October 24, 2002
Aspirin and Mortality from Coronary Bypass Surgery
In patients undergoing coronary-artery bypass surgery, aspirin is often avoided during the perioperative period because of concern about bleeding. This large, multicenter, observational study found that aspirin therapy initiated within 48 hours after surgery was associated with reduced mortality and fewer ischemic complications affecting the heart, brain, kidneys, and gastrointestinal tract. There was no excess bleeding. These findings are provocative, but they were not derived from a randomized trial and are therefore subject to undetected bias. The substantial reduction in mortality with aspirin therapy is very important but must be confirmed in a randomized trial before aspirin therapy becomes routine.
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Subtotal versus Total Abdominal Hysterectomy
A total of 279 women who were referred for hysterectomy because of benign disease were randomly assigned to undergo subtotal or total abdominal hysterectomy. Twelve months after surgery, the two groups had similar improvements in urinary symptoms and measures of urodynamic testing; neither type of surgery had adverse effects on bowel or sexual function. Total abdominal hysterectomy resulted in a longer hospital stay. Cyclical bleeding occurred postoperatively in 7 percent of the subtotal-hysterectomy group. These data provide reassurance that neither total nor subtotal abdominal hysterectomy is likely to have an adverse effect on bladder, bowel, or sexual function, although longer follow-up is needed to clarify the risk of cervical prolapse after surgery.
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Nonsurgical Reduction of the Septum in Hypertrophic Cardiomyopathy
Some patients with hypertrophic cardiomyopathy and left ventricular outflow tract obstruction do not have a response to medical therapy with beta-blockers or calcium-channel blockers. Surgical myomectomy is sometimes recommended. These investigators report preliminary observations on nonsurgical reduction of the hypertrophied septum by the injection of alcohol into the septal perforator vessels, causing controlled infarction of the septum. This procedure was effective in reducing outflow tract obstruction and improving functional capacity. The observations are important, but the procedure must still be regarded as experimental and should be reserved for carefully selected patients.
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Special Article: A National Survey of Contract Provisions
In 2001, the International Committee of Medical Journal Editors (ICMJE) called for independence of authors from industry sponsors and full disclosure of the sponsors' role in research. This national survey reveals that the vast majority of medical schools' clinical-trial agreements with industry sponsors do not adhere to the ICMJE guidelines regarding trial design, access to data, and publication rights. Many current contracts between industry and medical schools have not adequately safeguarded the integrity of privately funded biomedical research. Contracting officers at medical schools and hospitals need to be diligent in ensuring the academic freedom of their investigators.
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Clinical Practice: Type 2 Diabetes Mellitus
An asymptomatic 45-year-old Hispanic man has a fasting plasma glucose level of 142 mg per deciliter (7.9 mmol per liter) on initial evaluation and 139 mg per deciliter (7.7 mmol per liter) on reevaluation. Other than a steady gain in weight since college and borderline hypertension, his medical history is unremarkable. He is 175 cm (5 ft 9 in.) tall and weighs 95 kg (209 lb; body-mass index, 31.2), and his blood pressure is 138/88 mm Hg. Physical examination is notable only for abdominal obesity and absent ankle reflexes. How should this patient be treated?
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Clinical Implications of Basic Research: RNA Interference and HIV
A recently discovered type of RNA, small interfering RNA, silences messenger RNA (the transcript of an active gene) by binding to specific sequences in the messenger RNA. Small interfering RNAs can block the replication of HIV in vitro by triggering the degradation of specific viral messenger RNAs. This work reveals new possibilities for controlling not only HIV infection but also the growth of cancer cells. The recent explosion of research on small interfering RNA signals the opening of an entirely new approach to the control of viral replication and tumor-cell proliferation.
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Sounding Board: Collaborating with Industry — Choices for the Academic Medical Center
Ties between academic medical centers and commercial entities are increasing in number and magnitude. These ties have the potential to benefit the public through the development of novel diagnostic and therapeutic techniques. They can also be quite problematic, since the goals of an academic medical center and those of a commercial entity may differ in many respects. In this article, leaders of major academic medical institutions provide guidance on the successful management of several specific points of interaction.
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