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1 July 2008 Annals of Internal Medicine Tip Sheet

Annals of Internal Medicine is published by the American College of Physicians on the first and third Tuesday of every month. These highlights are not intended to substitute for articles as sources of information. For a copy of an article, call 1-800-523-1546, ext. 2656, or 215-351-2656, or visit Past highlights are accessible as well.

1. Benefits of Tight Glucose Control Remain Uncertain for Older Diabetics

In a computer modeling study, researchers set out to assess the effects of comorbid illnesses and functional status on the expected benefits of intensive glucose control. They found that in patients aged 60-80 with Type 2 diabetes and intensive glucose control (HbA1C <7 percent), the presence of comorbid illnesses or functional impairment was a more important predictor of life expectancy than the benefits of intensive glucose control. The results of the study imply that the challenge for older patients and their physicians is deciding on the value of pursuing a complex regimen of intensive glucose control.

2. U.S. Task Force Reaffirms Screening Recommendations for Bacteria in Urine

The U.S. Preventive Services Task Force (USPSTF) strongly reaffirmed an earlier recommendation supporting doing a urine culture to screen for asymptomatic bacteriuria (no symptoms despite presence of bacteria) in pregnant women at 12 to 16 weeks' gestation or at the first prenatal visit, if later. In 2004 and now in 2008, the USPSTF recommends against routinely screening men and non-pregnant women. In pregnant women, asymptomatic bacteriuria has been associated with low birthweight babies. Then and now, the USPSTF found strong evidence that screening pregnant women with asymptomatic bacteriuria reduces urinary tract infections in mothers and low birthweight in babies. They found adequate evidence that screening non-pregnant adults with asymptomatic bacteriuria does not improve outcomes. Screening has one potential harm: it could lead to the use of antibiotics in people who would have gotten better without treatment, exposing them to possible antibiotic side effects and increasing antibiotic resistance.

3. "Four-Hour Rule" for Treating Pneumonia Has Lessons for Performance Measurement

Since 2002, all U.S. hospitals have had to publicly report their adherence to a controversial performance standard -- that all patients with community-acquired pneumonia (CAP) receive antibiotics within four hours of hospital admission. Since 2006, adherence brought additional hospital payments. The authors of this article detail the evolution of this performance standard -- from the research behind it to the criticism against it. They describe four lessons for future pay-for-performance standards. The authors say that while missteps will happen, they "should not dissuade us from promoting interventions that can improve patient care nor lead us to insist on unattainable levels of evidence before proceeding."

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