Current Table of Contents

• CLINICAL CROSSROADS: A 50-Year-Old Woman Addicted to Heroin
  
• THIS WEEK IN JAMA: This Week in JAMA
  
• ORIGINAL CONTRIBUTION: Changes in the Risk of Death After HIV Seroconversion Compared With Mortality in the General Population
  

  Context  Mortality among human immunodeficiency virus (HIV)–infected individuals has decreased dramatically in countries with good access to treatment and may now be close to mortality in the general uninfected population.

  Objective  To evaluate changes in the mortality gap between HIV-infected individuals and the general uninfected population.

  Design, Setting, and Population  Mortality following HIV seroconversion in a large multinational collaboration of HIV seroconverter cohorts (CASCADE) was compared with expected mortality, calculated by applying general population death rates matched on demographic factors. A Poisson-based model adjusted for duration of infection was constructed to assess changes over calendar time in the excess mortality among HIV-infected individuals. Data pooled in September 2007 were analyzed in March 2008, covering years at risk 1981-2006.

  Main Outcome Measure  Excess mortality among HIV-infected individuals compared with that of the general uninfected population.

  Results  Of 16 534 individuals with median duration of follow-up of 6.3 years (range, 1 day to 23.8 years), 2571 died, compared with 235 deaths expected in an equivalent general population cohort. The excess mortality rate (per 1000 person-years) decreased from 40.8 (95% confidence interval [CI], 38.5-43.0; 1275.9 excess deaths in 31 302 person-years) before the introduction of highly active antiretroviral therapy (pre-1996) to 6.1 (95% CI, 4.8-7.4; 89.6 excess deaths in 14 703 person-years) in 2004-2006 (adjusted excess hazard ratio, 0.05 [95% CI, 0.03-0.09] for 2004-2006 vs pre-1996). By 2004-2006, no excess mortality was observed in the first 5 years following HIV seroconversion among those infected sexually, though a cumulative excess probability of death remained over the longer term (4.8% [95% CI, 2.5%-8.6%] in the first 10 years among those aged 15-24 years).

  Conclusions  Mortality rates for HIV-infected persons have become much closer to general mortality rates since the introduction of highly active antiretroviral therapy. In industrialized countries, persons infected sexually with HIV now appear to experience mortality rates similar to those of the general population in the first 5 years following infection, though a mortality excess remains as duration of HIV infection lengthens.

• CARING FOR THE CRITICALLY ILL PATIENT: Epidemiology and Treatment of Painful Procedures in Neonates in Intensive Care Units
  

  Context  Effective strategies to improve pain management in neonates require a clear understanding of the epidemiology and management of procedural pain.

  Objective  To report epidemiological data on neonatal pain collected from a geographically defined region, based on direct bedside observation of neonates.

  Design, Setting, and Patients  Between September 2005 and January 2006, data on all painful and stressful procedures and corresponding analgesic therapy from the first 14 days of admission were prospectively collected within a 6-week period from 430 neonates admitted to tertiary care centers in the Paris region of France (11.3 millions inhabitants) for the Epidemiology of Procedural Pain in Neonates (EPIPPAIN) study.

  Main Outcome Measure  Number of procedures considered painful or stressful by health personnel and corresponding analgesic therapy.

  Results  The mean (SD) gestational age and intensive care unit stay were 33.0 (4.6) weeks and 8.4 (4.6) calendar days, respectively. Neonates experienced 60 969 first-attempt procedures, with 42 413 (69.6%) painful and 18 556 (30.4%) stressful procedures; 11 546 supplemental attempts were performed during procedures including 10 366 (89.8%) for painful and 1180 (10.2%) for stressful procedures. Each neonate experienced a median of 115 (range, 4-613) procedures during the study period and 16 (range, 0-62) procedures per day of hospitalization. Of these, each neonate experienced a median of 75 (range, 3-364) painful procedures during the study period and 10 (range, 0-51) painful procedures per day of hospitalization. Of the 42 413 painful procedures, 2.1% were performed with pharmacological-only therapy; 18.2% with nonpharmacological-only interventions, 20.8% with pharmacological, nonpharmacological, or both types of therapy; and 79.2% without specific analgesia, and 34.2% were performed while the neonate was receiving concurrent analgesic or anesthetic infusions for other reasons. Prematurity, category of procedure, parental presence, surgery, daytime, and day of procedure after the first day of admission were associated with greater use of specific preprocedural analgesia, whereas mechanical ventilation, noninvasive ventilation and administration of nonspecific concurrent analgesia were associated with lower use of specific preprocedural analgesia.

  Conclusion  During neonatal intensive care in the Paris region, large numbers of painful and stressful procedures were performed, the majority of which were not accompanied by analgesia.

• REVIEW: Early Invasive vs Conservative Treatment Strategies in Women and Men With Unstable Angina and Non-ST-Segment Elevation Myocardial Infarction: A Meta-analysis
  

  Context  Although an invasive strategy is frequently used in patients with non–ST-segment elevation acute coronary syndromes (NSTE ACS), data from some trials suggest that this strategy may not benefit women.

  Objective  To conduct a meta-analysis of randomized trials to compare the effects of an invasive vs conservative strategy in women and men with NSTE ACS.

  Data Sources  Trials were identified through a computerized literature search of the MEDLINE and Cochrane databases (1970-April 2008) using the search terms invasive strategy, conservative strategy, selective invasive strategy, acute coronary syndromes, non-ST-elevation myocardial infarction, and unstable angina.

  Study Selection  Randomized clinical trials comparing an invasive vs conservative treatment strategy in patients with NSTE ACS.

  Data Extraction  The principal investigators for each trial provided the sex-specific incidences of death, myocardial infarction (MI), and rehospitalization with ACS through 12 months of follow-up.

  Data Synthesis  Data were combined across 8 trials (3075 women and 7075 men). The odds ratio (OR) for the composite of death, MI, or ACS for invasive vs conservative strategy in women was 0.81 (95% confidence interval [CI], 0.65-1.01; 21.1% vs 25.0%) and in men was 0.73 (95% CI, 0.55-0.98; 21.2% vs 26.3%) without significant heterogeneity between sexes (P for interaction = .26). Among biomarker-positive women, an invasive strategy was associated with a 33% lower odds of death, MI, or ACS (OR, 0.67; 95% CI, 0.50-0.88) and a nonsignificant 23% lower odds of death or MI (OR, 0.77; 95% CI, 0.47-1.25). In contrast, an invasive strategy was not associated with a significant reduction in the triple composite end point in biomarker-negative women (OR, 0.94; 95% CI, 0.61-1.44; P for interaction = .36) and was associated with a nonsignificant 35% higher odds of death or MI (OR, 1.35; 95% CI, 0.78-2.35; P for interaction = .08). Among men, the OR for death, MI, or ACS was 0.56 (95% CI, 0.46-0.67) if biomarker-positive and 0.72 (95% CI, 0.51-1.01) if biomarker-negative (P for interaction = .09).

  Conclusions  In NSTE ACS, an invasive strategy has a comparable benefit in men and high-risk women for reducing the composite end point of death, MI, or rehospitalization with ACS. In contrast, our data provide evidence supporting the new guideline recommendation for a conservative strategy in low-risk women.

• CLINICAL CROSSROADS: A 70-Year-Old Man With a Transient Ischemic Attack: Review of Internal Carotid Artery Stenosis
  

  Mr V, a man with severe coronary, aortic, and peripheral artery disease, had an episode of brain ischemia caused by severe preocclusive carotid artery disease in the neck. The major treatment options for his symptomatic carotid artery disease are optimizing medical treatment, carotid endarterectomy, and carotid artery stenting. Selection of treatment must take into consideration his severe symptomatic coronary artery disease as well as Mr V's concerns about surgery. Carotid endarterectomy presents a risk of myocardial infarction unless his coronary disease is treated effectively before surgery. Carotid stenting is problematic because the severity of the preocclusive arterial narrowing makes passing a protective device beyond the stenosis difficult without first performing potentially hazardous angioplasty. Optimizing medical treatment may be the best option for his severe systemic atherosclerosis. Treatment decisions in complex patients like Mr V require weighing the particular risks and benefits of available options, and the patient's own wishes and fears. These decisions, in this and other complex patients, often cannot be directly informed by results from randomized trials.

• CLINICAL CROSSROADS UPDATE: Update: A 76-Year-Old Man With Macular Degeneration
  
• COMMENTARY: Population Health and Economic Development in the United States
  
• COMMENTARY: Health Care Reform Requires Accountable Care Systems
  
• EDITORIAL: Correspondence Course: Tips for Getting a Letter Published in JAMA
  
• LETTERS: Ventilation Strategies for Acute Lung Injury and Acute Respiratory Distress Syndrome
  
• LETTERS: Ventilation Strategies for Acute Lung Injury and Acute Respiratory Distress Syndrome
  
• LETTERS: Ventilation Strategies for Acute Lung Injury and Acute Respiratory Distress Syndrome
  
• LETTERS: Ventilation Strategies for Acute Lung Injury and Acute Respiratory Distress Syndrome
  
• LETTERS: Ventilation Strategies for Acute Lung Injury and Acute Respiratory Distress Syndrome
  
• LETTERS: Ventilation Strategies for Acute Lung Injury and Acute Respiratory Distress Syndrome--Reply
  
• LETTERS: Ventilation Strategies for Acute Lung Injury and Acute Respiratory Distress Syndrome--Reply
  
• LETTERS: Ventilation Strategies for Acute Lung Injury and Acute Respiratory Distress Syndrome--Reply
  
• LETTERS: Randomized Controlled Trials in Critical Care Medicine
  
• LETTERS: Randomized Controlled Trials in Critical Care Medicine--Reply
  
• LETTERS: Physician Roles, Payment Models, and Partnerships in Primary Care
  
• LETTERS: Physician Roles, Payment Models, and Partnerships in Primary Care--Reply
  
• MEDICAL NEWS & PERSPECTIVES: US Launches Undiagnosed Diseases Program
  
• MEDICAL NEWS & PERSPECTIVES: States Try Medication Recycling Programs
  
• MEDICAL NEWS & PERSPECTIVES: Researchers Probe Effects of Pregnancy, Birth on Childhood Asthma and Allergy
  
• MEDICAL NEWS & PERSPECTIVES: Cardiac Studies Reveal Clues Into Asthma and Decreased Lung Function
  
• LAB REPORTS: Microbes Ward Off Bowel Disease
  
• LAB REPORTS: Tomatoes and Cancer
  
• LAB REPORTS: Mutation Linked to Epilepsy
  
• LAB REPORTS: Growth Hormone and Addiction
  
• FROM THE CENTERS FOR DISEASE CONTROL AND PREVENTION: Use of Enhanced Surveillance for Hepatitis C Virus Infection to Detect a Cluster Among Young Injection-Drug Users--New York, November 2004-April 2007
  
• FROM THE CENTERS FOR DISEASE CONTROL AND PREVENTION: Increased Detections and Severe Neonatal Disease Associated With Coxsackievirus B1 Infection--United States, 2007
  
• THE COVER: Washington Under the Council Tree, Coryell's Ferry, Pennsylvania
  
• A PIECE OF MY MIND: Physicians Behaving Badly
  
• POETRY AND MEDICINE: Water
  
• JAMA 100 YEARS AGO: AMERICAN MEDICAL ADMINISTRATION IN PANAMA THROUGH BRITISH EYES.
  
• BOOK AND MEDIA REVIEWS: Global Perspectives on Health Promotion Effectiveness
  
• BOOK AND MEDIA REVIEWS: Medical Effects of Ionizing Radiation
  
• BOOK AND MEDIA REVIEWS: Elderly Medicine: A Training Guide
  
• BOOK AND MEDIA REVIEWS: Textbook of Pediatric Emergency Procedures
  
• BOOK AND MEDIA REVIEWS: Clinical Protocols in Obstetrics and Gynecology
  
• JAMA PATIENT PAGE: Acute Coronary Syndromes
  
• ABOUT THIS JOURNAL: About This Journal