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Annals of Internal Medicine 16 August 2005 Volume 143 Issue 4 Articles gfedc Warfarin plus Aspirin after Myocardial Infarction or the Acute Coronary Syndrome: Meta-Analysis with Estimates of Risk and Benefit Michael B. Rothberg, Carmel Celestin, Louis D. Fiore, Elizabeth Lawler, and James R. Cook After acute coronary syndromes, warfarin plus aspirin was associated with fewer myocardial infarctions, ischemic strokes, and revascularization procedures. Warfarin was associated with an increase in major bleeding, but mortality did not differ. For patients who are at low or intermediate risk for bleeding, the cardiovascular benefits of warfarin outweigh the bleeding risks.(241-264) gfedc Clinical Outcomes and Cost-Effectiveness of Strategies for Managing People at High Risk for Diabetes David M. Eddy, Leonard Schlessinger, and Richard Kahn The authors used a novel decision model to estimate the long-term outcomes and costs of care when patients with impaired glucose tolerance use metformin or enroll in a lifestyle modification program. Although the program used in the Diabetes Prevention Program prevented diabetes in some patients and delayed it in others, the authors found that it was not cost-effective for health plans to implement.(265-273) gfedc A Prognostic Index for Systemic AIDS-Related Non-Hodgkin Lymphoma Treated in the Era of Highly Active Antiretroviral Therapy Mark Bower, Brian Gazzard, Sundhiya Mandalia, Tom Newsom-Davis, Christina Thirlwell, Tony Dhillon, Anne Marie Young, Tom Powles, Andrew Gaya, Mark Nelson, and Justin Stebbing The International Prognostic Index predicts death in non-Hodgkin lymphoma, including AIDS-related lymphoma before highly active antiretroviral therapy (HAART). Since the advent of HAART, the prognosis has improved for AIDS-related non-Hodgkin lymphoma. A combination of the International Prognostic Index and the CD4 cell count defines 4 strata of risk for death in AIDS-related lymphoma in the HAART era.(274-281) Improving Patient Care gfedc Quality of Care Is Associated with Survival in Vulnerable Older Patients Takahiro Higashi, Paul G. Shekelle, John L. Adams, Caren J. Kamberg, Carol P. Roth, David H. Solomon, David B. Reuben, Lillian Chiang, Catherine H. MacLean, John T. Chang, Roy T. Young, Debra M. Saliba, and Neil S. Wenger The authors studied the effect of the quality of care received by 372 community-dwelling vulnerable older patients on their survival over the next 3 years. Three-year survival improved steadily as the quality score improved. Better performance on process quality measures is strongly associated with better survival in vulnerable older adults. (282-292) Reviews gfedc Evaluation and Management of the Patient with Pulmonary Arterial Hypertension Lewis J. Rubin and David B. Badesch Pulmonary arterial hypertension raises several diagnostic possibilities: idiopathic or familial cause, systemic diseases (connective tissue disease, HIV infection, or chronic liver disease), or drugs (fenfluramine anorexigens, amphetamines, or cocaine). In this review, the authors present approaches to the diagnosis and management of pulmonary arterial hypertension, using a typical case to highlight the key management points. (293-300) Perspectives gfedc Promoting Informed Choice: Transforming Health Care To Dispense Knowledge for Decision Making Steven H. Woolf, Evelyn C.Y. Chan, Russell Harris, Stacey L. Sheridan, Clarence H. Braddock, III, Robert M. Kaplan, Alex Krist, Annette M. O'Connor, and Sean Tunis This article is about providing patients with the information they need to participate in difficult decisions about their health care. The authors look to health systems to meet these information needs. Their proposed solutions include expanding information resources for decision support and linking the information to decision counseling. (301-302) Editorials gfedc Trying To Predict the Future for People with Diabetes: A Tough but Important Task Michael M. Engelgau The article by Eddy and colleagues describes a novel approach to modeling the costs and outcomes of health interventions. As applied to programs to alter lifestyle to prevent diabetes in patients with impaired glucose tolerance, the model's predictions are similar in most respects to previous work but differ about cost-effectiveness. This difference leads the authors to diametrically opposed conclusions about whether health plans should offer programs to modify lifestyle. (303-304) gfedc Modeling Complex Medical Decision Problems with the Archimedes Model Margaret L. Brandeau In an ideal world, low-cost, powerful, and ethical clinical trials would decide which treatments work best. In the real world, clinical trials are often too time-consuming, too expensive, unethical, or even impossible to perform. How, then, can we obtain answers to inform patient care? We need a structured framework that uses the best evidence and captures relevant complexities. Decision analysis meets these requirements but raises a new question: "How do we decide if we can trust the predictions of a decision model?" (305-306) gfedc Improving Patient Care Can Set Your Brain on Fire Sankey V. Williams In this issue, Higashi and colleagues conclude that "better performance on process quality measures is strongly associated with better survival among community-dwelling vulnerable older adults." This conclusion, if true, is important because it appears to validate a fundamental assumption underlying most quality improvement efforts: A better process of care will lead to better patient outcomes. (307-308) On Being a Doctor gfedc Lessons from a Patient William Rifkin Whenever a patient shares with me her tale of misery, I experience the following, perhaps common to most doctors: first, horror at how cruel and harsh the world can be, then appreciation of the relatively insignificant hurts I have experienced in comparison, followed by compassion and a compunction to "make it all better." Finally, once reality sets in, I realize that what I have to offer is very unlikely to help in the end. I often feel that I am simply not giving enough. (309-316) Letters Screening for Abdominal Aortic Aneurysms Jack L. Cronenwett Ned Calonge and Diana Petitti—RESPONSE(I-14) Target Blood Pressure and Kidney Disease Chester B. Good Yujiro Kida Mark J. Sarnak, Andrew S. Levey, and Tom Greene—RESPONSE(I-22) High-Output Heart Failure Associated with Anagrelide Therapy for Essential Thrombocytosis Peter J. Engel, Heide Johnson, Robert P. Baughman, and Arthur I. Richards(I-28) Subungual Splinter Hemorrhages: A Clinical Window to Inhibition of Vascular Endothelial Growth Factor Receptors? Caroline Robert, Sandrine Faivre, Eric Raymond, Jean-Pierre Armand, and Bernard(I-33) Escudier Disseminated Aspergillosis Mimicking Hepatic Veno-Occlusive Disease George L. Daikos, Vassiliki Syriopoulou, George Aperis, Christos Toubanakis, George Petrikkos, and Maria Demonakos Correction: Recommendations for the Diagnosis and Treatment of the Acute Porphyrias Ancillary Content Medical Notices Summaries for Patients Benefits and Harms of Warfarin plus Aspirin after Acute Coronary Events The Outcomes and Costs of Diabetes Prevention with a Diet and Exercise Program or Metformin: A Computer Model Estimating Outcome in Patients with HIV-Related Lymphoma Association of Quality of Care with Survival of Elderly Managed Care Patients Annals of Internal Medicine Article Warfarin plus Aspirin after Myocardial Infarction or the Acute Coronary Syndrome: Meta-Analysis with Estimates of Risk and Benefit Michael B. Rothberg, MD, MPH; Carmel Celestin, MD; Louis D. Fiore, MD, MPH; Elizabeth Lawler, MPH; and James R. Cook, MD, MPH Background: After the acute coronary syndrome, adding warfa- Data Synthesis: Ten trials involving a total of 5938 patients rin to standard aspirin therapy decreases myocardial infarction and (11 334 patient-years) met the study criteria. Compared with as- stroke but increases major bleeding. pirin alone, warfarin plus aspirin was associated with a decrease in the annual rate of myocardial infarction (0.022 vs. 0.041; rate Purpose: To quantify the risks and benefits of warfarin therapy ratio, 0.56 [95% CI, 0.46 to 0.69]), ischemic stroke (0.004 vs. after the acute coronary syndrome. 0.008; rate ratio, 0.46 [CI, 0.27 to 0.77]), and revascularization Data Sources: MEDLINE from 1990 to October 2004. Additional (0.115 vs. 0.135; rate ratio, 0.80 [CI, 0.67 to 0.95]). Warfarin was data were obtained from study authors. Clinical risk factors were associated with an increase in major bleeding (0.015 vs. 0.006; used to classify hypothetical patients into cardiovascular and rate ratio, 2.5 [CI, 1.7 to 3.7]). Mortality did not differ. bleeding risk groups on the basis of published data. Limitations: Two large studies provided most of the data. Stud- Study Selection: Randomized trials comparing intensive warfa- ies did not include coronary stenting, and results should not be rin therapy (international normalized ratio > 2.0) plus aspirin with applied to patients with stents. Relative risk reductions may not aspirin alone after the acute coronary syndrome. be consistent across risk groups. Data Extraction: Two reviewers independently selected studies Conclusions: For patients with the acute coronary syndrome and extracted data on study design; quality; and clinical outcomes, who are at low or intermediate risk for bleeding, the cardiovas- including myocardial infarction, stroke, revascularization, death, cular benefits of warfarin outweigh the bleeding risks. and major and minor bleeding. Rate ratios for outcomes were calculated and
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