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In This Issue of Archives of Internal Medicine
May 28, 2007

In This Issue of Archives of Internal Medicine

Arch Intern Med. 2007;167(10):986. doi:10.1001/archinte.167.10.986
Helping Patients With Type 2 Diabetes Mellitus Make Treatment Decisions

In a randomized trial of 98 patients with type 2 diabetes mellitus, Weymiller et al found that a decision aid used by clinicians during the visit was acceptable to patients and clinicians; was able to improve patient knowledge of the potential benefits and risks of statins; effectively communicated risk information (including the absolute risk reduction in cardiovascular events expected from statin use); and led to less conflicted choices about using or not using statins. Furthermore, the trial results suggest that the use of decision aids in practice may improve short-term patient adherence to their choice of preventive medications.

Intakes of Calcium and Vitamin D and Breast Cancer Risk in Women

Lin et al prospectively evaluated intakes of total calcium and vitamin D in relation to breast cancer incidence among more than 30 000 women 45 years or older and free of cancer at baseline from the Women's Health Study between 1993 and 2004. The authors found that higher intakes of total calcium and vitamin D were moderately associated with a lower risk of breast cancer in premenopausal women, and the lower risk was more pronounced for more aggressive tumors including larger and poorly differentiated breast tumors. By contrast, intakes of both nutrients were not inversely associated with the risk of breast cancer among postmenopausal women. These findings suggest that calcium and vitamin D may have the potential utility in reducing the risk of breast cancer in younger women.

Evaluation of Clostridium difficile–Associated Disease Pressure as a Risk Factor for C difficile–Associated Disease

Colonization pressure is recognized as a risk factor for acquiring methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococcus. Dubberke et al examine whether Clostridium difficile–associated disease (CDAD) pressure is a risk factor for developing CDAD. CDAD pressure is a modified form of colonization pressure in which only clinically symptomatic cases of CDAD were included to measure exposure to C difficile. Only 1 patient who developed CDAD had a CDAD pressure of zero, compared with 50% of patients who did not develop CDAD. CDAD pressure remained an independent risk factor for CDAD on multivariable analyses and was the variable most strongly associated with the development of CDAD.

Management Patterns in Relation to Risk Stratification Among Patients With Non–ST Elevation Acute Coronary Syndromes

This study examined the treatment patterns of of 4414 patients enrolled in the prospective, multicenter Canadian Acute Coronary Syndromes I and II Registries, in relation to risk stratification by the validated Global Registry of Acute Coronary Event risk score. Despite a substantial temporal increase in the use of cardiac catheterization during index hospitalization, this invasive procedure remained paradoxically targeted toward low-risk patients. Similar management patterns were observed with the preferential use of coronary revacularization and evidence-based medical therapies in the low-risk group. These findings highlight the need for strategies aimed at eliminating the treatment-risk paradox to improve cost-effectiveness and clinical outcome in the management of acute coronary syndromes.

Exploring the Treatment-Risk Paradox in Coronary Disease

To explore the cause of the treatment-risk paradox reported for patients with coronary disease, McAlister et al examined data from a prospective cohort study of 3871 consecutive patients with angiographically proven coronary disease. They found that 1 month after angiogram, high-risk patients were less likely to be taking statins compared with lower-risk patients (56% vs 64%; crude risk ratio [RR], 0.88, but this treatment-risk paradox was completely attenuated by adjusting for exertional capacity and depressive symptoms (RR, 0.99). These results were robust across drug classes: while high-risk patients were less likely to be taking angiotensin-converting enzyme inhibitors, aspirin, and statins (26% vs 32%; crude RR, 0.80), this association did not persist in the adjusted model (RR, 0.99). This suggests that the treatment-risk paradox reported in administrative database analyses may be attributable to clinical factors not typically captured in databases.

Odds ratio for statin prescription in patients with a high-risk Duke Coronary Index.

Odds ratio for statin prescription in patients with a high-risk Duke Coronary Index.