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In This Issue of Archives of Internal Medicine
March 13, 2006

In This Issue of Archives of Internal Medicine

Arch Intern Med. 2006;166(5):485. doi:10.1001/archinte.166.5.485

In This Issue ofArchives of Internal Medicine

Carotid Sinus Hypersensitivity in Asymptomatic Older Persons

Carotid sinus hypersensitivity is a common cause of falls and syncope in older persons. However, its prevalence in the community remains unclear. This study was carried out to determine the prevalence of carotid sinus hypersensitivity in an unselected sample of community-dwelling older persons, using standardized methods. A hypersensitive response to carotid sinus massage was found in 39% and was accompanied by symptoms in 16%. Carotid sinus hypersensitivity was seen in 35% of a subsample with no history of falls, syncope, or dizziness. The authors conclude that carotid sinus hypersensitivity is common in community-dwelling older persons and that its presence in patients presenting with syncope should not preclude investigation for other causes.

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The Importance of Echocardiography in Physicians' Support of Endocarditis Prophylaxis

A survey of 560 physicians examined the importance of echocardiography when making decisions regarding the provision of antimicrobial endocarditis prophylaxis. Despite a limited role for echocardiography in present guidelines, echocardiography was ranked as the most important factor in supporting the recommendation for endocarditis prophylaxis and overshadowed other clinical factors including guidelines and physical examination. Moreover, physicians who placed greater importance on echocardiography supported endocarditis prophylaxis at lower severities of valvular abnormality. These findings call for further studies evaluating the role of echocardiography in assessing endocarditis risk to assist in the development of clear clinical guidelines.

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Changes Over Time in Risk of Initial Virological Failure of Combination Antiretroviral Therapy

Lampe et al examined trends over time in the risk of initial virological failure of triple-combination antiretroviral therapy (CART) among 3825 individuals starting treatment for the first time from 1996 to 2002. The results show that the risk of initial virological failure has at least halved over this 7-year period. This marked trend is partly explained by improvements in starting regimens. The additional improvement is likely to reflect increasing clinical experience and more effective use of CART in practice. Risk of initial failure is now very low for patients first starting CART who remain on treatment. However, failure due to treatment discontinuation or loss to follow-up remains more common, suggesting potential for continued improvement in future years.

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Periodontal Infections and Coronary Heart Disease

Periodontal infection, a widespread problem in the general population, is a possible trigger of chronic inflammation. Spahr and colleagues examined the association between periodontal infection and coronary heart disease (CHD), focusing on microbiological aspects in 263 patients with CHD and 526 population-based, age- and sex-matched controls. A statistically significant association between periodontitis and the presence of CHD was seen. More importantly, however, the authors found a strong, statistically significant association between the periodontal pathogen burden and the presence of CHD, and these microbiological parameters were stronger predictors for the presence of CHD compared with the clinical assessment of periodontal disease. These findings suggest an association between periodontal infection and presence of CHD and furthermore point to the fact that periodontal pathogen burden may play a prominent role.

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The Accuracy of Surrogate Decision Makers

Current reliance on surrogates to make end-of-life treatment decisions for incapacitated patients typically is defended on the grounds that they are able to predict what choices the patient would have made if capacitated. Yet, a number of commentators have argued that surrogates are not able to predict patients' treatment pREFERENCES. To assess these claims, a systematic literature search was conducted. Overall, patient-designated and next-of-kin surrogates incorrectly predict patients' end-of-life treatment pREFERENCES in one third of all cases. These data undermine the claim that reliance on surrogates is justified by their ability to predict incapacitated patients' treatment pREFERENCES. Future research should assess whether reliance on surrogates is justified on other grounds. For example, serving as a surrogate may offer psychological benefits to patients' families and loved ones, or patients may be more concerned with who makes decisions for them, as opposed to what decisions are made for them at the end of life.

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