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In This Issue of Archives of Internal Medicine
Arch Intern Med. 2002;162:863.
Simplification of the Diagnostic Management of Suspected Deep Vein
Thrombosis
This management study including consecutive outpatients suspected of
having deep vein thrombosis of the legs shows that it is safe to withhold
repeated ultrasound testing in patients with normal ultrasound and SimpliRED
D-dimer test results at presentation. The combination of a low clinical pretest
probability with either a normal compression ultrasound test or a normal D-dimer
test result appears to be equally safe in refuting the diagnosis of deep vein
thrombosis. Refuting the diagnosis on the basis of a normal compression ultrasound
test result, a normal D-dimer test result, or a low clinical pretest probability
alone is not safe.
(SEE ARTICLE)
Antithrombotic Treatment and the Incidence of Angina Pectoris
There is so far only limited information on the effects of antithrombotic
regimens on the incidence of angina pectoris. However, because angina is a
powerful predictor of major events of coronary heart disease, these effects
should be evaluated. Warfarin has an immediate effect on blood coagulability
and thrombosis, and recent evidence suggests that it may exert some of its
benefit through a delayed effect, perhaps on the vessel wall. The study by
Knottenbelt et al provides some, though far from conclusive, support for a
delayed effect and also suggests that low-dose aspirin may increase rather
than reduce the incidence of angina. However, the value of aspirin in the
prevention of nonfatal myocardial infarction is reemphasized, as is the benefit
of combined treatment with low-intensity anticoagulation and aspirin in preventing
both fatal and nonfatal events of coronary heart disease.
(SEE ARTICLE)
Anger in Young Men and Subsequent Premature Cardiovascular Disease:
The Precursors Study
Anger can trigger myocardial ischemia. We examined the risk of premature
and total cardiovascular disease (CVD) associated with anger during early
adult life in a prospective study of 1055 men followed up to 48 years. A total
of 205 men developed CVD, 77 before age 55 years (defined as premature disease).
The highest level of anger in response to stress, compared with lower levels,
was associated with an increased risk of premature CVD, including premature
coronary heart disease and myocardial infarction, but not total CVD. Anger
predicts incidence of premature CVD.
(SEE ARTICLE)
Primary Prevention of High Blood Cholesterol Concentrations in the
United States
Mean concentrations of total cholesterol (TC) among adults have declined
in the United States for decades. Whether the decline has been due to prevention
of high TC levels or to treatment of high TC levels once present is not known.
Goff et al examined changes in the entire distribution of TC levels across
US birth cohorts as sampled in the National Health Examination Survey and
the National Health and Nutrition Examination Surveys I, II, and III. Data
were analyzed on 49 536 participants born between 1887 and 1975 and examined
at ages 18 through 74 years between 1959 and 1994. The entire distribution
of TC has shifted to lower concentrations during this period. This downward
shift supports the contention that a strong prevention effect occurred in
the US population during the period 1959 through 1994. Greater understanding
of this dramatic change could support future cardiovascular disease prevention
efforts.
(SEE ARTICLE)
Identifying Undiagnosed Human Immunodeficiency Virus: The Yield of
Routine, Voluntary Inpatient Testing
Human immunodeficiency virus (HIV) testing efforts targeted to only
symptomatic patients are inadequate to identify the one third of HIV-positive
people in the United States who are unaware of their infection. In their study,
Walensky et al implemented 1993 Centers for Disease Control and Prevention
recommendations and offered routine HIV counseling and testing to inpatients
in an urban Boston (Mass) hospital. This program identified nearly twice the
number of HIV infections as background testing alone. Patients who were tested
during the program, who would likely not have been tested if this initiative
had not been in place, had an estimated HIV seroprevalence of 3.8% (95% confidence
interval, 1.8%-5.8%). The authors have shown that offering voluntary, routine
inpatient HIV counseling and testing can be successful as a screening program
and in identifying a substantial number of patients with undiagnosed HIV infection
who can be informed, counseled, and linked to care and treatment.
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Dotted lines represent 95% upper and lower confidence intervals.
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(SEE ARTICLE)
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