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This Week in JAMA
November 8, 2000

This Week in JAMA

JAMA. 2000;284(18):2285. doi:10.1001/jama.284.18.2285

Underuse of Necessary Care Among Elderly

Asch and colleaguesArticle developed a set of 47 clinical indicators for measuring underuse of necessary care for 15 common medical conditions and for preventive care among the elderly Medicare population and applied them to administrative data. For 16 of 40 indicators, beneficiaries received the indicated care less than two thirds of the time. African Americans, residents of poverty areas, and residents of Health Professional Shortage Areas had significantly more underuse compared with other beneficiaries. In an editorial, HannanArticle emphasizes the urgent need to develop ongoing systems to measure and monitor the quality of care in the United States.

Protection After 3 Doses of Hib Conjugate Vaccine

Many countries recommend a booster dose of Haemophilus influenzae type b (Hib) vaccine in the second year of life, but there is little evidence indicating that a booster dose is necessary. The recommended schedule for Hib vaccination of infants in the United Kingdom consists of 3 doses at 2, 3, and 4 months of age and no booster dose. Heath and colleagues report that between October 1992 and March 1999, the clinical vaccine failure rate in the United Kingdom derived from the observed number of true vaccine failures after 3 doses of Hib conjugate vaccine was 2.2 per 100,000 vaccinees. Clinical protection remained high until the sixth year of life despite a small but significant decline after the first year of life and waning levels of antibody to Hib capsular polysaccharide.

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Community Program to Prevent Alcohol-Related Injuries

The availability of alcohol in a community may be associated with motor vehicle crashes and violent assaults. Holder and colleagues evaluated the effect of a community-based environmental intervention on the rate of high-risk drinking and alcohol-related motor vehicle injuries and assaults in 3 communities. Self-reported heavy drinking declined in the intervention communities and, compared with matched control communities, driving after drinking crashes decreased by 6%, nighttime injury crashes decreased by 10%, and assault injuries observed in emergency departments declined by 43%.

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Smoking and Anxiety Disorders

Cigarette smoking has been associated with some anxiety disorders, but whether anxiety disorders predict risk for future smoking or whether smoking predicts risk for subsequent anxiety disorders is not known. Johnson and colleagues assessed psychiatric disorders and smoking among 688 adolescents in 1985-1986 (mean age, 16 years) and reevaluated study participants in 1991 through 1993 at mean age 22 years. The risk for agoraphobia, generalized anxiety disorder, and panic disorder during early adulthood was increased among adolescents who smoked 20 cigarettes or more per day. Anxiety disorders in adolescence were not significantly associated with cigarette smoking during early adulthood.

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Noninvasive Ventilation in Acute Respiratory Failure

To study the effectiveness of noninvasive techniques of ventilatory support, Delclaux and colleaguesArticle assigned patients with acute hypoxemic, nonhypercapnic respiratory insufficiency to receive either oxygen therapy plus continuous positive airway pressure (CPAP) or oxygen therapy alone. There were no significant differences between the groups in the rate of endotracheal intubation, in-hospital mortality, or mean intensive care unit (ICU) length of stay, but adverse events in the ICU were significantly more common in the CPAP group. In a case-control study among patients with acute exacerbation of chronic obstructive pulmonary disease or hypercapnic cardiogenic pulmonary edema, Girou and colleaguesArticle found that the incidence of nosocomial infections and pneumonia was significantly lower among patients who were treated with noninvasive ventilation compared with matched controls treated with mechanical ventilation. In an editorial, KeenanArticle observes that the benefit of noninvasive positive pressure ventilation is less consistent among patients with hypoxemic respiratory failure than among patients with hypercarbic respiratory failure.

A Piece of My Mind

"Medicine is the people we meet along the way—pain, worry, or suffering provides the excuse to meet them." From "I Have Always Been Fascinated . . . "

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Medical News & Perspectives

The continuing priority of avoiding medical error and injury was highlighted by the recent presentation of National Patient Safety Awards to the designers of innovative improvement programs.

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Evaluation of Patients With Early Arthritis

Three case presentations illustrate the broad clinical spectrum of early inflammatory synovitis.

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JAMA Patient Page

For your patients: A primer on mechanical ventilation.

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A JAMA theme issue on end-of-life care.