Arch Intern Med
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Atrial fibrillation is associated with an increased risk of ischemic stroke. Data on individual patients were pooled from five recently completed randomized trials comparing warfarin (all studies) or aspirin (the Atrial Fibrillation, Aspirin, Anticoagulation Study and the Stroke Prevention in Atrial Fibrillation Study) with control in patients with atrial fibrillation. The purpose of the analysis was to (1) identify patient features predictive of a high or low risk of stroke, (2) assess the efficacy of antithrombotic therapy in major patient subgroups (eg, women), and (3) obtain the most precise estimate of the efficacy and risks of antithrombotic therapy in atrial fibrillation. For the warfarin-control comparison there were 1889 patient-years receiving warfarin and 1802 in the control group. For the aspirin-placebo comparison there were 1132 patient-years receiving aspirin and 1133 receiving placebo. The daily dose of aspirin was 75 mg in the Atrial Fibrillation, Aspirin, Anticoagulation Study and 325 mg in the Stroke Prevention in Atrial Fibrillation Study. To monitor warfarin dosage, three studies used prothrombin time ratios and two used international normalized ratios. The lowest target intensity was a prothrombin time ratio of 1.2 to 1.5 and the highest target intensity was an international normalized ratio of 2.8 to 4.2. The primary end points were ischemic stroke and major hemorrhage, as assessed by each study. ⋯ In these five randomized trials warfarin consistently decreased the risk of stroke in patients with atrial fibrillation (a 68% reduction in risk) with virtually no increase in the frequency of major bleeding. Patients with atrial fibrillation younger than 65 years without a history of hypertension, previous stroke or transient ischemic attack, or diabetes were at very low risk of stroke even when not treated. The efficacy of aspirin was less consistent. Further studies are needed to clarify the role of aspirin in atrial fibrillation.
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Randomized Controlled Trial Clinical Trial
Long-term efficacy of intranasal mupirocin ointment. A prospective cohort study of Staphylococcus aureus carriage.
We investigated the long-term effect of a single 5-day application of intranasal mupirocin calcium ointment on Staphylococcus aureus nasal and hand colonization. The subjects were 68 healthy volunteers who were health care workers with stable S aureus nasal carriage and who had participated in a randomized, double-blind placebo-controlled clinical trial of intranasal mupirocin ointment. ⋯ A single brief treatment course of intranasal mupirocin was effective in reducing nasal S aureus carriage for up to 1 year. When S aureus was recovered after nasal decolonization, the new isolate was as likely to represent colonization with a new strain as reisolation of the original strain. Staphylococcus aureus hand carriage was significantly decreased 6 months after therapy, further implicating the nares as the primary reservoir site for hand carriage.
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The current literature does not provide an answer to the question, "What prompts patients to sue doctors or hospitals?" Not all adverse outcomes result in suits, and threatened suits do not always involve adverse outcomes. The exploration of other factors has been hampered by the lack of a methodology to contact plaintiffs and elicit their views about their experience in delivered health care. This study employed the transcripts of discovery depositions of plaintiffs as a source of insight into the issues that prompted individuals to file a malpractice claim. ⋯ In our sample, the decision to litigate was often associated with a perceived lack of caring and/or collaboration in the delivery of health care. The issues identified included perceived unavailability, discounting patient and/or family concerns, poor delivery of information, and lack of understanding the patient and/or family perspective. Particular attention should be paid to the postadverse-event consultant-patient interaction.
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Randomized Controlled Trial Clinical Trial
Effect of postmenopausal estrogen replacement on plasma Lp(a) lipoprotein concentrations.
Women who receive postmenopausal estrogen replacement experience a lower rate of coronary heart disease than women who do not receive these hormones. Evidence suggests that mechanisms in addition to decreases in plasma low-density lipoprotein levels and increases in high-density lipoprotein concentrations are responsible for the apparent beneficial effect of estrogens. Therefore, we studied the effect of estrogen on plasma Lp(a) lipoprotein, newly suggested to be a risk factor for coronary heart disease in postmenopausal women. ⋯ Estrogen decreases the plasma Lp(a) lipoprotein concentration, which could explain some of the protective effect of estrogen replacement therapy on coronary heart disease.
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Randomized Controlled Trial Multicenter Study Clinical Trial
Nicotine replacement therapy for patients with coronary artery disease. Working Group for the Study of Transdermal Nicotine in Patients with Coronary artery disease.