Combination antiretroviral therapy without resistance testing is the
standard empirical initial treatment of individuals infected with human immunodeficiency
virus (HIV), despite evidence of transmission of drug-resistant HIV. In a
cohort of 80 individuals newly infected with HIV, Boden and colleagues identified
13 (16.3%) with virus strains with known resistance-conferring mutations to
any antiretroviral agent. Fifty-seven of 67 HIV variants had phenotypic drug
susceptibility consistent with the genotypic analysis. In a second study,
Little and colleagues identified 3 individuals infected with HIV strains with
greater than 10-fold reduction in antiretroviral susceptibility among 141
individuals recently infected with HIV. Intermediate drug resistance (greater
than 2.5- to 10-fold reduction in susceptibility) was identified in viral
isolates from 36 individuals (26%). In an editorial, Pomerantz emphasizes
the need to establish the clinical relevance of the levels of phenotypic drug
resistance identified in these studies and suggests that resistance testing
be used when full viral suppression is not achieved during initial combination
See Article and Article and editorial Article
To assess outcomes of early newborn hospital discharge in low-income
populations, Kotagal and colleagues reviewed Ohio Medicaid claims data linked
to vital statistics files from 102,678 full-term healthy newborns born to
women receiving Medicaid for at least 30 days after birth. The mean hospital
length of stay for newborns decreased from 2.2 days in 1991 to 1.6 days in
1995, and the proportion of newborns discharged after a short stay (less than
1 day after a vaginal delivery and less than 2 days after cesarean delivery)
increased from 21% to 59.8%. The proportion of newborns who received outpatient
care increased significantly during this period, but rehospitalization rates
at 7 and 14 days after discharge decreased. In multivariate analyses, short
stay was not significantly associated with rehospitalization rates.
In clinical trials, the assessment of change in health status is typically
derived from calculating the difference between serial measurements, but in
clinical practice, change in health status is assessed by retrospective patient
report. Fischer and coworkers found that in a longitudinal study of 202 patients
starting new therapy for chronic arthritis, the overall agreement of serial
measurement of change in health status with retrospective assessment was poor.
Retrospective assessment was more sensitive to change than serial measurement
and was correlated more strongly with patient satisfaction with change.
Enforcement of health care fraud and abuse laws has been increasing.
Kalb describes 3 principal types of fraudulent conduct (false claims, kickbacks,
and self-referral), their direct civil and criminal consequences, and their
secondary consequences, such as loss of licensure. In an editorial, Sage traces
the recent evolution of fraud and abuse law as the health care system has
changed and offers common sense advice to physicians.
See Article and editorial Article
Ms B and her partner had been using periodic abstinence for contraception
for 6 years. When she learned she was pregnant soon after missing her menstrual
period, she wanted an abortion and was referred to a family planning clinic.
Grimes discusses the epidemiology of abortion, access to abortion, psychological
outcomes, and new developments in medical and surgical abortion in early pregnancy.
"While my wife is in the OR, I will drink dark, bitter coffee in a crowded
room as I await the surgeon to give me good news." From "What We Are Made
Pediatric poisoning: Recent epidemiologic trends and treatment advances.
New reports on the surgical treatment of patients with Parkinson disease
include the results of several studies around the world focusing on deep brain
stimulation and fetal cell transplantation.
A report of the key findings from the National Committee for Quality
Assurance Committee on Performance Measurement outlines essential elements
of an integrated electronic health information framework to measure clinical
For your patients: A primer on newborn care.
New! The Virtual Mentor Web site, a joint project of
MSJAMA and the AMA Institute
This Week in JAMA. JAMA. 1999;282(12):1107. doi:10.1001/jama.282.12.1107