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Studies have reached conflicting conclusions about whether early tracheotomy improves outcomes of patients who require prolonged mechanical ventilation. In this randomized trial of patients still requiring mechanical ventilation 4 days after cardiac surgery, immediate tracheotomy did not decrease mortality and durations of mechanical ventilation, intensive care unit stay, or hospitalization, compared with waiting 2 weeks to consider tracheotomy. Early tracheotomy did, however, reduce the use of sedatives, ease nursing care, and improve patient comfort.
The reasons for variation among hospitals in mortality rates for patients with acute myocardial infarction are not well-understood. This qualitative study of interviews with staff of high- and low-performing hospitals found that such characteristics as organizational values of excellence, innovative approaches to problem solving, and good coordination among clinicians distinguished hospitals with low mortality rates from those with high rates. Without accompanying changes in organizational culture, evidence-based protocols and processes may not be sufficient to achieve high hospital performance in care of patients with acute myocardial infarction.
The number of vaccines recommended for health care workers has increased over the past 2 decades, but national data on prematriculation vaccine policies of health professional schools were unavailable. This 2008–2009 survey of deans of 563 U.S. schools of medicine and nursing found that most schools' policies adhere to the Advisory Committee on Immunization Practices recommendations for health care workers. However, exemption policies, measurement of titers to confirm vaccination, and payment mechanisms varied. In particular, nursing and osteopathic schools were less likely than allopathic medical schools to pay for influenza vaccination.
Guidelines recommend cardiac resynchronization therapy (CRT) for patients with reduced left ventricular ejection fraction and advanced symptoms of heart failure. This meta-analysis of 25 trials found that CRT is beneficial for patients with reduced left ventricular ejection fraction, symptoms, and prolonged QRS duration, regardless of New York Heart Association symptom class.
Prospective electrocardiography (ECG) gating is a new technique for coronary computed tomography (CT) angiography that uses much lower radiation doses than previous techniques. This meta-analysis included 16 studies that compared results of prospective ECG-gated CT angiography with those of catheter angiography in patients with suspected coronary artery disease. Evidence suggests that low-dose ECG-gated CT angiography matches the sensitivity of catheter-based angiography, has low radiation exposure, and is a potentially valid alternative for triaging symptomatic patients with clinically suspected coronary artery disease.
Guidelines for reporting various research designs have been published, but none is fully suited to genetic risk prediction studies, an emerging field of investigation with specific methodological challenges. These recommendations from the GRIPS (Genetic RIsk Prediction Studies) Group were developed by an international group of risk-prediction researchers, epidemiologists, geneticists, methodologists, statisticians, and journal editors.
Clinical practice is above all a matter of performance, in the best and deepest sense of the word. This essay highlights 10 lessons that music can teach us about better ways to become and remain expert performers of health care.
This article outlines several identified barriers to physician support for meaningful health care delivery redesign, focusing on the inability to effectively translate the business language of payers, health care administrators, and physician leaders to and from the language of clinical medicine. The author provides examples and recommendations from successful projects to bridge this communication divide.
In this issue, Trouillet and colleagues report a randomized trial of early versus late tracheotomy in patients requiring mechanical ventilation 4 days after cardiac surgery that showed improvements in subjective outcomes, such as patient comfort, but no improvements in mortality or the durations of mechanical ventilation, intensive care unit stay, or hospitalization. The editorialists believe that the critical care community should temper enthusiasm for early tracheotomy until more definitive data are available and we are better able to identify patients who will require prolonged ventilation.
In this issue, Al-Majed and colleagues report a systematic review of 25 trials that suggests that CRT benefits patients with reduced left ventricular ejection fraction, symptoms, and prolonged QRS duration, regardless of New York Heart Association symptom class. The editorialists caution that simply adopting an amalgam of inclusion criteria from the clinical trials would handicap the success of CRT in mild heart failure and squander health care resources when we have little to spare.