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This Week in JAMA
February 24, 1999

This Week in JAMA

JAMA. 1999;281(8):681. doi:10.1001/jama.281.8.681
Predictive Value of ECG in Acute Cardiac Ischemia

Optimal treatment of patients with acute myocardial infarction (MI), particularly with reperfusion therapies, depends on prompt and accurate diagnosis. Savonitto and colleaguesArticle found that specific electrocardiographic signs of acute myocardial ischemia on the initial electrocardiogram (ECG) were highly predictive of mortality and reinfarction. However, the ECG may be less helpful in the presence of left bundle-branch block (LBBB). Shlipak and coworkersArticle retrospectively applied previously validated ECG criteria to the initial ECG of patients with LBBB and acute cardiopulmonary symptoms and found that these criteria poorly predicted MI. From their decision analysis, the authors concluded that thrombolytic treatment of all patients with LBBB and acute cardiopulmonary symptoms improved stroke-free survival more than treating only those patients who met the ECG criteria. In an editorial, Estes and SalemArticle discuss the implications of these 2 studies for treatment of patients with acute coronary syndromes.

Breast Cancer Care in HMO and Fee-for-Service Settings

In this analysis of data from the Surveillance, Epidemiology, and End Results program, Riley and colleaguesArticle report that among elderly women with breast cancer, fewer cases were diagnosed at late stages in women enrolled in Medicare health maintenance organizations (HMOs) than in women in fee-for-service (FFS) settings. Marked regional variations in comparative treatment patterns were observed, but overall, rates of breast-conserving surgery in women with early-stage disease were similar in HMO and FFS settings, and radiation therapy after surgery was more common in HMOs. In an editorial, RetchinArticle discusses organizational factors that influence the coordination and quality of care in HMOs.

Atherosclerosis in Youth and Young Adults

Strong and colleagues report the final results of the Pathobiological Determinants of Atherosclerosis in Youth Study, a multi-institutional autopsy study of almost 3000 adolescents and young adults who died of external causes. Even in the youngest age group (15-19 years), fatty streaks and raised atherosclerotic lesions on the intimal surface of the aorta and right coronary arteries were visible, and lesions increased in prevalence and extent with increasing age through 30 to 34 years, the oldest age group studied.

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Antibiotic Resistance of Pathogens in Acute Cystitis

In a cross-sectional study of more than 4000 women aged 18 to 50 years with uncomplicated acute cystitis, Gupta and colleagues found that among Escherichia coli isolates, the most common uropathogen (86% of infections), the prevalence of in vitro resistance to ampicillin, cephalothin, and sulfamethoxazole exceeded 20% in all study years, and the prevalence of resistance to trimethoprim and trimethoprim-sulfamethoxazole increased from 9% in 1992 to 18% in 1996. These findings suggest that these antibiotics may not be useful for first-line empirical treatment of acute cystitis. Prevalence of resistance to nitrofurantoin and ciprofloxacin was low and did not change during the study period.

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An Asymptomatic 41-Year-Old Man Infected With HIV

Mr K has been infected with the human immunodeficiency virus (HIV) for almost 10 years but has remained asymptomatic. Zidovudine monotherapy was initiated at the time of diagnosis, but Mr K discontinued treatment 6 months ago after a period of taking the medication irregularly during the terminal illness of his partner. Recently, Mr K's CD4 cell counts fell to just under 0.50 × 109/L, but HIV was not detectable on an ultrasensitive RNA viral load test. Makadon discusses the comprehensive medical and social-emotional care of asymptomatic individuals living with HIV infection and emphasizes the importance of shared decision making and individualized treatment.

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Contempo 1999

Recent progress and findings of practice-based primary care research networks.

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Medical News & Perspectives

At a conference on the interactive relationship between pain and sleep, experts explored the effects of various diseases on pain and sleep and discussed the benefits of different interventions.

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Health Law and Ethics

An analysis of the protection from discrimination afforded individuals with human immunodeficiency virus infection and other health conditions by the Americans With Disabilities Act and state antidiscrimination laws.

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Policy Perspectives

In this interview, Bruce Vladeck, PhD, former administrator of the Health Care Financing Administration (HCFA), reflects on his accomplishments while at HCFA and discusses prospects for future federal health policy.

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JAMA Patient Page

For your patients: A primer on breast cancer.

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