Critical pathways define the essential steps of complex clinical management
processes. Marrie and colleagues report that at 9 hospitals randomly assigned
to use a critical pathway for treatment of patients with community-acquired
pneumonia, admission of low-risk patients was reduced 18% and the number of
bed days per patient managed was reduced 1.7 days compared with 10 hospitals
assigned to conventional management. Health-related quality of life scores
6 weeks after treatment and the rate of complications, readmissions, and mortality
were similar in both hospital groups.
The risk of developmental problems among offspring of women with phenylketonuria
(PKU) may be reduced if metabolic control (plasma phenylalanine level ≤10
mg/dL [ ≤605 µmol/L]) is achieved prior to or early in pregnancy.
In a group of 149 children of women with PKU, Waisbren and colleagues found
that scores on McCarthy Scales of Children's Abilities at age 4 years were
highest among children of women who attained metabolic control prior to pregnancy
and decreased as the number of weeks to achieve metabolic control during pregnancy
increased. In logistic regression analyses, factors that best predicted a
score on the General Cognitive Index of the McCarthy Scales of 1 SD or more
below the normative mean included low maternal IQ, a maternal plasma phenylalanine
level greater than 20 mg/dL (1210 µmol/L) when on an unrestricted diet,
delayed maternal metabolic control during pregnancy, and a low score on a
measure of home environmental stimulation.
Weight loss complicating human immunodeficiency virus (HIV) infection
in men has been associated with low testosterone levels and increased morbidity
and mortality. In this placebo-controlled trial, Bhasin and colleagues randomly
assigned 61 men with HIV infection, moderate weight loss, and low serum testosterone
levels to receive placebo, testosterone supplementation, resistance exercise
and placebo, or testosterone combined with resistance exercise. After 16 weeks,
testosterone supplementation and resistance exercise were each associated
with significant increases in muscle strength, thigh muscle volume, and body
weight compared with baseline, but testosterone combined with resistance exercise
was not associated with greater increases than either intervention alone.
To assess how well medical textbooks cover end-of-life care, Rabow and
colleagues estimated the quantity of information on care for patients at the
end of life in 50 textbooks from multiple specialties and rated the usefulness
of the information in 13 content domains. Overall, information was rated helpful
in 24.1% of the expected end-of-life content domains, minimal in 19.1% of
the domains, and absent in 56.9% of the domains. The content domains that
were covered the least well were social, spiritual, ethical, and family issues,
and physician responsibilities after a patient's death. Twenty-four of the
50 texts listed chapters on topics related to end-of-life care in the table
of contents and the percentage of total textbook pages with end-of-life care
key words listed in the index ranged from 0% to 12%.
In this controlled trial comparing endotracheal intubation with bag-valve-mask
ventilation for out-of-hospital airway management by paramedics of critically
ill patients aged 12 years or younger, Gausche and colleaguesArticle found no significant
difference in the rate of survival to hospital discharge or the rate of achieving
a good neurological outcome between the 2 treatment groups. In an editorial,
GlaeserArticle considers factors that may have influenced these findings and discusses
the implications of the results.
New therapies for acute and chronic wounds.
Institutional review boards are meeting the challenge to change with
warnings from the federal government and guidance from their own membership
Testosterone and estrogen levels in healthy young men after oral administration
Recently approved type-specific serologic tests for herpes simplex virus
offer a new opportunity to address the high proportion of unrecognized genital
herpes simplex virus 2 infections.
An analysis of the use of personal health information in pharmacy benefits
management programs highlights concerns about the pending federal regulations
on standards for privacy of individually identifiable health information.
See Article and Article
For your patients: A primer on pneumonia.
Part II of "Why Aren't There More Women Surgeons?" an interview with
3 women with careers in surgery, and a bibliography from the Women Physician's
Health Study, the first large, national study of US women physicians.
This Week in JAMA. JAMA. 2000;283(6):707. doi:10.1001/jama.283.6.707