In This Issue of Archives of Internal Medicine

In a national cohort of 1621 incident dialysis patients whose demographic and clinical characteristics indicated eligibility for peritoneal dialysis (PD), Kutner et al found that only 61% reported that PD had been discussed with them and only 10.9% of informed patients actually initiated PD. Selection of PD differed substantially among patients treated by the 3 largest dialysis organizations and among patients located in the 18 End-Stage Renal Disease (ESRD) Network geographic regions. Patient counseling in dialysis modality treatment options is a key element affecting quality improvement within the revised reimbursement structure proposed by the Centers for Medicare and Medicaid Services for the federal ESRD Network Program.

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Xue et al evaluated the association of active and passive smoking with the incidence of breast cancer based on data from the Nurses' Health Study, including follow-up of 111 140 women from 1976 to 2006. A total of 8772 incident cases of breast cancer arose during 3 005 863 person-years of follow-up. Ever smokers had a slightly higher incidence of breast cancer than never smokers (hazard ratio [HR], 1.06). The incidence of breast cancer was positively associated with higher quantity of current and past smoking, younger age of initiation, longer duration, and more pack-years of smoking. While premenopausal smoking was associated with a slightly higher incidence of breast cancer (HR, 1.11 for increase of every 20 pack-years) especially smoking before first birth (HR, 1.18 for increase of every 20 pack-years), the direction of the association between postmenopausal smoking and breast cancer was reversed (HR, 0.93 for increase of every 20 pack-years). Passive smoking in childhood or adulthood was not associated with the incidence of breast cancer.

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In this 1-year prospective study, performed in a teaching hospital, the utility of this microbiologic test in the diagnosis and antimicrobial guidance of patients hospitalized with community-acquired pneumonia (CAP) was assessed. A total of 474 CAP episodes were included, 171(36.1%) of which were pneumococcal pneumonias. In terms of diagnostic accuracy, specificity of the test was 96%, positive predictive value ranged from 88.8% to 96.5%, and positive likelihood ratio ranged from 14.6 to 19.9. The results of the test led the clinicians to reduce the spectrum of antibiotics in 41 patients, and CAP was cured in all of them. The authors conclude that, when findings are positive, pneumococcal urinary antigen test is a useful tool in the treatment of hospitalized adult patients with CAP because it may allow the clinician to optimize antimicrobial treatment with good clinical outcomes.

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Most outpatients in the United States are treated with in-center hemodialysis (HD); however, 7% are treated with peritoneal dialysis (PD). Since the mid-1990s, there has been no change in the first-year mortality of HD patients, but short- and long-term outcomes of PD patients have improved. In this study, secular trends in relative survival of patients treated with HD and PD on day 90 of end-stage renal disease in the United States in three 3-year cohorts (1996-1998, 1999-2001, and 2002-2004) for up to 5 years were examined. There was a progressive attenuation in the higher risk for death seen in patients treated with PD across the 3 cohorts; for the 2002-2004 cohort, there was no significant difference in the death risk of patients treated with either dialysis modality throughout the 5 years of follow-up. The median life expectancy of HD and PD patients was 38.4 and 36.6 months, respectively. The equivalency of outcomes with the 2 therapies and lower cost of PD provides support for expanding the use of PD in the United States.

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Barzilay et al examined whether the presence of albuminuria is associated with the presence of impaired cognition and with the development of impaired cognitive function. A total of 28 384 participants with vascular disease or diabetes mellitus who were participants in 2 large clinical trials were examined. Compared with participants with no albuminuria, those with albuminuria had a 26% to 49% increased odds of having a reduced Mini-Mental State Examination (MMSE) score. During a median follow-up of 56 months, participants with baseline albuminuria had 21% increased odds of cognitive decline compared with those with no albuminuria. Participants who developed new albuminuria during follow-up had a 30% to 77% increased odds of cognitive decline compared with those who remained normoalbuminuric. All these findings were statistically significant. These data suggest an association between albuminuria and cognitive function, supporting the notion that both conditions share a common microvascular pathogenesis.

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