In This Issue of Archives of Internal Medicine

Over the previous decade, many strategies for the prevention of acute myocardial infarction found to be effective in clinical trials have been adopted by practitioners in the community. Understanding whether this has led to declines in the incidence of myocardial infarction is critical to evaluating the success of such approaches. Yeh and Go review the selected studies examining trends in the incidence of myocardial infarction in distinct communities, discuss methodological challenges limiting these studies, and identify opportunities for future research. The authors argue that more contemporary assessments of community-wide changes in the epidemiology of myocardial infarction are needed to help assess the effectiveness of primary and secondary cardiovascular prevention.

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Sabaté et al conducted a pooled analysis to estimate the effect of nuts on blood lipid profile and to examine whether different factors modify the effects. Individual primary data from 25 nut trials conducted in 7 countries with 583 normolipidemic and hypercholesterolemic men and women with no concomitant lipid-lowering medication were pooled, and mixed linear models were used to assess the effect of nuts and potential interactions. The effect of nuts was dose-related, and different types of nuts had similar effects on blood lipid levels. The effect of nuts was significantly modified by low-density lipoprotein cholesterol level, body mass index, and diet type: the lipid-lowering effect of nuts was greatest among subjects with high baseline low-density lipoprotein cholesterol concentrations and low body mass index levels and those consuming Western-type diets.

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Proton pump inhibitors (PPIs) are frequently prescribed as “stress ulcer” prophylaxis for medical inpatients without clear risk factors for nosocomial upper gastrointestinal tract bleeding. In this single-center study, Yachimski et al report the impact of standardized guidelines on inpatient PPI use rates. Of the 942 patients in the study, 458 (49%) received PPIs while inpatients and 387 (41%) were prescribed PPIs at discharge, with outpatient PPI therapy representing the strongest predictor of inpatient PPI use. Implementation of guidelines resulted in lower rates of inpatient PPI use (27% before vs 16% after guidelines; P = .001) and PPI prescription at discharge (16% before vs 10% after guidelines; P = .03) among the subset of patients not receiving outpatient PPI therapy.

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Bravata et al sought to identify processes of stroke care that are associated with patient outcomes (in-hospital mortality, discharge to hospice, or discharge to a skilled nursing facility) after adjustment for both patient characteristics and quality of care. Seven processes of care were evaluated: fever management, hypoxia management, blood pressure management, neurological evaluation, swallowing evaluation, deep vein thrombosis (DVT) prophylaxis, and early mobilization. The following patient characteristics were included in risk adjustment: age, medical history, concomitant medical illness, symptom course, prestroke functional status, code status, stroke severity, nonneurological status, modified APACHE (Acute Physiology, Age, Chronic Health Evaluation) III score, and brain imaging. Among the 1487 patients with ischemic stroke or transient ischemic attack, Bravata et al found that patients who received a swallowing evaluation, DVT prophylaxis, and oxygen for all episodes of hypoxia were less likely to have a poor outcome. The authors recommend that organizations that establish national performance measures add treatment of hypoxia to their assessment of stroke care quality and continue to measure DVT prophylaxis and swallowing assessment.

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Proton pump inhibitors (PPIs) have been associated with an increased risk for Clostridium difficile infection (CDI). Linsky et al examined data from 1166 patients with incident CDI in the New England Veterans Healthcare Administration between 2003 and 2008 to evaluate the association of PPIs with recurrent CDI. They found that the adjusted hazard ratio of recurrent infection within 90 days was 42% greater for those prescribed PPIs during the 14 days after incident infection than for those not exposed to PPIs (hazard ratio, 1.42; 95% confidence interval, 1.11-1.82). These findings warrant careful consideration of the indications for prescribing PPIs during treatment of CDI.