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Journal Cover JAMA The Journal of the American Medical Association     [SJR: 4.843]   [H-I: 456]
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   Full-text available via subscription Subscription journal
   ISSN (Print) 0098-7484 - ISSN (Online) 1538-3598
   Published by American Medical Association Homepage  [11 journals]
  • Babies With Low Birth Weight
    • Authors: Jin J.
      PubDate: Tue, 27 Jan 2015 00:00:00 GMT
  • JAMA
    • PubDate: Tue, 27 Jan 2015 00:00:00 GMT
  • Upswing in Skin Cancer Costs
    • Abstract: The cost of treating skin cancer outpaced treatment costs for all other cancers combined by 5-fold from 2002 to 2011, according to a Centers for Disease Control and Prevention (CDC) study.
      PubDate: Tue, 27 Jan 2015 00:00:00 GMT
  • Man in Armour Holding a Pike Jan van Bijlert
    • Authors: Smith JM.
      Abstract: The paintings of many of the cast of characters created by Jan van Bijlert (1597/98-1671) occurred in a milieu of sociopolitical theater involving the Dutch struggle against Spanish sovereignty during the Eighty Years’ War. With the dénouement of the war in 1648, the Dutch achieved their independence. It was against this backdrop of drama that van Bijlert seemed to use a bit of stagecraft to confer a star quality on subjects not unlike the glam shots seen in the present-day popular press.
      PubDate: Tue, 27 Jan 2015 00:00:00 GMT
  • Lou Gehrig’s Disease
    • Authors: Collins M.
      Abstract: The crowd sees the ball curve down and almostaway from the blur of bat. At the point of contact,the pitcher, following through, sees a home run arc upover the stands: Again, Lou writes his signature on airwith sound and blur and the stadium’s outcry. For 2000 games, he’s the Iron Man—till a synapse
      PubDate: Tue, 27 Jan 2015 00:00:00 GMT
  • The Architecture of Viruses
    • Abstract: Because the viruses possess properties characteristic of living organisms and may cause disease they interest not only the biologist and bacteriologist but also the pathologist. As some of them have characteristics of molecules they likewise draw the attention of the chemist. Even the philosopher is attracted by them because they throw new light on the question of the nature of life. In a recent review Stanley, whose name is intimately associated with the study of proteins, not only presents recent advances in virus research but also speculates on the possible relationship between the atomic theory of matter, the germ theory of disease and the cell theory of life. The architecture of viruses is even more complex than that of the proteins; while simpler viruses seem to be composed of protein and nucleic acid, others also contain carbohydrate and the most complex contain materials which are indistinguishable from those found in bacteria. Although certain of the viruses exhibit chemical and physical characteristics of nucleoproteins and are called molecules by some investigators, the same particles are referred to by others as organisms or cells. Since a number of the viruses have been obtained in crystalline form, it is interesting to note Stanley’s conclusion that crystallinity of itself is not evidence as to the animate or inanimate nature of a material.
      PubDate: Tue, 27 Jan 2015 00:00:00 GMT
  • Hyperkalemia Controlled With 2 Novel Medications
    • Authors: Slomski A.
      Abstract: Three recent randomized clinical trials have shown that 2 distinct oral medications can effectively lower plasma potassium levels in patients with hyperkalemia, a notoriously challenging but common problem in chronic kidney disease and heart failure. The drugs, which haven’t been approved by the US Food and Drug Administration, have different mechanisms of action. Patiromer binds potassium, primarily in the colon. Sodium zirconium cyclosilicate is a highly selective cation exchanger that traps potassium in the intestines.
      PubDate: Tue, 27 Jan 2015 00:00:00 GMT
  • Short Therapy Reduces Depression in Family Caregivers of Patients With
    • Authors: Slomski A.
      Abstract: Therapy using a series of coping strategies to provide stress relief and emotional support for family members caring for relatives with dementia can reduce depression and anxiety and improve well-being at no extra cost to standard care, according to a randomized clinical trial conducted in the United Kingdom (Livingston G et al. Lancet Psychiatry. doi:10.1016/S2215-0366(14)00073-X [published online November 18, 2014]).
      PubDate: Tue, 27 Jan 2015 00:00:00 GMT
  • New Kidney Allocation System
    • Authors: Hampton T.
      Abstract: After nearly 10 years of reviewing studies and considering feedback, an Organ Procurement and Transplantation Network (OPTN) committee has finalized changes to the US kidney allocation system.
      PubDate: Tue, 27 Jan 2015 00:00:00 GMT
  • New Modeling Software Evaluates Coronary Artery Blood Flow
    • Authors: Hampton T.
      Abstract: A new computer modeling program approved by the US Food and Drug Administration (FDA) will permit clinicians to noninvasively evaluate blood flow in the coronary arteries of patients with symptoms of coronary artery disease (
      PubDate: Tue, 27 Jan 2015 00:00:00 GMT
  • Proposal Seeks to Enhance Availability of Clinical Trial Results
    • Authors: Hampton T.
      Abstract: A recent proposal by the Department of Health and Human Services and the National Institutes of Health (NIH) aims to improve public access to clinical trial information.
      PubDate: Tue, 27 Jan 2015 00:00:00 GMT
  • Avoiding Diabetes Self-management
    • Abstract: Few privately insured people with newly diagnosed diabetes participate in diabetes self-management education and training (DSMT), jeopardizing their ability to improve glycemic control and reduce the risk of complications and hospitalizations. The American Diabetes Association recommends starting DSMT when patients are first diagnosed and most receptive to the education.
      PubDate: Tue, 27 Jan 2015 00:00:00 GMT
  • Revised Wording
    • Abstract: In the JAMA Viewpoint entitled, “The Role of Private Payers in Payment Reform,” published in the January 6, 2015, issue of JAMA (2015;313[1]:25-26 doi:10.1001/jama.2014.15904), part of the basis for efforts to slow health care spending was reworded. On page 25, the last sentence of the second full paragraph should read, “Combined with the sizeable share of US health care spending deemed wasteful, slowing the rate of increase of health care costs becomes increasingly important.” Additionally, on page 26, the fourth complete sentence has been omitted. This article was corrected online.
      PubDate: Tue, 27 Jan 2015 00:00:00 GMT
  • Mary L. (Nora) Disis, MD Ready to Become Editor in Chief of the New JAMA
    • Authors: Hampton T.
      Abstract: In February, JAMA Oncology joins the JAMA family of journals to address all aspects of medical, radiation, and surgical oncology and its subspecialties. The need for the journal stems from an increasing volume of work and innovative discoveries in cancer research as investigators strive to provide optimal care for the increasing numbers of patients diagnosed with cancer.
      PubDate: Tue, 27 Jan 2015 00:00:00 GMT
  • Hospital Consolidation Isn’t the Key to Lowering Costs and Raising
    • Authors: Frakt AB.
      Abstract: The headline of a mid-September op-ed in The Wall Street Journal by Kenneth Davis, MD, CEO and president of Mount Sinai Health System in New York City, trumpeted a familiar claim: “Hospital Mergers Can Lower Costs and Improve Medical Care.” But larger size is neither a necessary nor sufficient condition for hospital systems to trim waste and enhance quality. In fact, studies show that greater competition, not consolidation, is more likely to hold down costs and lead to better care.
      PubDate: Tue, 27 Jan 2015 00:00:00 GMT
  • Ethical Testing of Experimental Ebola Treatments
    • Authors: Folayan M; Haire B, Peterson K.
      Abstract: To the Editor In his Viewpoint, Dr Joffe sought to justify the need for randomization of experimental drugs used for the management of the Ebola crisis due to the need for scientific information. He explicitly argued against the compassionate use of experimental interventions.
      PubDate: Tue, 27 Jan 2015 00:00:00 GMT
  • Ethical Testing of Experimental Ebola Treatments
    • Authors: Kanters S; Thorlund K, Mills EJ.
      Abstract: To the Editor Dr Joffe argued for the importance of randomized study designs to ensure the acquisition of scientific knowledge required for the response to the Ebola epidemic to progress, as well as to ensure ethical treatment of patients. Many calls for RCTs have culminated with the establishment, by the Wellcome Trust, of an international consortium to conduct clinical trials of experimental therapeutics for Ebola virus disease in West Africa.
      PubDate: Tue, 27 Jan 2015 00:00:00 GMT
  • Ethical Testing of Experimental Ebola Treatments—Reply
    • Authors: Joffe S.
      Abstract: In Reply Dr Folayan and colleagues and Mr Kanters and colleagues offer thoughtful responses to my Viewpoint, which advocated for RCTs of therapies against Ebola virus disease and cautioned against compassionate use. Their contrasting criticisms of and support for the use of RCTs demonstrate that consensus on this controversial and emotionally charged question is far off.
      PubDate: Tue, 27 Jan 2015 00:00:00 GMT
  • Incorrect Footnote Order
    • Abstract: In the Original Investigation entitled “Association of the 2011 ACGME Resident Duty Hour Reform With General Surgery Patient Outcomes and With Resident Examination Performance” in the December 10, 2014, issue of JAMA (2014;312[22]:2374-2384. doi:10.1001/jama.2014.15277), the footnote order of a and b in the notes below Table 4 should be reversed. This article was corrected online.
      PubDate: Tue, 27 Jan 2015 00:00:00 GMT
  • Protocolized Sedation vs Usual Care in Pediatric Patients Mechanically
           Ventilated for Acute Respiratory Failure A Randomized Clinical Trial
    • Authors: Curley MQ; Wypij D, Watson R, et al.
      Abstract: ImportanceProtocolized sedation improves clinical outcomes in critically ill adults, but its effect in children is unknown.ObjectiveTo determine whether critically ill children managed with a nurse-implemented, goal-directed sedation protocol experience fewer days of mechanical ventilation than patients receiving usual care.Design, Setting, and ParticipantsCluster randomized trial conducted in 31 US pediatric intensive care units (PICUs). A total of 2449 children (mean age, 4.7 years; range, 2 weeks to 17 years) mechanically ventilated for acute respiratory failure were enrolled in 2009-2013 and followed up until 72 hours after opioids were discontinued, 28 days, or hospital discharge.InterventionIntervention PICUs (17 sites; n = 1225 patients) used a protocol that included targeted sedation, arousal assessments, extubation readiness testing, sedation adjustment every 8 hours, and sedation weaning. Control PICUs (14 sites; n = 1224 patients) managed sedation per usual care.Main Outcomes and MeasuresThe primary outcome was duration of mechanical ventilation. Secondary outcomes included time to recovery from acute respiratory failure, duration of weaning from mechanical ventilation, neurological testing, PICU and hospital lengths of stay, in-hospital mortality, sedation-related adverse events, measures of sedative exposure (wakefulness, pain, and agitation), and occurrence of iatrogenic withdrawal.ResultsDuration of mechanical ventilation was not different between the 2 groups (intervention: median, 6.5 [IQR, 4.1-11.2] days; control: median, 6.5 [IQR, 3.7-12.1] days). Sedation-related adverse events including inadequate pain and sedation management, clinically significant iatrogenic withdrawal, and unplanned endotracheal tube/invasive line removal were not significantly different between the 2 groups. Intervention patients experienced more postextubation stridor (7% vs 4%; P = .03) and fewer stage 2 or worse immobility-related pressure ulcers (
      PubDate: Tue, 27 Jan 2015 00:00:00 GMT
  • Moral Concerns and the Willingness to Donate to a Research Biobank
    • Authors: Tomlinson T; De Vries R, Ryan K, et al.
      Abstract: Research biobanks are increasing in number and importance, with great potential for advancing knowledge of human health, disease, and treatment. Recruitment of donors is vital to their success and relies largely on blanket consent, in which donors give one-time permission for any future research uses of their coded specimen. This approach to consent has been endorsed recently in proposed changes to federal regulations.
      PubDate: Tue, 27 Jan 2015 00:00:00 GMT
  • Heterogeneity in Meta-analysis of FDG-PET Studies to Diagnose Lung Cancer
    • Authors: Mills EJ; Jansen JP, Kanters S.
      Abstract: To the Editor Dr Deppen and colleagues conducted a large meta-analysis that showed the limitations of lung cancer diagnosis using fludeoxyglucose F 18 combined with positron emission tomography (FDG-PET) in areas with endemic infectious lung disease. Although the sensitivity and specificity of FDG-PET diagnosis was heterogeneous across the included studies, thereby compromising interpretation of the pooled results, the relevance of presenting an I2 statistic to underscore and interpret the extent of the heterogeneity should be questioned.
      PubDate: Tue, 27 Jan 2015 00:00:00 GMT
  • Heterogeneity in Meta-analysis of FDG-PET Studies to Diagnose Lung
    • Authors: Blume JD; Deppen SA, Grogan EL.
      Abstract: In Reply Dr Mills and colleagues wish to deemphasize I2 statistics. We agree that I2 statistics can be problematic and that the naive pooled model (ie, the model assuming no study-to-study heterogeneity) is often inappropriate for meta-analyses. This is why, in our study, I2 statistics were only reported for completeness and never factored into our analysis.
      PubDate: Tue, 27 Jan 2015 00:00:00 GMT
  • Diagnosing Endocarditis in Patients With Staphylococcus aureus Bacteremia
    • Authors: Schoenfeld M; Machhar R, Maw A.
      Abstract: To the Editor Dr Holland and colleagues performed a systematic review of the clinical management of patients with Staphylococcus aureus bacteremia and concluded that for those with certain low-risk characteristics, transesophageal echocardiography can be safely deferred. Our objection to this assertion is 2-fold.
      PubDate: Tue, 27 Jan 2015 00:00:00 GMT
  • Diagnosing Endocarditis in Patients With Staphylococcus aureus
    • Authors: Holland TL; Fowler VG, Jr.
      Abstract: In Reply Dr Schoenfeld and colleagues emphasize the low quality of the available evidence regarding the use of transesophageal echocardiography in patients with S aureus bacteremia and the possibility that cases of endocarditis may have been missed in the relevant studies. We agree with this point and would welcome definitive high-quality studies to address this possibility.
      PubDate: Tue, 27 Jan 2015 00:00:00 GMT
  • Antiviral Drugs for Seasonal Influenza 2014-2015
    • Abstract: This article reviews the antiviral drugs available to treat influenza this season—including oseltamivir and zanamivir—as well as their indications and possible adverse effects.
      PubDate: Tue, 27 Jan 2015 00:00:00 GMT
  • Decision Curve Analysis
    • Authors: Fitzgerald M; Saville BR, Lewis RJ.
      Abstract: This Guide to Statistics and Methods describes how a decision curve analysis can be used to evaluate the benefits of a diagnostic test, such as 3 prostate biopsy strategies.
      PubDate: Tue, 27 Jan 2015 00:00:00 GMT
  • Nonleg Venous Thrombosis in Critically Ill Adults
    • Authors: Castellucci LA; Wells PS, Duffett L.
      Abstract: JAMA Internal MedicineNonleg Venous Thrombosis in Critically Ill Adults: A Nested Prospective Cohort StudyFrancois Lamontagne, MD, MSc; Lauralyn McIntyre, MD, MSc; Peter Dodek, MD, MHSc; Diane Heels-Ansdell, MS; Maureen Meade, MD, MSc; Julia Pemberton, MSc; Yoanna Skrobik, MD; Ian Seppelt, MBBS; Nicholas E. Vlahakis, MBBS; John Muscedere, MD; Graham Reece, MD; Marlies Ostermann, MBBS; Soundrie Padayachee, PhD, CSci; Jamal Alhashemi, MBBS, MSc; Michael Walsh, MD, PhD; Bradley Lewis, MD; David Schiff, MD; Alan Moody, MBBS; Nicole Zytaruk, RN; Martine LeBlanc, MD; Deborah J. Cook, MD, MSc; for the PROTECT (Prophylaxis for Thromboembolism in Critical Care Trial) Investigators, on behalf of the Canadian Critical Care Trials Group and the Australian and New Zealand Intensive Care Society Clinical Trials Group Importance Critically ill patients are at risk of venous thrombosis, and therefore guidelines recommend daily thromboprophylaxis. Deep vein thrombosis (DVT) commonly occurs in the lower extremities but can occur in other sites including the head and neck, trunk, and upper extremities. The risk of nonleg deep venous thromboses (NLDVTs), predisposing factors, and the association between NLDVTs and pulmonary embolism (PE) or death are unclear.Objective To describe the frequency, anatomical location, risk factors, management, and consequences of NLDVTs in a large cohort of medical-surgical critically ill adults.Design, Setting, and Participants A nested prospective cohort study in the setting of secondary and tertiary care intensive care units (ICUs). The study population comprised 3746 patients, who were expected to remain in the ICU for at least 3 days and were enrolled in a randomized clinical trial of dalteparin vs standard heparin for thromboprophylaxis.Main Outcomes and Measures The proportion of patients who had NLDVTs, the mean number per patient, and the anatomical location. We characterized NLDVTs as prevalent or incident (identified within 72 hours of ICU admission or thereafter) and whether they were catheter related or not. We used multivariable regression models to evaluate risk factors for NLDVT and to examine subsequent anticoagulant therapy, associated PE, and death.Results Of 3746 trial patients, 84 (2.2%) developed 1 or more non–leg vein thromboses (superficial or deep, proximal or distal). Thromboses were more commonly incident (n = 75 [2.0%]) than prevalent (n = 9 [0.2%]) (P 
      PubDate: Tue, 27 Jan 2015 00:00:00 GMT
  • Diagnosis and Treatment of Clostridium difficile in Adults A Systematic
    • Authors: Bagdasarian N; Rao K, Malani PN.
      Abstract: ImportanceSince 2000, the incidence and severity of Clostridium difficile infection (CDI) have increased.ObjectiveTo review current evidence regarding best practices for the diagnosis and treatment of CDI in adults (age ≥18 years).Evidence ReviewOvid MEDLINE and Cochrane databases were searched using keywords relevant to the diagnosis and treatment of CDI in adults. Articles published between January 1978 and October 31, 2014, were selected for inclusion based on targeted keyword searches, manual review of bibliographies, and whether the article was a guideline, systematic review, or meta-analysis published within the past 10 years. Of 4682 articles initially identified, 196 were selected for full review. Of these, the most pertinent 116 articles were included. Clinical trials, large observational studies, and more recently published articles were prioritized in the selection process.FindingsLaboratory testing cannot distinguish between asymptomatic colonization and symptomatic infection with C difficile. Diagnostic approaches are complex due to the availability of multiple testing strategies. Multistep algorithms using polymerase chain reaction (PCR) for the toxin gene(s) or single-step PCR on liquid stool samples have the best test performance characteristics (for multistep: sensitivity was 0.68-1.00 and specificity was 0.92-1.00; and for single step: sensitivity was 0.86-0.92 and specificity was 0.94-0.97). Vancomycin and metronidazole are first-line therapies for most patients, although treatment failures have been associated with metronidazole in severe or complicated cases ofCDI. Recent data demonstrate clinical success rates of 66.3% for metronidazole vs 78.5% for vancomycin for severe CDI. Newer therapies show promising results, including fidaxomicin (similar clinical cure rates to vancomycin, with lower recurrence rates for fidaxomicin, 15.4% vs vancomycin, 25.3%; P = .005) and fecal microbiota transplantation (response rates of 83%-94% for recurrent CDI).Conclusions and RelevanceDiagnostic testing for CDI should be performed only in symptomatic patients. Treatment strategies should be based on disease severity, history of prior CDI, and the individual patient’s risk of recurrence. Vancomycin is the treatment of choice for severe or complicated CDI, with or without adjunctive therapies. Metronidazole is appropriate for mild disease. Fidaxomicin is a therapeutic option for patients with recurrent CDI or a high risk of recurrence. Fecal microbiota transplantation is associated with symptom resolution of recurrent CDI but its role in primary and severe CDI is not established.
      PubDate: Tue, 27 Jan 2015 00:00:00 GMT
  • Comparison of MR/Ultrasound Fusion–Guided Biopsy With
           Ultrasound-Guided Biopsy for the Diagnosis of Prostate Cancer
    • Authors: Siddiqui M; Rais-Bahrami S, Turkbey B, et al.
      Abstract: ImportanceTargeted magnetic resonance (MR)/ultrasound fusion prostate biopsy has been shown to detect prostate cancer. The implications of targeted biopsy alone vs standard extended-sextant biopsy or the 2 modalities combined are not well understood.ObjectiveTo assess targeted vs standard biopsy and the 2 approaches combined for the diagnosis of intermediate- to high-risk prostate cancer.Design, Setting, and ParticipantsProspective cohort study of 1003 men undergoing both targeted and standard biopsy concurrently from 2007 through 2014 at the National Cancer Institute in the United States. Patients were referred for elevated level of prostate-specific antigen (PSA) or abnormal digital rectal examination results, often with prior negative biopsy results. Risk categorization was compared among targeted and standard biopsy and, when available, whole-gland pathology after prostatectomy as the “gold standard.”InterventionsPatients underwent multiparametric prostate magnetic resonance imaging to identify regions of prostate cancer suspicion followed by targeted MR/ultrasound fusion biopsy and concurrent standard biopsy.Main Outcomes and MeasuresThe primary objective was to compare targeted and standard biopsy approaches for detection of high-risk prostate cancer (Gleason score ≥4 + 3); secondary end points focused on detection of low-risk prostate cancer (Gleason score 3 + 3 or low-volume 3 + 4) and the biopsy ability to predict whole-gland pathology at prostatectomy.ResultsTargeted MR/ultrasound fusion biopsy diagnosed 461 prostate cancer cases, and standard biopsy diagnosed 469 cases. There was exact agreement between targeted and standard biopsy in 690 men (69%) undergoing biopsy. Targeted biopsy diagnosed 30% more high-risk cancers vs standard biopsy (173 vs 122 cases, P 
      PubDate: Tue, 27 Jan 2015 00:00:00 GMT
  • Highlights
    • PubDate: Tue, 27 Jan 2015 00:00:00 GMT
  • Digital Medical Tools and Sensors
    • Authors: Topol EJ; Steinhubl SR, Torkamani A.
      Abstract: In this Viewpoint, Eric Topol and colleagues discuss the effect that mobile devices as biomedical sensors could have on health care.
      PubDate: Tue, 27 Jan 2015 00:00:00 GMT
  • Sharing and Reporting the Results of Clinical Trials
    • Authors: Hudson KL; Collins FS.
      Abstract: This Viewpoint advocates initiating greater transparency in reporting results of clinical trials as a responsibility that will benefit the health of many.
      PubDate: Tue, 27 Jan 2015 00:00:00 GMT
  • Focusing to Achieve a World Without AIDS
    • Authors: Fauci AS; Marston HD.
      Abstract: This Viewpoint discusses essential steps to attaining a world without AIDS.
      PubDate: Tue, 27 Jan 2015 00:00:00 GMT
  • Maximizing Antiretroviral Therapy in Developing Countries The Dual
           Challenge of Efficiency and Quality
    • Authors: Murray CL.
      Abstract: This Viewpoint discusses the need for improvement in both efficiency and quality of antiretroviral therapy programs in developing countries.
      PubDate: Tue, 27 Jan 2015 00:00:00 GMT
  • What I Learned About Adverse Events From Captain Sully It’s Not What
           You Think
    • Authors: Stiegler M.
      Abstract: This is not a piece about how medicine should take a cue from aviation and incorporate simulations into training. It is not about how medicine should learn from aviation and develop emergency checklists and algorithms. It is not about how medicine should learn from aviation and promote blame-free error reporting. No, it is not even about how medicine should learn from aviation and incorporate briefings, debriefings, and safety language models. Medicine safety culture is experiencing a bit of “aviation fatigue,” and it is often noted that patients are not airplanes. Patients are not airplanes, it is true. But humans are human whether they be pilots, physicians, or patients. And so when folks say a key difference between aviation and medicine is that the pilot goes down with the plane, I beg to differ. The well-being of physicians is directly tied to the well-being of their patients.
      PubDate: Tue, 27 Jan 2015 00:00:00 GMT
  • MR/Ultrasound Fusion–Guided Biopsy in Prostate Cancer What Is the
           Evidentiary Standard'
    • Authors: Schwartz LH; Basch E.
      Abstract: Although the benefits of prostate cancer screening have come into question recently, for men who are screened and have elevated prostate-specific antigen (PSA) levels, or those who present with symptoms, prostate biopsy remains the next step in the diagnostic workup. The objective of biopsy is first to determine whether any cancer is present and then to determine tumor grade (ie, Gleason score) because it predicts clinical outcomes. Lower-grade localized tumors are generally felt to be amenable to active surveillance, whereas higher-grade tumors are more commonly recommended for a definitive intervention. Moreover, for men undergoing definitive radiation therapy, the grade of the tumor is a key determinant in whether concomitant androgen deprivation therapy is recommended. However, biopsies underestimate tumor grade compared with subsequent prostatectomy up to 40% of the time. Therefore, any new technology that improves the ability of biopsy to distinguish between men with lower- and higher-risk cancers has the potential to influence clinical decisions and improve patient outcomes.
      PubDate: Tue, 27 Jan 2015 00:00:00 GMT
  • Chlorhexidine Bathing and Health Care–Associated Infections A
           Randomized Clinical Trial
    • Authors: Noto MJ; Domenico HJ, Byrne DW, et al.
      Abstract: ImportanceDaily bathing of critically ill patients with the broad-spectrum, topical antimicrobial agent chlorhexidine is widely performed and may reduce health care–associated infections.ObjectiveTo determine if daily bathing of critically ill patients with chlorhexidine decreases the incidence of health care–associated infections.Design, Setting, and ParticipantsA pragmatic cluster randomized, crossover study of 9340 patients admitted to 5 adult intensive care units of a tertiary medical center in Nashville, Tennessee, from July 2012 through July 2013.InterventionsUnits performed once-daily bathing of all patients with disposable cloths impregnated with 2% chlorhexidine or nonantimicrobial cloths as a control. Bathing treatments were performed for a 10-week period followed by a 2-week washout period during which patients were bathed with nonantimicrobial disposable cloths, before crossover to the alternate bathing treatment for 10 weeks. Each unit crossed over between bathing assignments 3 times during the study.Main Outcomes and MeasuresThe primary prespecified outcome was a composite of central line–associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), ventilator-associated pneumonia (VAP), and Clostridium difficile infections. Secondary outcomes included rates of clinical cultures that tested positive for multidrug-resistant organisms, blood culture contamination, health care–associated bloodstream infections, and rates of the primary outcome by ICU.ResultsDuring the chlorhexidine bathing period, 55 infections occurred: 4 CLABSI, 21 CAUTI, 17 VAP, and 13 C difficile. During the control bathing period, 60 infections occurred: 4 CLABSI, 32 CAUTI, 8 VAP, and 16 C difficile. The primary outcome rate was 2.86 per 1000 patient-days during the chlorhexidine and 2.90 per 1000 patient-days during the control bathing periods (rate difference, −0.04; 95% CI, −1.10 to 1.01; P = .95). After adjusting for baseline variables, no difference between groups in the rate of the primary outcome was detected. Chlorhexidine bathing did not change rates of infection-related secondary outcomes including hospital-acquired bloodstream infections, blood culture contamination, or clinical cultures yielding multidrug-resistant organisms. In a prespecified subgroup analysis, no difference in the primary outcome was detected in any individual intensive care unit.Conclusion and RelevanceIn this pragmatic trial, daily bathing with chlorhexidine did not reduce the incidence of health care–associated infections including CLABSIs, CAUTIs, VAP, or C difficile. These findings do not support daily bathing of critically ill patients with chlorhexidine.Trial Identifier: NCT02033187
      PubDate: Tue, 27 Jan 2015 00:00:00 GMT
  • Protocolized Sedation in Critically Ill Children
    • Authors: Mehta S.
      Abstract: Light sedation or no sedation has become the therapeutic goal in critically ill adults. Large randomized trials and systematic reviews have demonstrated that this goal is feasible, safe, and beneficial. The benefits include shorter durations of mechanical ventilation and stay in the intensive care unit (ICU). However, prospective data supporting the benefits of minimizing sedation in children are lacking, with only 1 randomized trial of 102 children showing shorter durations of mechanical ventilation and ICU stay with daily interruption of midazolam infusions compared with no interruption.
      PubDate: Tue, 27 Jan 2015 00:00:00 GMT
  • Daily Chlorhexidine Bathing for Critically Ill Patients A Note of Caution
    • Authors: Pittet D; Angus DC.
      Abstract: With increasing concern about health care–associated infections and transmission of multidrug-resistant organisms (MDROs), there has been substantial support for universal decolonization strategies, especially for high-risk patients, such as those in the intensive care unit (ICU). One such strategy that is being adopted widely is the use of daily chlorhexidine bathing. However, the findings of Noto and colleagues in this issue of JAMA challenge this approach.
      PubDate: Tue, 27 Jan 2015 00:00:00 GMT
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