Annual review of medicine
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Annual review of medicine · Jan 2000
ReviewManagement of patients with hereditary hypercoagulable disorders.
The inherited hypercoagulable states can be divided into those that are common and associated with a modest risk of thrombosis (i.e. factor V Leiden and G20210A prothrombin gene) and those that are uncommon but associated with a high risk of thrombosis. There is no convincing evidence that, independent of other clinical factors, the presence of factor V Leiden or the prothrombin gene mutation should influence the use of primary prophylaxis or the duration of anticoagulant therapy following an episode of thrombosis. ⋯ The presence of one of these three abnormalities also favors more prolonged anticoagulant therapy following venous thrombosis. However, their presence or absence appears to have less influence on the risk of recurrent venous thromboembolism than whether thrombosis was provoked by a major reversible risk factor, such as surgery.
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Indices of heart rate variability (HRV) provide a window onto autonomic modulation of the heart. HRV indices, determined in either the time or frequency domain, are closely related and reflect parasympathetic, mixed sympathetic, and parasympathetic and circadian rhythms. In population studies, decreased HRV has had predictive value for mortality among healthy adults. ⋯ Reduced HRV identifies diabetic patients with autonomic neuropathy. HRV in combination with other risk stratifiers, e.g. ejection fraction, can identify cardiac patients at especially high risk of mortality. Many but not all interventions associated with increased HRV are also associated with better survival rates.
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Obesity is perhaps the most significant public health problem facing the United States today. Obese patients are at increased risk for numerous medical problems, which can adversely affect surgical outcome. ⋯ Obese patients can be treated as safely and effectively as their normal weight counterparts under most circumstances and should not be denied surgical treatment for any disorder when surgery constitutes the most appropriate therapy. When indicated, surgical treatment should be considered for patients with clinically severe obesity, since currently it appears to offer the best long-term results for weight control and amelioration of comorbidity.
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Goodpasture's, or anti-glomerular basement membrane, disease is an uncommon, usually severe disease caused by autoimmunity to a component of certain basement membranes. Alport's syndrome is an inherited, degenerative disorder that affects specific basement membranes. The two are linked by the involvement of type-IV collagen (basement membrane collagen) in their pathogenesis.
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Streptococcus pneumoniae, Enterococcus faecalis, Enterococcus faecium, Staphylococcus aureus, and Klebsiella pneumoniae have become increasingly resistant to antimicrobial agents. This chapter reviews the epidemiology of this resistance, its detection in the laboratory, the mechanisms of resistance, and the options for therapy and infection control.