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Shock is characterized by increased serum lactate and tissue hypoperfusion. Hernández and colleagues randomized 424 patients with septic shock and found that a resuscitation strategy targeting normalization of capillary refill time, compared with a strategy targeting serum lactate levels, did not reduce all-cause 28-day mortality. In an Editorial, Angus suggests that these resuscitation strategies are straightforward, inexpensive, and complementary.
Patients with memories of frightening intensive care unit experiences are at risk for longer-term psychological morbidity. Wade and colleagues for the POPPI Trial Investigators randomized 1458 critically ill patients and found that a nurse-led psychological intervention did not reduce the severity of posttraumatic stress. In an Editorial, Kross and colleagues suggest that lessons from this trial could be used to develop other interventions for survivors and their families.
CME and Visual Abstract
Transmucosal immediate-release fentanyls (TIRFs), indicated solely for breakthrough cancer pain in opioid-tolerant patients, are subject to a US Food and Drug Administration (FDA) Risk Evaluation and Mitigation Strategy to prevent them from being inappropriately prescribed. Rollman and colleagues reviewed 4877 pages of FDA documents and found that most surveyed pharmacists, prescribers, and patients understood that TIRFs are contraindicated in nonopioid-tolerant patients, yet analyses of claims data indicated substantial rates of inappropriate TIRF use. In an Editorial, Sarpatwari and Curfman propose 3 reforms that would improve the design of the REMS program, make FDA documents publicly available, and enhance FDA enforcement.
Risk factors for postoperative delirium include pain as well as the use of opioids and sedatives. Subramaniam and colleagues randomized 121 patients undergoing cardiac surgery and found that postoperative acetaminophen, combined with propofol or dexmedetomidine, reduced in-hospital delirium compared with placebo.
Summary Video and CME
In this JAMA Guide to Statistics and Methods, Lee and colleagues discuss the use of mediation analysis to determine how an intervention may have achieved its intended outcome.
This JAMA Clinical Challenge by Piggott and Rao presents a 26-year-old man with recurrent inflammation of tattooed skin and inflammatory cells in the anterior chamber of one eye. What would you do next?
This JAMA Diagnostic Test Interpretation article by McCarthy and colleagues presents a 5-year-old girl with chronic constipation, poor weight gain, and indeterminate sweat chloride tests for cystic fibrosis. What would you do next?
Highlights. JAMA. 2019;321(7):623–625. doi:10.1001/jama.2018.15201
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