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In This Issue of Archives of Internal Medicine
February 23, 2004

In This Issue of Archives of Internal Medicine

Arch Intern Med. 2004;164(4):353. doi:10.1001/archinte.164.4.353

Inpatient to Outpatient Transfer of Care in Urban Patients With Diabetes

A key opportunity for continuing diabetes care is to assure outpatient follow-up after hospitalization, but little is known about postdischarge follow-up among patients with diabetes, particularly in an urban setting. This retrospective study, which analyzed a cohort predominantly composed of African Americans with type 2 diabetes mellitus discharged from a large county hospital, showed that most individuals accomplished a postdischarge visit. However, a substantial percentage had a visit only to an acute care setting or had no documented follow-up. New efforts need to be devised to track patients after discharge to assure care is achieved, especially in this patient population particularly vulnerable to diabetes.

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Vertebral Deformities in Rheumatoid Arthritis

Osteoporosis is a substantial problem in chronic inflammatory diseases such as rheumatoid arthritis (RA) and an established risk factor for fractures. In a population-based study on 249 female patients with RA aged 50 to 73 years and matched controls, vertebral deformities were evaluated by 2 validated techniques. Patients with RA had significantly more vertebral deformities compared with controls, especially multiple and moderate or severe deformities. Age- and weight-adjusted bone mineral density (BMD) was significantly decreased in RA patients with vertebral deformities compared with those without. In multivariate analysis, a diagnosis of RA was related to vertebral deformities independent of BMD and long-term corticosteroid use. This indicates that although BMD is a reliable tool for assessing fracture risk, other disease-related factors contribute to the development of vertebral deformities in patients with RA.

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Clinical and Autopsy Diagnoses in the Intensive Care Unit

Autopsy rates have declined worldwide, but recent retrospective intensive care unit (ICU) data have indicated major discrepancies between more than 25% of clinical and autopsy diagnoses. To determine how many patients might have benefited from different care, had the autopsy diagnosis been made pre mortem, a 3-year prospective study was conducted in a university hospital medical-surgical ICU. All clinical diagnoses were compared with autopsy findings at monthly clinical-pathological meetings. Of the 1492 patients admitted to the ICU, 315 died and 167 (53%) autopsies were performed. The most common reason for not obtaining an autopsy was family refusal, accounting for more than 80%. Among the intensivists' 694 premortem diagnoses, 33 (5%) were refuted and 13 (2%) were judged incomplete by autopsy. Autopsies revealed 171 new diagnoses, including 21 cancers, 12 strokes, 11 myocardial infarctions, 10 pulmonary emboli, and 9 endocarditis. Major diagnostic errors (Goldman class I and II discrepancies) were established in 53 patients (32%), and a higher percentage of immunocompromised patients was observed in the class I and II groups. Even in the era of modern diagnostic technology, regular comparisons of clinical and autopsy diagnoses provide pertinent information that might affect management of ICU patients.

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The Effects of Age, Sex, Ethnicity, and Sleep-Disordered Breathing on Sleep Architecture

Polysomnography is used to assess sleep quality and to gauge the functional impact of sleep disorders. In this study, data from the Sleep Heart Health Study (N = 2685; ages, 37-92 years) are used to assess the variation in sleep architecture across the population subgroups and to evaluate the extent to which sleep-disordered breathing contributes to poor sleep independent of other factors. Lighter sleep was found in men relative to women and in American Indians and blacks relative to other ethnic groups. Increasing age was associated with impaired sleep in men, with less consistent associations in women. Notably, women, compared with men, had, on average, 106% more slow wave sleep (Figure 1). Marked reductions in slow wave sleep with increasing age were seen in men and not women. Sleep-disordered breathing was associated with poorer sleep; however, these associations were generally smaller than associations with sex, ethnicity, and age. Current smokers had lighter sleep than former or never smokers. Little impact on sleep was associated with obesity. These data show that sleep quality varies with sex, age, ethnicity, and sleep-disordered breathing. Men, but not women, show evidence of poorer sleep with aging, suggesting important sex differences in sleep physiology.

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