Commentary: Garson's “physicians,coverage, quality,and cost: the intertwined caduceus”

It is not sufficient to recommend that we adopt information systems, promote cost-effective care, improve processes of care through education, and implement evidence-based practice. Specific strategies must be tested, reformulated, and tested again so that policymakers will have a useful set of strategies available to them.     

AIDS, T cells, chemotherapy: HAART-breaking?

Chemotherapy depletes T cells in AIDS patients on HAART, but preexisting lymphopenia limits the scale compared with non-AIDS patients. Thus T-cell recovery time to baseline may be rapid, but the risk of additional AIDS-related complications persists.     

Myocardial Viability: Whom,What, Why,Which, and How?

Viability imaging might be useful to guide decisions for revascularization in patients with ischemic cardiomyopathy. Recent trial results raise important points for clinicians regarding which modalities to use and in which patients.     

Diabetes: Statins, fibrates, or both?

Cardiovascular disease is the leading cause of mortality in patients with type 2 diabetes. Among the many factors that are involved in the pathogenesis of atherosclerosis in diabetic patients, dyslipidemia plays a major role. It is characterized by an increase in triglycerides, a decrease in high-density lipoprotein cholesterol and normal or mildly elevated low-density lipoprotein cholesterol. The management of patients with diabetic dyslipidemia is difficult because we lack studies specifically designed for diabetic patients. Thus, strategy has to rely on post hoc analyses of landmark intervention trials, which usually include only a small number of diabetic patients, or on rare trials enrolling small cohorts of diabetic patients. When lifestyle changes fail, monotherapy should be tried first with either a statin or a fibrate, depending on triglyceride level. If lipid target values are not reached, a combination therapy can then be initiated, with close follow-up of potential side effects.     

Insulin secretagogues: Who,what, when,and how?

Sulfonylurea compounds were the first available oral antidiabetic agents and they remain an important tool in our quest for optimal glycemic control. The more recent introduction of meglitinides offers an approach to short-term insulin release with minimal hypoglycemic risk during fasting periods. Published trials suggest that individuals with a hemoglobin A_1c above 8.5% are unlikely to reach currently recommended targets (6.5% to 7%) without the use of one of these insulin secretagogues. Starting and probable maximally effective doses for glimepiride are 1 to 2 mg initially and 4 mg thereafter. For glyburide and glipizide, these are 2.5 to 5 mg initially, and 10 mg effective at a maximum. The large majority of the effect can be seen within a week, making them very attractive when rapid lowering of glucose is needed. An understanding of the principles will facilitate more effective use of initial and combination therapy.