The available armamentarium of agents used in the treatment of acute coronary syndromes continues to expand. It includes well-tested agents such as aspirin, unfractionated heparin, early-generation fibrinolytic agents, and newer agents such as low–molecular-weight heparins, direct thrombin inhibitors, thienopyridines, platelet glycoprotein IIb/IIIa receptor inhibitors, and bolus-administered fibrinolytic agents. In this article, studies of these established agents as well as newer ones are critically reviewed, and recommendations are given regarding use of antithrombin, antiplatelet, and thrombolytic agents in patients with acute coronary syndromes.
In a prospective cohort study of 13 643 men and women who participated in the National Health and Nutrition Examination I (NHANES I) Epidemiologic Follow-up Study, the incidence of congestive heart failure was positively and significantly associated with male gender, less than a high school education, low physical activity, cigarette smoking, being overweight, diabetes, valvular heart disease, and coronary disease. More than 60% of the congestive heart failure cases in the United States may be attributable to coronary heart disease.
Research involving human subjects may be approaching a crossroads: tension is growing between established policies of protection and more recent policies encouraging access to and participation in research. This tension is underscored by shortcomings in research protections, including subjects' confusion about the difference between research and therapy, misperceptions regarding the potential therapeutic benefits of research, and inadequacies in the informed consent process. The authors argue that unless shortcomings in research protections are addressed, the foundation of the research enterprise—embodied in the trust of subjects and the public—will be irreparably undermined. They conclude that attention to these issues is the responsibility of researchers, institutions, and others who represent the research community.
Adverse drug events are a major cause of morbidity, mortality, reduced compliance, and higher health care costs. Because most adverse effects are dose-related, the selection of dosage is often key to avoiding or minimizing adverse effects. Although physicians are frequently advised to use the lowest effective dose of drugs, this analysis reveals that many low doses that are proven effective are not provided in the Physicians' Desk Reference (PDR), the leading source of drug information for physicians. Because no mechanism exists for ensuring that relevant premarketing and postmarketing studies are included in the PDR, there is a gap in readily available, clinically important information on low-dose treatment. Mechanisms need to be created so that physicians (and interested consumers) have access to information about the full range of effective drug doses. This article contains a compilation of low-dose alternatives for 48 major medications.
Suicide in medically ill patients may be linked with depressive and substance abuse disorders, the most commonly found psychiatric conditions in people who commit suicide. This article assesses the rate of suicide shortly after discharge and diagnostic risk factors for suicide in general hospital patients (who were not initially admitted because of suicide attempts). The suicide rate in this population was 3-fold higher than in the general population. Seven of 11 patients committed suicide within 12 months after being in the hospital. Depressive and/or substance abuse disorders were risk factors for suicide, but were also frequently found in patients who did not commit suicide after being discharged. The authors conclude that improvement is needed in detecting psychiatric conditions and initiating psychiatric referrals to reduce psychiatric morbidity and possibly also suicide rates in general hospital patients.
In This Issue of Archives of Internal Medicine. Arch Intern Med. 2001;161(7):921. doi:10.1001/archinte.161.7.921