Table of Contents

The authors sought alternatives to polysomnography for making a diagnosis of obstructive sleep apnea (OSA). They created a clinical algorithm that used clinical methods and overnight home oximetry to calculate the probability of OSA. Sixty-eight patients with a probability of OSA of 90% or greater were randomly assigned to usual care (polysomnography before starting continuous positive airway pressure [CPAP]) or ambulatory management (start CPAP without doing polysomnography). After 3 months, the 2 groups had the same results on overnight polysomnography.

The authors screened all adult medical inpatients at an inner-city teaching hospital and randomly assigned 341 risky drinkers to a 30-minute motivational counseling intervention followed by treatment planning or to usual care. By 3 months, the same proportion of patients from both groups had received alcohol assistance. At 12 months, both groups had reduced their drinking to the same degree. A 30-minute intervention was insufficient to change behavior in these risky drinkers, 76% of whom were alcohol-dependent.

Data from a national registry of end-stage renal disease patients showed that the number of octogenarians and nonagenarians starting dialysis has nearly doubled from 1996 to 2003. Patients starting dialysis in 2003 had higher glomerular filtration rates and less morbidity related to chronic kidney disease than those starting dialysis in 1996. Although people starting dialysis in 2003 had less advanced kidney disease, the 1-year mortality rate on dialysis was approximately 50% in 1996 and 2003.

When patients on long-term warfarin therapy require surgery, low-molecular-weight heparins are often used as bridging therapy between full anticoagulation with warfarin and no anticoagulation during surgery. Because of safety concerns, the authors measured heparin activity after an evening dose of low-molecular-weight heparin. They found that two thirds of 94 patients—who received their last dose of enoxaparin 14 hours before surgery—had elevated heparin levels when surgery was scheduled to begin. They suggest a longer interval between the last dose of heparin and the time of surgery.

Home-based primary care for homebound elderly patients is complex, practice constraints are unique, and no quality-of-care standards exist. An expert panel reviewed established standards for geriatric care and modified some to make them more applicable to home-based care. A separate panel used a modified Delphi process to rate the validity of the indicators and found that the quality indicator set provides a comprehensive framework for evaluating home-based primary care.

Intravenous immunoglobulin (IVIG) therapy is a proposed adjuvant treatment for sepsis, although the benefits remain unclear and it is not currently recommended. This meta- analysis identified 20 randomized trials that studied a total of 2621 critically ill adults with sepsis. Polyclonal IVIG decreased mortality more than placebo or no intervention. The largest survival benefits occurred with higher doses and prolonged administration and in more severely ill patients.

Venous thromboembolism is a common condition affecting 7.1 community residents per 10 000 person-years. Incidence rates are higher for men and African Americans and increase substantially with age. The target audience for the guidelines in this issue is all clinicians who care for patients with deep venous thromboembolism or pulmonary embolism.

New treatments are available for venous thromboembolism. This background paper to the guidelines on treatment of venous thromboembolism from the American College of Physicians and the American Academy of Family Physicians in this issue reviews the evidence on the efficacy of interventions for treatment of deep venous thrombosis and pulmonary embolism.

In this issue, Saitz and colleagues studied the effects of a brief intervention in hospitalized problem drinkers. The result is disappointing: The intervention had no effect on any of the 2 primary outcomes or the 9 secondary outcomes. The study, which was of extremely high scientific quality, may have had more success with interventions that were targeted at specific subpopulations.

In this issue, the On Being a Doctor story of Squatter Sam is well worth reading and sharing. It is a physician's story—a story about the kind of patient we all remember well. With a few words, this vignette goes deeply into the physician–patient experience and speaks to critical professional qualities of caring, bonding, doing what's right, and reflecting on what we have done.

It was a cold winter afternoon in Fairbanks, Alaska. There was a slight air of expectation in our 2-doctor internal medicine office. After a 5-year hiatus, Sam had finally made an appointment. I first met Sam some 15 years ago, and even in a place famous for colorful characters, he was a standout.

The second issue of In the Clinic provides a clinical overview of the health consequences of smoking as well as a comprehensive discussion on prevention of smoking-related disease, treatment, and practice improvement. Readers can complete the accompanying CME quiz for up to 1.5 credits.