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
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withdrawn from the US market because of reports of associated heart valve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
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.
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.
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.
"Faith is only possible when there is doubt." From "Faith and Doubt."
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.
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.
See Article and Article
International medical graduates: perspectives on training and evaluation
and analyses of US immigration policies and physician workforce issues.
For your patients: Information about pain management.
This Week in JAMA. JAMA. 2000;283(13):1655. doi:10.1001/jama.283.13.1655