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This Week in JAMA
April 5, 2000

This Week in JAMA

JAMA. 2000;283(13):1655. doi:10.1001/jama.283.13.1655
Combination Therapy for Type 2 DM Improves Control

Treatment of type 2 diabetes mellitus (DM) using drugs with different mechanisms of action might improve glycemic control better than treatment with a single antidiabetic agent. In this trial that randomized 348 patients with type 2 DM that was inadequately controlled with metformin monotherapy, Fonseca and colleagues found that patients assigned to receive 4 or 8 mg/d of rosiglitazone in addition to metformin had a significant dose-dependent decrease in glycosylated hemoglobin and fasting plasma glucose levels compared with baseline and with patients who received metformin alone. Insulin sensitivity and β-cell function also improved more with combination treatment than with metformin monotherapy, and adverse events were similar in all treatment groups.

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Fenfluramines and Risk of Cardiac Valve Abnormalities

In 1997, antiobesity drugs fenfluramine and dexfenfluramine were voluntarily withdrawn from the US market because of reports of associated heart valve abnormalities. To determine the prevalence of cardiac valve abnormalities among patients treated for obesity with fenfluramines, Gardin and colleaguesArticle compared echocardiographic and clinical findings of 479 patients who received dexfenfluramine and 455 patients who received phentermine/fenfluramine with those of 539 untreated matched control patients. Prevalence and relative risk of aortic regurgitation based on echocardiographic criteria were significantly higher among treated compared with untreated patients, but moderate or severe aortic regurgitation was uncommon. Cardiovascular signs and symptoms and rates of serious cardiac events were similar among treated and untreated patients. In an editorial, JickArticle points out that the evidence to date suggesting a causal connection between use of fenfluramines and cardiac valve abnormalities is persuasive.

Medical Use of Opioids and Opioid Abuse Trends

Concerns about drug abuse may prevent medical use of opioid analgesics, but there is little information about the relationship between the use of opioids to treat pain and their rate of abuse. In this analysis of data on medical opioid use from the Automated Reports and Consolidated Orders System and on opioid abuse from hospital emergency departments in the Drug Abuse Warning Network, Joranson and colleagues found that despite increases in medical opioid use between 1990 and 1996, opioid abuse levels remained low and the proportion of opioid abuse reports to total drug abuse reports decreased.

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Clinical Vignettes Valid Measure of Quality of Care

To determine the validity of clinical vignettes as a method of measuring physician competence and quality of outpatient care, Peabody and colleaguesArticle compared scores from 3 quality of care measures—structured reports by standardized patients (SPs); medical record abstraction of the SP visits; and physician responses to clinical vignettes that corresponded to the SP visits—in a randomly selected sample of 20 physicians. Quality scores from the vignettes were consistently closer to SP scores (measurement standard) than those obtained from chart abstraction. In an editorial, FihnArticle emphasizes the importance of clinical knowledge as a determinant of quality of medical care in addition to structure and process.

E5 Fails to Reduce Mortality in Gram-Negative Sepsis

In 2 prior efficacy trials, treatment of severe gram-negative sepsis with E5, a murine monoclonal antibody directed against endotoxin, was not associated with a significant reduction in mortality. In this third and largest efficacy trial of E5, Angus and colleagues found no significant difference in mortality at day 14 or 28 among patients with severe documented or probable gram-negative sepsis randomly assigned to receive 2 doses of E5 compared with those who received placebo. Among patients who presented without shock, 28-day mortality was slightly lower in the E5 group compared with placebo, but the difference was not significant.

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A Piece of My Mind

"Faith is only possible when there is doubt." From "Faith and Doubt."

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Medical News & Perspectives

Recognizing the power of the Internet to provide reliable health information, the National Library of Medicine has embarked on a more than $1-million initiative to provide Web access to millions of Americans.

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Medical Malpractice Litigation

History of the origins and growth of medical malpractice litigation in the United States and why tort reform is necessary to promote reporting of medical errors and improve patient safety.

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International medical graduates: perspectives on training and evaluation and analyses of US immigration policies and physician workforce issues.

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JAMA Patient Page

For your patients: Information about pain management.

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