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This Week in JAMA
JAMA. 2000;283:1103.
Outcomes of Thrombolytic Therapy for Acute Stroke
In the National Institute of Neurological Disorders and Stroke (NINDS) clinical trial, early thrombolytic therapy for acute ischemic stroke with intravenous tissue-type plasminogen activator (tPA) was associated with improved neurologic outcomes, but concern about increased risk of intracerebral hemorrhage (ICH) and the narrow therapeutic window of 3 hours from stroke onset have limited its use in general clinical practice. In this prospective study of 389 adults at 24 academic and 33 community medical centers treated with intravenous tPA, Albers and colleagues (SEE ARTICLE) report that 30 days after treatment, mortality was 13%, and 35% of patients had a very favorable neurologic outcome (modified Rankin score, 0-1). The rate of symptomatic ICH within 3 days of treatment was 3.3%. Based on data from 29 Cleveland-area hospitals in the Cleveland Health Quality Choice project, Katzan and colleagues (SEE ARTICLE) found that 70 (1.8%) of 3948 patients with ischemic stroke received intravenous tPA. Symptomatic ICH occurred in 11 (15.7%) of these patients, and in-hospital mortality was 15.7%, significantly higher than among patients who did not receive tPA (mortality rate, 5.1%). Deviation from national treatment guidelines was identified in 50% of patients who received tPA. In an editorial, Mohr (SEE ARTICLE) discusses hypotheses about the etiology of ischemia and infarction in stroke and about the mechanism of action of thrombolytic therapy.
Hospital Volume, Mortality Risk, and Selective Referral
Using data from published studies, Dudley and colleagues (SEE ARTICLE) identified 11 procedures and diagnoses for which in-hospital mortality was significantly lower at high-volume hospitals (HVHs) compared with low-volume hospitals (LVHs) and calculated odds ratios for in-hospital mortality for LVHs vs HVHs based on the highest-quality study for each condition. Applying the calculated odds ratios to the total number of patients with these conditions hospitalized at LVHs in California in 1997, the researchers estimated that 602 deaths could potentially have been avoided by treatment at an HVH. In an editorial, Birkmeyer (SEE ARTICLE) discusses ways to implement selective referral for high-risk surgery and possible disadvantages of and barriers to regionalization.
Risk and Timing of Mother-to-Infant HIV Transmission
Although human immunodeficiency virus (HIV) is known to be transmitted through breastfeeding, World Health Organization guidelines have recommended breastfeeding for some areas regardless of maternal HIV status because of the mortality risk from diarrheal disease and malnutrition associated with formula feeding. In this trial comparing outcomes of breastfeeding and formula feeding among infants of 401 untreated HIV-seropositive women in Nairobi, Kenya, Nduati and colleagues (SEE ARTICLE) estimated that the rate of breast milk transmission of HIV was 16.2% during the first 2 years of life, most of which occurred in the first 6 months, accounting for 44% of all HIV infections among infants exposed to breast milk. The rate of HIV-free survival was significantly lower among infants in the breastfeeding group compared with formula feeding, but 2-year mortality rates were similar. De Cock and coauthors (SEE ARTICLE) present current estimates of the risk of mother-to-child HIV transmission in developing countries and discuss results of intervention studies and implementation of prevention strategies in resource-poor areas.
Ban on Carrying Guns Reduces Homicides in Colombia
In 1993, firearms were involved in 80% of homicides in Colombia, and the homicide rate was 88 per 100,000. In this study conducted in Cali and Bogotá, Colombia, Villaveces and colleagues (SEE ARTICLE) found that a police-enforced ban on carrying firearms during periods expected to have high rates of homicide was associated with a significant reduction in homicide rates compared with similar days when the ban was not in effect. In an editorial, Sherman (SEE ARTICLE) compares these findings with US rates of weapons arrests and homicide and discusses implications for enforcement of gun-carrying laws.
A Piece of My Mind
"My body aches with unspoken wishes that my daughters will develop a full sense of trust and feel the stability of a family." From "A Mother's Prayer."
(SEE ARTICLE)
Medical News & Perspectives
A novel class of drugs designed to prevent HIV from invading cells shows promise, according to new findings presented at the Conference on Retroviruses and Opportunistic Infections.
(SEE ARTICLE)
Peripartum Cardiomyopathy
A review of the literature on peripartum cardiomyopathy and recommendations for future research from the Workshop on Peripartum Cardiomyopathy convened by the National Heart, Lung, and Blood Institute and the Office of Rare Diseases of the National Institutes of Health.
(SEE ARTICLE)
MSJAMA
The many faces of societal violence and the role of medicine.
(SEE ARTICLE)
JAMA Patient Page
For your patients: Information about infant feeding.
(SEE ARTICLE)
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