JAMA. 1999;281:163-168.
Context Quality end-of-life care is increasingly recognized as an ethical obligation of health care providers, both clinicians and organizations. However, this concept has not been examined from the perspective of patients. Objective To identify and describe elements of quality end-of-life care from the patient's perspective. Design Qualitative study using in-depth, open-ended, face-to-face interviews and content analysis. Setting Toronto, Ontario. Participants A total of 126 participants from 3 patient groups: dialysis patients (n = 48), people with human immunodeficiency virus infection (n = 40), and residents of a long-term care facility (n = 38). Outcome Measures Participants' views on end-of-life issues. Results Participants identified 5 domains of quality end-of-life care: receiving adequate pain and symptom management, avoiding inappropriate prolongation of dying, achieving a sense of control, relieving burden, and strengthening relationships with loved ones. Conclusion These domains, which characterize patients' perspectives on end-of-life care, can serve as focal points for improving the quality of end-of-life care.
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. 2002;288:1632-1639.
ABSTRACT
Polyarteritis nodosa (PAN) is regarded rightly as the grandfather of the vasculitides. In this Grand Rounds, the case of a 30-year-old man with a 12-year illness is described. The patient presented with daily fevers, tachycardia, and cutaneous ulcers on his distal extremities. He eventually developed mononeuritis multiplex. Because of the striking pattern of his fevers, he was diagnosed for many years as having adult-onset Still disease. Following the addition of daily cyclophosphamide to his long-standing regimen of prednisone, the patient's disease entered remission for the first time in more than a decade. He was ultimately able to discontinue all of his immunosuppressive medications. The case is discussed in the context of the first patient ever described with PAN, the classic report of Kussmaul and Maier.
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. 1998;279:1094-1099.
Objective.— To review the validity of the clinical assessment and diagnostic tests in patients with suspected deep vein thrombosis (DVT). Methods.— A comprehensive review of the literature was conducted by searching MEDLINE from 1966 to April 1997. Results.— Individual symptoms and signs alone do not reliably predict which patients have DVT. Overall, the diagnostic properties of the clinical examination are poor; the sensitivity of the clinical examination ranges from 60% to 96%, and the specificity ranges from 20% to 72%. However, using specific combinations of risk factors, symptoms, and physical signs for DVT, clinicians can reliably stratify patients with suspected DVT into low, moderate, or high pretest probability categories of actually suffering from DVT. This stratification process in combination with noninvasive testing, such as compression ultrasonography, simplifies the management strategies for patients with suspected DVT. Conclusions.— Use of a clinical prediction guide that includes specific factors from both the history and physical examination in combination with noninvasive tests simplifies management strategies for patients with suspected DVT.
JAMA. 2002;287:755-761.
ABSTRACT
Viral respiratory tract infections are a common cause of asthma attacks. Study of this phenomenon has revealed multiple mechanisms and contributed to understanding of the increase in airway inflammation and bronchoconstriction observed in this context. Changes in the neural control of the airways contribute to bronchoconstriction, which is reflected in an increased efficacy of anticholinergic medications during acute asthma attacks. The ability to prevent or treat viral respiratory tract infections is currently limited. However, as more effective antiviral treatments and vaccines become available, such therapies are likely to be effective in patients with asthma. Clinical management of this problem is illustrated in this article by the case of a 40-year-old woman with history of mild asthma who was admitted to an intensive care unit with severe bronchospasm and an upper respiratory tract infection.
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.