In This Issue of Archives of Internal Medicine

There is limited and conflicting data on the effects of postmenopausal estrogen therapy on the risk of kidney stone formation. In this study, Maalouf et al reviewed the incidence of nephrolithiasis in 27 347 healthy postmenopausal women enrolled in the Women's Health Initiative hormone trials. Estrogen therapy was associated with a significant increase in nephrolithiasis risk among women using estrogen compared with women taking placebo (hazard ratio, 1.21; 95% confidence interval, 1.03-1.44). The mechanisms underlying this higher susceptibility remain to be determined.

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Hemolytic uremic syndrome (HUS) is a recognized potential complication of infection with Escherichia coli O157 but has not been well described in US outbreaks associated with other serotypes of Shiga toxin–producing E coli (STEC). Piercefield et al describe illness among persons hospitalized in the largest outbreak of STEC O111 in the United States to date, comparing patients who received a diagnosis of HUS with those hospitalized for outbreak-related illness who did not receive a diagnosis of HUS. In 156 confirmed or probable E coli O111 infections, HUS was identified in 26; 65% of patients with HUS required dialysis and 1 patient died. The majority of cases (58%) occurred among adults 18 years or older. Findings at the time of hospital admission associated with subsequent diagnosis of HUS included white blood cell count of at least 20 × 10³/μL, elevated serum creatinine level for age, and vomiting prior to admission.

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Inappropriate medication use is a major problem in elderly patients who have more comorbid chronic diseases and are more likely have adverse drug effects than younger populations. Much attention is given to frameworks for starting treatments. Much less attention is given to approaches to discontinuing medication. A feasibility study of a new systematic approach for simultaneous discontinuation of multiple medications was carried out in community-dwelling elderly patients with multiple comorbidities. The number of drugs was reduced by a mean of 4.2 per patient with no serious adverse effects attributable to discontinuation, and 88% reported global improvement in health. Restarting medication therapy was rarely required after successful discontinuation. Taking nonconsent and failures together, successful discontinuation was achieved in 81%.

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In this observational cohort study of 62 746 patients with chronic obstructive pulmonary disease (COPD) who had an identifiable primary care physician (PCP) in a year prior to the hospitalization, Sharma et al examined the effect of early follow-up visit following acute hospitalization on the 30-day risk of an emergency department (ED) visit and readmission. Overall, 74.1% were exclusively treated by their PCP and 25.9% were cotreated with a pulmonary physician in the year prior to hospitalization. Between 1996 and 2006, 66.9% of patients with COPD had an outpatient visit with their PCP or pulmonologist within 30 days of discharge. In a multivariable, time-dependent analysis, patients who had a follow-up visit had a significantly reduced risk of an ED visit (hazard ratio, 0.86; 95% confidence interval [CI], 0.83-0.90) and readmission (HR, 0.91, 95% CI, 0.87-0.96).

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This randomized controlled trial tested the impact of continuing education training on physicians' (n = 87) and community pharmacists' (n = 83) counseling behavior in 16 southeast Texas communities. Pretraining and posttraining surveys assessed health care providers' perceived ability, confidence, and intention (ACI) to address smoking, and patient exit interviews assessed counseling practices at 12-month follow-up. Comparing pretraining with posttraining assessments, there was a significant increase in the percentage of physicians and pharmacists with a high ACI in the intervention vs control group. Exit interviews with patients showed an increase in physicians in the intervention group assisting patients with quitting, but not in the control group. Hence, continuing education training led to significant and lasting improvement in counseling among physicians.

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