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JAMA. 2000;284:3095.

Outcomes of Percutaneous Coronary Procedures
In an analysis of data from the National Registry of Myocardial Infarction, Magid and colleagues (SEE ARTICLE) found that at hospitals with high or intermediate volumes of primary angioplasty, in-hospital mortality was lower among patients with acute myocardial infarction treated with primary angioplasty than among those treated with thrombolysis, but at hospitals with low angioplasty volumes, mortality outcomes were similar. McGrath and colleagues (SEE ARTICLE) , using data from the Medicare National Claims History files from 1997, found that rates of coronary artery bypass graft surgery after a percutaneous coronary intervention (PCI) were lower among patients treated by physicians with high PCI volumes compared with those treated by low-volume physicians. Thirty-day mortality after a PCI was lower among patients treated at centers with high procedural volumes compared with those treated at low-volume centers. Among patients who received coronary artery stents (57.7% of PCI procedures), outcomes for procedures by low-volume physicians or at low-volume centers were still inferior to those achieved by high-volume physicians and centers. In an editorial, Jollis and Romano (SEE ARTICLE) suggest that PCIs generally should not be performed at low-volume hospitals.

Immunization Exemption and Risk of Measles, Pertussis
In the United States, 48 states allow religious exemptions from mandatory childhood immunizations, and 15 states allow philosophical exemptions. Feikin and colleagues (SEE ARTICLE) report that in Colorado, which had more than twice the national rate of unvaccinated children with exemptions in 1994, the risk for measles during 1987-1998 was 22.2 times higher among school-aged children with vaccine exemptions compared with vaccinated children, and the risk for pertussis was 5.9 times higher. The incidence of measles and pertussis in vaccinated school-aged children at the county level and in school outbreaks was associated with the frequency of children with exemptions. In an editorial, Edwards (SEE ARTICLE) discusses criteria for evaluating which vaccines should be mandated for day care or school entry.

Domestically Acquired Ceftriaxone-Resistant Salmonella
In previous national surveys, ceftriaxone-resistant Salmonella infections have all been acquired outside of the United States, but recently, the first case of a domestically acquired ceftriaxone-resistant Salmonella infection from a bovine source was reported. Dunne and colleagues report that the prevalence of ceftriaxone-resistant Salmonella was 0.1% (1 of 1326 isolates) in 1996, 0.4% (5 of 1301) in 1997, and 0.5% (7 of 1466) in 1998. Ten of 11 patients with ceftriaxone-resistant infections interviewed in this study reported no recent travel outside the United States. Most ceftriaxone-resistant Salmonella isolates had similar AmpC plasmid-mediated resistance.

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Testing for Diabetes in the Afternoon
Current diagnostic criteria for diabetes are based on morning fasting plasma glucose levels and may not be applicable to patients who are tested in the afternoon when plasma glucose levels are lower. Using data from the Third National Health and Nutrition Examination Survey, Troisi and colleagues estimated that about half of all cases of undiagnosed diabetes in patients evaluated in the afternoon would be missed if current diagnostic criteria are applied. The diagnostic fasting plasma glucose level for patients evaluated in the afternoon should be 0.67 mmol/L (12 mg/dL) lower than the current diagnostic criterion of 7.0 mmol/L (126 mg/dL).

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Pulmonary Hypertension
Mrs JL, a 44-year-old woman who took anorexigens intermittently between 1994 and 1996, had a 10-month history of progressive shortness of breath before the diagnosis of pulmonary hypertension was made in 1998. Gaine discusses the diagnostic classification of pulmonary hypertension, evaluation of patients suspected of having pulmonary hypertension, and management of pulmonary arterial hypertension.

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A Piece of My Mind
"One day we look around us and we see that our circle of friends and acquaintances is finally, irreparably broken." From "From Rites of Passage to Last Rights."

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Contempo Updates
Obsessive-compulsive disorder in children: epidemiology, diagnosis, and advances in treatment.

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Medical News & Perspectives
The burgeoning number of cases of HIV/AIDS in Eastern Europe, particularly Russia, is worrying public health officials and straining already scant medical resources.

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Controversies
Stem Cell Research
Lanza and coauthors (SEE ARTICLE) assert that using embryonic stem cells for therapeutic cloning to produce immunologically compatible cells and tissues for human transplantation is ethically valid. Juengst and Fossel (SEE ARTICLE) favor the development of nonembryonic sources of pluripotent stem cells as an ethically acceptable alternative to the use of human embryonic stem cells.

JAMA Patient Page
For your patients: Information about procedures for coronary heart disease.

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