Table of Contents

Indwelling urinary catheters increase risk for bacteriuria and clinically significant urinary tract infection. In a randomized trial, Stensballe and colleagues found that trauma patients who received a nitrofurazone-impregnated catheter were less likely than those who received a silicone catheter to develop catheter-associated bacteriuria and funguria or to need a change in or addition of new antibiotics. Use of nitrofurazone-impregnated catheters should therefore be considered in trauma patients. Whether other patients requiring indwelling urinary catheters would benefit from these catheters should be assessed in a randomized clinical trial.

The value of adding HLA genetic typing to serologic testing for celiac disease is not well defined. In this prospective study of patients referred for evaluation of suspected celiac disease, the performance of HLA-DQ typing and serologic testing combined was the same as either testing strategy alone. Relative to HLA-DQ typing alone, serologic testing raised the probability of celiac disease more when positive but lowered it less when negative. Although neither strategy is a substitute for small-bowel biopsy in the diagnosis of celiac disease, either can change the probability of celiac disease enough to affect decision making.

Fox and associates compared fondaparinux with enoxaparin for non–ST-segment acute coronary syndromes when the risk for bleeding was increased because of renal dysfunction. Among patients with a glomerular filtration rate (GFR) less than 58 mL/min per 1.73 m², fondaparinux had lower rates of combined death, major bleeding, myocardial infarction, or refractory angina than enoxaparin. The advantage of fondaparinux was largest among patients with a GFR less than 58 mL/min per 1.73 m².

Regression of left ventricular hypertrophy (LVH) has been associated with reductions in various cardiovascular outcomes, but heart failure outcomes have not been carefully studied. Okin and colleagues found that regression of LVH by Cornell product electrocardiographic criteria was associated with fewer hospitalizations for new-onset heart failure. This relationship appeared to be separate from blood pressure reduction and type of therapy. Whether clinicians should adjust antihypertensive therapy on the basis of electrocardiographic findings of LVH is not yet known.

Does adhering to depression practice guidelines improve depression outcomes? This observational study from 45 primary care practices found relatively poor adherence: Clinicians consistently followed only one third of the guideline recommendations for depression. Most clinicians initially recognized depression and started appropriate treatment, but they frequently did not address suicide risk, assess alcohol use, adjust treatment appropriately, or follow through on long-term treatment plans. Better adherence to recommendations was associated with a lower probability of persistent depressive symptoms.

Hyperkyphosis is a widely recognized yet largely ignored condition whose causes and consequences are not well understood. This narrative review presents evidence that osteoporosis and vertebral fractures do not fully explain hyperkyphosis. It is a distinct geriatric syndrome that deserves more attention. With increased clinical awareness informed by continued research, physicians can begin to help prevent and treat hyperkyphosis and may ameliorate its adverse health consequences.

Some people find the experience of illness and dying to be primarily physical, emotional, and spiritual. However, many others find that the intellect offers ways to frame the complexity of these experiences. Such patients find that intellectual frameworks help them to integrate illness and mortality into their bodies of knowledge. The 2001 film Wit, in particular, suggests the context for considering the intellect and meaning-making within illness and dying.

Hadithi and colleagues explored the possible use of the combination of HLA typing and serologic testing for diagnosing celiac disease. Instead of doing both tests, however, the editorialists suggest that clinicians should use serology or HLA typing (but not both), depending on the clinical situation. They describe clinical situations in which the use of HLA typing can be beneficial and discuss some of its potential restrictions.

Whereas guidelines make suggestions, performance measures convey what must be done for a patient. To transform a guideline recommendation into a performance measure, the supporting evidence should be unassailable, and the net benefit to patients should be clear. The article by Hepner and colleagues provides an example of the type of research that we should strive to provide before we transform guideline recommendations based on imperfect evidence into a performance measure.

Current guidelines for managing mild, persistent asthma recommend inhaled corticosteroids as first-line therapy. However, long-term use of these agents in high doses may cause adverse effects that require alternate strategies, including low-dose, once-daily inhaled corticosteroids and oral regimens that do not use corticosteroids. Two recently published trials, the Leukotriene or Corticosteroid or Corticosteroid-Salmeterol trial and the Beclomethasone plus Salbutamol Treatment multinational trial, describe the effects of these approaches.

This issue provides a clinical overview of dyslipidemia, focusing on prevention and screening, diagnosis, treatment, practice improvement, and patient information. Readers can complete the accompanying CME quiz for 1.5 credits.