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This Week in JAMA
March 15, 2000

This Week in JAMA

JAMA. 2000;283(11):1387. doi:10.1001/jama.283.11.1387
Carotid Artery Stenosis and Causes of Ischemic Stroke

In the previously published North American Symptomatic Carotid Endarterectomy Trial (NASCET), patients with high-grade symptomatic internal carotid artery stenosis randomly assigned to undergo carotid endarterectomy had a lower risk of stroke or death than those assigned to medical treatment alone. In this follow-up analysis of stroke risk during a mean of 5 years, Barnett and colleaguesArticle found that approximately 30% of 1021 ischemic strokes among patients in NASCET were not of large-artery origin and would be unlikely to be prevented by carotid endarterectomy. The 5-year risk of an ischemic stroke in any territory of cardioembolic origin was 2.6%; lacunar origin, 6.9%; and large-artery origin, 19.7%. Among patients with 70% to 99% stenosis, the proportion of cardioembolic and lacunar strokes was 43.5% with asymptomatic large-artery lesions and 21.6% with symptomatic lesions. In an editorial, CaplanArticle explains that because several risk conditions for ischemic stroke often coexist, no single strategy can prevent all causes of stroke.

Advance Directives Reduce Health Care Utilization

To assess the effect of an advance directive program in nursing homes on satisfaction with health care and health care costs, Molloy and colleaguesArticle pair-matched 6 nursing homes and randomly assigned 1 nursing home in each pair to implement the Let Me Decide advance directive program, a multifaceted program with instructional and proxy components for patients and an educational program for staff. Over 18 months, hospitalizations per nursing home resident were significantly lower in the intervention nursing homes and mean health services costs per resident were less than in the control homes. Mortality rates and satisfaction with health care were similar in intervention and control homes. In an editorial, TenoArticle emphasizes the importance of developing plans that ensure appropriate palliation at the end of life in addition to completing advance directives.

Short-Course Regimen Effective for TB Prevention

Guidelines for prevention of tuberculosis (TB) in individuals with a positive tuberculin skin test result recommend 6 to 12 months of daily isoniazid, a regimen often complicated by poor adherence, hepatotoxicity, and isoniazid resistance. In this trial comparing a 2-month regimen of rifampin and pyrazinamide with a 12-month isoniazid regimen among 1583 individuals infected with HIV with a positive tuberculin skin test result, Gordin and colleagues found that rates of culture-confirmed TB after a mean follow-up of 37 months were similar in the 2 study groups. Eighty percent of patients completed the short-course preventive regimen, whereas 69% completed isoniazid therapy.

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Cost-effectiveness of Pneumococcal Vaccine in Children

In this analysis of the cost-effectiveness of the pneumococcal conjugate vaccine, Lieu and colleagues estimated that vaccination of healthy infants would prevent more than 12,000 cases of meningitis and bacteremia, 53,000 cases of pneumonia, 1 million episodes of otitis media, and 116 deaths. Considering direct medical costs and work-loss and productivity costs, routine infant pneumococcal vaccination would result in net savings if the vaccine cost less than $46 per dose.

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Glucosamine and Chondroitin for Osteoarthritis

Glucosamine and chondroitin have been promoted as effective alternatives to nonsteroidal anti-inflammatory drugs for the treatment of osteoarthritis. In this analysis of 15 randomized placebo-controlled trials of glucosamine or chondroitin for knee or hip osteoarthritis, McAlindon and colleaguesArticle found that these preparations had moderate to large treatment effects on osteoarthritis symptoms. The mean trial quality score was 35.5% of the maximum score (range, 12.3% to 55.4%), however, and evidence of publication bias was apparent. In an editorial, Towheed and AnastassiadesArticle explain why the treatment benefit of glucosamine and chondroitin is probably less than that estimated by the meta-analysis.

From the JAMA Web Sites

Association between stress and recurrence of symptomatic genital herpes in women.

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Medical News & Perspectives

Concerned about the increase in eating disorders among young people in Spain, the government has issued a report and recommendations emphasizing sociocultural factors that contribute to the problem.

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Sedation for Critically Ill Patients

A systematic review of 32 randomized controlled trials comparing medications for sedation of critically ill adult patients receiving mechanical ventilation.

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Risk Stratification and Cardiac Rehabilitation

Current risk stratification guidelines reduce access to medically supervised exercise training programs for patients with cardiac disease who would benefit from these rehabilitation services.

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JAMA Patient Page

For your patients: Information about advance directives.

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