In the National Institute of Neurological Disorders and Stroke (NINDS)
clinical trial, early thrombolytic therapy for acute ischemic stroke with
intravenous tissue-type plasminogen activator (tPA) was associated with improved
neurologic outcomes, but concern about increased risk of intracerebral hemorrhage
(ICH) and the narrow therapeutic window of 3 hours from stroke onset have
limited its use in general clinical practice. In this prospective study of
389 adults at 24 academic and 33 community medical centers treated with intravenous
tPA, Albers and colleaguesArticle report that 30 days after treatment, mortality
was 13%, and 35% of patients had a very favorable neurologic outcome (modified
Rankin score, 0-1). The rate of symptomatic ICH within 3 days of treatment
was 3.3%. Based on data from 29 Cleveland-area hospitals in the Cleveland
Health Quality Choice project, Katzan and colleaguesArticle found that 70 (1.8%)
of 3948 patients with ischemic stroke received intravenous tPA. Symptomatic
ICH occurred in 11 (15.7%) of these patients, and in-hospital mortality was
15.7%, significantly higher than among patients who did not receive tPA (mortality
rate, 5.1%). Deviation from national treatment guidelines was identified in
50% of patients who received tPA. In an editorial, MohrArticle discusses hypotheses
about the etiology of ischemia and infarction in stroke and about the mechanism
of action of thrombolytic therapy.
Using data from published studies, Dudley and colleaguesArticle identified
11 procedures and diagnoses for which in-hospital mortality was significantly
lower at high-volume hospitals (HVHs) compared with low-volume hospitals (LVHs)
and calculated odds ratios for in-hospital mortality for LVHs vs HVHs based
on the highest-quality study for each condition. Applying the calculated odds
ratios to the total number of patients with these conditions hospitalized
at LVHs in California in 1997, the researchers estimated that 602 deaths could
potentially have been avoided by treatment at an HVH. In an editorial, BirkmeyerArticle
discusses ways to implement selective referral for high-risk surgery and possible
disadvantages of and barriers to regionalization.
Although human immunodeficiency virus (HIV) is known to be transmitted
through breastfeeding, World Health Organization guidelines have recommended
breastfeeding for some areas regardless of maternal HIV status because of
the mortality risk from diarrheal disease and malnutrition associated with
formula feeding. In this trial comparing outcomes of breastfeeding and formula
feeding among infants of 401 untreated HIV-seropositive women in Nairobi,
Kenya, Nduati and colleaguesArticle estimated that the rate of breast milk transmission
of HIV was 16.2% during the first 2 years of life, most of which occurred
in the first 6 months, accounting for 44% of all HIV infections among infants
exposed to breast milk. The rate of HIV-free survival was significantly lower
among infants in the breastfeeding group compared with formula feeding, but
2-year mortality rates were similar. De Cock and coauthorsArticle present current
estimates of the risk of mother-to-child HIV transmission in developing countries
and discuss results of intervention studies and implementation of prevention
strategies in resource-poor areas.
In 1993, firearms were involved in 80% of homicides in Colombia, and
the homicide rate was 88 per 100,000. In this study conducted in Cali and
Bogotá, Colombia, Villaveces and colleaguesArticle found that a police-enforced
ban on carrying firearms during periods expected to have high rates of homicide
was associated with a significant reduction in homicide rates compared with
similar days when the ban was not in effect. In an editorial, ShermanArticle compares
these findings with US rates of weapons arrests and homicide and discusses
implications for enforcement of gun-carrying laws.
"My body aches with unspoken wishes that my daughters will develop a
full sense of trust and feel the stability of a family." From "A Mother's
A novel class of drugs designed to prevent HIV from invading cells shows
promise, according to new findings presented at the Conference on Retroviruses
and Opportunistic Infections.
A review of the literature on peripartum cardiomyopathy and recommendations
for future research from the Workshop on Peripartum Cardiomyopathy convened
by the National Heart, Lung, and Blood Institute and the Office of Rare Diseases
of the National Institutes of Health.
The many faces of societal violence and the role of medicine.
For your patients: Information about infant feeding.
This Week in JAMA. JAMA. 2000;283(9):1103. doi:10.1001/jama.283.9.1103