This Week in JAMA FREE

Critical access hospitals (CAHs)—defined as having 25 or fewer acute care beds and located more than 35 miles from the nearest hospital—are crucial to the US rural safety net. In a retrospective analysis of national Medicare and other data, Joynt and colleagues Article compared quality of care and outcomes among patients with acute myocardial infarction, congestive heart failure, and pneumonia at CAHs vs non-CAHs. The authors found that CAHs had fewer clinical capabilities, worse measured processes of care, and higher mortality rates for the 3 conditions examined. In an editorial, Lipsky and Glasser Article discuss strategies to improve quality of care in CAHs.

Approximately 600 000 percutaneous coronary interventions (PCIs) are performed annually in the United States; however, the appropriateness of these procedures is unknown. Chan and colleagues analyzed national cardiovascular registry data from patients undergoing PCI in 2009 and 2010 and assessed PCI appropriateness using the appropriate use criteria for coronary revascularization developed by 6 professional organizations. The authors report that nearly all PCIs for acute indications could be classified as appropriate. Among PCIs performed for nonacute indications, 12% were classified as inappropriate and 38% of uncertain appropriateness, with substantial variation across hospitals.

Sudden cardiac death may be the first manifestation of coronary heart disease, particularly among women, and primary preventive strategies are needed. Chiuve and colleagues analyzed data from the prospective Nurses' Health Study and found that adherence to a low-risk lifestyle—defined as not smoking, having a body mass index of less than 25, exercising 30 minutes a day or longer, and consuming a diet that closely resembles a Mediterranean-style diet—was associated with a low risk of sudden cardiac death during 26 years of follow-up.

When prenatal antiretroviral treatment of women with human immunodeficiency virus infection is considered suboptimal, infant treatment guidelines include the option to reinforce postnatal treatment with combination antiretroviral therapy. Lopinavir-ritonavir is one combination in use, but toxicity in premature and very young newborns has been reported. In a retrospective cross-sectional analysis of national data from France, Simon and colleagues found that compared with standard postnatal zidovudine treatment, immediate postnatal treatment with lopinavir-ritonavir was associated with transient adrenal dysfunction, including life-threatening adrenal insufficiency in premature infants.

Ms X, a healthy high school student, fell while skiing without a helmet. Passersby found her unconscious, but she was alert and oriented when emergency personnel arrived at the scene. Results of head computed tomography and neck plain films were normal in the emergency department. Several days later she reported amnesia, periorbital headache, neck pain, fatigue, and malaise. Zafonte discusses the evaluation, prognosis, and management of sports-associated concussion.

“This case brings forth a nasty secret that physicians know full well but few will admit, at least publicly: We are afraid of being sued for malpractice.” From “The Silent Majority.”

A resurgence of pertussis in countries with high vaccination rates is troubling and not well understood.

FDA regulation of food safety

Clinical decision support and malpractice risk

Electronic health records and patient safety

(ARTICLE AND AUTHOR INTERVIEW)

Do nice patients receive better care?

Dr Bauchner's vision for JAMA

Join Gordon D. Schiff, MD, Wednesday, July 20, from 2 to 3 PM eastern time to discuss addressing diagnostic delays and communication across institutions. To register, go to http://www.ihi.org/AuthorintheRoom.

Dr Bauchner summarizes and comments on this week's issue. Go to http://jama.ama-assn.org/misc/audiocommentary.dtl.

Mr Y, a healthy 42-year-old divorced man, is at relatively low risk for HIV infection. Should he be encouraged to undergo screening for HIV infection? Go to www.jama.com to read the case. Submit your response by August 7 for possible online posting.

For your patients: Information about concussion in young athletes.