JAMA internal medicine
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JAMA internal medicine · May 2014
Randomized Controlled Trial Multicenter StudyNonleg venous thrombosis in critically ill adults: a nested prospective cohort study.
Critically ill patients are at risk of venous thrombosis, and therefore guidelines recommend daily thromboprophylaxis. Deep vein thrombosis (DVT) commonly occurs in the lower extremities but can occur in other sites including the head and neck, trunk, and upper extremities. The risk of nonleg deep venous thromboses (NLDVTs), predisposing factors, and the association between NLDVTs and pulmonary embolism (PE) or death are unclear. ⋯ The proportion of patients who had NLDVTs, the mean number per patient, and the anatomical location. We characterized NLDVTs as prevalent or incident (identified within 72 hours of ICU admission or thereafter) and whether they were catheter related or not. We used multivariable regression models to evaluate risk factors for NLDVT and to examine subsequent anticoagulant therapy, associated PE, and death. RESULTS Of 3746 trial patients, 84 (2.2%) developed 1 or more non-leg vein thromboses (superficial or deep, proximal or distal). Thromboses were more commonly incident (n = 75 [2.0%]) than prevalent (n = 9 [0.2%]) (P < .001) and more often deep (n = 67 [1.8%]) than superficial (n = 31 [0.8%]) (P < .001). Cancer was the only independent predictor of incident NLDVT (hazard ratio [HR], 2.22; 95% CI, 1.06-4.65). After adjusting for Acute Physiology and Chronic Health Evaluation (APACHE) II scores, personal or family history of venous thromboembolism, body mass index, vasopressor use, type of thromboprophylaxis, and presence of leg DVT, NLDVTs were associated with an increased risk of PE (HR, 11.83; 95% CI, 4.80-29.18). Nonleg DVTs were not associated with ICU mortality (HR, 1.09; 95% CI, 0.62-1.92) in a model adjusting for age, APACHE II, vasopressor use, mechanical ventilation, renal replacement therapy, and platelet count below 50 × 10(9)/L. CONCLUSIONS AND RELEVANCE Despite universal heparin thromboprophylaxis, nonleg thromboses are found in 2.2% of medical-surgical critically ill patients, primarily in deep veins and proximal veins. Patients who have a malignant condition may have a significantly higher risk of developing NLDVT, and patients with NLDVT, compared with those without, appeared to be at higher risk of PE but not higher risk of death.
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JAMA internal medicine · May 2014
Randomized Controlled Trial Multicenter Study Comparative Study Pragmatic Clinical TrialProactive tobacco treatment and population-level cessation: a pragmatic randomized clinical trial.
Current tobacco use treatment approaches require smokers to request treatment or depend on the provider to initiate smoking cessation care and are therefore reactive. Most smokers do not receive evidence-based treatments for tobacco use that include both behavioral counseling and pharmacotherapy. ⋯ Proactive, population-based tobacco cessation care using proactive outreach to connect smokers to evidence-based telephone or in-person smoking cessation services is effective for increasing long-term population-level cessation rates.
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JAMA internal medicine · May 2014
Review Meta AnalysisReappraisal of routine oral care with chlorhexidine gluconate for patients receiving mechanical ventilation: systematic review and meta-analysis.
Regular oral care with chlorhexidine gluconate is standard of care for patients receiving mechanical ventilation in most hospitals. This policy is predicated on meta-analyses suggesting decreased risk of ventilator-associated pneumonia, but these meta-analyses may be misleading because of lack of distinction between cardiac surgery and non-cardiac surgery studies, conflation of open-label vs double-blind investigations, and insufficient emphasis on patient-centered outcomes such as duration of mechanical ventilation, length of stay, and mortality. ⋯ Routine oral care with chlorhexidine prevents nosocomial pneumonia in cardiac surgery patients but may not decrease ventilator-associated pneumonia risk in non-cardiac surgery patients. Chlorhexidine use does not affect patient-centered outcomes in either population. Policies encouraging routine oral care with chlorhexidine for non-cardiac surgery patients merit reevaluation.
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JAMA internal medicine · May 2014
Randomized Controlled TrialEffect of long-chain ω-3 fatty acids and lutein + zeaxanthin supplements on cardiovascular outcomes: results of the Age-Related Eye Disease Study 2 (AREDS2) randomized clinical trial.
Dietary supplements have been proposed as a mechanism to improve health and prevent disease. ⋯ Dietary supplementation of long-chain ω-3 polyunsaturated fatty acids or macular xanthophylls in addition to daily intake of minerals and vitamins did not reduce the risk of CVD in elderly participants with age-related macular degeneration.