Jones and colleagues Article report results of a multicenter randomized trial that tested the hypothesis that lactate clearance is noninferior to central venous oxygen saturation for monitoring the adequacy of tissue oxygen delivery during the emergency department resuscitation of patients with severe sepsis or septic shock. Patients enrolled in the trial were randomly assigned to resuscitation protocols to normalize central venous and mean arterial pressures and to either a lactate clearance of at least 10% or a central venous oxygen saturation of at least 70%. The authors found that among patients with septic shock who were treated to normalize central venous and mean arterial pressure, additional management to normalize lactate clearance compared with management to normalize central venous oxygen saturation did not result in significantly different in-hospital mortality rates. In an editorial, Lewis Article discusses goal-directed therapy for sepsis and outlines the advantages of adaptive clinical trials to define effective resuscitation targets.
Much of the research and policy debate on the US physician workforce has focused on the number of current and future physicians, but little is known about changes in physician work hours over time, which may affect predictions of physician workforce needs. In an analysis of data from the US Census Bureau Current Population Survey (1976-2008), Staiger and colleagues found a steady decrease in physicians' hours worked per week between 1996 and 2008, which was temporally and geographically associated with lower physician fees.
In a prospective, observational study of 1069 consecutive patients who were receiving optimal clopidogrel therapy and undergoing elective percutaneous coronary intervention with stent implantation, Breet and colleagues evaluated the capability of a variety of platelet function tests to predict patients who would experience a composite outcome of all-cause death, nonfatal acute myocardial infarction, stent thrombosis, or ischemic stroke during a 1-year follow-up. The authors assessed platelet reactivity with 6 platelet function tests and found that only 3 of the tests (light transmittance aggregometry, VerifyNow, and Plateletworks) could discriminate—and only with modest predictability—between patients with and without the composite outcome. None of the tests provided accurate prognostic information to identify patients at higher risk of bleeding.
Critical illness has been associated with long-term cognitive impairment, but most studies have failed to consider the contribution of premorbid cognitive functioning to cognitive status following a critical illness. In a prospective cohort of older adults who were without dementia at baseline and who underwent assessment of cognitive abilities at regular intervals, Ehlenbach and colleagues examined whether decline in cognitive function was greater among individuals who experienced acute care or critical illness hospitalizations compared with persons not hospitalized. In analyses that adjusted for premorbid cognitive function, the authors found that older adults hospitalized for acute care or critical illness had a greater likelihood of cognitive decline compared with those without hospitalizations.
“I yearned to say that I knew that fat jokes followed you even after you left the middle-school playground and that I had been, at one point or another, labeled as lazy and slow by my colleagues.” From “Döppelganger.”
Many of the more than 100 000 anticipated US deaths due to chronic hepatitis B and C infections over the next decade could be prevented through screening and treatment.
Front-of-package food labels: public health or propaganda?
Registering results of drug clinical trials
Deep brain stimulation studies: publication ethics
Appreciation for JAMA's peer reviewers and authors
Join Frank Davidoff, MD, Wednesday, March 17, from 2 to 3 PM eastern time to discuss how insights from health care improvement initiatives can reduce the ambivalence about heterogeneity in determining efficacy of treatment. To register, go to http://www.ihi.org/AuthorintheRoom.
How would you manage a 31-year-old woman with a transformed low-grade glioma? Go to www.jama.com to read the case and submit your response by March 7 for possible online publication.
For your patients: Information about sepsis.
This Week in JAMA . JAMA. 2010;303(8):693. doi:10.1001/jama.2010.204