In the previously reported Trilège trial, patients infected with
HIV were more likely to sustain viral suppression while receiving 3-drug maintenance
therapy compared with 2-drug regimens. Comparing 58 patients with virologic
failure (HIV RNA level >500 copies/mL) and 58 matched controls with sustained
viral suppression, Descamps and colleaguesArticle found that virologic failure was
more highly associated with treatment nonadherence and suboptimal drug potency
than with emergence of drug-resistant strains. In a substudy of the AIDS Clinical
Trials Group 343 study, Havlir and colleaguesArticle found that viral rebound (HIV
RNA level ≥200 copies/mL) during maintenance with triple-drug therapy or
with indinavir monotherapy in 26 patients was not associated with indinavir
resistance or with differences in mean plasma indinavir concentrations compared
with patients with sustained suppression. In an editorial, MarkowitzArticle points
out the importance of resistance testing when viral rebound occurs during
maintenance anti-HIV therapy.
Dissemination of quality improvement (QI) programs in managed primary
care settings that enhance opportunities for treatment of depression may improve
depression treatment without mandating specific processes of care. Wells and
colleagues report that patients with depression followed up in primary care
clinics randomly assigned to QI for depression treatment were more likely
to receive counseling or antidepressant medication and have visits for mental
health problems than patients in usual care clinics. The rate of probable
depressive disorder among patients in the QI clinics was significantly lower
at 6 and 12 months and employment retention at 12 months was significantly
higher than in the usual care group.
The increased risk of cardiovascular disease (CVD) in individuals with
impaired glucose tolerance and type 2 diabetes mellitus might be explained
by an association of hyperinsulinemia with impaired fibrinolysis and hypercoagulability,
increasing thrombotic risk. In this cross-sectional analysis of data from
2962 adults without diabetes or CVD enrolled in the Framingham Offspring Study,
Meigs and colleagues found that mean levels of plasminogen activator inhibitor
1 (PAI-1) antigen, tissue-type plasminogen activator (tPA) antigen, factor
VII antigen, von Willebrand factor antigen, fibrinogen, and plasma viscosity
increased across fasting insulin quintiles. Levels of PAI-1 antigen and tPA
antigen were higher among individuals with glucose intolerance compared with
those with normal glucose tolerance.
In this prospective study of 40 patients with hypoxemic acute respiratory
failure (ARF) following solid organ transplantation randomly assigned to receive
either noninvasive positive-pressure ventilation (NIV) delivered through a
face mask or standard intervention with supplemental oxygen administration,
Antonelli and colleagues found that NIV was associated with a significantly
reduced rate of endotracheal intubation and fatal complications in the intensive
care unit after intubation compared with standard intervention. Fourteen patients
in the NIV group improved their ratio of PaO2 to FIO2
within the first hour of treatment and 12 had sustained improvement without
intubation whereas 5 patients receiving standard treatment had improved gas
exchange within 1 hour and 5 had sustained improvement.
The threat of biological and chemical terrorism against US civilian
populations requires formulation of comprehensive communitywide emergency
response programs. Macintyre and colleaguesArticle present an emergency response
plan for health care facilities for decontamination of large numbers of people
exposed to chemical or biological warfare agents. In an editorial, WaeckerleArticle
critiques existing community preparedness programs and emphasizes the importance
of including health care professionals and facilities in preparedness planning.
"Do not think about the woman at the YWCA with the puckered scar over
her heart." From "How to Have Your First Mammogram."
Update on 2 topical immunomodulating drugs and advances in the management
of toxic epidermal necrolysis.
Fleshy mass on the iris of the left eye of a 60-year-old woman.
Researchers seeking to understand and alleviate chronic pain are hoping
to treat humans with a molecular neurosurgical approach that selectively targets
the nerves involved in pain transmission.
Orentlicher and Caplan assert that the Pain Relief Promotion Act of
1999, recently introduced before Congress, would compromise the quality of
palliative care by making use of controlled substances to cause or assist
in causing a patient's death subject to criminal prosecution and punishment.
For your patients: A primer on type 2 diabetes mellitus.
This Week in JAMA. JAMA. 2000;283(2):163. doi:10.1001/jama.283.2.163