In This Issue of Archives of Internal Medicine FREE

The medical management of atrial fibrillation has changed significantly over the last decade. Fang and colleagues examined national trends in the medical management of atrial fibrillation from 1991 through 2000 using data from the National Ambulatory Medical Care Survey. They found a significant decline in the use of digoxin for atrial fibrillation without increases in β-blocker or calcium channel blocker use. Amiodarone hydrochloride replaced quinidine as the most commonly used sinus rhythm medication. Although oral anticoagulant use increased over time, fewer than half of patients at high risk for stroke were taking anticoagulants in 1999-2000.

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To determine the cost-effectiveness of a comprehensive program to prevent human immunodeficiency virus (HIV) infection after sexual or injection-drug use exposure for 401 persons seeking postexposure prophylaxis (PEP), Pinkerton et al conducted a retrospective cost analysis to evaluate the cost of the PEP intervention. The authors combined this information with model-based effectiveness estimates to determine the PEP program's "cost-utility ratio," which is the ratio of net program costs to the total number of quality-adjusted life-years saved by the program. The results indicate that PEP can be a cost-effective component of a balanced public health portfolio of HIV prevention interventions.

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Many recent reports warn of the increasing burden of end-stage renal disease projected in the coming years. A related concern is the attendant complications of hemodialysis, such as bacteremia, and most importantly, the episodes of infective endocarditis that can result from these infections. The available data involving the incidence, valvular distribution, and outcomes are either dated or based on studies with cohorts of, at most, 20 patients. In this retrospective study, data were obtained from medical records of the largest cohort of patients with "definite endocarditis" to date, with a large representation of patients using an arterial-venous fistula for vascular access. The overall mortality of patients in this cohort was 53%, the mitral valve was most commonly affected, and Staphylococcus aureus was identified as the causative organism in 50% of the patients. Despite improved diagnostic maneuvers, more standardized antibiotic therapy, and more sophisticated valve replacement, the mortality of infective endocarditis in end-stage renal disease remains high, and more work is needed to improve outcomes of this potentially lethal complication.

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Each year, thousands of preventable deaths and hospitalizations result from complications of influenza and pneumococcal disease, mostly in elderly persons, despite the availability of vaccines. Obtaining signed consent prior to administering the vaccines represents an obstacle to achieving goals for vaccinating individuals against influenza and pneumococcal disease. Signed consent is neither legally mandated nor a guarantee that the patient (or proxy) has given informed consent. Nonetheless, many health care providers and institutions currently require signed consent before administering these vaccines. Rather, health care providers should use the Vaccine Information Sheets developed by the Centers for Disease Control and Prevention to inform patients about the risks and benefits associated with these vaccines. Requiring signed consent before administering these low-risk, high-benefit vaccines is inconsistent with the current practice of not requiring signed consent before prescribing other common treatments whose risk levels are the same or higher.

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In 5 randomized trials of secondary prevention with pravastatin sodium, consisting of 73 900 patient-years of observation, aspirin was prescribed in varying frequencies and data were available on a large number of confounding variables. Individual trials and all meta-analyses demonstrated similar additive benefits on cardiovascular disease. More widespread and appropriate combined use of statins and aspirin in the secondary prevention of cardiovascular disease will avoid large numbers of premature deaths.

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