Palliation rather than curative interventions may be more appropriate
for treatment of acute illness in patients with severe dementia if the prognosis
after acute illness is poor. In this prospective study of a cohort of patients
aged 70 years or older, Morrison and SiuArticle found that 6-month mortality among
patients with severe dementia hospitalized with pneumonia or hip fracture
was much higher than among patients who were cognitively intact. Despite increased
mortality, patients with severe dementia received as many painful or uncomfortable
procedures as patients with intact cognition. In an editorial, RiesenbergArticle
emphasizes the importance of discussing goals of care and advance directives
with patients with dementia and with their families.
In 1993, the state of Georgia initiated the Preschool Immunization Project
(PIP) in which proof of up-to-date immunization status for each child aged
6 years and younger was required to receive Aid to Families With Dependent
Children benefits for that child. To evaluate the effect of this policy on
immunization rates, Kerpelman and colleaguesArticle compared immunization rates of
preschool children in 1000 families randomly selected to be exempt from the
PIP (control group) with immunization rates of children in 1500 families randomly
selected from those subject to the PIP policy intervention. In all 4 years
of the study, age-appropriate immunization rates for 5 childhood immunizations
were higher for children in the intervention group than in the control group.
In a commentary, Davis and LantosArticle question whether the reported increase in
immunization rates in the intervention group justified the burden imposed
by the threat of loss of welfare benefits and assert that ethical standards
for protection of participants in public policy demonstration projects should
be the same as those required in clinical research.
When treatment of acute myocardial infarction (MI) is delayed, the effectiveness
of therapy is limited and mortality increases. In the Rapid Early Action for
Coronary Treatment Trial, Luepker and colleagues evaluated the effect of a
multifaceted community-wide education program designed to decrease delay in
access to medical care for patients with acute MI. Use of emergency medical
services by patients with chest pain increased significantly in communities
that received the intervention compared with matched reference communities,
but there was no difference in the change in delay time from symptom onset
to hospital arrival in the 2 community groups.
In the current American Heart Association (AHA) guidelines for antibiotic
prophylaxis to prevent infectious endocarditis (IE), echocardiography was
recommended to determine IE risk in patients with suspected valvular lesions.
Based on AHA clinical and echocardiographic criteria, Seto and colleagues
classified patients who underwent outpatient transthoracic echocardiography
into 3 risk categories (high, moderate, negligible) and evaluated whether
physician recommendations regarding IE prophylaxis as reported by patient
survey were consistent with AHA guidelines. Most high-risk patients, but only
55 of 90 moderate-risk patients, reported receiving physician instructions
to take IE prophylaxis. Contrary to AHA guidelines, 29 of 110 patients in
the negligible-risk category reported receiving instructions to take IE prophylaxis.
Oral contraceptive (OC) use has been inconsistently associated with
several adverse cardiovascular events. To assess whether OC use is associated
with ischemic stroke, Gillum and colleagues analyzed results of 16 observational
studies identified in a review of the published literature from January 1960
through November 1999. Summary risk estimates indicated that current use of
OCs, including newer low-estrogen preparations, was associated with a significantly
increased risk of ischemic stroke.
Although drugs have largely replaced the divan when psychiatrists treat
people with mental problems, the patient-physician relationship is still crucial
to making rational pharmacological decisions.
How to evaluate clinical decision rules for use in clinical practice.
JAMA's new authorship criteria require authors
to identify their specific contributions.
LeapeArticle responds to the assertion by McDonald and coauthorsArticle that the recent
Institute of Medicine report overestimates the number of preventable deaths
among hospitalized patients that are attributable to medical error.
"The magnificent vistas of Earth from space do not hint at the human
suffering below." From "A View From There."
For your patients: A guide to caring for persons with dementia.
This Week in JAMA. JAMA. 2000;284(1):9. doi:10.1001/jama.284.1.9