The African American Study of Kidney Disease and Hypertension is an
ongoing trial to compare the effects of 3 drugs—ramipril, amlodipine,
and metoprolol—and 2 blood pressure goals on the progression of hypertensive
renal disease in African American patients. The amlodipine treatment arm was
terminated early due to safety concerns. In this analysis comparing the ramipril
and amlodipine groups, Agodoa and colleaguesArticle report that among patients with
baseline urine protein to creatinine ratio greater than 0.22 (urinary protein
excretion greater than about 300 mg/d), the glomerular filtration rate (GFR)
decline over 3 years was significantly slower in the ramipril group. The risk
of the composite end point of GFR decline, end-stage renal disease, or death
was significantly less in patients treated with ramipril. In an editorial,
PapademetriouArticle discusses treatment of hypertension in patients with hypertensive
Elevated levels of high-density lipoprotein cholesterol (HDL-C) have
been associated with reduced risk of coronary artery disease. To evaluate
whether increased HDL-C levels are protective against ischemic stroke, Sacco
and colleagues analyzed data from the Northern Manhattan Stroke Study, an
incident case-control study in an elderly, multiethnic population. Overall,
high levels of HDL-C (35 mg/dL or greater) were associated with a reduced
risk of ischemic stroke. In subgroup analyses, the association between elevated
HDL-C levels and reduced risk of ischemic stroke was significant among participants
aged 75 years or older and was present among different racial and ethnic groups.
Risk-adjusted outcomes have been used to assess the effectiveness and
quality of care for a variety of clinical conditions. In this study of patients
hospitalized with hip fracture at 4 hospitals, Hannan and colleagues used
medical record data and information from interviews with patients and their
proxies to develop models to predict functional status (locomotion) and mortality
6 months after hospitalization. Significant predictors of 6-month mortality
included low prefracture locomotion, paid helper at home prior to fracture,
and higher modified APACHE score; significant predictors of locomotion status
included prefracture locomotion, age, and nursing home residence prior to
fracture. Adjustment for baseline patient characteristics altered interhospital
differences in outcomes, and the performance of 2 of the 4 hospitals differed
for functional status and mortality outcomes.
Fabry disease is a rare X-linked recessive glycosphingolipid storage
disorder without a specific treatment. It is caused by deficiency of the lysosomal
enzyme α-galactosidase A that results in accumulation of globotriaosylceramide
in a variety of cells, including endothelial, vascular smooth muscle, renal
epithelial, and dorsal root ganglia neuronal cells. In this trial, Schiffman
and colleagues found that patients with Fabry disease and neuropathic pain
who received infusions of α-galactosidase A had significantly greater
reductions in the severity of neuropathic pain and improvements in pain-related
quality of life than patients who received placebo. Renal pathology, renal
function, and cardiac conduction also improved in the α-galactosidase
A group, and body weight increased.
Walter and CovinskyArticle present a framework to guide cancer screening decisions
in older patients that starts with quantitative estimates of life expectancy,
risk of cancer death, and screening outcomes, and includes a qualitative consideration
of the benefits and harms of cancer screening based on a patient's unique
values and preferences. In an editorial, WelchArticle discusses the downsides of
cancer screening and illustrates the difficulty of communicating information
that patients need to make an informed choice.
"The opportunity to reveal this part of their past, to uncover the recollections
seared into their minds, and to recall the memories of their murdered loved
ones seems to have strengthened the bonds of our patient-physician relationship."
From "The List."
To reduce the number of suicides in the United States—approximately
30 000 deaths per year—Surgeon General David Satcher recently released
the nation's first coordinated suicide prevention strategy.
Mr R presented with headache, weakness of the left side of his face
and left arm, and a right-sided Horner syndrome. Magnetic resonance imaging
showed an infarction in the right frontal-parietal region, and cerebral angiography
showed the underlying cause.
This fifth article in the series of consensus statements from the Working
Group on Civilian Biodefense discusses medical and public health management
after the use of tularemia as a bioweapon.
For your patients: Information about low bone density and hip fracture.
This Week in JAMA. JAMA. 2001;285(21):2681. doi:10.1001/jama.285.21.2681