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This Week in JAMA
October 23/30, 2002

This Week in JAMA

JAMA. 2002;288(16):1943. doi:10.1001/jama.288.16.1943
Nurse Staffing, Patient Outcomes, and Nurse Retention

Nursing shortage has been a growing problem in US hospitals. To determine whether hospital nurse staffing levels affect patient outcomes and nurse retention, Aiken and colleaguesArticle conducted a survey of registered nurses at adult general hospitals in Pennsylvania and analyzed data on 30-day mortality and deaths following complications (failure-to-rescue) among surgical patients and on hospital characteristics obtained from hospital administrative databases. In hospitals with high patient-to-nurse ratios, surgical patients experienced higher risk-adjusted 30-day mortality and failure-to-rescue rates, and nurses were more likely to experience burnout and job dissatisfaction. In an editorial, O'Neil and SeagoArticle discuss changes in nursing education, nursing practice, and professional organization that are necessary to address the nursing shortage.

Exercise Type and Intensity and CHD Risk in Men

Studies indicate that risk of coronary heart disease (CHD) is inversely related to physical activity. In this analysis of data from men enrolled in the Health Professionals' Follow-up Study, a prospective cohort study of men aged 40 through 75 years that began in 1986, Tanasescu and colleagues found that increased total physical activity was associated with reduced risk of CHD in a dose-dependent manner. Running, rowing, and weight training were each associated with reduced CHD risk. Average exercise intensity was associated with reduced CHD risk independent of the total volume of physical activity.

Traumatic or Bloody Lumbar Puncture in Childhood ALL

Traumatic or bloody lumbar puncture (LP) reduces the diagnostic value of the procedure and may adversely affect outcomes of patients with acute lymphoblastic leukemia (ALL) if leukemic cells or bacteria circulating in the blood are introduced into the cerebrospinal fluid. Howard and colleagues analyzed outcomes of lumbar punctures performed on children with newly diagnosed ALL to determine risk factors for traumatic or bloody LP. Unmodifiable risk factors included black race, age younger than 1 year, a traumatic or bloody previous LP performed within the past 2 weeks, and a previous LP performed when the platelet count was 50 × 103/µL or less. Modifiable risk factors included procedural factors as reflected by treatment era, platelet count of 100 × 103/µL or less, an interval of 15 days or less between LPs, and a less experienced practitioner.

Homocysteine and Risk of Cardiovascular Disease

Evidence on the association between homocysteine levels and risk of cardiovascular disease has been inconsistent. In a meta-analysis of observational studies of associations between ischemic heart disease or stroke risk and homocysteine concentrations, the Homocysteine Studies CollaborationArticle found that lower homocysteine levels were modestly associated with reduced risk of ischemic heart disease and stroke. Risks of these cardiovascular events associated with homocysteine level were weaker in prospective studies than in retrospective studies. In a meta-analysis of case-control studies, Klerk and colleaguesArticle assessed the association between the MTHFR 677C→T polymorphism, a genetic alteration in an enzyme involved in folate metabolism that causes elevated homocysteine levels, and risk of coronary heart disease. Individuals with the MTHFR 677 TT genotype had a significantly higher risk of coronary heart disease than individuals with the CC genotype. In an editorial, WilsonArticle suggests that measurement of homocysteine levels and genetic testing for MTHFR variants be reserved for selected high-risk individuals.

CLINICIAN'S CORNER

Mr J has obstructive sleep apnea but was unable to tolerate treatment with nasal continuous positive airway pressure. Kuna discusses the definition and diagnosis, epidemiology, pathophysiology, and clinical assessment and management of obstructive sleep apnea.

Contempo Updates

Applications of clinical informatics.

Medical News & Perspectives

Scientists have long sought the identity of a substance secreted by certain white blood cells of individuals infected with HIV whose immune system keeps the virus in check. Now researchers report that they have identified components of this elusive anti-HIV factor.

Platelet Activation in Obese Women

A study of obese women suggests that android obesity may be associated with a low-grade inflammatory state that triggers persistent platelet activation, mediated perhaps by enhanced lipid peroxidation.

Academic General Internal Medicine: On Call: Issues in Graduate Medical Education

A discussion of career options and training pathways in academic general internal medicine.

JAMA Patient Page

For your patients: Information about lumbar puncture.

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