing the 1996 Nationwide Inpatient Sample (a data set of all hospitalizations from a 20% sample of nonfederal US hospitals) to obtain generalizable estimates of in-hospital mortality in patients admitted for acute exacerbation of COPD, describe the admission characteristics of these patients, and identify risk factors for in-hospital mortality based on administrative data routinely collected in this population. The study population included 71 130 patients 40 years or older with an acute exacerbation of COPD at hospital discharge. The authors found that in-hospital mortality for patients with an acute exacerbation of COPD was 2.5%, with multivariable analyses identifying older age, male sex, higher income, nonroutine admission sources, and more comorbid conditions as independent risk factors for in-hospital mortality, and conclude that these findings demonstrate that administrative data collected in large patient populations can provide useful information regarding patient outcomes in acute exacerbations of COPD.

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Aspirin and Clopidogrel in Acute Coronary Syndromes

Thrombus formation over a disrupted atherosclerotic plaque causes acute coronary syndrome. Inhibition of the platelet-rich thrombus formation can be achieved with the use of aspirin (which inhibits thromboxane A2 production) and clopidogrel (which inhibits adenosine diphosphate–induced platelet aggregation). While there is a wealth of data showing the benefits from oral antiplatelet therapy in primary and secondary prevention of coronary artery disease, recent evidence demonstrated the safety and efficacy of using the combination of aspirin and clopidogrel in acute non–ST-segment elevation coronary syndromes.

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"Building" a History Rather Than "Taking" One

Patients and physicians enter the medical encounter with unique perspectives on the illness experience. These perspectives influence the way that information is shared during the initial phase of the interview. Previous research has demonstrated that patients who are able to fully share their perspective often achieve better outcomes. However, studies of patient-physician communication have shown that the patient's perspective is often lost. Researchers and educators have responded with calls for practitioners to adopt a "narrative-based medicine" approach to the medical interview. In this article, Haidet and Paterniti review the literature on narrative-based medicine with an emphasis on information sharing during the medical interview and suggest a framework of skills and attitudes that can act as a foundation for future work in educating practitioners and researching the medical interview.

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A Randomized Controlled Trial of Test-and-Treat Strategy for Helicobacter pylori

Guidelines recommend Helicobacter pylori (HP) testing and treatment for patients with a history of peptic ulcer disease (PUD), assuming that PUD has been documented and that successful HP eradication would eliminate the need for further therapy and medical utilization. In an open-label randomized controlled trial in a managed care setting, Allison et al evaluated the clinical outcomes and costs of a HP test-and-treat strategy vs usual care in 650 patients receiving long-term acid suppression therapy for PUD diagnosed by a physician. Only 17% of study participants had PUD confirmed by radiography or endoscopy; only 38% of the test-and-treat subjects tested positive for HP. The authors conclude that most patients receiving long-term acid suppression therapy for physician-diagnosed PUD in community practice settings are likely to have HP-negative, uninvestigated dyspepsia and that routine testing and treating for HP in these settings will not reduce acid-peptic–related costs and will have only a modest effect in reducing clinical symptoms and use of acid-reducing medication.

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