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JAMA. 2005;293(11):1297. doi:10.1001/jama.293.11.1297.
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Regional variations in treatment intensity of acute myocardial infarction (AMI) exist, but there has been little exploration of any long-term clinical implications. Stukel and colleaguesArticle evaluated patient characteristics in a cohort of Medicare beneficiaries with a first AMI and assessed whether patients who resided in regions with higher rates of cardiac catheterization or medical management had better long-term survival than patients residing in regions with less intensive treatment patterns. They found that in regions with greater cardiac catheterization capacity, patients were more likely to receive invasive treatment and less medical management, regardless of clinical indication or risk profile. However, intensive medical management was associated with a survival benefit, with little or no additional benefit from increased invasive treatment. In a commentary, Rathore and colleaguesArticle discuss purported benefits and potential limitations of regionalized care for acute coronary syndromes.


Experimental and epidemiological data suggest vitamin E supplementation may protect against cardiovascular events and cancer, but short-term clinical trials have failed to demonstrate benefit. HOPE (Heart Outcomes Prevention Evaluation) and HOPE-TOO (HOPE–The Ongoing Outcomes) investigatorsArticle report results from both trials in which patients with diabetes or vascular disease were randomly assigned to take daily vitamin E (400 IU) or placebo. The mean duration of follow-up was 7.2 years. The investigators found that vitamin E did not significantly reduce the rates of cancer incidence, cancer death, or cardiovascular events. In a subgroup analysis, vitamin E was associated with an increased risk of heart failure. In an editorial, Brown and CrowleyArticle discuss the implications of these and other randomized trial results for counseling patients about antioxidant vitamin use.


Although inappropriate medication use among elderly patients in the United States has been studied and strategies to reduce risk instituted, little is known about the prevalence of inappropriate medication use in Europe. Fialová and colleagues examined data from elderly home care patients in 8 European nations, applied expert criteria to identify potentially inappropriate medication use, and determined associated patient-related characteristics. The authors found that 19.8% of patients used at least 1 inappropriate medication, but there was substantial variation among countries. Associated factors included patient’s low economic status, polypharmacy, anxiolytic drug use, and depression.

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Mandatory error reporting systems for hospitals and other health care settings are controversial. Weissman and colleagues surveyed chief executive and chief operating officers (CEOs/COOs) at 203 randomly selected hospitals in 6 states to determine the CEOs/COOs’ perceptions of and attitudes toward mandatory reporting. The CEOs/COOs were concerned that mandatory reporting would discourage event reporting to internal hospital systems, would increase the risk of lawsuits, and would have no effect or a negative effect on patient safety. A majority of CEOs/COOs favored confidential reporting. Responding to hypothetical vignettes, almost all would report serious injuries to a state system, but far fewer would report injuries of moderate or minor severity.

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New findings show that breast tumors that have a “gene signature” reflecting activity of a number of genes involved in wound healing are more likely to progress and result in poorer clinical outcomes.

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RNA interference, a gene-silencing mechanism present in mammalian cells, may have therapeutic potential.

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Back and Arnold examine conflicts that can arise in the care of seriously ill patients and strategies for conflict resolution, in their discussion of Mrs B, an 84-year-old woman with advanced dementia and aspiration pneumonia.

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For your patients: Information about palliative care.

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The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
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