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;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. 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. 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. 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. 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. 2002;288:1909-1914.
This article reviews research evidence showing to what extent the chronic care model can improve the management of chronic conditions (using diabetes as an example) and reduce health care costs. Thirty-two of 39 studies found that interventions based on chronic care model components improved at least 1 process or outcome measure for diabetic patients. Regarding whether chronic care model interventions can reduce costs, 18 of 27 studies concerned with 3 examples of chronic conditions (congestive heart failure, asthma, and diabetes) demonstrated reduced health care costs or lower use of health care services. Even though the chronic care model has the potential to improve care and reduce costs, several obstacles hinder its widespread adoption.
JAMA. 2007;297:196-204.
Ms M, a 74-year-old woman with type 2 diabetes of 6 years' duration, has a glycated hemoglobin (HbA1C) value of 7.4% despite taking 3 oral antidiabetic medications, as well as coexistent hypertension and abdominal obesity. She has no known microvascular or macrovascular complications of diabetes and is otherwise healthy. She is reluctant to commence insulin treatment as she dislikes the idea of injections and wonders if there are any alternate options if she is to get her HbA1C value below 7%. The natural history of type 2 diabetes, reasons why many patients begin requiring insulin over time, rationale for tight glycemic control, and therapeutic options for Ms M are discussed.
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. 2007;298(23):2768-2778.
The supraventricular arrhythmias include a wide spectrum of disorders including, in descending order of frequency, atrial fibrillation, atrial flutter, atrioventricular nodal reentry, Wolff-Parkinson-White syndrome, and atrial tachycardia. While not life-threatening in most cases, they may cause important symptoms, such as palpitations, chest discomfort, breathlessness, anxiety, and syncope, which significantly impair quality of life. Medical therapy has variable efficacy, and most patients are not rendered free of symptoms. Research over the past several decades has revealed fundamental mechanisms involved in the initiation and maintenance of all of these arrhythmias. Knowledge of mechanisms has in turn led to highly effective surgical and catheter-based treatments. Atrial fibrillation remains a therapeutic challenge but is also yielding to investigation and therapeutic efforts. The supraventricular arrhythmias and their treatment are described in this report.
JAMA. 2003;289:1042-1046.
The advanced access model of patient scheduling is based on the core principle that if the capacity to provide patient appointments balances the demand for appointments, patients calling to see their physician are offered an appointment the same day. The accompanying article in the series "Innovations in Primary Care" presents the theory behind advanced access scheduling. In this article we describe 4 case studies of primary care practices that successfully implemented advanced access and 3 examples of practices that were unable to achieve advanced access despite considerable efforts. The lessons of these case studies should be useful for primary care practices desiring to improve timely access to care and wishing to avoid the pitfalls that can derail this innovation.
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. 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. 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;294:1083-1087.
Because of the traditional subordination of education to service, graduate medical education (GME) in the United States has never realized its full educational potential. This article suggests 4 strategies for reasserting the primacy of education in GME: limit the number of patients house officers manage at one time, relieve the resident staff of noneducational chores, improve educational content, and ease emotional stresses. Achieving these goals will require regulatory reform, adequate funding, and institutional competency in the use of educational resources. Modern medicine grows ever more complex. The need to address the deficiencies of GME is urgent.
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. 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. 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. 2003;289:2113-2119.
Cessation of life-support treatment is an appropriate option for situations in which the burdens of therapy substantially outweigh the benefits. Decisions to withdraw dialysis now precede 1 in 4 deaths of patients who have end-stage renal disease. Guidelines have been recently published to assist clinicians in making these complex and emotionally charged determinations, and they include: relying on shared decision making by all participants, obtaining informed consent, estimating the prognosis on dialysis, adopting a systematic approach for conflict resolution of disagreements, honoring advance directives, and ensuring the provision of palliative care. These principles are discussed in relation to an elderly man with dementia whose family decided to terminate maintenance hemodialysis.