June 6, 2002
Sirolimus-Eluting Stent for Coronary Revascularization
Despite advances in coronary angioplasty and stenting, restenosis remains an important problem that limits clinical success. This study compared a new coronary stent coated with sirolimus (rapamycin) with a standard (uncoated) stent in patients undergoing stenting for a single coronary lesion. At six months, the rate of restenosis was 26.6 percent in the standard-stent group and 0 percent in the sirolimus-stent group. The results after six months of follow-up are striking and suggest that the sirolimus-eluting stent has considerable promise. However, longer follow-up will be essential to examine the durability of the results, and it will be necessary to determine whether this new device is effective in patients with more complex coronary lesions.
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Screening Colonoscopy among Persons 40 to 49 Years of Age
Because the prevalence of colonic neoplasms before the age of 50 is thought to be low, screening for colonic neoplasms by colonoscopy is currently recommended for people 50 years of age or older. In this retrospective study, investigators reviewed the records of 906 consecutive persons 40 to 49 years of age who participated in an employer-sponsored colonoscopic-screening program. No cancers were detected in this group, but hyperplastic polyps, tubular adenomas, or lesions scored as "advanced neoplasms" were found in 21 percent of those screened. Between 250 and 1000 people 40 to 49 years old would need to be screened to detect a single case of colon cancer. These data provide strong support for the recommendation that colonoscopic screening start at the age of 50. However, because the incidence of colon cancer among those less than 50 years of age is not zero, research is needed to develop a cost-effective method of finding these relatively rare cancers.
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Misdiagnosis of Hereditary Amyloidosis
Of 350 patients who were referred to the National Amyloidosis Centre in London with biopsy-proved amyloidosis and a presumed diagnosis of immunoglobulin light-chain amyloidosis, almost 10 percent actually had hereditary amyloidosis due to genetic variants of transthyretin, apolipoprotein A-I, lysozyme, or fibrinogen A The surprisingly high frequency of hereditary amyloidosis at this referral center has important clinical implications, because chemotherapy, a common treatment for immunoglobulin light-chain amyloidosis, is contraindicated in hereditary amyloidosis. Immunohistochemical analysis of the biopsy specimen or genetic tests may be required before combination chemotherapy is prescribed for a patient with amyloidosis.
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Improving Diagnostic Accuracy in Congenital Syphilis
Of 76 infants born to women with syphilis who had no in utero or postnatal exposure to antibiotics, 17 (22 percent) had spirochetes detected in the cerebrospinal fluid. Most of the infants with central nervous system infection could be identified by abnormalities on the physical examination, radiographic studies, or conventional tests, such as the cerebrospinal fluid white-cell count and the Venereal Disease Research Laboratory test. However, the results of IgM immunoblotting of serum and the polymerase-chain-reaction assay of serum or blood proved to be the best predictors of the detection of central nervous system infection by the rabbit-infectivity test. These results show that central nervous system involvement is common in infants infected with Treponema pallidum. Although identifying central nervous system infections has been difficult in infants with congenital syphilis, such testing is important because the result affects the treatment strategy.
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Special Article: Cost Effectiveness of Aspirin and Clopidogrel in Coronary Disease
Aspirin and clopidogrel, alone or together, reduce the rate of cardiovascular events in patients with coronary disease, but their relative cost effectiveness is uncertain. In this study, the use of aspirin in all patients eligible to receive it was very cost effective. In contrast, clopidogrel as a substitute for or in addition to aspirin was not cost effective. At its current price, clopidogrel was cost effective only when used in the small number of patients who cannot take aspirin. One 75-mg tablet of clopidogrel ($3.22) is 80 times as expensive as one 325-mg tablet of aspirin ($0.04), which is why clopidogrel is not a cost-effective therapy. It becomes cost effective only when the price falls to $0.60 per tablet or less. A different point of view is presented in an accompanying editorial.
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Clinical Practice: Carpal Tunnel Syndrome
A 64-year-old woman has a three-month history of intermittent numbness, tingling, and burning pain in the three radial digits of both hands. These symptoms awaken her several times each night. She has no atrophy of the thenar muscles. How should she be evaluated and treated? This article reviews the diagnosis and management of carpal tunnel syndrome.
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Clinical Problem-Solving: Diagnosis Still in Question
A 59-year-old man who lives on a ranch in California has a three-week history of fevers and a rash. His aminotransferase levels are elevated, and his erythrocyte sedimentation rate is 125 mm per hour.
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-chain. Some of these patients had an incidental monoclonal gammopathy. 
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