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In This Issue of Archives of Internal Medicine
July 10, 2006

In This Issue of Archives of Internal Medicine

Arch Intern Med. 2006;166(13):1341. doi:10.1001/archinte.166.13.1341
Unanswered Questions for Management of Acute Coronary Syndrome

Bugiardini and colleagues provide data on the 1-year follow-up in a group of 710 patents with non–ST-segment elevation–acute coronary syndromes and nonobstructive coronary disease. The results demonstrate a wide range of outcomes. The majority of events were driven by repeated admission for unstable angina (10.1%). However, the mean risk was high even for death and myocardial infarction (2.1%). The Thrombolysis in Myocardial Infarction core risk proved to have a good discriminating power for death and myocardial infarction also in this group of patients (from 0.6% to 4.1%).

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Evaluation and Treatment of Pharyngitis in Primary Care Practice: The Difference Between Guidelines Is Largely Academic

Guidelines from the American College of Physicians and the Infectious Diseases Society of America differ regarding the best way to evaluate adults with pharyngitis, mainly for adults with a high probability of having streptococcal pharyngitis. Despite this controversy, this retrospective analysis found that clinicians failed to follow either guideline in 66% of visits, mainly through indiscriminant testing and prescribing antibiotics to adults at low risk for streptococcal pharyngitis, patients for whom the guidelines agree. The authors conclude that the major problem in the management of adults with pharyngitis is not which guideline to follow, but that clinicians failed to follow any guideline.

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Healthy Lifestyle and the Risk of Stroke in Women

In a prospective cohort study among more than 37 000 women, Kurth and colleagues evaluated the association between lifestyle and risk of stroke as well as stroke subtypes. The authors found that a healthy lifestyle composed of abstinence from smoking, low body mass index, moderate alcohol consumption, regular exercise, and healthy diet was associated with a substantially reduced risk of total and ischemic stroke but not hemorrhagic stroke.

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The Association Between Marijuana Smoking and Lung Cancer

By conducting a systematic review, Mehra et al assessed the impact of marijuana smoking on the development of premalignant changes in the lung and lung cancer. The resulting 19 studies included in the review found an association of marijuana smoking with increased tar exposure, alveolar macrophage tumoricidal dysfunction, increased oxidative stress, and bronchial mucosal histopathologic abnormalities compared with tobacco smokers or nonsmoking controls. Observational studies of subjects with marijuana exposure failed to demonstrate significant associations between marijuana smoking and lung cancer after adjusting for tobacco use. The primary methodological deficiencies noted include selection bias, small sample size, limited generalizability, overall young participant age precluding sufficient lag time for lung cancer outcome identification, and lack of adjustment for tobacco smoking. Given the prevalence of marijuana smoking and studies predominantly supporting biological plausibility of a marijuana smoking–lung cancer association on the basis of molecular, cellular, and histopathologic findings, physicians should advise patients regarding potential adverse health outcomes until further rigorous studies are performed allowing definitive conclusions.

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Renal Function and Heart Failure Risk in Older Black and White Individuals

Chronic kidney disease is a risk factor for heart failure, an association that may be particularly important in black individuals who are disproportionately affected by both processes. Bibbins-Domingo et al determined whether the association of chronic kidney disease with incident heart failure differs between blacks and whites using several markers of kidney function including cystatin C, which may be sensitive for detecting small decrements in function. In this study of 1124 black and 1676 white older persons without heart failure followed up for 5.7 years in the Health, Aging, and Body Composition Study, lower levels of kidney function were associated with the risk of heart failure. The magnitude of the association of lower kidney function with incident heart failure was greater for blacks than for whites, particularly when cystatin C was used. The population attributable risk of heart failure associated with moderate or high concentrations of cystatin C (≥0.94 mg/dL) was 47% for blacks but only 5% among whites.

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