JAMA. 2005;293:1367-1373.
The discovery of RNA interference (RNAi), an endogenous cellular gene-silencing mechanism, has already provided a powerful tool for basic science researchers to study gene function. The subsequent finding that RNAi also operates in mammalian cells has generated excitement regarding potential therapeutic applications. In this article we discuss the basic mechanism of RNAi and the therapeutic opportunities and obstacles for harnessing RNAi for therapy of human disease.
JAMA. 2004;292:1474-1479.
Many 21st-century observers explain international efforts to control infectious diseases as a function of globalization and recent transformations in international commerce, transportation, and human migration. However, these contemporary global health initiatives can be more fully understood by also exploring the origins of international health organizations and regulations, which were initially dedicated exclusively to stemming the tide of infectious epidemics. This article reviews 3 eras of international approaches to controlling infectious diseases (1851-1881, 1881-1945, and 1945 to the present) and concludes by assessing how nations have a strong fiscal and humanitarian incentive to invest in infectious disease control programs and infrastructures in and beyond their own borders.
JAMA. 2008;299(18):2188-2193.
A 19-year-old woman living with relatives in the United States who was admitted for elective cranial surgery for complications related to a congenital disorder developed an acute intracranial hemorrhage 10 days after surgery. The patient was declared dead following repeat negative apnea tests. The patient's father requested that the treating team administer an unverified traditional medicinal substance to the patient. Because of the unusual nature of this request, the treating team called an ethics consultation. The present article reviews this case and discusses other cases that share key features to determine whether and when it is appropriate to accommodate requests for interventions on patients who have been declared dead.
JAMA. 2005;293:855-862.
Molecular imaging is an emerging field that aims to integrate patient-specific and disease-specific molecular information with traditional anatomical imaging readouts. The information provided by this field may ultimately allow for noninvasive or minimally invasive molecular diagnostic capabilities, better clinical risk stratification, more optimal selection of disease therapy, and improved assessment of treatment efficacy. In this update, we first provide an overview of clinically relevant molecular imaging technologies and imaging agents. Next, their applications to disease detection, drug discovery, and biomedical research are discussed. To specifically demonstrate the potential of molecular imaging, we highlight recent advances in clinical and preclinical molecular imaging of cancer and atherosclerosis.
JAMA. 2004;291:599-604.
The use of complementary and alternative medicine (CAM) has grown dramatically in recent years, as has research on the safety and efficacy of CAM treatments. Minimal attention, however, has been devoted to the ethical issues relating to research on CAM. We argue that public health and safety demand rigorous research evaluating CAM therapies, research on CAM should adhere to the same ethical requirements for all clinical research, and randomized, placebo-controlled clinical trials should be used for assessing the efficacy of CAM treatments whenever feasible and ethically justifiable. In addition, we explore the legitimacy of providing CAM and conventional therapies that have been demonstrated to be effective only by virtue of the placebo effect.
JAMA. 2002;288:1775-1779.
The chronic care model is a guide to higher-quality chronic illness management within primary care. The model predicts that improvement in its 6 interrelated components—self-management support, clinical information systems, delivery system redesign, decision support, health care organization, and community resources—can produce system reform in which informed, activated patients interact with prepared, proactive practice teams. Case studies are provided describing how components of the chronic care model have been implemented in the primary care practices of 4 health care organizations.
JAMA. 2003;290:2470-2475.
Pain is a complex clinical problem. Assessment depends on verbal report, and the patient's physical perceptions may be modified by cognitive and affective factors. The salience of pain as a problem in its own right has grown since 1945 and new therapeutic alternatives have developed from research and from new theoretical perspectives. This short historical review of the highlights of the history of pain management gives particular emphasis to the 20th century and to chronic and cancer pain.
JAMA. 2005;294:1380-1384.
Health-related research in the United States is funded by US citizens, either as taxpayers or as consumers. Public support is critical to the success of the research enterprise, and it is essential for stakeholders in research to pay attention to the public’s views about the investment level in research and the nature of its conduct, as well as to understand the public’s level of awareness and opinions about research to improve health. This article reviews key results from surveys concerning public attitudes and perceptions toward health-related research. Collectively, these data demonstrate that Americans rate research as a high national priority, and they strongly support greater investment by public and private funders.
JAMA. 2005;294:3019-3023.
Protein-polysaccharide conjugate vaccines that protect against Haemophilus influenzae type b (Hib), serogroup C Neisseria meningitidis, and multiple capsular serotypes of Streptococcus pneumoniae have had a major impact on invasive bacterial disease in childhood when incorporated into routine infant immunization schedules. However, effectiveness data from the United Kingdom suggest that primary infant immunization alone may not be associated with long-term protection. Both immunological priming and antibody persistence are important aspects of long-term protection induced by these vaccines. An improved understanding of the immunobiology of the B-cell response to these vaccines may direct development of immunization strategies that provide sustained protection.
JAMA. 2002;288:1097-1101.
Since family practice was first recognized as a specialty in the late 1960s, considerable intellectual and organizational change has occurred in medicine, especially during the 1990s. To reflect on and reconsider the role of family practice in US health care, this article reviews the development of family practice as a specialty, provides a current assessment of the status of family medicine in the United States, and comments on issues that are of ongoing importance to family practice.
JAMA. 1998;279:1377-1382.
There has been a great deal of interest in recent years in developing measures of health care quality that can be used to characterize and study the effects of health plans. However, because of the recent emergence of diverse types of health care organizations, it is often difficult to know which parts of a plan should be combined for analysis purposes. Also, simple taxonomies of health maintenance organizations (eg, staff, independent practice associations, group, and network) no longer adequately describe the diverse types of organizations that have become common. In this article we describe these trends, explain why older taxonomies of health care plans are not adequate, and present a new framework for characterizing and studying the effects of diverse types of plans.
JAMA. 2002;288:889-893.
This article—the first in a series on primary care—outlines the daunting challenges facing primary care today. Most people in the United States desire a primary care "home" to provide for and coordinate their health care needs. Yet primary care is endangered by physician stress, inadequate performance in managing chronic illness, and inability to provide prompt access and reliable continuity of care. Fundamental redesign is needed to improve access to and quality of care while easing physicians' workload without causing major increases in health care costs.
JAMA. 2000;284:1284-1289.
The growth of specialization in graduate medical education (GME) and physician practice continues at a rapid rate, generating increasing national attention. Although the major educational, accrediting, and certifying bodies have mechanisms for approving new areas of study and practice, the results of their efforts have not been consistently congruent. This article presents information about GME since the beginnings of its standardization and accreditation in the early 20th century, its growth during and following World War II, and the variations among accredited specialties and subspecialties, certificates, and self-designated practice areas that have resulted from this long period of unstructured growth.
JAMA. 2003;289:2709-2716.
Researchers, clinicians, and policy makers face 3 challenges in writing about race and ethnicity: accounting for the limitations of race/ethnicity data; distinguishing between race/ethnicity as a risk factor or as a risk marker; and finding a way to write about race/ethnicity that does not stigmatize and does not imply a we/they dichotomy between health professionals and populations of color. Josurnals play an important role in setting standards for research and policy literature. The authors outline guidelines that might be used when race and ethnicity are addressed in biomedical publications.
JAMA. 2005;294:2618-2622.
The National Institute for Health and Clinical Excellence (NICE) was established as a part of the British National Health Service in 1999 to set standards for the adoption of new health care technologies and the management of specific conditions. In doing so it was required explicitly to take into account both clinical effectiveness and cost-effectiveness. This article describes how NICE has responded to the challenge and considers whether its experience of balancing quality, innovation, and value for money holds policy lessons for the United States.
JAMA. 1998;280:1371-1375.
Information and communication technologies may help reduce health disparities through their potential for promoting health, preventing disease, and supporting clinical care for all. Unfortunately, those who have preventable health problems and lack health insurance coverage are the least likely to have access to such technologies. Barriers to access include cost, geographic location, illiteracy, disability, and factors related to the capacity of people to use these technologies appropriately and effectively. A goal of universal access to health information and support is proposed to augment existing initiatives to improve the health of individuals and the public. Both public- and private-sector stakeholders, particularly government agencies and private corporations, will need to collaboratively reduce the gap between the health information "haves" and "have-nots." This will include supporting health information technology access in homes and public places, developing applications for the growing diversity of users, funding research on access-related issues, ensuring the quality of health information and support, enhancing literacy in health and technology, training health information intermediaries, and integrating the concept of universal access to health information and support into health planning processes.
JAMA. 2004;292:972-977.
The concept of manipulation of the vascular bed to either increase or decrease the number of blood vessels has attracted considerable interest. This review focuses on angiogenesis as a therapeutic target, particularly in the context of cancer and arthritis, as well as on promoting angiogenesis in cardiovascular disease and the healing of bone fractures. Although once touted almost as a panacea for treatment of tumors, as well as other diseases associated with angiogenesis, such as diabetic retinopathy or rheumatoid arthritis, it is now clear that such enthusiasm was somewhat premature. Similarly, some clinical trials of therapeutic angiogenesis for the management of cardiovascular disease have been disappointing. Nevertheless, this exciting field of research holds promise for more targeted therapies.
JAMA. 2004;292:1044-1050.
Conducting educational research in medical schools is challenging partly because interventional controlled research designs are difficult to apply. In addition, strict accreditation requirements and student/faculty concerns about educational inequality reduce the flexibility needed to plan and execute educational experiments. Consequently, there is a paucity of rigorous and generalizable educational research to provide an evidence-guided foundation to support educational effectiveness. "Educational epidemiology," ie, the application across the physician education continuum of observational designs (eg, cross-sectional, longitudinal, cohort, and case-control studies) and randomized experimental designs (eg, randomized controlled trials, randomized crossover designs), could revolutionize the conduct of research in medical education. Furthermore, the creation of a comprehensive national network of educational epidemiologists could enhance collaboration and the development of a strong educational research foundation.
JAMA. 2005;293:90-95.
Discovery that the hormone erythropoietin (EPO) and its receptor play a significant biological role in tissues outside of the hematopoietic system has fueled significant interest in EPO as a novel cytoprotective agent in both neuronal and vascular systems. Erythropoietin is now considered to have applicability in a variety of disorders that include cerebral ischemia, myocardial infarction, and chronic congestive heart failure. Erythropoietin modulates a broad array of cellular processes that include progenitor stem cell development, cellular integrity, and angiogenesis. As a result, cellular protection by EPO is robust and EPO inhibits the apoptotic mechanisms of injury, including the preservation of cellular membrane asymmetry to prevent inflammation. As the investigation into clinical applications for EPO that maximize efficacy and minimize toxicity progresses, a deeper appreciation for the novel roles that EPO plays in the brain and heart and throughout the entire body should be acquired.
JAMA. 1998;280:659-664.
The French health care system combines a strong tradition of autonomous private practice with nearly universal health care coverage through the social security system. The French state's responses to rising health care expenditures have included limitation of the number of medical students, control over physician fees, rules to prohibit certain clinical practices, experiments with generalist physicians coordinating care and access to specialists, and collective physician responsibility for expenditures beyond the health care budget. The failure of physicians' protests, including a strike of French residents and fellows in 1997, may signify the end of traditional private practice in the face of France's statist version of managed care.