In This Issue of Archives of Internal Medicine FREE

An analysis of 42 delayed diagnoses among 454 women with breast cancer found that most delays were related to previously known limitations of current diagnostic practices. Despite widespread screening mammography, inappropriate reassurance that a palpable mass was benign—without a biopsy—continued to be the leading cause of delay. Novel factors related to delay were the patient finding her own mass, fine-needle aspiration biopsy by a physician without specific training for the procedure, and current use of hormone replacement therapy.

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The predictive power of a single total plasma homocysteine (tHcy) measurement on subsequent hospitalizations due to cardiovascular disease (CVD) was examined. The study included 17 361 individuals aged 40 to 67 years at baseline recruited from the general population in western Norway, who in 1992 and 1993 participated in a CVD screening program and had been followed up for mortality and cardiovascular hospitalization end points. A total of 1275 individuals were hospitalized due to CVD during follow-up (mean time, 5.3 years). The risk of hospitalization increased significantly with increasing baseline tHcy only among the oldest participants and particularly among those with preexisting CVD. No significant associations among the youngest individuals were observed. The authors conclude that plasma tHcy level is a strong predictor of hospitalizations due to CVD only among older individuals with established vascular disease.

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Despite the historically held belief that American Indian populations have lower rates of heart disease and its risk factors than the general US population, rates now appear to be rising among some tribal groups. This study documents increasing incidence rates of coronary artery disease, acute myocardial infarction, and cardiac events for the years 1987 through 1996 among tribal members aged 45 to 79 years in a Southwest American Indian tribal group. The study also documents a high prevalence of cardiac risk factors in a young convenience sample of tribal members. These findings highlight the need for immediate attention to this growing problem through appropriate policy formation, prevention funding, and health interventions.

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This systematic review and meta-analysis evaluated the efficacy and safety of sildenafil citrate in the treatment of male erectile dysfunction. Trials were eligible for this review if they included men with erectile dysfunction, compared sildenafil with control, were randomized, were of at least 7 days' duration, and assessed clinically relevant outcomes. Data sources included multiple electronic databases, bibliographies of retrieved articles and review articles, conference proceedings abstracts, the Food and Drug Administration's Internet Web site, and the manufacturer. Twenty-seven trials (N = 6659 men), published from January 1995 through December 2000, met all criteria for inclusion. Based on parallel-group, flexible dosing, and administration on an as-needed basis trials, sildenafil was significantly more likely than placebo to lead to successful sexual intercourse, with a higher percentage of successful intercourse attempts (57% vs 21%) and a greater percentage of men experiencing at least 1 intercourse success during treatment (83% vs 45%). In data pooled from parallel-group, fixed-dose trials, efficacy appeared slightly greater at higher doses. Treatment response appeared to vary between patient subgroups; however, relative to placebo, sildenafil significantly improved erectile function in all evaluated subgroups. In trials with parallel-group design, flexible dosing, and administration on an as-needed basis, specific adverse events occurring in men who received sildenafil included flushing (12%), headache (11%), dyspepsia (5%), and visual disturbances (3%); all were significantly less likely with placebo. Sildenafil was not significantly associated with serious cardiovascular events or death.

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