Observational studies have suggested that valve surgery is effective
for patients with complicated left-sided native valve endocarditis, but there
are no randomized trials of surgery for endocarditis or validated prognostic
classification systems to guide management decisions. Using data collected
retrospectively from a cohort of adults with complicated left-sided native
valve endocarditis, Hasbun and colleaguesArticle derived
and validated a risk classification system based on 5 baseline clinical features
that were independently associated with 6-month mortality. In an editorial,
Granowitz and LongworthArticle note that this validated
quantitative model will be useful for designing randomized clinical trials
of valve surgery for patients with active endocarditis and explain why the
model should not be used to decide whether individual patients with endocarditis
should undergo surgery.
Leukocytes in blood products have been associated with increased risk
of infection and mortality, but evidence of the clinical benefit of leukoreduction
of blood products is inconsistent. In this issue of THE JOURNAL, 2 retrospective
studies evaluated outcomes after red blood cell transfusions in high-risk
populations before and after implementation of a universal leukoreduction
program for red blood cell products in Canada. In a cohort of adults who received
red blood cell transfusions after cardiac surgery or repair of hip fracture
or who required intensive care following surgery, Hébert and colleaguesArticle found that all-cause in-hospital mortality risk and
risk of posttransfusion fevers decreased significantly after introduction
of the leukoreduction program, but risk of serious nosocomial infection was
not significantly different. Among premature infants weighing less than 1250
g admitted to a neonatal intensive care unit, Fergusson and colleaguesArticle found that neonatal intensive care unit mortality
and rate of nosocomial bacteremia in the leukoreduction period did not differ
significantly from that in the nonleukoreduction period. In an editorial,
Corwin and AuBuchonArticle consider whether a universal
leukoreduction policy should be adopted in the United States.
External hip protectors are designed to decrease the force of a fall
on the trochanter below the fracture threshold. van Schoor and colleagues
conducted a randomized trial to assess the effectiveness of hip protectors
for reducing the incidence of hip fractures in a population of elderly persons
with low bone density and/or high risk of falling. During a mean follow-up
of 69.6 weeks, time to first hip fracture among individuals assigned to receive
hip protectors and written information on bone health and external risk factors
for falls was not significantly different from that among individuals who
received written information only.
When invasive procedures are required emergently, critically ill patients
may not be capable of providing informed consent, and their proxies may not
be available. In this prospective study of the informed consent process among
patients admitted to an intensive care unit, Davis and colleagues found that
during a 2-month baseline period, 53% of procedures were performed with written
informed consent. After introduction of a universal consent form with which
patients or their proxies were able to provide advanced written consent for
8 procedures commonly performed in the intensive care unit, 90% of procedures
were performed with consent. In both the baseline and intervention periods,
the majority of consents were provided by proxies.
"I have never been sorry for an instant that I provided my patients
with dreadful news sooner rather than later." From "The ‘Magic' Word."
Risa Lavizzo-Mourey, MD, MBA, who recently became the first woman to
direct the Robert Wood Johnson Foundation, reflects on her new position and
the foundation's goals for the future.
Berwick examines the theory of dissemination of innovation within an
organization, identifying factors that influence the rate of spread of innovation,
and suggests ways to disseminate innovation in health care.
Scientific Review/Clinical Applications
Evidence on screening and treatment of hearing loss in older adults
is reviewed in part 1Article of this 2-part article.
In part 2Article, clinical cases common to the primary
care setting illustrate diagnostic and therapeutic strategies to improve detection,
evaluation, and treatment of adult hearing loss.
For your patients: Information about adult hearing loss.
This Week in JAMA. JAMA. 2003;289(15):1889. doi:10.1001/jama.289.15.1889