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This Week in JAMA
February 27, 2008

This Week in JAMA

JAMA. 2008;299(8):871. doi:10.1001/jama.299.8.871

Selective serotonin reuptake inhibitors (SSRIs), psychotherapy, or both are recommended for the acute management of adolescents with depression. However, at least 40% of patients do not respond to initial treatment with these therapies, and evidence-based guidance for subsequent treatment is lacking. Brent and colleagues report results of a clinical trial in which adolescents with depression who had not responded to an initial 2-month treatment with an SSRI and had not received cognitive behavioral therapy (CBT) were randomly assigned to switch for 12 weeks to 1 of the following treatment strategies: (1) a second, different SSRI, (2) a different SSRI and CBT, (3) venlafaxine (a selective serotonin and noradrenergic reuptake inhibitor), or (4) venlafaxine and CBT. The authors found that the combination of switching to a different antidepressant agent and receiving CBT resulted in a higher rate of clinical response than switching only to a different medication. There was no difference in response to the medication switches, and patients who were switched to a different SSRI experienced fewer adverse effects than patients taking venlafaxine.

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Prior studies have documented an increased risk of venous thromboembolism (VTE) in patients with cancer-associated anemia who are treated with the erythropoiesis-stimulating agents (ESAs). In an updated investigation of safety concerns related to ESAs, Bennett and colleagues analyzed data from phase 3 clinical trials published or presented between January 1993 and January 2007 to assess ESA-associated risks of VTE and mortality. The authors report that anemic patients with cancer who were treated with ESAs had a 1.55-fold increased risk of VTE and a 1.10-fold increased risk of mortality compared with patients who received placebo or standard care.

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Investigation of the clinical applications of embryonic stem cells has been hampered by methodological and ethical challenges. In contrast, stem cells from peripheral or umbilical cord blood and bone marrow can be easily and safely harvested. Burt and colleagues reviewed the literature and surveyed investigators to examine patient outcomes and mortality associated with current clinical applications of blood-derived and bone marrow–derived stem cells for nonmalignant nonhematologic diseases. Their analysis suggests that stem cells harvested from blood or bone marrow may provide modest disease-ameliorating effects in selected patients with some autoimmune diseases and some cardiovascular disorders.

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Perspectives on Care at the Close of Life

Ms H is a 56-year-old woman who was diagnosed with breast cancer in 1986 and treated with mastectomy, chemotherapy, and chest wall radiotherapy. Bone metastases were initially diagnosed in 1990, and Ms H has received medical, surgical, and radiation therapy to treat these and subsequent bone metastases. Recently, she experienced pain and neurological symptoms from a recurrent metastatic tumor at the T6 and T7 vertebrae. Abrahm and colleagues discuss the diagnosis, treatment, and prognosis of malignant spinal cord compression.

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“Although ‘transfusion’ is not mentioned in the Bible, the relevant passages warn about the consequences of eating blood.” From “Listening to Leviticus.”

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A clinical trial testing a combination of 2 anticholesterol drugs (exetimibe/simvastatin, or Vytorin) is embroiled in controversy after results revealed that the therapy failed to prevent progression of atherosclerosis.

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The health care cost-coverage trade-off

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Organize care to maximize health

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Lessons from the ENHANCE trial

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Environmental change and health

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Join Stephen Shortell, PhD, on March 19, 2008, from 2 to 3 PM eastern time to discuss improving patient safety. To register, go to http://www.ihi.org/AuthorintheRoom.

How would you manage a 74-year-old man who has moderate daily alcohol use, memory loss, and progressive neuropathy? Go to www.jama.com to read the case and submit your response. Your response may be selected for online publication. Submission deadline is February 27.

For your patients: Information about spinal stenosis.

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