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Clinical Impact of High-Normal Blood Pressure
Although frank hypertension is clearly associated with an increased risk of cardiovascular events, the implications of high-normal blood pressure are less clear. This prospective analysis from the Framingham Study demonstrates that the relative risk of cardiovascular events is significantly higher among both men and women with high-normal blood pressure than among those with optimal blood pressure.
High-normal blood pressure is associated with an increased risk of cardiovascular events. It remains to be shown whether treating blood pressure in the high-normal range can reduce this risk.
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Fondaparinux versus Enoxaparin to Prevent Venous Thromboembolism after Hip-Fracture Surgery
In a study of the prevention of venous thromboembolism after surgery for hip fracture, fondaparinux was compared with the low-molecular-weight heparin enoxaparin. Fondaparinux was superior to enoxaparin for thromboprophylaxis and was well tolerated.
Venous thromboembolism after surgery for hip fracture is a troublesome problem, and its incidence is high (10 to 20 percent) even with the use of low-molecular-weight heparin for thromboprophylaxis. The promising results with fondaparinux, a new synthetic pentasaccharide that causes selective inhibition of activated factor X, in preventing venous thromboembolism after surgery for hip fracture merit wide attention.
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Fondaparinux versus Enoxaparin to Prevent Venous Thromboembolism after Major Knee Surgery
Major knee surgery poses a considerable risk of postoperative venous thromboembolism. In this study, fondaparinux, a new antithrombotic pentasaccharide, was found to surpass the ability of enoxaparin, a low-molecular-weight heparin, to prevent venous thromboembolism after knee surgery.
Fondaparinux is a synthetic anticoagulant that binds to antithrombin, thereby causing it rapidly to inactivate activated factor X (factor Xa), an indispensable coagulant protein. The finding of its superiority over enoxaparin in patients undergoing knee surgery is important, because postoperative venous thromboembolism has been difficult to prevent after this operation.
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Effects of Eliminating Gatekeeping in a Health Maintenance Organization
Although gatekeeping — prior approval of referrals to specialists by a primary care physician — has been considered an important tool for controlling costs and coordinating care within health plans, many patients and physicians do not like it. This study showed no substantial effect on the use of specialty services by adults during the first 18 months after the elimination of a gatekeeping system.
These findings suggest that the use of gatekeeping to limit access to specialists may have a smaller effect on health care costs than previously thought. However, the study was conducted in one group-model health maintenance organization; the results may not be generalizable to other health plans.
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Medical Progress: Infective Endocarditis in Adults
The clinical features of this complex infection have changed in the past several decades. It is now an infection of older people, and mitral-valve prolapse is the most common predisposing cardiovascular problem in developed countries. In contrast, rheumatic heart disease is an important predisposing problem in developing countries. This review article provides a comprehensive assessment of this serious infectious disease, including diagnostic challenges, cardiovascular and neurologic complications, and approaches to therapy.
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Advances in Immunology: Maternal Antibodies, Childhood Infections, and Autoimmune Diseases
With this article by Nobel laureate Rolf Zinkernagel, the Immunology series that began in July 2000 comes to an end. Zinkernagel's thesis concerns the influence of a mother's immunologic memory on the effectiveness of childhood vaccination and the susceptibility of her child to infectious diseases. He reviews how immunity in the entire community (herd immunity) affects immune protection not only in the mother but also in succeeding generations. Zinkernagel warns that lax vaccination programs and complacency produced by improved living standards will have global effects on susceptibility to infection and autoimmune diseases.
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