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This Week in JAMA
JAMA. 2002;287:1491.
Treatment of Acute Exacerbation of Heart Failure
Little randomized evidence is available to guide in-hospital therapy for acute exacerbation of chronic heart failure (CHF). In this issue of THE JOURNAL, 2 randomized trials evaluated treatments for this serious condition. The Vasodilation in the Management of Acute Congestive Heart Failure (VMAC) investigators (SEE ARTICLE) compared the efficacy and safety of intravenous nesiritide (a recombinant human brain [B-type] natriuretic peptide), intravenous nitroglycerin, and placebo added to standard therapy for patients with decompensated congestive heart failure. At 3 hours after initiation of study drug, hemodynamic function improved most in the nesiritide group, and improvement in self-reported symptoms was greater in both active treatment groups compared with placebo. In the second trial, Cuffe and colleagues (SEE ARTICLE) report that among patients with acute exacerbation of CHF for whom inotropic therapy was indicated but not required, the median number of days of hospitalization for a cardiovascular cause within 60 days following randomization was not significantly different in those who received short-term intravenous milrinone plus standard care compared with those who received placebo plus standard care, and episodes of sustained hypotension and new atrial arrhythmias occurred significantly more frequently in the milrinone group. In an editorial, Poole-Wilson (SEE ARTICLE) considers the mechanisms of action and differences in short- and long-term outcomes of drugs used to treat acute heart failure and discusses the importance of conducting clinical trials to evaluate new therapies for heart failure.
Pulse Pressure and Mortality Risk in Patients With ESRD
Elevated blood pressure is associated with adverse clinical outcomes in the general population, but in patients with end-stage renal disease (ESRD) receiving maintenance hemodialysis, elevated blood pressure is associated with improved survival. Elevated pulse pressure, however, has been associated with poor clinical outcomes in studies of non-ESRD populations and in a small study of patients with ESRD. In this large retrospective study of patients with ESRD undergoing maintenance hemodialysis, Klassen and colleagues found that after adjusting for systolic blood pressure, increasing pulse pressure was directly associated with increased 1-year mortality.
(SEE ARTICLE)
Reproductive Outcomes After Anthrax Vaccination
To investigate whether anthrax vaccination has adverse reproductive effects in women, Wiesen and Littell analyzed data in administrative and clinical databases from a cohort of women aged 17 to 44 years in the US Army. Pregnancy rates and birth rates after receiving at least 1 anthrax vaccination were not significantly different from those among unvaccinated women.
(SEE ARTICLE)
Pregnancy Termination and Overall Infant Mortality
Prenatal diagnosis of congenital anomalies and termination of affected pregnancies have led to declines in the birth prevalence of congenital anomalies and to decreases in infant deaths due to congenital anomalies. To determine the effect of these changes on overall infant mortality, Liu and colleagues conducted a population-based analysis of live births, stillbirths, and infant deaths by birth cohort for 1991-1998 in Canada. Infant mortality rates decreased in 1996 and 1997 in association with reductions in infant deaths from congenital anomalies. These reductions in infant mortality were preceded by increases in fetal deaths due to pregnancy termination at 20 to 23 weeks' gestation in 1994 and by increased fetal deaths due to congenital anomalies at 20 to 21 weeks' gestation beginning in 1995.
(SEE ARTICLE)
Contempo Updates
Advances in laparoscopic general surgical procedures.
(SEE ARTICLE)
Medical News & Perspectives
Critical care physicians are seeking new ways to address emerging pathogens, septic shock, and bioweapons—threats to patients worldwide.
(SEE ARTICLE)
CLINICIAN'S CORNER
A 75-Year-Old Man With Depression
Kroenke discusses depression in the elderly, illustrated by the case of Mr S, a 75-year-old man who experienced his first episode of depression several years ago after coronary artery bypass graft surgery, followed by an ablation procedure for persistent atrial fibrillation.
(SEE ARTICLE)
JAMA Patient Page
For your patients: Information about prenatal care.
(SEE ARTICLE)
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