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April 10, 2003 Vol. 348 No. 15
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The standard therapy for idiopathic venous thromboembolism is anticoagulation with heparin followed by 3 to 12 months of warfarin therapy, but after warfarin is discontinued, venous thrombosis may recur. This clinical trial compared long-term, low-intensity warfarin therapy (target international normalized ratio, 1.5 to 2.0) with placebo after completion of standard anticoagulant therapy. Low-intensity warfarin therapy was very effective and was associated with a low risk of bleeding.
Patients with atherosclerotic disease may have generalized activation of the coagulation system. This study used ultrasonography to quantify carotid-artery atherosclerosis in patients with deep venous thrombosis and control subjects. Patients with deep venous thrombosis had a significantly higher incidence of carotid-artery disease than controls.
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The cause of drug-resistant epilepsy, a common and debilitating illness affecting one third of patients with epilepsy, is unknown. In this genetic study, patients with drug-resistant epilepsy were more likely to have a polymorphism in a drug-transporter gene (ABCB1) than patients with drug-responsive epilepsy.
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Mutations in the sonic hedgehog gene have been linked to holoprosencephaly. Mosaicism for the sonic hedgehog mutation was identified by single-sperm testing in a man who had fathered two affected children. Genomic DNA was normal in both parents on screening. The use of preimplantation genetic diagnosis led to the birth of a healthy girl who was confirmed to be free of the sonic hedgehog mutation.
A 71-year-old woman who had a myocardial infarction five years previously and underwent coronary-artery bypass surgery six months ago visits a primary care physician. She had no complications after surgery, but intraoperative transesophageal echocardiography revealed a grade V atheroma in the descending aorta. She has no cardiac or neurologic symptoms but notes that she feels depressed and has difficulty concentrating. The low-density lipoprotein cholesterol level is 128 mg per deciliter, the high-density lipoprotein cholesterol level is 40 mg per deciliter, and the triglyceride level is 200 mg per deciliter. What should the physician advise to improve her long-term outcome?
Nitric oxide, a key factor in the maintenance of vascular tone, causes vascular smooth muscles to relax. Hemoglobin rapidly destroys nitric oxide, thereby limiting the activity of the gas to the local environment. Recent work suggests that nitric oxide reacts with hemoglobin at high oxygen tensions to form relatively long-lived products. At low oxygen tensions, these products release vasodilatory nitric oxide. This work is controversial, but it provides evidence of the potential of inhaled nitric oxide as a therapeutic agent.
The new privacy regulations of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) become effective April 14, 2003. This article outlines the implications of the new policy for practicing physicians. The regulations will affect virtually every physician, because they apply to any health care provider who conducts any business electronically, including billing. The regulations require health care providers to provide patients with a privacy notice that informs them who will have access to their records without their explicit consent and about patients' rights to inspect and amend their own records.
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