The therapeutic effect of nonsteroidal anti-inflammatory drugs (NSAIDs)
is attributed to inhibition of cyclooxygenase (COX)-2, whereas the adverse
gastrointestinal effects of NSAIDs are thought to be mediated by inhibition
of COX-1. Silverstein and colleaguesArticle report that patients with osteoarthritis
and rheumatoid arthritis treated for 6 months with celecoxib, a selective
COX-2 inhibitor, in dosages 2 to 4 times the maximum recommended dosages,
had a lower combined incidence of ulcer complications and symptomatic ulcers
than patients treated with standard dosages of conventional NSAIDs. The decreased
rate of ulcer complications and symptomatic ulcers, however, was found only
among patients who were not also taking low-dosage aspirin, and overall, rates
of ulcer complications alone were similar in the 2 treatment groups. In an
editorial, Lichtenstein and WolfeArticle consider how current understanding of the
physiologic activity of COX-1 and COX-2 might explain these findings.
The cost of medical care at academic health centers is often higher
than at nonteaching hospitals, but data on differences in the quality of care
between the 2 types of institutions are also necessary to formulate health
care policy and quality improvement programs. Allison and colleagues assessed
the quality of care for 114,411 fee-for-service Medicare patients with acute
myocardial infarction (MI) admitted to teaching and nonteaching hospitals.
Quality of care was significantly better among patients admitted to teaching
hospitals than among those admitted to nonteaching hospitals on 3 of 4 quality
indicators. Unadjusted mortality rates at 30 days, 60 days, 90 days, and 2
years were lowest at major teaching hospitals, intermediate at minor teaching
hospitals, and highest at nonteaching hospitals.
Niacin treatment may be an effective and safe lipid-modifying therapy
even among patients with diabetes. In this analysis of data from the Arterial
Disease Multiple Intervention Trial, Elam and colleagues found that participants
with and without diabetes who received niacin had increased levels of high-density
lipoprotein cholesterol and decreased levels of triglycerides and low-density
lipoprotein cholesterol after 18 weeks of treatment. Changes in lipoprotein
levels were significantly greater in the niacin treatment group than in the
placebo group. Glucose levels were modestly increased among participants with
and without diabetes who received niacin. Among participants with diabetes,
HbA1c levels were unchanged in the niacin group, but decreased
in the placebo group.
In this summary of postlicensure safety surveillance for varicella vaccine,
Wise and colleagues report that 6574 cases of adverse events in recipients
of varicella vaccine were reported to the US Vaccine Adverse Event Reporting
System between March 17, 1995, and July 25, 1998, a rate of 67.5 reports per
100,000 doses sold. Approximately 4% of reports described serious adverse
events, including 14 deaths, but a vaccine etiology for most of these serious
events could not be confirmed.
In 2 recent trials, combined radiation therapy and androgen suppression
therapy for locally advanced prostate cancer (T3, T4) was associated with
better cancer-specific survival than treatment with radiation alone. In a
retrospective study of men with clinically localized prostate cancer (T1,
T2), D'Amico and colleagues found no difference in risk of prostate-specific
antigen (PSA) failure between low-risk patients who received treatment with
radiation therapy alone and those who also received 6 months of androgen suppression
therapy, but risk of PSA failure was significantly reduced among intermediate-
and high-risk patients who received combined treatment compared with radiation
A review of recent studies that investigate the relationship between
dental and oral diseases and general health.
Results of a recent nationwide survey make it clear that, contrary to
general belief, physicians in nearly every state need not fear legal action
if they prescribe sterile needles for injection drug users.
An examination of the unstructured, rapid growth of medical specialization
in the United States since the early 20th century raises questions about what
is a rational balance of generalists and specialists in the physician workforce
and how balance should be achieved.
See Article and Article
Fundamental principles of evidence-based medicine that underlie the
application of the Users' Guides to patient care.
For your patients: A primer on medical research.
This Week in JAMA. JAMA. 2000;284(10):1207. doi:10.1001/jama.284.10.1207