Table of Contents

The authors randomly assigned 80 adults (body mass index 30 to 34 kg/m²) to surgical treatment using laparoscopic adjustable gastric banding or to intensive nonsurgical therapy. Weight loss with the 2 treatments was similar for the first 6 months. In the next 18 months, weight loss continued with surgical treatment, while the comparison group regained weight. Surgery was also more effective in resolving components of the metabolic syndrome and improving quality of life.

This study tested the use of new guidelines that allowed emergency medical services (EMS) personnel to withhold resuscitation if a patient had a terminal condition and if the patient, family, or caregivers asked them not to resuscitate. The EMS units that implemented the guidelines withheld more resuscitations as a result of verbal requests than EMS units that did not implement the guidelines.

The authors tested the hypothesis that physicians working in geographic regions with high use of medical care feel better able to care for patients than physicians in low-intensity regions. They analyzed data from a survey of 10 577 physicians who provided care to adults from 1998 to 1999. Despite having access to substantially more resources, physicians in regions of high health care intensity did not report that they found it easier to obtain needed services or provide high-quality care.

Most patients with multidrug-resistant tuberculosis had negative sputum cultures within 12 weeks after starting DOTS. Bilateral cavitary disease on chest radiography, high colony count in the sputum, and resistance to more drugs were associated with a slower rate of sputum conversion. Sputum culture conversion was associated with a better final outcome of treatment.

The authors randomly assigned 40 older adults with symptomatic peripheral arterial disease to ramipril, 10 mg/d, or to placebo. After adjustment for between-group baseline differences, mean pain-free walking time after ramipril treatment was 227 seconds (95% CI, 175 seconds to 278 seconds; P < 0.001) longer than after placebo treatment. Similarly, maximum walking time improved by 451 seconds in the ramipril group (CI, 367 seconds to 536 seconds; P < 0.001) but did not change in the placebo group. No adverse events were reported.

In this cohort study of 236 vulnerable older patients, respondents rated their communication with doctors and the global quality of their health care. Using the patients' medical records, research personnel rated the technical quality of their care. Patients' global ratings of their care were associated with better ratings of patient–doctor communication but not with the technical quality of their care. On the basis of these findings, assessments of quality of care should include both patient ratings and independent assessments of technical quality.

Many research institutions comply with the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule by adding long, complex statements to their research consent documents. These measures are often unnecessary, since the U.S. federal requirements for informed consent for human subjects research overlap substantially with the HIPAA Privacy Rule's requirements for individual authorization. Consent forms that satisfy the U.S. federal regulations for human subjects research require only a small amount of additional text to satisfy the requirements under the HIPAA Privacy Rule.

The authors analyzed studies of bleeding rates in patients who were taking low-molecular-weight heparin. Patients who have a creatinine clearance of 30 mL/min or less and are taking enoxaparin have an increased risk for major bleeding relative to patients with a creatinine clearance of more than 30 mL/min. Empirical dose adjustment of enoxaparin may be indicated in patients with severe renal insufficiency. The evidence was not adequate to form conclusions about other low-molecular-weight heparins.

The report by O'Brien and colleagues in this issue provides the strongest evidence to date of the benefits of bariatric surgery compared with lifestyle modification and pharmacotherapy. It will undoubtedly increase the public's already substantial and growing interest in this procedure. We hope, however, that the findings will not cause primary care providers or their patients to overlook the positive health benefits of a 5% to 10% weight loss achieved with lifestyle modification.

In this issue, Feder and colleagues report on guidelines in King County, Washington, that allowed emergency medical services (EMS) personnel to withhold resuscitation from a terminally ill patient if a family member or caregiver at the scene verbally reported that the patient did not want it. In the 16 EMS agencies that adopted the guidelines, EMS personnel withheld resuscitation nearly twice as often (5.9% before using the guidelines vs. 11.8% after using them), mostly because of honoring verbal requests. The guidelines raise some practical concerns but offer an alternative to the “always resuscitate” approach.

In this issue, Sirovich and colleagues extended their previous research on high-intensity and low-intensity health care spending to include the topic of physician attitudes. They report that physicians in regions of high care intensity who have access to more resources feel no better able to provide quality care than physicians in other areas and are somewhat less satisfied with their practice environments. Should policymakers now accept that higher health care spending does not improve health and act accordingly?

I remain uncomfortable when entering my patients' homes, especially when there is little to offer beyond the dubious benefit of my presence. But that night's visit felt different. Neither my patient nor I knew yet that he was dying, and neither of us knew that the same disease that would take his life would soon touch me, too.