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In This Issue of Archives of Internal Medicine
October 27, 2008

In This Issue of Archives of Internal Medicine

Arch Intern Med. 2008;168(19):2063. doi:10.1001/archinte.168.19.2063
Preadmission Use of Statins and Outcomes After Hospitalization With Pneumonia

The evidence for statins improving pneumonia outcomes is conflicting. Thomsen et al conducted a population-based study of 29 900 adults hospitalized for the first time with pneumonia between 1997 and 2004 in northern Denmark. Current statin use was associated with lowered mortality (30-day mortality rate ratio, 0.69), adjusting for a wide range of potential confounders; the findings remained robust and consistent in various subanalyses and in a propensity score–matched model. Statin users tended to have fewer pulmonary complications but a similar risk of concomitant bacteremia. These findings add to the accumulating evidence that statin use may be associated with improved prognosis after severe infections and emphasize the need for randomized trials.

See page 2081

Current Features of Infective Endocarditis in Elderly Patients

Infective endocarditis (IE) increasingly affects elderly subjects, but it is unclear whether it has unique features in this setting. Durante-Mangoni et al made a comprehensive assessment of risk factors, predisposing conditions, etiology, clinical features, and course and outcome of IE, comparing 1056 elderly subjects with 1703 younger ones. The study showed that IE in elderly subjects commonly develops after health care procedures in chronically ill patients, with diabetes and cancer as common underlying conditions. Peculiar patterns of cardiac involvement, causative pathogens, and type and frequency of complications characterize IE in elderly subjects. Clinical presentation may not be obvious, and surgical treatment is poorly applied. Diagnosis of IE is often challenging in elderly patients, and its prognosis is always worse in this major subgroup.

See page 2095

Cardiovascular Outcomes in Trials of Oral Diabetes Medications

Selvin et al systematically review the peer-reviewed literature on cardiovascular risk associated with oral agents (second-generation sulfonylureas, biguanides, thiazolidinediones, and meglitinides) for treating adults with type 2 diabetes mellitus. By pooling the results from 40 publications, the authors found that treatment with metformin was associated with a decreased risk of cardiovascular mortality (pooled odds ratio, 0.74; 95% confidence interval, 0.62-0.89). No other significant associations of oral diabetes agents with fatal or nonfatal cardiovascular disease or all-cause mortality were observed. When compared with any other agent or placebo, rosiglitazone was the only diabetes medication associated with an increased risk of cardiovascular morbidity or mortality, but this result was not statistically significant (odds ratio, 1.68; 95% confidence interval, 0.92-3.06). This analysis suggests that, compared with other oral diabetes agents and placebo, metformin was moderately protective and rosiglitazone possibly harmful, but lack of power prohibited firmer conclusions.

See page 2070

Dissociation Between Hospital Performance of the Smoking Cessation Counseling Quality Metric and Cessation Outcomes After Myocardial Infarction

Smoking cessation counseling, defined as medical record documentation that a patient received cessation instructions, is currently used by the Centers for Medicare & Medicaid Services and the Joint Commission on Accreditation of Healthcare Organizations as a metric of hospital quality for patients with acute myocardial infarction. In this study, Reeves et al show that improved documentation of smoking cessation counseling did not necessarily correlate with higher downstream smoking cessation rates at either the patient or the hospital level. These results raise concerns about the adequacy of the smoking cessation counseling metric as it is currently structured. Revision of this metric should be considered to more effectively reflect the goal of promoting smoking cessation.

See page 2111

National Trends in Treatment of Type 2 Diabetes Mellitus, 1994-2007

To describe US trends in type 2 diabetes treatment from 1994 through 2007, Alexander et al analyzed national prescribing data. Along with an increasing population of patients with diabetes, diabetes treatment has become more complex, with an increasing number of medications used per patient and a shift away from sulfonylureas and standard insulin preparations to an increasingly diverse range of newer medication classes and new forms of insulin. Aggregate drug expenditures for diabetes increased from $7 billion in 2001 to $13 billion in 2007. These increasing costs reflect greater use of thiazolidinediones, new insulin preparations, and medications in new therapeutic classes, such as sitagliptin and exenatide. The authors advocate for increased attention to cost-effective prescribing so that decisions to adopt newer and more costly therapies are correlated with benefits in clinical outcomes.

See page 2088