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In patients with acute coronary syndromes, early invasive intervention (coronary angiography at a median of 14 hours) was compared with delayed intervention (angiography at a median of 50 hours). There was no difference in outcomes between the two groups overall, but high-risk patients had better outcomes with the early strategy and in particular had less risk of refractory ischemia.
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Glycoprotein IIb/IIIa inhibitors are used routinely in patients with acute coronary syndromes who are undergoing invasive procedures, but the optimal timing of administration is unknown. The early, routine use of eptifibatide was found to be no better than the delayed, provisional use of the drug and was associated with more bleeding.
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In this randomized, double-blind, placebo-controlled trial of twice-daily extended-release dipyridamole and aspirin, used after the placement of a new arteriovenous graft, the primary outcome was loss of primary unassisted patency; secondary outcomes included cumulative graft failure and death. Active treatment had a significant but modest effect of reducing the risk of stenosis and improving the primary unassisted patency of newly created grafts.
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The Institute of Medicine recently made new recommendations to reduce the work hours and workload of residents. This economic analysis suggests that implementation of these recommendations would be costly (annual labor costs, $1.6 billion), but if they are highly effective in reducing patient harm, they may be cost-effective.
A 35-year-old man is brought to the emergency department after ingesting automobile antifreeze. His pH is 7.30, and his urinalysis reveals calcium oxalate crystals, findings consistent with ethylene glycol poisoning. Treatment with fomepizole is recommended. Fomepizole is a competitive inhibitor of alcohol dehydrogenase that prevents the formation of the toxic metabolites of ethylene glycol and methanol.
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A 32-year-old pregnant woman was admitted to the hospital at 23.1 weeks of gestation, because of an abnormal fetal ultrasound study. Nineteen days before admission, a sonogram revealed a thickened fetal nuchal fold, bilateral nuchal cystic hygromas, and pericardial and pleural effusions. Fetal echocardiography revealed normal cardiac anatomy and function. Testing for infectious diseases was negative. The pregnancy was terminated, and a fetal autopsy was performed.
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