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This Week in JAMA
February 19, 2003

This Week in JAMA

JAMA. 2003;289(7):805. doi:10.1001/jama.289.7.805
Bivalirudin vs Heparin During PCI

Low-dose heparin plus glycoprotein IIb/IIIa (Gp IIb/IIIa) blockade is the current standard of adjunctive antithrombin therapy during percutaneous coronary intervention (PCI). In this randomized trial among patients undergoing urgent or elective PCI, Lincoff and colleaguesArticle compared the direct thrombin inhibitor bivalirudin plus provisional Gp IIb/IIIa inhibition for complications during PCI with heparin plus planned Gp IIb/IIIa inhibition. For the composite primary end point—30-day incidence of death, myocardial infarction, urgent repeat revascularization, or in-hospital major bleeding, and the secondary end point of efficacy outcomes alone—bivalirudin plus provisional Gp IIb/IIIa blockade was statistically not inferior to heparin plus planned Gp IIb/IIIa inhibition. In an editorial, AntmanArticle discusses clinical situations in which bivalirudin could be considered as an alternative to heparin during PCI.

Patient Appeals of Preservice Coverage Denials

The first recourse available to most health maintenance organization (HMO) enrollees who have been denied coverage for care is an appeal to an appeals system administered by the health plan itself. Studdert and GresenzArticle reviewed a sample of preservice appeals from the administrative files of 2 large HMOs to examine the sources, types, and outcomes of conflicts between patients and managed care organizations over coverage of services. Approximately one third of preservice appeals involved medical necessity disputes; another third, the scope of contractually covered benefits; and most of the remainder, out-of-network care. Enrollee wins were more frequent among medical necessity appeals. In an editorial, RosenbaumArticle emphasizes the importance of the ability of individuals to secure the health care services for which they are eligible.

Digoxin Concentrations and Heart Failure Mortality

In the Digitalis Investigation Group trial, a randomized placebo-controlled trial among patients with heart failure, mortality in the digoxin group was not significantly different from that in the placebo group, but rates of hospitalization due to worsening heart failure were modestly reduced. Rathore and colleagues conducted a post hoc analysis of data from men enrolled in this trial to determine whether variations in serum digoxin concentration were associated with differences in mortality at a mean of 37 months of follow-up. All-cause mortality rates increased significantly as serum digoxin concentrations increased. Patients with a serum digoxin concentration of 0.5 to 0.8 ng/mL had a significantly lower mortality rate compared with patients receiving placebo, but mortality rates among patients with serum digoxin concentrations greater than 0.8 ng/mL were not reduced compared with placebo.

Community Campaign to Increase Booster Seat Use

Child booster seats are more effective than seat belts at reducing risk of injury for children aged 4 to 8 years who have outgrown car seats. Ebel and colleagues conducted a multifaceted booster seat campaign in 4 communities to increase observed booster seat use. Fifteen months after the start of the campaign, booster seat use among booster-eligible children in the intervention communities increased significantly compared with control communities.

Antimicrobial Resistance in Intensive Care Units

In a previous national surveillance study of antimicrobial resistance among gram-negative aerobic isolates recovered from patients in intensive care units (ICUs), Neuhauser and colleagues found that the incidence of ceftazidime-resistant Klebsiella pneumoniae and Enterobacter species increased from 1990 through 1993. In this report of national rates of antimicrobial resistance in ICUs from 1994 through 2000, the investigators found that ceftazidime resistance for K pneumoniae and Enterobacter species continued to increase. The activity of most antimicrobial agents against gram-negative aerobic isolates decreased by 6% or less. The overall susceptibility to ciprofloxacin decreased from 86% in 1994 to 76% in 2000 and was associated with increased national use of fluoroquinolones.

A Piece of My Mind

"While I did not fully grasp what it would mean to live in a male body without potency, I had not begun to contemplate the meaning of continuing to live without the experience of desire." From "An Essay on Desire."

Medical News & Perspectives

Preliminary survey findings that suggest that many physicians believe prescription drug advertisements serve positive public health functions are met with skepticism.

Medical Monitoring

Health Law and Ethics An examination of the usefulness of expanding tort law to include medical monitoring—a court-ordered program that provides diagnostic tests to facilitate early detection of adverse health effects of a pharmaceutical product among exposed individuals who have no current injury.

CLINICIAN'S CORNER

The Rational Clinical Examination

A systematic review of the accuracy of symptoms, signs, and laboratory tests for the diagnosis of perimenopause.

The Resident Match and Antitrust Law

On Call

In May 2002, several physicians filed a class action lawsuit alleging that the National Resident Matching Program violates antitrust law. RothArticle reviews the history and design of the resident match. Miller and GreaneyArticle discuss the complex legal issues involved in the recent lawsuit and the important questions that litigation will not address.

JAMA Patient Page

For your patients: Information about perimenopause.

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