This Week in JAMA

Patients infected with HIV who achieve virologic suppression with antiretroviral therapy may have intermittent episodes of low-level viremia during continued therapy, but it is not known whether low-level viremia is associated with virologic failure or with acquisition of drug resistance. In a retrospective analysis of patients with HIV enrolled in treatment trials who had achieved virologic suppression, Havlir and colleaguesArticle found that intermittent viremia (transient increases in plasma HIV RNA levels >50 copies/mL) occurred frequently but was not associated with virologic failure. Hermankova and colleaguesArticle, in a related study, used a novel method to amplify the HIV-1 pol gene in a group of patients receiving antiretroviral therapy who had prolonged suppression of viral replication and very low levels of viral genome in plasma. Genotypic analysis did not show evidence of new drug resistance mutations in plasma virus that were clearly attributable to the antiretroviral regimen, but resistant virus selected by prior nonsuppressive therapy persisted whether or not those drugs were continued. In an editorial, DeeksArticle considers possible mechanisms to explain why drug resistance mutations and virologic failure were uncommon in patients with low-level viremia and discusses the implications of these findings for antiretroviral therapy.

The Framingham coronary heart disease (CHD) prediction functions, developed to predict the risk of clinical CHD events, were based on data from the Framingham Heart Study, which enrolled only white middle-class individuals. To evaluate the generalizability of the prediction functions, D'Agostino and colleagues applied them to 6 prospectively studied, ethnically diverse cohorts, including whites, blacks, Native Americans, Japanese American men, and Hispanic men. The Framingham functions performed well for white men and women and for black men and women in different settings within 5 years of follow-up. After recalibration for different prevalences of risk factors and underlying rates of CHD events, the Framingham functions also performed well for other ethnic groups.

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The alignment of the hip, knee, and ankle influences load distribution at the knee—varus alignment increases force across the medial compartment of the knee and valgus alignment increases force across the lateral compartment. In this prospective cohort study of persons with primary knee osteoarthritis, Sharma and colleagues assessed whether knee alignment at baseline influenced the risk of structural progression and functional decline during 18 months of follow-up. Varus alignment at baseline was associated with a 4-fold increase in the odds of medial progression; and valgus alignment at baseline, almost a 5-fold increase in the odds of lateral progression. The severity of malalignment at baseline correlated with the magnitude of joint space loss, and the burden of malalignment at baseline predicted deterioration in physical function.

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The use of herbal medications is widespread and may pose particular risks for patients undergoing surgery. In this review, Ang-Lee and colleagues consider safety and regulatory issues for herbal medications, summarize important pharmacological effects of 8 commonly used herbal medications—echinacea, ephedra, garlic, ginkgo, ginseng, kava, St John's wort, and valerian—that may affect perioperative care, and propose strategies for managing the preoperative use of these medications.

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Pathological gambling: prevalence, neurobiological features, diagnosis, and treatment.

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An estimated 4.5 million people in the United States are bitten by dogs each year. To address this public health problem, the American Veterinary Medical Association has published "A Community Approach to Dog Bite Prevention," new guidelines for local action and education efforts.

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Studdert and BrennanArticle contend that the current negligence-based system of medical malpractice is not compatible with the "systems approaches" proposed to reduce error in medicine, and argue in favor of a no-fault compensation system.Article

For your patients: Information about pathological gambling.

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