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This Week in JAMA
January 5, 2000

This Week in JAMA

JAMA. 2000;283(1):9. doi:10.1001/jama.283.1.9
Primary Care by Nurse Practitioners or Physicians

To compare outcomes of primary care provided by nurse practitioners or by physicians, Mundinger and colleaguesArticle randomly assigned patients to receive follow-up and ongoing primary care after an emergency department or urgent care visit from either a nurse practitioner in independent practice or a physician. Patient satisfaction after the initial appointment, health status at 6 months, disease-specific physiologic measures for patients with asthma and diabetes, and health services utilization after 6 and 12 months were similar in the 2 study groups. In an editorial, SoxArticle considers the generalizability of these findings to long-term care and to other patient populations and clinical practices.

Quality of Life of Children Surviving Massive Burns

In this evaluation of 68 children who survived burns involving 70% or more of the body surface, Sheridan and colleagues found that after an average of 14.7 years after injury, scores on a health-related quality-of-life instrument were similar to national norms and slightly better in the mental health domain. Factors associated with higher scores in individual domains included better functional status of the family, early reintegration with preburn activities, and consistent follow-up in a multidisciplinary burn clinic for 2 years.

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Risk of Hepatotoxicity and Antiretroviral Therapy

In a cohort of patients infected with human immunodeficiency virus (HIV) beginning a new antiretroviral regimen, Sulkowski and colleagues found that severe hepatotoxicity occurred in 31 of 298 patients, including 19 of 158 patients coinfected with hepatitis C or B virus, or both. Antiretroviral drug regimens that included ritonavir were associated with the highest incidence of severe hepatotoxicity. Coinfection with hepatitis C or B virus was associated with a significantly increased risk of severe hepatotoxicity among patients prescribed nonritonavir containing regimens, but most patients with chronic viral hepatitis did not experience severe hepatotoxicity during antiretroviral therapy.

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Screening for Cervical Cancer Using HPV DNA Testing

Human papillomavirus (HPV) DNA testing for detection of cervical cancer may provide an option for screening self-collected specimens and an alternative to cytologic techniques. In a study of previously unscreened women, Wright and colleaguesArticle found that testing of patient-collected vaginal swabs for HPV DNA was as sensitive as Papanicolaou smears of clinician-obtained cervical samples for detection of high-grade squamous intraepithelial lesions (HSILs) or invasive cancer, but less specific. In a cohort of women at high risk for cervical cancer, Schiffman and colleaguesArticle found that a second-generation HPV DNA test performed best at a positivity cut point HPV DNA level of 1.0 pg/mL for detection of HSIL and cancer (sensitivity, 88.4%; specificity, 89%; referral for colposcopic examination, 12.3% of women). Papanicolaou testing using atypical squamous cells of undetermined significance as the cut point was less sensitive (77.7%) but more specific (94.2%), and the referral rate was 6.9%. In an editorial, CuzickArticle points out that the usefulness of HPV DNA testing and self-sampling depends on the clinical setting in which they are used.

Target LDL Levels for Secondary Prevention of CHD

National Cholesterol Education Program (NCEP) guidelines recommend reduction of low-density lipoprotein cholesterol (LDL-C) to 100 mg/dL (2.59 mmol/L) or less in patients with coronary heart disease (CHD). Recently, the National Committee for Quality Assurance (NCQA) established a performance measure that set an LDL-C target level of less than 130 mg/dL (3.36 mmol/L) for patients with a major CHD event between 60 and 365 days after hospital discharge. Lee and colleagues discuss the rationale for each threshold and explain why the NCEP target level, a clinical goal for the treatment of individual patients, is consistent with the NCQA target level, a performance measure for the care of populations.

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A Piece of My Mind

"In the field, ‘human rights' is not a theoretical concept or an abstract set of laws. It is the difference between respect and rape, between safety and death." From "For What Purpose?"

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Medical News & Perspectives

The new year ushers in a reassessment of goals for the health of the nation, a major study on heart disease in one minority population, and a renewed call for care during surgical operations.

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Private Practitioners Tackle Access to Care

A report on 39 community-based projects in the Robert Wood Johnson national Reach Out program organized by practicing physicians to increase access to health care for the uninsured and underinsured.

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From the New Editor of JAMA

Catherine D. DeAngelis, MD, MPH, new editor of JAMA and editor-in-chief of Scientific Publications and Multimedia, reaffirms unconditional editorial independence and academic integrity of JAMA and the ARCHIVES Journals during her tenure.

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MSJAMA

The complex nature of pain and approaches to pain management and palliative care.

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JAMA Patient Page

For your patients: A primer on burns in children.

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