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.
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
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.
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.
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
Association between stress and recurrence of symptomatic genital herpes
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.
A systematic review of 32 randomized controlled trials comparing medications
for sedation of critically ill adult patients receiving mechanical ventilation.
Current risk stratification guidelines reduce access to medically supervised
exercise training programs for patients with cardiac disease who would benefit
from these rehabilitation services.
For your patients: Information about advance directives.
This Week in JAMA. JAMA. 2000;283(11):1387. doi:10.1001/jama.283.11.1387