Antiarrhythmic drugs can prevent recurrent atrial fibrillation (AF), but their efficacy may be inconsistent and adverse effects are common. Radiofrequency catheter ablation has been proposed as an alternative treatment for symptomatic paroxysmal AF. Wilber and colleagues report results of a prospective randomized trial designed to compare catheter ablation with antiarrhythmic drug therapy in patients who were unresponsive to initial drug therapy. During a 9-month follow-up, the authors found that compared with antiarrhythmic drug therapy—consisting of a drug not previously administered to the patient—catheter ablation was associated with a longer time to protocol-defined treatment failure, which included symptomatic paroxysmal AF, repeat ablation 80 days or more following initial ablation, changes in the specified drug regimen, or an adverse event requiring medication discontinuation.
Corticosteroid therapy may be considered for adults in septic shock, but hyperglycemia associated with corticosteroid therapy has been associated with an increased risk of mortality. The Corticosteroids and Intensive Insulin Therapy for Septic Shock trial assessed the effects of intensive insulin therapy for patients who had been treated with hydrocortisone for septic shock and the benefit of adding fludrocortisone in this setting. Patients with septic shock were randomly assigned to receive a continuous intravenous infusion of insulin to maintain euglycemia or to receive conventional insulin therapy and either hydrocortisone alone or hydrocortisone plus fludrocortisone. The investigators Article report that compared with conventional insulin therapy, intensive insulin therapy was not associated with a lower risk of in-hospital mortality. In addition, they found no in-hospital mortality difference among patients treated with hydrocortisone plus fludrocortisone compared with hydrocortisone alone. In an editorial, Van den Berghe Article discusses continued uncertainty regarding insulin therapy and target glucose levels for patients with septic shock who are receiving corticosteroids.
Mrs H, an 86-year-old retired health professional with progressive congestive heart failure and multiple chronic conditions, is experiencing worsening function and quality of life despite maximum medical therapies. She lives alone, leaves her apartment rarely, and has a personal care attendant to assist with meal preparation and instrumental activities of daily living. Mrs H worries about the inevitable deterioration of her health and does not want to be a burden on her family. She is seeking advice about how she might control how her life ends. Kutner discusses Mrs H's prognosis and clinical options, issues important to patients and families at the end of life, and the role and potential success of hospice care in helping patients with limited life expectancy and their families achieve an end of life that is consistent with their goals.
“I am not a chief resident type, the type who rattles off lists of differential diagnoses and acronyms and a bibliography of recent articles to support them.” From “Recertification.”
The US Food and Drug Administration is developing more explicit rules for online advertising of drugs and devices, including the use of social networking to market such products.
Taxes and tobacco
Evidence-based decision tools in medical practice
Legal standards of care in public health emergencies
Personalized, prospective health planning
Join David Reuben, MD, Wednesday, February 17, from 2 to 3 PM eastern time to discuss medical care in the final years of life. To register, go to http://www.ihi.org/AuthorintheRoom.
Dr DeAngelis summarizes and comments on this week's issue. Go to http://jama.ama-assn.org/misc/audiocommentary.dtl.
For your patients: Information about atrial fibrillation
This Week in JAMA . JAMA. 2010;303(4):299. doi:10.1001/jama.2010.30