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In This Issue of Archives of Internal Medicine
July 27, 2009

In This Issue of Archives of Internal Medicine

Author Affiliations

Copyright 2009 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.2009

Arch Intern Med. 2009;169(14):1259. doi:10.1001/archinternmed.2009.200
Antipsychotic Drugs and Hyperglycemia in Older Patients With Diabetes

This population-based nested case-control study evaluated the association between new antipsychotic treatment and hyperglycemia in seniors with preexisting diabetes. Compared with remote treatment, current treatment with both typical and atypical antipsychotic agents was associated with a 50% increase in the risk of hospital visits for hyperglycemia after adjusting for baseline risk factors. The risk of hyperglycemia was increased regardless of baseline diabetes treatment and was particularly high among first-time antipsychotic drug users (only 1 prescription before the event). This study highlights the importance of enhanced glucose monitoring in all patients with diabetes treated with an antipsychotic agent, particularly after treatment initiation.

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Yield of Diagnostic Tests in Evaluating Syncopal Episodes in Older Patients

Mendu et al examined the yield and costs of tests used to evaluate older persons with syncope. Cardiac and neurologic tests were commonly obtained, despite minimal effect on diagnosis or management. Postural blood pressure recordings were performed in only about a third of older patients but had the highest yield among all tests examined in this study. In addition, postural blood pressure recordings represented the lowest cost per test affecting diagnosis or management. Patient characteristics, such as shortness of breath, history of heart failure, abnormal electrocardiogram, or low hematocrit level or systolic blood pressure, greatly increased the likelihood that a test would affect diagnosis or management. Costly and unnecessary testing is often used in evaluating older patients with syncope. Using patient characteristics and prioritizing higher yield tests would result in a more efficient and cost-effective approach to the evaluation of syncope.

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Psychological Distress in Long-term Survivors of Adult-Onset Cancer

Data from a US national survey of 4636 long-term survivors of adult-onset cancer and 122 220 respondents never diagnosed as having cancer show that long-term survivors are more likely to report serious psychological distress than respondents never diagnosed as having cancer, after adjustment for clinical and sociodemographic variables. Among long-term survivors, those who were younger, were unmarried, had less than a high school education, were uninsured, had more comorbidities, or had difficulty performing instrumental activities of daily living were more likely to report psychological distress. Physicians should be aware of the potential increased risk of psychological distress among long-term cancer survivors. This study identifies several clinical and sociodemographic factors associated with psychological distress that may help target high-risk survivors for psychological screening and mental health support.

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Modern-Day Clinical Course of Type 1 Diabetes Mellitus After 30 Years' Duration

Since the introduction of insulin therapy, which transformed type 1 diabetes mellitus from a uniformly fatal disease to a chronic degenerative one, persons with type 1 diabetes have experienced a litany of long-term complications resulting in loss of vision, renal failure, foot ulcers and amputations, and a heightened risk of cardiovascular disease. The demonstration by the Diabetes Control and Complications Trial that near-normal glucose level control decreases the microvascular and cardiovascular complications has heralded a new era of diabetes care. This study describes the current-day outcomes that patients with type 1 diabetes can expect with conventional therapy and intensive therapy. After 30 years of diabetes, 22%, 9%, and 9% of intensively treated patients developed proliferative retinopathy, advanced nephropathy, and cardiovascular disease, respectively. Fewer than 1% lost vision (<20/200), required a kidney transplant or dialysis, or had an amputation because of their diabetes. The remarkable improvement in long-term outcomes should inform clinicians and patients alike to implement intensive diabetes therapy as early in the course of diabetes as possible.

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Hospital Variation in Time to Defibrillation After In-Hospital Cardiac Arrest

Chan et al examined the degree to which hospitals vary in defibrillation response time for cardiac arrests due to ventricular fibrillation and pulseless ventricular tachycardia. Within the National Registry of Cardiopulmonary Resuscitation, they found that adjusted rates of delayed defibrillation (>2 minutes) varied widely across 200 hospitals (range, 2.4%-50.9%). Although the hospital at which a patient was admitted explained a greater proportion of the variation in rates of delayed defibrillation than did patient factors, the hospital effect was largely unexplained by traditional facility characteristics. Importantly, patients admitted at hospitals in the top-performing quartile for defibrillation time were 41% more likely to survive to discharge than patients admitted in the bottom-performing quartile. Given the association of defibrillation with improved survival, the authors conclude that future research is needed to better understand best practices in the delivery of defibrillation at top-performing hospitals.

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