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This Week in JAMA
JAMA. 2000;283:163.
Virologic Failure During Maintenance Anti-HIV Therapy
In the previously reported Trilège trial, patients infected with HIV were more likely to sustain viral suppression while receiving 3-drug maintenance therapy compared with 2-drug regimens. Comparing 58 patients with virologic failure (HIV RNA level >500 copies/mL) and 58 matched controls with sustained viral suppression, Descamps and colleagues (SEE ARTICLE) found that virologic failure was more highly associated with treatment nonadherence and suboptimal drug potency than with emergence of drug-resistant strains. In a substudy of the AIDS Clinical Trials Group 343 study, Havlir and colleagues (SEE ARTICLE) found that viral rebound (HIV RNA level  200 copies/mL) during maintenance with triple-drug therapy or with indinavir monotherapy in 26 patients was not associated with indinavir resistance or with differences in mean plasma indinavir concentrations compared with patients with sustained suppression. In an editorial, Markowitz (SEE ARTICLE) points out the importance of resistance testing when viral rebound occurs during maintenance anti-HIV therapy.
Improving Treatment of Depression in Primary Care
Dissemination of quality improvement (QI) programs in managed primary care settings that enhance opportunities for treatment of depression may improve depression treatment without mandating specific processes of care. Wells and colleagues report that patients with depression followed up in primary care clinics randomly assigned to QI for depression treatment were more likely to receive counseling or antidepressant medication and have visits for mental health problems than patients in usual care clinics. The rate of probable depressive disorder among patients in the QI clinics was significantly lower at 6 and 12 months and employment retention at 12 months was significantly higher than in the usual care group.
(SEE ARTICLE)
Hyperinsulinemia and Impaired Hemostatic Function
The increased risk of cardiovascular disease (CVD) in individuals with impaired glucose tolerance and type 2 diabetes mellitus might be explained by an association of hyperinsulinemia with impaired fibrinolysis and hypercoagulability, increasing thrombotic risk. In this cross-sectional analysis of data from 2962 adults without diabetes or CVD enrolled in the Framingham Offspring Study, Meigs and colleagues found that mean levels of plasminogen activator inhibitor 1 (PAI-1) antigen, tissue-type plasminogen activator (tPA) antigen, factor VII antigen, von Willebrand factor antigen, fibrinogen, and plasma viscosity increased across fasting insulin quintiles. Levels of PAI-1 antigen and tPA antigen were higher among individuals with glucose intolerance compared with those with normal glucose tolerance.
(SEE ARTICLE)
Noninvasive Ventilation for ARF After Transplantation
In this prospective study of 40 patients with hypoxemic acute respiratory failure (ARF) following solid organ transplantation randomly assigned to receive either noninvasive positive-pressure ventilation (NIV) delivered through a face mask or standard intervention with supplemental oxygen administration, Antonelli and colleagues found that NIV was associated with a significantly reduced rate of endotracheal intubation and fatal complications in the intensive care unit after intubation compared with standard intervention. Fourteen patients in the NIV group improved their ratio of PaO2 to FIO2 within the first hour of treatment and 12 had sustained improvement without intubation whereas 5 patients receiving standard treatment had improved gas exchange within 1 hour and 5 had sustained improvement.
(SEE ARTICLE)
Preparedness for Chemical and Biological Terrorism
The threat of biological and chemical terrorism against US civilian populations requires formulation of comprehensive communitywide emergency response programs. Macintyre and colleagues (SEE ARTICLE) present an emergency response plan for health care facilities for decontamination of large numbers of people exposed to chemical or biological warfare agents. In an editorial, Waeckerle (SEE ARTICLE) critiques existing community preparedness programs and emphasizes the importance of including health care professionals and facilities in preparedness planning.
A Piece of My Mind
"Do not think about the woman at the YWCA with the puckered scar over her heart." From "How to Have Your First Mammogram."
(SEE ARTICLE)
Contempo Updates
Update on 2 topical immunomodulating drugs and advances in the management of toxic epidermal necrolysis.
(SEE ARTICLE)
Photo/Essay
Fleshy mass on the iris of the left eye of a 60-year-old woman.
(SEE ARTICLE)
Medical News & Perspectives
Researchers seeking to understand and alleviate chronic pain are hoping to treat humans with a molecular neurosurgical approach that selectively targets the nerves involved in pain transmission.
(SEE ARTICLE)
Proposed Legislation Imperils Palliative Care
Orentlicher and Caplan assert that the Pain Relief Promotion Act of 1999, recently introduced before Congress, would compromise the quality of palliative care by making use of controlled substances to cause or assist in causing a patient's death subject to criminal prosecution and punishment.
(SEE ARTICLE)
JAMA Patient Page
For your patients: A primer on type 2 diabetes mellitus.
(SEE ARTICLE)
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