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This Week in JAMA
March 18, 2009

This Week in JAMA

JAMA. 2009;301(11):1097. doi:10.1001/jama.2009.361

Acyl coenzyme A:cholesterol acyltransferase (ACAT), which plays a key role in intracellular cholesterol accumulation, has been investigated as a potential atherosclerosis treatment target. Meuwese and colleagues report results of the randomized, placebo-controlled Carotid Atherosclerosis Progression Trial Investigating Vascular ACAT Inhibition Treatment Effects (CAPTIVATE) study, which evaluated the efficacy and safety of an ACAT inhibitor—pactimibe—in patients heterozygous for familial hypercholesterolemia. The investigators found that compared with placebo, pactimibe had no effect on the change in maximum carotid intima-media thickness measured by ultrasound examination, the primary study outcome. Pactimibe was associated with an increase in mean carotid intima-media thickness, a secondary outcome, and an increased incidence of major cardiovascular events.

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Patients with cancer often report religious faith as a coping mechanism, but little is known about the association between religious coping and use of intensive life-prolonging care at the end of life. In an analysis of data from the Coping with Cancer study, a multisite prospective cohort study of 345 patients with advanced cancer, Phelps and colleagues examined the relationship between patients' use of religious coping—assessed in a baseline interview a median 122 days prior to death—and the receipt of intensive medical care at the end of life. In analyses that adjusted for advanced care planning and other potential confounding psychosocial factors, the authors found that positive religious coping at baseline was significantly associated with receipt of mechanical ventilation, cardiopulmonary resuscitation, or both during the last week of life.

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Modafinil, a wake-promoting drug, is approved for use in the treatment of narcolepsy and other sleep disorders. It is also being prescribed off-label for the treatment of cognitive dysfunction in some psychiatric disorders, and there are concerns about its nonmedical diversion as a “cognitive enhancer.” The mechanism of action of modafinil is not well understood, but it is believed to differ from that of other stimulant medications such as methylphenidate and amphetamine, which increase dopamine levels in the brain. To investigate the effects of modafinil on dopamine in the brain, Volkow and colleagues administered oral modafinil at a therapeutic dose (200 mg or 400 mg) to 10 healthy men and measured dopamine receptor and dopamine transporter availability compared with baseline placebo using positron emission tomography. The authors found that compared with baseline placebo, modafinil blocked dopamine transporters and increased extracellular dopamine levels in the brain.

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Caring for patients at the close of life can be stressful. Kearney and colleagues use the experiences of Dr C, a 45-year-old oncologist in private practice for 11 years, to highlight factors that contribute to the syndromes of burnout and compassion fatigue and to discuss self-care strategies that can enhance physician well-being.

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“I’m not a physician, although I’ve been around enough good ones to know that medicine is as much an art as it is a science.” From “Apostrophe.”

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An increasing number of suicides among soldiers have prompted US Army officials to redouble efforts to address the problem and enlist the help of researchers to probe factors that affect soldiers' risk of suicide.

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Impaired endocannabinoid signaling and depression

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Social policy and health

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A definition of irreversible coma

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Join Michael K. Kearney, MD, April 15, from 2 to 3 PM eastern time to discuss self-care of physicians who care for patients at the end of life. To register, go to http://www.ihi.org/AuthorintheRoom.

How would you manage a 41-year-old African American man with poorly controlled hypertension who has difficulty adhering to recommended treatment? Go to www.jama.com to read the case and submit your response, which may be selected for online publication. Submission deadline is March 22.

For your patients: Information about brain death.

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