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In This Issue of JAMA |

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JAMA. 2014;311(21):2147-2148. doi:10.1001/jama.2013.279528.
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In a multicenter randomized trial that enrolled 734 high-risk patients undergoing major gastrointestinal surgery, Pearse and colleagues compared a cardiac output–guided hemodynamic therapy algorithm to direct perioperative intravenous fluid and inotrope infusion with usual care. The authors found no difference in a composite outcome of 30-day moderate or major complications and mortality between the 2 treatment groups. In an Editorial, Bennett-Guerrero discusses hemodynamic goal-directed therapy in high-risk surgical patients.

In an analysis of data from 2932 patients who had been randomly assigned to undergo coronary artery bypass graft surgery with cardiopulmonary bypass (on-pump) or using a beating-heart technique (off-pump), Garg and colleagues assessed the risk of acute kidney injury within 30 days of the surgery. The authors report that compared with the on-pump procedure, off-pump coronary artery bypass graft surgery was associated with a reduced risk of postoperative acute kidney injury but no difference in loss of kidney function at 1 year.

Practice guidelines recommend combination therapy including macrolide drugs such as azithromycin as first-line therapy for patients hospitalized with community-acquired pneumonia. However, recent data suggest that azithromycin may be associated with increased risk of cardiovascular events. In a retrospective cohort study that included 73 690 patients aged 65 years or older hospitalized with pneumonia, Mortensen and colleagues found that a treatment regimen that included azithromycin was associated with a lower risk of 90-day mortality and a small increased risk of myocardial infarction.

To assess survival associated with prophylactic placement of implantable cardioverter-defibrillators (ICDs) in patients with heart failure and a left ventricular ejection fraction between 30% and 35%, Al-Khatib and colleagues analyzed data from 408 patients in the National Cardiovascular Data Registry ICD registry and 408 patients (ICD-eligible but not treated) in the Get With the Guidelines–Heart Failure database. The authors report better survival at 3 years among patients who received a prophylactic ICD than among comparable patients not treated with an ICD.

CLINICAL REVIEW & EDUCATION

Resistant hypertension—uncontrolled hypertension despite optimal doses of 3 or more antihypertensive agents—is increasingly common. Based on a review of 36 relevant studies, Vongpatanasin discusses the diagnosis of resistant hypertension, lifestyle modifications to lower blood pressure, secondary causes of treatment-resistant hypertension, and the efficacy of pharmacological and nonpharmacaological treatments.

It is unclear whether prophylactic antibiotics are associated with lower rates of exacerbation of chronic obstructive pulmonary disease (COPD). In this JAMA Clinical Evidence Synopsis article, Herath and colleagues summarize a Cochrane review of 7 randomized trials (3170 patients) addressing this question. Among the findings was a clinically significant reduction in exacerbations associated with continuous macrolide antibiotic prophylaxis.

A patient with a 23-year history of polycythemia vera reported left upper quadrant pain of 2 weeks’ duration. Three years earlier he was diagnosed with a splenic hemangioma. Examination revealed splenomegaly. A hemoglobin level was 6.8 g/dL. An abdominal computed tomographic scan was performed. What would you do next?

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The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
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