Table of Contents

Women with coronary disease are at high risk for myocardial infarction or death from coronary heart disease even in the absence of other risk factors, and their risk increases up to sixfold when they have many risk factors. Physicians frequently fail to prescribe established drugs for secondary prevention, including aspirin, β-blockers, and lipid-lowering agents, for these women at especially high risk.

Actual use of chemotherapy for breast cancer differs markedly from consensus recommendations, and the gap between ideal and actual care widens for older women. Decreased use with age may reflect knowledge of clinical trials that show decreasing efficacy of chemotherapy with increasing age. Are the recommendations too aggressive, or are practicing oncologists using chemotherapy too conservatively?

Pravastatin is effective and appears safe for secondary prevention of cardiovascular events in persons with mild chronic renal insufficiency. Since statins may be underused in this setting, physicians should consider prescribing them for patients with chronic renal insufficiency and known coronary disease.

Intensive immunosuppressive therapy can lead to sustained clinical remission in patients with refractory autoimmune thrombotic thrombocytopenic purpura.

The authors review the test characteristics of the history, physical examination, and laboratory findings, individually and in combination, in diagnosing community-acquired pneumonia and predicting short-term risk for death from this condition. The knowledge base for prognostication in pneumonia is far better than the knowledge base for diagnosis.

This review summarizes current knowledge of the congenital prothrombotic states and proposes a simple classification system that divides them into two broad groups: those associated with reduced levels of the inhibitors of the coagulation cascade and those associated with increased levels or function of the coagulation factors.

Linezolid is the first of a new class of antimicrobial agents, the oxazolidinones, to be approved for clinical use in the United States and elsewhere. The drug is a totally synthetic compound, which lessens the likelihood of naturally occurring resistance mechanisms. It has excellent activity against almost all important gram-positive pathogens. Development of resistance to the compound has occurred infrequently thus far.

Urban public hospitals and community health centers share a common mission: to care for the uninsured and other vulnerable populations. In most communities, however, these two components of the safety net are administratively and clinically separate, which inhibits continuity of care and creates substantial inefficiencies. This paper describes Denver Health, a long-standing vertically and horizontally integrated system for vulnerable populations. Fully integrating public hospitals and community health centers benefits the patient and serves as a model for the U.S. safety net.

In this issue, Vittinghoff and colleagues analyze data from the Heart and Estrogen/progestin Replacement Study to identify risk factors for myocardial infarction and death from coronary heart disease and describe the participants' use of secondary prevention strategies. The most striking aspect of this analysis is the alarming underuse of proven therapies for secondary prevention of cardiovascular disease in women.

Zheng and colleagues' well-documented report of a woman whose refractory thrombotic thrombocytopenic purpura (TTP) responded to rituximab and cyclophosphamide illustrates beautifully the defining phrase of translational research, “From the bench to the bedside.” Is her experience representative of many patients with TTP, or is her case exceptional? How can we apply the care she received to clinical practice in the community?

The few of us who examined 2 years of correspondence before Mr. J.'s arrival at Massachusetts General Hospital were even more interested in meeting the man than in validating the exotic diagnosis we had made from his letters.

This Update discusses hormone replacement therapy, detection and treatment of osteoporosis, breast cancer screening, management of cervical cancer, exercise, domestic violence, urinary tract infections, and unintended pregnancy.