HIV Therapy Benefit Persists Despite Low-Level Viremia
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.
Validation of the Framingham CHD Prediction Scores
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.
Knee Alignment and Progression of Knee Osteoarthritis
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.
Perioperative Risks of Herbal Medications
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.
Pathological gambling: prevalence, neurobiological features, diagnosis,
Medical News & Perspectives
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.
No-Fault Compensation for Medical Injuries
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
For your patients: Information about pathological gambling.