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JAMA. 2000;283(2):163. doi:10.1001/jama.283.2.163.
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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 colleaguesArticle 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 colleaguesArticle 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, MarkowitzArticle 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.

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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.

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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.

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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 colleaguesArticle 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, WaeckerleArticle 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."

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CONTEMPO UPDATES

Update on 2 topical immunomodulating drugs and advances in the management of toxic epidermal necrolysis.

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PHOTO/ESSAY

Fleshy mass on the iris of the left eye of a 60-year-old woman.

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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.

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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.

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JAMA PATIENT PAGE

For your patients: A primer on type 2 diabetes mellitus.

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