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September 26, 2002 Vol. 347 No. 13
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Antithrombotic therapy is routinely prescribed after myocardial infarction. This study compared the effect of warfarin, aspirin, or the combination of both medications on a composite end point of death, nonfatal reinfarction, or thromboembolic stroke. Both warfarin regimens were superior to the aspirin regimen. The combined-therapy regimen was somewhat more favorable than the warfarin-alone regimen but not significantly so.
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Interferon-based therapies combined with ribavirin are effective for chronic hepatitis C, but many patients do not have a response and side effects are common. Pegylated interferons are more efficacious than standard interferons. In this large trial, peginterferon alfa-2a plus ribavirin resulted in a higher rate of sustained virologic response (56 percent) than interferon alfa-2b plus ribavirin (44 percent) and peginterferon alfa-2a alone (29 percent). Side effects occurred less often with peginterferon alfa-2a plus ribavirin than with interferon alfa-2b plus ribavirin.
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Familial aggregation occurs among persons with renal calcium stones or bone demineralization, suggesting a genetic propensity toward these disorders. In this study of 14 patients with stones and 6 with bone demineralization, all of whom also had hypophosphatemia and decreased renal phosphate reabsorption, 2 patients were found to have unique mutations in the type 2a sodium–phosphate cotransporter.
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Recombinant human activated protein C has been shown to reduce mortality among patients with severe sepsis. Given the high cost of activated protein C ($6,800 per therapeutic course) and the high incidence of severe sepsis, the economic implications of widespread use of activated protein C are important. In this cost-effectiveness analysis, the authors report that activated protein C is associated with a cost of about $28,000 per year of life gained and $47,000 per quality-adjusted year of life gained. However, treatment of patients with an APACHE II score of 24 or less is associated with a cost of $575,000 per year of life gained.
Prostacyclin inhibits platelets and dilates blood vessels, whereas thromboxane A2 activates platelets and constricts vessels. In mice lacking receptors for prostacyclin, intimal injury provokes a severe reaction within the artery, whereas in mice lacking thromboxane A2 receptors the response is subdued. These findings are relevant to clinical concerns that cyclooxygenase-2 inhibitors, which specifically impair the formation of prostacyclin, may increase susceptibility to cardiovascular events. Aspirin, which inhibits both prostacyclin and thromboxane A2, protects against arterial thrombosis.
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