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JAMA. 2006;296:363.

Identifying Patients at Risk of Recurrent Thrombosis
Thrombin generation is key to hemostasis and can be measured with a commercial assay. Hron and colleagues hypothesized that thrombin generation is a marker of risk for recurrent venous thromboembolism (VTE). They tested their hypothesis in a cohort of patients who had completed therapy for a first spontaneous VTE and had been followed up for a mean duration of 47 months. Recurrent VTE was documented in 11% of patients. The authors found patients with a peak thrombin generation of less than 400 nM had a 60% lower risk of VTE recurrence compared with patients with higher values.

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Multidetector CT for Coronary Stenosis
Multidetector computed tomography (MDCT) has been proposed as a noninvasive method of detecting coronary artery stenosis. In a multicenter trial of patients referred for nonemergent coronary angiography, Garcia and colleagues assessed the accuracy of 16-row MDCT to detect a more than 50% luminal narrowing in coronary artery segments. The authors found an unacceptably high number of false-positive and nonevaluable segments using MDCT, limiting the utility of 16-row MDCT for primary diagnosis of coronary artery stenosis.

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Management of Recalled Pacemakers and ICDs
Little guidance is available to direct clinician and patient decision making when an implantable device is put under advisory. Amin and colleagues report results of a decision analysis designed to evaluate the risks and benefits associated with immediate device replacement vs continued monitoring for patients with recalled pacemakers or implantable cardioverter-defibrillators. The authors identified several factors to consider when deciding whether to replace or monitor, including the incidence of device malfunction, likely effects of device failure, and replacement procedure mortality.

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Youth-Onset Type 2 Diabetes, ESRD, and Death
To investigate long-term outcomes of youth-onset type 2 diabetes, Pavkov and colleagues examined the incidence rate of diabetic end-stage renal disease (ESRD) and mortality in a longitudinal study of Pima Indians. In a comparison of participants whose type 2 diabetes was diagnosed before they were 20 years old vs patients who were diagnosed between the ages of 20 and 55 years, the authors found that youth-onset disease was associated with a significantly increased incidence of ESRD and mortality between 25 and 55 years of age.

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Improving Glycemic Control in Type 2 Diabetes
Numerous quality improvement (QI) strategies aimed at helping patients with type 2 diabetes with glycemic control have been reported. Shojania and colleagues conducted a systematic literature review and meta-regression analysis to assess the effectiveness of these interventions. The authors found that QI strategies produced small to modest improvements in glycemic control. Strategies involving changes in the team members participating in patient care and strategies involving case management, particularly when the case manager could independently adjust medications, were associated with the greatest improvement in glycemic control.

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A Piece of My Mind
"Through the years Bob had gotten pretty good at leaving work at work and arriving home without any apparent effect of the day's cases." From "Easy Love."

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Medical News& Perspectives
Researchers suggest that aggressive treatment for patients with diabetes, including an inexpensive "polypill" of common drugs to reduce complications of the disease, could save thousands of lives and millions in health care costs.

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Hearing Disorders in the Developing World
Many persons with disabling hearing impairment live in developing nations, fail to receive appropriate education, and lack opportunities for economic independence.

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CLINICIAN'S CORNER
Hyperthermic Biology and Cancer Therapy
Coffey and colleagues discuss the effects of hyperthermia in development, immunity, and cancer therapy and a potential molecular mechanism to explain the "Lance Armstrong effect."

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JAMA Patient Page
For your patients: Information about thrombophlebitis.

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