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This Week in JAMA
July 5, 2000

This Week in JAMA

JAMA. 2000;284(1):9. doi:10.1001/jama.284.1.9

Prognosis of Patients With Dementia and Acute Illness

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.

Requiring Immunizations to Receive Welfare Benefits

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.

Community Intervention to Speed Care of Acute MI

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.

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Physician Instructions for Endocarditis Prophylaxis

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.

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Oral Contraceptive Use and Stroke Risk

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.

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Medical News & Perspectives

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.

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Users' Guides to the Medical Literature

How to evaluate clinical decision rules for use in clinical practice.

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New JAMA Authorship Criteria

JAMA's new authorship criteria require authors to identify their specific contributions.

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Error in Estimates of Medical Error?

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.

A Piece of My Mind

"The magnificent vistas of Earth from space do not hint at the human suffering below." From "A View From There."

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JAMA Patient Page

For your patients: A guide to caring for persons with dementia.

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