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May 10, 2001
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Use of Transesophageal Echocardiography to Guide Cardioversion in Patients with Atrial Fibrillation
Conventional management of atrial fibrillation requiring cardioversion calls for three weeks of anticoagulation with warfarin before the procedure. In this study, transesophageal echocardiography was performed before cardioversion to look for atrial thrombi. If there were no thrombi, cardioversion was performed after a short period of anticoagulation. This approach was safe and resulted in a much shorter time to successful cardioversion.
The results of this study provide a basis for expediting cardioversion in patients with atrial fibrillation in whom transesophageal echocardiography reveals no evidence of atrial thrombi. In experienced centers, this approach provides advantages over conventional practice.
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Chelation Therapy and Neuropsychological Development in Children Exposed to Lead
In a randomized trial, children with blood lead levels of 20 to 44 µg per deciliter were assigned to receive either succimer, a chelating agent, or placebo. Treatment with succimer reduced the blood lead levels, but after 36 months, when the children were about five years old, there were no statistically significant differences between the two groups in IQ scores, scores on a behavioral index, or scores on tests of neuropsychological development.
This carefully controlled study found no benefit from lead-chelation therapy in children. With succimer treatment, there were trends toward slightly worse outcomes with respect to intelligence, behavior, and linear growth. Chelation therapy cannot be recommended for children with moderate blood lead levels.
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Control of Vancomycin-Resistant Enterococcal Infections in a Region
In the Siouxland region of Iowa, Nebraska, and South Dakota, vancomycin-resistant enterococci were first detected in 1996. In 1997 all 32 health care facilities in the region implemented recommendations to obtain surveillance cultures and to isolate infected patients. The prevalence of resistant organisms declined from 2.2 percent in 1997 to 1.4 percent in 1998 and to 0.5 percent in 1999.
Once vancomycin-resistant enterococci are introduced into a health care facility, they usually become endemic and very difficult to control or eradicate. This report shows that a coordinated program can lead to reductions in the rate of colonization and to the elimination of the infection at many of the facilities.
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Effect of Parathyroid Hormone (1-34) on Fractures and Bone Mineral Density in Postmenopausal Women
Once-daily administration of parathyroid hormone increases bone formation and bone resorption, but the effect of this treatment on the risk of fracture is not known. In this study, postmenopausal women with osteoporosis received 20 µg or 40 µg of parathyroid hormone (1-34) or placebo subcutaneously each day for a mean of approximately 18 months. Both doses of parathyroid hormone significantly increased the bone mineral density of the lumbar spine and femoral neck and reduced the risk of fractures, as compared with placebo. There were few side effects.
Spontaneously occurring hyperparathyroidism, in which there is sustained hypersecretion of parathyroid hormone, stimulates bone resorption and therefore causes osteoporosis. In contrast, intermittent hyperparathyroidism induced by once-daily injections of parathyroid hormone stimulates bone formation to a greater extent than bone resorption and thus increases bone density. In this study, the increase in bone density was accompanied by a decrease in vertebral and other fractures.
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Racial Differences in the Use of Cardiac Catheterization
Black patients with coronary artery disease are less likely to undergo cardiac procedures than are white patients, and racial bias has been proposed as an explanation. In this study of a large population of Medicare beneficiaries who were hospitalized after myocardial infarction, black patients had lower rates of cardiac catheterization than did white patients. However, this was true regardless of whether the black patients were under the care of a white physician or a black physician.
The findings suggest that factors other than overt racial bias may explain the lower rates of cardiac catheterization among black patients. This pattern of care appears to be independent of the race of the physician and had no effect on survival rates.
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Medical Progress: Spontaneous Intracerebral Hemorrhage
Intracerebral hemorrhage accounts for 10 to 15 percent of all strokes. Primary hemorrhages arise from the rupture of small blood vessels damaged by hypertension or amyloid angiopathy. Secondary hemorrhages arise from vascular malformations, aneurysms, or tumors or are due to coagulation disorders. This review article surveys the important clinical features of this serious, often life-threatening, but potentially preventable disorder.
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