Low-risk Settings Research Articles

New Pharmacological Adjuncts for Coronary Stenting: Can New Anticoagulants Improve Outcomes?

The purpose of this review is to discuss the use of new adjunctive pharmacological agents to improve the outcome of patients with obstructive coronary disease treated with stents. The goal of any form of adjunctive therapy is to improve procedural, in‐hospital, and long‐term outcome. In terms of stenting, this goal may be accomplished by developing strategies to prevent procedural and postprocedural thrombosis and to prevent postprocedural intimai hyperplasia. Recent studies suggest that more potent anticoagulant agents, particularly the new antiplatelet agents, may have an important role in this regard. High risk subsets in whom benefits may be more striking, including both clinical risk factors (acute MI, unstable angina, vein graft disease, and diabetes) and procedural risk factors (visible thrombus, uncovered persistent dissections, overlapping stents, suboptimal deployment, poor distal run‐off, and “bail‐out” use). Current “standard” anticoagulant therapy for stent placement would include aspirin, heparin, ticlopidine, and possibly (though much less popular now than previously) coumadin. More recent newer adjuncts include low molecular weight heparin, platelet IIb/IIIa antagonists (such as ReoPro), and thrombolylic agents. A number of other potential agents may find their way into clinked usage in the not‐too‐distant future. Adjunctive therapy can be considered not only for use “prophylactically”, prior to the procedure in high risk cases, but intraprocedurally for clinical situations or complications that may arise. There is increasing experience and an increasing comfort level with ReoPro usage in stent cases. Platelet GP IIb/IIIa‐targeted therapy appears to be a useful adjunct to high risk stent procedures, Intraprocedural versus prophylactic administration of IIb/IIIa‐targeted therapy in this setting continues to be highly controversial. Its utility in low risk settings is unknown, but will be clarified by ongoing clinical trials. A large number of additional exciting new pharmacological agents will be entering clinical trials in the very near future.SummaryObviously, we are working at the fringes of our knowledge as we “push the envelope” of stenting and as we begin to incorporate new forms of adjunctive therapy. In the absence of hard data from randomized controlled trials, we make clinical decisions on the best information we have available at the time. What do we know at present?1. Platelet GP IIb/IIIa‐targeted therapy does appear to be a useful adjunct for certain high risk stent procedures.2. Intraprocedural versus prophylactic administration of IIb/IIIa‐targeted therapy as an adjunct to stent procedures continues to be highly controversial.3. The utility of IIb/IIIa‐targeted therapy for low‐risk stent procedures is unknown at present, but will be clarified by ongoing clinical trials.4. A large number of exciting new pharmacological agents, including oral and IV thrombin inhibitors, oral and IV IIb/IIIa blockers, tissue factor pathway inhibitor, adhesion molecule blockers, and other new anti‐platelet agents will be undergoing clinical trials with stents in the very near future.With this information in hand, we can hopefully apply adjunctive therapy (regardless of the specific agent used) in a rational, efficacious, and cost‐effective manner. We have learned a lot in recent years, especially about how much more we need to learn. Empiricism and controlled clinical trials only go so far on their own. By judiciously and critically evaluating the information in hand, we can continue to advance the safety and efficacy of intracoronary stents.

The Use of Cervical Cytology to Identify Women at Risk for Chlamydial Infection

Testing asymptomatic women for chlamydial infection is advocated for high-risk populations, but testing criteria in low-risk settings are less clear. To determine whether findings from Papanicolaou (Pap) smears could identify women at risk for Chlamydia, we studied 512 women, 18 to 50 years of age, seeking routine gynecologic care. The prevalence of positive cultures for Chlamydia was 4.7%. Three cytologic findings were independently associated with Chlamydia on logistic regression: transformed lymphocytes, polymorphonuclear leukocytes, and squamous metaplasia. The sensitivity and the specificity of the presence of any two of these three findings were 75% and 73.6%, respectively. The prevalence of Chlamydia if two findings were present was 12.2%, nearly three times the population prevalence. Certain findings on cervical cytology may be useful as an adjunct in preventive care for chlamydial cervicitis.

The use of a recombinant immunoblot assay in the interpretation of anti-hepatitis C virus reactivity among prospectively followed patients, implicated donors, and random donors.

Samples from prospectively followed recipients, their respective donors, and a cohort of random donors were used to evaluate the specificity and efficacy of a recombinant immunoblot assay (RIBA) as an adjunct to anti-hepatitis C virus (HCV) testing by enzyme immunoassay (EIA). RIBA reacted (RIBA+) in 100 percent of patients who developed hepatitis associated with anti-HCV seroconversion documented by EIA and in 100 percent of the EIA-positive (EIA+) donors implicated in these cases. In contrast, RIBA reacted in none of 10 recipients who were EIA+ but did not develop hepatitis, in none of 7 EIA+ patients with hepatitis B or cytomegalovirus infection, in 33 percent of EIA+ donors who were not implicated in hepatitis transmission, and in 37 percent of EIA+ random donors. Hence, the vast majority of EIA+ individuals who have ancillary evidence of HCV infection react on RIBA, whereas the majority of EIA+ individuals in low-risk settings do not react (RIBA-negative, or RIBA-). There was a strong association between RIBA reactivity and the presence of a surrogate marker (elevated alanine aminotransferase [ALT] and/or antibody to hepatitis B core antigen); 43 percent of RIBA+ implicated donors had a surrogate marker as compared to none of 14 EIA+, RIBA- donors. Among EIA+ random donors, 77 percent of those with a surrogate marker were RIBA+, as compared with 29 percent of those without a surrogate marker. In addition, in EIA+ donors, RIBA reactivity correlated with the extent of ALT elevation; 86 percent of those with an ALT greater than 135 IU per L were RIBA+ compared with 18 percent of those with an ALT less than 30 IU per L.(ABSTRACT TRUNCATED AT 250 WORDS)

Behavioral marital therapy: An evaluation of treatment effects across high and low risk settings

The present study examined the generalization of treatment effects of a cognitive-behavioral treatment program for marital distress. Following a baseline phase, each of four couples received two phases of marital therapy within a multiple baseline across subjects design. The first phase of treatment was behavioral marital therapy (BMT) focusing on communication and problem solving skills. The second phase was cognitive-behavioral marital therapy (CBMT) which focused on conflict management skills in high risk interactive settings at home. Couples' communication was assessed in a training setting in the clinic and each of two generalization probe settings at home (a low risk and a high risk) setting. The BMT phase produced a clear reduction in communication negativity in the training setting which generalized to both the low and the high risk setting. The CMBT phase produced little additional changes in communication, however, it was associated with changes on a measure of positive and negative partner-referent thoughts.