Search Medical Journals & Research Articles

Automated Modes to Improve Mechanical Ventilation Outcomes

Invasive mechanical ventilation, one of the defining interventions in critical care medicine, is received by more than 20 million patients annually in intensive care units (ICUs) worldwide. In any given ICU, usually half or more of patients require invasive ventilatory support. Among those needing at least 2 days of mechanical ventilation, the ICU mortality rate is high (>30%), as is the proportion of patients with difficult or prolonged weaning (>35%).

Precision Therapy for Sepsis

Sepsis is a macabre dance between host and pathogen. With development of germ theory by Lister, Semmelweis, Pasteur, and Koch, pathogen eradication was the focus. Only in recent decades, with observations by Roger Bone and others that patients succumbed to sepsis despite successful eradication of the pathogen, did attention swing to the host. It is now well accepted that a hallmark of sepsis is the systemic host immune response to infection that is directly injurious to vital organs. Unfortunately, the response is also extremely complex and highly variable in a way that is not easily appreciated from routine clinical examination or laboratory tests. This clinically elusive heterogeneity in the underlying pathogenesis of sepsis has bedeviled attempts to develop immune modulating therapies, with a litany of failed trials. The great hope is that success will lie in a strategy of precision therapy for sepsis, where a particular host response pattern can be identified swiftly and treated with more targeted interventions. Although ideas abound on how to measure and treat specific host-response patterns, the hope has remained largely theoretical, with little demonstration that it is practical and effective in clinical practice.

New COVID-19 Vaccination Guidelines for Immunocompromised Individuals

The Infectious Diseases Society of America (IDSA) issued a “strong recommendation” for COVID-19 vaccination in immunocompromised individuals based on a “moderate certainty of evidence” in new guidelines. The IDSA panel conducted a literature review of 14 COVID-19 vaccine effectiveness studies published since June 2024, which primarily examined messenger RNA vaccination, in immunocompromised populations.

An Oasis in the Platelet Desert?

A substantial proportion of the global population lacks reliable, timely access to platelet transfusions, largely due to constraints in donor supply and the inherently short shelf life of platelets. Even in high-income countries, including the US, platelet availability remains limited, as an aging donor population is not being sufficiently replenished by younger donors. As a result, the platelet supply is increasingly at risk of failing to meet clinical demand, particularly for cardiac surgery, the management of hypoproliferative thrombocytopenia in oncology patients, and the treatment of patients with acute or chronic bleeding disorders—needs that are all expected to rise as the population ages.

Moving the Field Forward to Safely Do Less With Febrile Neonates

Newborns with suspected infections are a common source of anxiety for pediatricians. As the adage goes, “never trust a newborn,” and for good reason. Young infants are immunologically vulnerable and at risk for rapid progression of bacterial infections during their postnatal transition. Most pediatricians can vividly describe neonates who rapidly declined despite appropriate therapy, and these experiences inform an understandable bias toward clinical conservatism that prioritizes interventions aimed at minimizing risk. At the same time, there is undeniable evidence of the iatrogenic harm from invasive testing, early antimicrobial exposure, and hospitalization for newborns. How best to balance the common—a young febrile infant who recovers uneventfully—with the catastrophic—the rare case of an infant with invasive bacterial infection—remains the heart of this clinical conundrum. On initial presentation, these infants are often clinically indistinguishable. Emerging evidence allows pediatricians to perennially recalibrate as we strive to determine what neonates can safely receive fewer interventions.

Evidence for Clinical Treatment Decisions Without Randomized Data

Among critically ill patients, serum magnesium levels are commonly checked and repleted. Like many clinical decisions, the rationale for this practice is based on a combination of physiological conjecture and observational data linking lower magnesium levels with worse clinical outcomes. In the absence of better evidence, the 2017 American Heart Association/American College of Cardiology/Heart Rhythm Society guidelines provide a relatively weak recommendation (“it remains quite reasonable…”) without specifying thresholds, doses, or comprehensive indications for repletion for preventing ventricular arrhythmias. Since a major goal of magnesium repletion is to reduce arrythmias, some of which can be lethal, clinicians are reluctant to wait for definitive evidence of benefit.

Tailored COX-2 Inhibition for Precision Adjuvant Therapy of Localized Metastatic Colon Cancer

CALGB/SWOG 80702 Alliance was a placebo-controlled randomized clinical trial (RCT) of daily celecoxib (400 mg/d vs placebo) as an adjuvant therapy to fluorouracil, leucovorin, and oxaliplatin (FOLFOX) toward improving disease-free survival (DFS) of minimal residual localized (stage III) metastatic colon cancer. The rationale for the trial was a preponderance of evidence from RCTs and observational studies showing that selective cyclooxygenase 2 (COX-2 or prostaglandin-endoperoxide synthase 2 [PTGS2]) inhibitors, nonsteroidal anti-inflammatory drugs (NSAIDs) such as celecoxib and rofecoxib, reduce the incidence of premalignant colorectal polyps and colorectal cancer (CRC). Although the primary trial results did not show daily celecoxib to be statistically significantly associated with improvement in DFS or overall survival (OS), the results raised the possibility that yet-to-be-determined subgroups may experience a significant benefit. Indeed, Nowak et al reported in 2024 that a significant protective effect was observed among patients with tumors harboring mutations to exons 9 or 20 of the PIK3CA gene within the subset of the Alliance trial population with available whole-exome tumor sequencing data.

A New Gene for Congenital Stationary Night Blindness

Complete congenital stationary night blindness (cCSNB) is a form of inherited retinal disease (IRD) that entails lifelong nyctalopia, often accompanied by high myopia, reduced visual acuity, and often nystagmus. While retinal examination and imaging are unremarkable, other than changes associated with high myopia, electroretinogram (ERG) findings are highly characteristic. The condition is nonprogressive, although myopia-associated complications may arise later in life. To date, there have been a handful of genes associated with this condition: one is X-linked (NYX); the others are associated with autosomal recessive inheritance (TRPM1, GRM6, GPR179, LRIT3).

ARNI Over ACEI Lacks Clinical Benefit in Patients With Chagas Cardiomyopathy

Chagas cardiomyopathy is the most common presentation of the determinate form of Trypanosoma cruzi infection and carries a worse prognosis than other common causes of heart failure. The 3 most common causes of death from Chagas cardiomyopathy are sudden cardiac death due to malignant ventricular arrhythmias, progression of heart failure, and, less frequently, thromboembolic events. Although traditionally a neglected disease in Latin America, the impact of Chagas cardiomyopathy is no longer confined to historically endemic areas, owing to population migration and northward expansion of the vector habitats. Chagas cardiomyopathy is endemic in the US, with autochthonous transmission (ie, transmission originating within the local environment) reported in at least 8 southern US states. Over the past 2 decades, there has been a growing recognition of Chagas cardiomyopathy, with dedicated clinical research uncovering key disease-specific insights. Potential preventive and therapeutic strategies include traditional infectious disease approaches aimed at parasite eradication as well as interventions directed at the cardiac manifestation of disease, such as reducing and treating arrhythmic burden and optimizing guideline-directed medical therapy.

Developmental Costs of Youth Social Media Require Policy Action

Recently, few questions in adolescent health have sparked more controversy than “is social media good or bad for youth?” This simple yet unresolved question is entrenched in a polarizing debate. For every study linking social media to harm, a counterclaim is made of no measurable impact. This controversy has arguably slowed progress toward policies that could provide clear guidance or protections for children and families. Yet, from a public health perspective, the most urgent question may not be whether social media is universally good or bad, but rather, what kind of evidence would be good enough to motivate policy action?

Painful Hand Swelling With Finger Contractures

A 56-year-old woman with no history of rheumatic disease or hand injury had swelling and tenderness of the bilateral wrists, metacarpophalangeal and proximal interphalangeal joints, nodular palmar tendon thickening, and flexion contractures of all fingers; results of serologic testing for autoimmune rheumatic diseases were negative. What is the diagnosis and what would you do next?

Blood Pressure–Centered Strategies and Perioperative Outcomes

Intraoperative hypotension is very common, affecting 30% to 80% of surgical patients. Results of observational studies suggest that even brief episodes of intraoperative hypotension are associated with an increased risk of postoperative complications, but the definition of hypotension varies across studies. Prior observational studies suggest that exposure to a mean arterial pressure (MAP) lower than 60 mm Hg to 65 mm Hg increases the risk of postoperative myocardial and kidney injury. Based on these data, current guidelines recommend maintaining MAP at 60 mm Hg or higher during surgery. However, several questions remain unsettled: Is intraoperative hypotension is a marker of underlying illness or a modifiable contributor to harm? Does the optimal MAP target vary across individuals, suggesting that a more personalized approach is warranted?

Adolescent Mental Health Theme Issue

In early 2023, we launched an ongoing theme issue in JAMA Pediatrics focused on adolescent mental health. The impetus for this theme issue was driven by the rise in adolescent mental health issues and heightened concerns following the COVID-19 pandemic contributing to worsened adolescent mental health. We called out the need for studies focused on adolescent mental health, as well as factors associated with better mental health, such as physical health, positive family relationships, and social support.

Measuring Nurses’ Subjective Workload in the Neonatal Intensive Care Unit

In this issue of JAMA Pediatrics, Tubbs-Cooley and colleagues describe findings from their prospective study of the association between workload and missed care among 247 nurses across 11 364 shifts in 10 neonatal intensive care units (NICUs). Replicating their prior single-center study, the researchers collected shift-level workload data for nurse participants, operationalized the following 3 ways: (1) number of assigned patients (verified with administrative data); (2) infant acuity scores for those patients (from the electronic health record [EHR]); and (3) subjective workload measured using 4 items from the NASA Task Load Index (NASA-TLX). Nurse participants completed the NASA-TLX and missed care measures near the end of each shift. The researchers found that nurses who reported higher subjective workload had significantly higher odds of reporting missed care across all 17 items on the missed care questionnaire in both individual and joint models. Both higher patient to nurse ratios and infant acuity scores were associated with significantly higher odds of missed care for fewer than a quarter of items in joint models.

Blood Tests for Alzheimer Disease—When the Holy Grail Is Found

In this issue of JAMA Neurology, Malek-Ahmadi and colleagues present a meta-analysis of 17 studies, conducted over just the last 5 years, of the ability of plasma phosphorylated tau 217 (p-tau217) to distinguish groups of individuals without cognitive impairment who test positive on traditional Alzheimer disease (AD) biomarkers from those who test negative. They conclude that plasma p-tau217 is a powerful tool to differentiate these groups, with consistent high effect sizes and areas under the receiver operating characteristic curve.