Table of Contents

The authors followed 1740 persons who did not have cognitive impairment at baseline. During a mean follow-up of 6.2 years, 158 participants developed dementia; the incidence rate was 13.0 per 1000 person-years for those who exercised 3 or more times per week at baseline and 19.7 per 1000 person-years for those who exercised less frequently. The results were similar in the 107 participants who developed Alzheimer disease.

The true causes of income-related health disparities are not known. In 3407 Canadian patients who were hospitalized for acute myocardial infarction, high income was associated with a lower 2-year mortality rate (crude hazard ratio, 0.45 [95% CI, 0.35 to 0.57]; P < 0.001). However, adjusting for income-related differences in age and the prevalence of preexisting cardiovascular events or risk factors substantially reduced the effect of high income (adjusted hazard ratio, 0.77 [CI, 0.54 to 1.10]; P = 0.150).

The authors compared Helicobacter pylori eradication rates among strains with different point mutations that confer clarithromycin resistance. Antibiotics eradicated Helicobacter pylori infection in 11 of 23 patients (48%) with the A2143G mutation and in 14 of 15 patients (93%) with either A2142G or A2142C strains. A sequential triple-therapy regimen achieved a higher cure rate than simultaneous triple therapy in A2143G mutation strains.

Retroperitoneal fibrosis is a progressive disease that can respond to corticosteroids but is sometimes steroid-resistant. Among 19 patients with retroperitoneal fibrosis who received tamoxifen, 20 mg twice daily, 15 reported substantial symptom resolution after a median of 2.5 weeks. Repeated computed tomography showed mass regression in 14 of 15 clinical responders. Treatment failed in 5 patients, and 1 patient developed severe hepatitis while receiving treatment.

Three ideas frame an effective system for managing poorly performing physicians: Subpar performance can be objectively defined; routine monitoring of the entire medical staff is necessary to detect problems fairly and early; and responses to deficiencies should be prompt, constructive, and sustained. The long-term objective is to enable physicians to continue to practice effectively and safely, not to “weed them out.”

The authors assessed the efficacy of currently marketed antimicrobial urinary catheters. In this systematic review of 12 trials, they concluded that antimicrobial urinary catheters can prevent bacteriuria in hospitalized patients during short-term catheterization. The cost implications of these catheters and their effect on infectious complications remain undefined.

The number of patients with opioid addiction who receive opioid agonist therapy (OAT) with methadone and buprenorphine is increasing, so that physicians will more frequently encounter such patients who have acutely painful conditions. This paper acknowledges the complex interplay among addictive disease, OAT, and acute pain management; describes 4 misconceptions that lead to suboptimal treatment of acute pain; and gives clinical recommendations for providing analgesia when a patient receiving OAT develops acute pain.

Larson and colleagues provide important evidence that more physical exercise is associated with lower rates of dementia, adding significantly to several other recent studies on the association between physical activity and dementia risk. We now need randomized trials to examine the effect of physical activity on cognitive function measures, and we need researchers to include clinical dementia end points in ongoing trials of lifestyle modification.

Do we really need another paper on socioeconomic inequalities in health? Alter and colleagues have added to our knowledge, but the assumption that we can reduce socioeconomic inequalities in survival after cardiovascular disease (CVD) by reducing morbidity and risk factors in poor people begs the key question. We must integrate our knowledge of the upstream social determinants that lead to differential burdens of CVD and its risk factors and the downstream, proximal biological factors that drive health outcomes. Building a bridge between these bodies of knowledge could provide a way to decrease socioeconomic inequalities in survival.

The work by De Francesco and colleagues showing the enhanced efficacy of sequential therapy is a timely advance for patients with peptic ulcer disease or mucosa-associated lymphoid tissue lymphoma, in whom Helicobacter pylori eradication is clearly indicated. A larger question is whether the relatively indiscriminate practice of “test and treat” for H. pylori infection treats the patient or the physician. In their zeal to remedy many ailments with antibiotics, physicians are contributing to new problems of antibiotic resistance and to changing human microecology.

Recently, my wife and I were out listening to a folk singer, and I realized how hard it is to listen to live music without leaning across a bar. It wasn't so long ago that 4 or 5 nights a week I poured beer and shook drinks while customers came and went. That life is so different from my current one that it could have been led by another person entirely.

During the physical examination, Aziza read me with astute observation: She sensed my aversion to physical contact with her and my attempt to end the session peacefully. I tried to understand the contents of her thoughts, since she easily transferred from the world of delusions to our world, complete with National Insurance forms. Why couldn't I, the sane one, identify with her hallucinations?