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This Week in JAMA
February 20, 2013

This Week in JAMA

JAMA. 2013;309(7):631. doi:10.1001/jama.2012.174765

The most effective method of weaning patients from prolonged (>21 days) mechanical ventilation is not known. In a randomized trial involving 316 patients admitted to 1 long-term acute care hospital for weaning from prolonged mechanical ventilation, Jubran and colleagues found that unassisted breathing through a tracheostomy collar resulted in a shorter median weaning time than weaning with pressure support. In an editorial, Kahn and Carson discuss the importance of empirical data to guide clinical care in long-term acute care hospitals.

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The safety of hydroxyethyl starch—a synthetic colloid used in volume resuscitation—is not clear. To address this question, Zarychanski and colleagues analyzed data from 38 randomized clinical trials that compared hydroxyethyl starch with other resuscitation fluids in critically ill patients. After exclusion of 7 studies with a high risk of bias, the authors found that hydroxyethyl starch was associated with increased risk of acute kidney injury and mortality. In an editorial, Antonelli and Sandroni discuss its use in volume resuscitation and the dangers of bias in clinical research.

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Wright and colleagues assessed uptake and predictors of robotically assisted hysterectomy in a cohort of 264 758 women who underwent hysterectomy for benign disorders at 441 US hospitals from 2007-2010. Among the authors' findings was that use of robotically assisted hysterectomy increased from 0.5% in 2007 to 9.5% in 2010. Predictors of robotic-assisted hysterectomy included year of surgery, race, insurance status, and hospital characteristics. In an editorial, Weissman and Zinner discuss the comparative effectiveness of robotic surgery.

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Age-related leukocyte telomere shortening has been associated with chronic disease-related morbidity and mortality. In a preliminary study involving 152 healthy adults aged 18 to 55 years who were quarantined, administered nasal drops containing a common cold virus, and monitored for 5 days, Cohen and colleagues found that shorter telomere length in the T-cell subset CD8CD28− was associated with an increased risk of experimentally induced acute upper respiratory tract infection and clinical illness.

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Ms J is a 51-year-old woman who reports a 16-year history of insomnia that began when her infant had very disrupted sleep. Ms J has good sleep hygiene and she is healthy and fit. Buysse discusses the prevalence, pathophysiology, diagnosis, and treatment of insomnia.

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Schuetz and colleagues analyzed data from 4211 adult patients with respiratory tract infections (14 clinical trials) and found that measurement of procalcitonin—a biomarker for bacterial infection—to guide antibiotic therapy was associated with lower antibiotic exposure and no increase in mortality or treatment failure.

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Sleep medications, particularly zolpidem, may decrease a patient's alertness the next day enough to impair driving, according to a safety warning from the US Food and Drug Administration.

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Reengineering US health care

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Treatment of renal artery stenosis

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Health care access: the ACA and EMTALA

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Out-of-hospital emergency care: financial and delivery reforms

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“We have the great privilege of telling our patients' stories—stories they relay to us with their words, with their crunching hearts, their splashing pleura, their umbilical veins that fill from above to below or vice-versa.” From “Remarkably Wise.”

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

Join Daniel J. Buysse, MD, March 20, 2013, from 2 to 3 PM eastern time to discuss insomnia. To register, go to http://www.ihi.org/AuthorintheRoom.

For your patients: Information about insomnia.

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