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In This Issue of Archives of Internal Medicine
January 23, 2006

In This Issue of Archives of Internal Medicine

Arch Intern Med. 2006;166(2):145. doi:10.1001/archinte.166.2.145
Association Between Circulating White Blood Cell Count and Cancer Mortality

Inflammatory processes are implicated in the development and progression of cancer. However, it is not clear whether systemic markers of inflammation predict cancer. In a population-based cohort of older individuals free of cancer at the baseline examination, white blood cell count in the highest quartile compared with the lowest quartile was found to be associated with a relative risk of 1.7 for all cancer mortality (P<.05), independent of several important confounders. These results provide epidemiological evidence of an association between circulating white blood cell count, a widely available marker of inflammation, and subsequent cancer mortality.

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A Prediction Rule to Identify Low-Risk Patients With Pulmonary Embolism

There is growing evidence that outpatient treatment with low-molecular-weight heparin is feasible and safe in many patients with nonmassive pulmonary embolism (PE). However, outpatient treatment for this disease is not well accepted because no explicit criteria exist to identify patients with PE who are at low risk of adverse outcomes. Using retrospective data from 15 752 patients with PE from 189 hospitals in the United States, Switzerland, and France, Aujesky et al derived and internally and externally validated a simple and objective clinical model that accurately identifies patients with PE who are at low risk for 30-day mortality and severe nonfatal medical outcomes.

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Acetylcysteine in the Prevention of Contrast-Induced Nephropathy

Over the past 5 years, 34 published studies have explored the role of acetylcysteine for prevention of contrast-induced nephropathy. These numerous studies have not, however, conclusively resolved this research question. In this article, Bagshaw et al use acetylcysteine as a case study of how research evidence accumulates and consider whether an alternative approach to investigating acetylcysteine could have resulted in a more definitive conclusion. The authors consider the broader lessons learned from this case study and propose specific steps that could potentially improve the future coordination of research activity to ultimately yield more meaningful and definitive evidence on important clinical questions.

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Value of D-Dimer Testing for the Exclusion of Pulmonary Embolism in Patients With Previous Venous Thromboembolism

As D-dimer level remains elevated in a significant proportion of patients after completion of a 6-month anticoagulant course for a first episode of venous thromboembolism (VTE), the clinical usefulness of D-dimer for ruling out a possible recurrence might be limited. In 1721 consecutive patients presenting in the emergency department with clinically suspected pulmonary embolism (confirmed in 24%), the D-dimer test result was negative in 33% of patients without previous VTE but was negative in only 16% of patients with a previous thromboembolic event (P<.001). The 3-month thromboembolic risk was 0% (95% confidence interval, 0.0%-7.9%) in patients with previous VTE and a negative D-dimer test result. The 2-fold lower chance of obtaining a negative D-dimer test result in patients with previous VTE was independent of older age, active malignancy, fever, and recent surgery. Therefore, in patients suspected of pulmonary embolism with a previous thromboembolic event, a negative D-dimer test result appears to safely rule out a recurrent event. However, owing to lower proportion of negative results in such patients, the clinical usefulness of D-dimer testing is somewhat reduced.

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The Prevalence of Erectile Dysfunction in the Primary Care Setting

Although erectile dysfunction (ED) and associated risk factors have been described in many clinical settings, there is little information regarding men seen by primary care physicians. Among 3921 Canadian men aged 40 to 88 years, seen by primary care physicians, Grover et al found that the prevalence of ED was 49.4%. Independent risk factors associated with ED included the presence of cardiovascular disease (odds ratio, 1.45), diabetes (odds ratio, 3.13), and increasing 10-year Framingham coronary risk scores or fasting blood glucose levels. These findings suggest that both cardiovascular disease and blood glucose abnormalities, even if previously undiagnosed, may significantly increase the likelihood that ED is present.

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