Table of Contents

July 20, 2004; 141 (2)

Articles

  • Researchers have hypothesized that certain Mycoplasma species may cause Gulf War veterans' illnesses (chronic diseases characterized by pain, fatigue, and cognitive symptoms) and that affected patients may benefit from doxycycline treatment. This study found that long-term treatment with doxycycline did not improve outcomes of these illnesses at 1 year.

  • Growth in incident end-stage renal disease (ESRD) outpaced growth in prevalent chronic renal insufficiency, demonstrating that the ESRD epidemic in the United States is not merely due to more cases of kidney disease. Other potential contributors to ESRD growth are improved survival from nonrenal diseases and more liberal entry criteria for treatment programs.

  • Survival benefits in the first year after acute myocardial infarction in patients 65 years of age or older seem to differ according to the specific angiotensin-converting enzyme inhibitor prescribed. Ramipril was associated with lower mortality than most other drugs in this class.

  • Living wills are associated with dying in a patient's residence rather than in a hospital. During advance care planning, physicians should discuss patients' preferences for location of death.

Improving Patient Care

  • A multicomponent intervention (patient notification, provider education, electronic alerts in patient chart) seemed to increase the rate of stopping hormone replacement therapy after the release of results from the Women's Health Initiative study in July 2002.

Academia and Clinic

  • The authors describe a patient who believes she is allergic to generic medications and a physician who refuses to prescribe brand-name drugs when generic alternatives are available. They discuss the ethical dilemmas of the patient's physician, who must weigh the interests of a patient who clings to beliefs that the physician thinks are unfounded against the interests of a just rationing program and the broader population it serves.

  • This statement offers guidance on preserving the patient–physician relationship; patient rights and responsibilities; confidentiality and privacy; resource allocation and stewardship; the obligation of health plans to foster an ethical environment for the delivery of care; and the physician's responsibility to individual patients, the community, and the public health.

Reviews

  • Previous studies on apolipoprotein E (apoE) ε4 allele as a risk factor for coronary heart disease have had conflicting results. This meta-analysis found that the apoE ε4 allele is strongly implicated as a risk factor for coronary heart disease.

  • In the context of a case presentation, the authors review the data on safe air travel after myocardial infarction and common complications of air travel after coronary artery revascularization; provide recommendations on safe air travel after myocardial infarction; discuss the safety of preflight screening and the in-flight environment for patients with pacemakers and implantable automatic defibrillators; and provide recommendations to prevent in-flight deep venous thrombosis.

Editorials

  • In this issue, Donta and colleagues report that doxycycline treatment has no effect on the health of symptomatic Gulf War veterans and that serologic evidence of Mycoplasma infection was unrelated to health. In the future, we cannot recommend long-term treatment with doxycycline or similar compounds for symptomatic veterans. It would, however, be naive to expect that this negative trial will be the end of the matter.

  • Pilote and colleagues' study in this issue indicates that in the absence of head-to-head randomized trials that test survival benefits of different angiotensin-converting enzyme inhibitors, the current level of scientific evidence is not sufficient to justify the selection of one proven drug in this class over another.

  • In principle, increasing the use of advance directives is important. However, they are not sufficient to address the important concerns of family members of dying patients. We must move from a focus on single interventions, such as the living will, to public policies that use multifaceted interventions to provide competent, coordinated, and compassionate end-of-life care.

Letters

Medical Writings: Book Notes

Current Clinical Issues

Book Listings

Medical Notices

Summaries for Patients