JAMA Current Issue

This Week in JAMA

Wed, 22 May 2013 00:00:00 GMT

May 22/29, 2013

Advances in Regulatory Science at the Food and Drug Administration Advances in Regulatory Science at the FDA

Psaty BM, Goodman SN, Breckenridge A. — Wed, 22 May 2013 00:00:00 GMT

Since the Kefauver-Harris amendments of 1962, the US Food and Drug Administration (FDA) has required evidence of efficacy to approve a drug for marketing in the United States. For many years, information about benefits and risks was assembled at the time of approval, and if the benefits appeared to exceed the risks known at the time, the drug was deemed safe for approval. In practice, a drug that demonstrated efficacy according to the prespecified outcomes in the phase 3 trials was approved for marketing unless there was convincing evidence of a serious risk.

Identification of Physician Impairment Identification of Physician Impairment

Pham J, Pronovost PJ, Skipper GE. — Wed, 22 May 2013 00:00:00 GMT

When a critical event occurs in most high-risk industries (such as airlines, nuclear power, or railways), a detailed investigation examines a variety of system and individual factors (such as fatigue and substance abuse) that caused or contributed to the event. Directly involved individuals are commonly tested for alcohol and other drugs. Airplane pilots and truck drivers are tested following crashes and near misses. Some law enforcement officers are tested following fatal shooting incidents.

Medication Nonadherence A Diagnosable and Treatable Medical Condition Medication Nonadherence

Marcum ZA, Sevick M, Handler SM. — Wed, 22 May 2013 00:00:00 GMT

Medication nonadherence is widely recognized as a common and costly problem. Approximately 30% to 50% of US adults are not adherent to long-term medications leading to an estimated $100 billion in preventable costs annually. The barriers to medication adherence are similar to other complex health behaviors, such as weight loss, which have multiple contributing factors. Despite the widespread prevalence and cost of medication nonadherence, it is undetected and undertreated in a significant proportion of adults across care settings. According to the World Health Organization, “increasing the effectiveness of adherence interventions may have far greater impact on the health of the population than any improvement in specific medical treatments.” How can adherence be improved? We propose that the first step is to view medication nonadherence as a diagnosable and treatable medical condition.

Value of Unique Device Identification in the Digital Health Infrastructure Unique Device Identification

Wilson NA, Drozda J. — Wed, 22 May 2013 00:00:00 GMT

In recent years, high-profile cases of medical device failure resulting in patient harm—such as implantable cardioverter-defibrillator leads and metal-on-metal hip implants—have received substantial attention both in the medical literature and popular press. These examples illustrate the need for a more effective system of monitoring device performance and protecting patient safety.

The Proud Paratrooper

Baggett TP. — Wed, 22 May 2013 00:00:00 GMT

Darkness surrendered to the Saturday dawn, unveiling a canvas of clear blue sky illuminated by the heatless light of a harshly cold winter morning. It was January in Boston. I backed my car into an empty parking space on Paul Sullivan Way, in the shadows of the Pine Street Inn homeless shelter. The digital clock on the dashboard read 6:58 AM. Across the street, a blanketed man hunkered down in an abandoned doorway. Skirting patches of ice on a broken sidewalk, I rounded the corner onto Harrison Avenue and entered the shelter. The smell of alcohol and rotten feet hit my nose. Inside the shelter's medical clinic, a seasoned nurse was already tending to a crowd of patients.

Effect of Escitalopram on Mental Stress–Induced Myocardial Ischemia Results of the REMIT Trial Escitalopram and Stress-Induced Myocardial Ischemia

Jiang W, Velazquez EJ, Kuchibhatla M, et al. — Wed, 22 May 2013 00:00:00 GMT

Importance

Mental stress can induce myocardial ischemia and also has been implicated in triggering cardiac events. However, pharmacological interventions aimed at reducing mental stress–induced myocardial ischemia (MSIMI) have not been well studied.

Objective

To examine the effects of 6 weeks of escitalopram treatment vs placebo on MSIMI and other psychological stress–related biophysiological and emotional parameters.

Design, Setting, and Participants

The REMIT (Responses of Mental Stress Induced Myocardial Ischemia to Escitalopram Treatment) study, a randomized, double-blind, placebo-controlled trial of patients with clinically stable coronary heart disease and laboratory-diagnosed MSIMI. Enrollment occurred from July 24, 2007, through August 24, 2011, at a tertiary medical center.

Interventions

Eligible participants were randomized 1:1 to receive escitalopram (dose began at 5 mg/d, with titration to 20 mg/d in 3 weeks) or placebo over 6 weeks.

Main Outcomes and Measures

Occurrence of MSIMI, defined as development or worsening of regional wall motion abnormality; left ventricular ejection fraction reduction of 8% or more; and/or horizontal or down-sloping ST-segment depression of 1 mm or more in 2 or more leads, lasting for 3 or more consecutive beats, during 1 or more of 3 mental stressor tasks.

Results

Of 127 participants randomized to receive escitalopram (n = 64) or placebo (n = 63), 112 (88.2%) completed end point assessments (n = 56 in each group). At the end of 6 weeks, more patients taking escitalopram (34.2% [95% CI, 25.4%-43.0%]) had absence of MSIMI during the 3 mental stressor tasks compared with patients taking placebo (17.5% [95% CI, 10.4%-24.5%]), based on the unadjusted multiple imputation model for intention-to-treat analysis. A significant difference favoring escitalopram was observed (odds ratio, 2.62 [95% CI, 1.06-6.44]). Rates of exercise-induced ischemia were slightly lower at 6 weeks in the escitalopram group (45.8% [95% CI, 36.6%-55.0%]) than in patients receiving placebo (52.5% [95% CI, 43.3%-61.8%]), but this difference was not statistically significant (adjusted odds ratio; 1.24 [95% CI, 0.60-2.58]; P = .56).

Conclusions and Relevance

Among patients with stable coronary heart disease and baseline MSIMI, 6 weeks of escitalopram, compared with placebo, resulted in a lower rate of MSIMI. There was no statistically significant difference in exercise-induced ischemia. Replication of these results in multicenter settings and investigations of other medications for reducing MSIMI are needed.

Trial Registration

clinicaltrials.gov Identifier: NCT00574847 .

Early Parenteral Nutrition in Critically Ill Patients With Short-term Relative Contraindications to Early Enteral Nutrition A Randomized Controlled Trial Early Parenteral Nutrition in Critically Ill Patients

Doig GS, Simpson F, Sweetman EA, et al. — Wed, 22 May 2013 00:00:00 GMT

Importance

Systematic reviews suggest adult patients in intensive care units (ICUs) with relative contraindications to early enteral nutrition (EN) may benefit from parenteral nutrition (PN) provided within 24 hours of ICU admission.

Objective

To determine whether providing early PN to critically ill adults with relative contraindications to early EN alters outcomes.

Design, Setting, and Participants

Multicenter, randomized, single-blind clinical trial conducted between October 2006 and June 2011 in ICUs of 31 community and tertiary hospitals in Australia and New Zealand. Participants were critically ill adults with relative contraindications to early EN who were expected to remain in the ICU longer than 2 days.

Interventions

Random allocation to pragmatic standard care or early PN.

Main Outcomes and Measures

Day-60 mortality; quality of life, infections, and body composition.

Results

A total of 1372 patients were randomized (686 to standard care, 686 to early PN). Of 682 patients receiving standard care, 199 patients (29.2%) initially commenced EN, 186 patients (27.3%) initially commenced PN, and 278 patients (40.8%) remained unfed. Time to EN or PN in patients receiving standard care was 2.8 days (95% CI, 2.3 to 3.4). Patients receiving early PN commenced PN a mean of 44 minutes after enrollment (95% CI, 36 to 55). Day-60 mortality did not differ significantly (22.8% for standard care vs 21.5% for early PN; risk difference, −1.26%; 95% CI, −6.6 to 4.1; P = .60). Early PN patients rated day-60 quality of life (RAND-36 General Health Status) statistically, but not clinically meaningfully, higher (45.5 for standard care vs 49.8 for early PN; mean difference, 4.3; 95% CI, 0.95 to 7.58; P = .01). Early PN patients required fewer days of invasive ventilation (7.73 vs 7.26 days per 10 patient × ICU days, risk difference, −0.47; 95% CI, −0.82 to −0.11; P = .01) and, based on Subjective Global Assessment, experienced less muscle wasting (0.43 vs 0.27 score increase per week; mean difference, −0.16; 95% CI, −0.28 to −0.038; P = .01) and fat loss (0.44 vs 0.31 score increase per week; mean difference, −0.13; 95% CI, −0.25 to −0.01; P = .04).

Conclusions and Relevance

The provision of early PN to critically ill adults with relative contraindications to early EN, compared with standard care, did not result in a difference in day-60 mortality. The early PN strategy resulted in significantly fewer days of invasive ventilation but not significantly shorter ICU or hospital stays.

Trial Registration

anzctr.org.au Identifier: ACTRN012605000704695

Effect of Early vs Late Tracheostomy Placement on Survival in Patients Receiving Mechanical Ventilation The TracMan Randomized Trial Early vs Late Tracheostomy Placement

Young D, Harrison DA, Cuthbertson BH, et al. — Wed, 22 May 2013 00:00:00 GMT

Importance

Tracheostomy is a widely used intervention in adult critical care units. There is little evidence to guide clinicians regarding the optimal timing for this procedure.

Objective

To test whether early vs late tracheostomy would be associated with lower mortality in adult patients requiring mechanical ventilation in critical care units.

Design and Setting

An open multicentered randomized clinical trial conducted between 2004 and 2011 involving 70 adult general and 2 cardiothoracic critical care units in 13 university and 59 nonuniversity hospitals in the United Kingdom.

Participants

Of 1032 eligible patients, 909 adult patients breathing with the aid of mechanical ventilation for less than 4 days and identified by the treating physician as likely to require at least 7 more days of mechanical ventilation.

Interventions

Patients were randomized 1:1 to early tracheostomy (within 4 days) or late tracheostomy (after 10 days if still indicated).

Main Outcomes and Measures

The primary outcome measure was 30-day mortality and the analysis was by intention to treat.

Results

Of the 455 patients assigned to early tracheostomy, 91.9% (95% CI, 89.0%-94.1%) received a tracheostomy and of 454 assigned to late tracheostomy, 44.9% (95% CI, 40.4%-49.5%) received a tracheostomy. All-cause mortality 30 days after randomization was 30.8% (95% CI, 26.7%-35.2%) in the early and 31.5% (95% CI, 27.3%-35.9%) in the late group (absolute risk reduction for early vs late, 0.7%; 95% CI, −5.4% to 6.7%). Two-year mortality was 51.0% (95% CI, 46.4%-55.6%) in the early and 53.7% (95% CI, 49.1%-58.3%) in the late group (P = .74). Median critical care unit length of stay in survivors was 13.0 days in the early and 13.1 days in the late group (P = .74). Tracheostomy-related complications were reported for 6.3% (95% CI, 4.6%-8.5%) of patients (5.5% in the early group, 7.8% in the late group).

Conclusions and Relevance

For patients breathing with the aid of mechanical ventilation treated in adult critical care units in the United Kingdom, tracheostomy within 4 days of critical care admission was not associated with an improvement in 30-day mortality or other important secondary outcomes. The ability of clinicians to predict which patients required extended ventilatory support was limited.

Trial Registration

isrctn.org Identifier: ISRCTN28588190

Effects of Targeting Higher vs Lower Arterial Oxygen Saturations on Death or Disability in Extremely Preterm Infants A Randomized Clinical Trial Arterial Oxygen Saturation Levels in Preterm Infants

Schmidt B, Whyte RK, Asztalos EV, et al. — Wed, 22 May 2013 00:00:00 GMT

Importance

The goal of oxygen therapy is to deliver sufficient oxygen to the tissues while minimizing oxygen toxicity and oxidative stress. It remains uncertain what values of arterial oxygen saturations achieve this balance in preterm infants.

Objective

To compare the effects of targeting lower or higher arterial oxygen saturations on the rate of death or disability in extremely preterm infants.

Design, Setting, and Participants

Randomized, double-blind trial in 25 hospitals in Canada, the United States, Argentina, Finland, Germany, and Israel in which 1201 infants with gestational ages of 23 weeks 0 days through 27 weeks 6 days were enrolled within 24 hours after birth between December 2006 and August 2010. Follow-up assessments began in October 2008 and ended in August 2012.

Interventions

Study participants were monitored until postmenstrual ages of 36 to 40 weeks with pulse oximeters that displayed saturations of either 3% above or below the true values. Caregivers adjusted the concentration of oxygen to achieve saturations between 88% and 92%, which produced 2 treatment groups with true target saturations of 85% to 89% (n = 602) or 91% to 95% (n = 599). Alarms were triggered when displayed saturations decreased to 86% or increased to 94%.

Main Outcomes and Measures

The primary outcome was a composite of death, gross motor disability, cognitive or language delay, severe hearing loss, or bilateral blindness at a corrected age of 18 months. Secondary outcomes included retinopathy of prematurity and brain injury.

Results

Of the 578 infants with adequate data for the primary outcome who were assigned to the lower target range, 298 (51.6%) died or survived with disability compared with 283 of the 569 infants (49.7%) assigned to the higher target range (odds ratio adjusted for center, 1.08; 95% CI, 0.85 to 1.37; P = .52). The rates of death were 16.6% for those in the 85% to 89% group and 15.3% for those in the 91% to 95% group (adjusted odds ratio, 1.11; 95% CI, 0.80 to 1.54; P = .54). Targeting lower saturations reduced the postmenstrual age at last use of oxygen therapy (adjusted mean difference, −0.8 weeks; 95% CI, −1.5 to −0.1; P = .03) but did not alter any other outcomes.

Conclusion and Relevance

In extremely preterm infants, targeting oxygen saturations of 85% to 89% compared with 91% to 95% had no significant effect on the rate of death or disability at 18 months. These results may help determine the optimal target oxygen saturation.

Trial Registrations

ISRCTN Identifier: 62491227; ClinicalTrials.gov Identifier: NCT00637169JAMA. 2013;309(20):2111-2120

Management of Active Crohn Disease Management of Active Crohn Disease

Cheifetz AS. — Wed, 22 May 2013 00:00:00 GMT

Importance

Treatment of Crohn disease is rapidly evolving, with the induction of novel biologic therapies and newer, often more intensive treatment approaches. Knowing how to treat individual patients in this quickly changing milieu can be a challenge.

Objective

To review the diagnosis and management of moderate to severe Crohn disease, with a focus on newer treatments and goals of care.

Evidence Review

MEDLINE was searched from 2000 to 2011. Additional citations were procured from references of select research and review articles. Evidence was graded using the American Heart Association level-of-evidence guidelines.

Results

Although mesalamines are still often used to treat Crohn disease, the evidence for their efficacy is lacking. Corticosteroids can be effectively used to induce remission in moderate to severe Crohn disease, but they do not maintain remission. The mainstays of treatment are immunomodulators and biologics, particularly anti–tumor necrosis factor.

Conclusion and Relevance

Immunomodulators and biologics are now the preferred treatment options for Crohn disease.

Sudden Purpuriform Rash in an Infant Sudden Purpuriform Rash in an Infant

Scheer H, Weibel L. — Wed, 22 May 2013 00:00:00 GMT

A 10-month-old boy presents with erythematous swelling of bothears and right eyelid and erythematous perioral macules following a respiratory tract infection 12 days before presentation (Figure, A). Within 4 days the lesions increased in size, becoming large erythematous plaques on the face (Figure, B). Targetoid, purpuric lesions developed on the limbs (Figure, C), along with hand edema. There were no trunk lesions and no involvement of the mucous membranes. The child is otherwise in good general health. On examination he is afebrile, has normal vital signs, and there is no lymphadenopathy or organomegaly. Findings from urinalysis, complete blood cell count, coagulation studies, and liver and kidney function studies are unremarkable.

Early Nutrition in Critically Ill Patients Feed Carefully and in Moderation Early Nutrition in Critically Ill Patients

Ochoa Gautier JB, Machado FR. — Wed, 22 May 2013 00:00:00 GMT

Clinicians in intensive care units (ICUs) have to decide whether supplemental parenteral nutrition should be ordered for a critically ill patient who cannot be fed and is kept “nil per os (NPO),” for instance, because of gastrointestinal tract dysfunction. Without early supplemental parenteral nutrition, the patient is temporarily starved, an approach based on the assumption that physiologic compensatory processes are protective and thus there will be no untoward clinical consequences. In contrast, clinicians who order early supplemental parenteral nutrition presumably consider the accumulating caloric deficit to be deleterious for critically ill patients. Although determining the best approach might seem straightforward, a clear answer remains evasive.

Oxygenation Targets and Outcomes in Premature Infants Oxygenation Targets and Outcomes in Premature Infants

Bancalari E, Claure N. — Wed, 22 May 2013 00:00:00 GMT

Many premature infants experience respiratory failure and receive supplemental oxygen for prolonged periods. While this therapy is crucial for their survival, it can be associated with complications such as retinopathy of prematurity (ROP), bronchopulmonary dysplasia (BPD), and central nervous system damage. In recent years, to minimize these complications clinicians have targeted progressively lower arterial oxygen saturation (SpO₂) levels in these infants. This occurred despite little evidence for the efficacy and safety of this approach. Several randomized controlled trials have been conducted to test if targeting oxygen saturations in the lower (85%-89%) vs the upper (91%-95%) part of the recommended range confer advantages in regard to neurodevelopmental outcome and severe ROP in extremely premature infants.

When Should a Mechanically Ventilated Patient Undergo Tracheostomy? Timing for Tracheostomy

Angus DC. — Wed, 22 May 2013 00:00:00 GMT

Each year, approximately 800 000 US residents undergo mechanical ventilation for acute respiratory insufficiency, often for a period of days or weeks. Although mechanical ventilation can be lifesaving, it is unnatural and invasive, can be extremely uncomfortable, and requires expensive intensive care support. Endotracheal intubation is the most efficient and convenient method by which to initiate mechanical ventilation. However, intubation is often not well tolerated by an awake patient; is prone to potentially disastrous dislodgement; and interferes with oral care, feeding, and communication.

Care for Transgender Persons

Lawrence AA, Zucker KJ. — Wed, 22 May 2013 00:00:00 GMT

To the Editor: The article by Dr Spack concerning the management of persons with gender identity disorders misstated the prerequisites for cross-sex hormone therapy and omitted any explanation of transsexual subtypes. Spack stated that adults should be living full-time as the opposite gender to be eligible for cross-sex hormone therapy.

Care for Transgender Persons

Danoff A, Daskalakis D, Aberg JA. — Wed, 22 May 2013 00:00:00 GMT

To the Editor: In a Clinical Crossroads article, Dr Spack reviewed key elements of psychological, hormonal, and surgical management of transgender and transsexual individuals. We suggest that testing for human immunodeficiency virus (HIV) also should be included as an integral component of transgender care.

Care for Transgender Persons—Reply

Spack NP. — Wed, 22 May 2013 00:00:00 GMT

In Reply: Dr Danoff and colleagues raise the issue of HIV testing in transgender care. Considering the data from the meta-analysis of 29 studies, it would be worthwhile for guidelines and review articles to mention the higher prevalence of HIV reported among transgender persons. Optimally, all transgender individuals would have a primary care physician to take a careful sexual history, discuss HIV risks, and offer screening. In the absence of a primary care physician, another physician involved in the patient's care should assume this role.

Duty Hour Reforms in Europe and the United States

Holsgrove DT. — Wed, 22 May 2013 00:00:00 GMT

To the Editor: The Viewpoint by Dr Axelrod and colleagues on the implications of the introduction of the European Working Time Directive on medical care and education highlighted important factors to be considered when reducing the working hours of physicians in training. However, it did not fully appreciate the protracted implementation of the legislation.

Duty Hour Reforms in Europe and the United States—Reply

Axelrod L, Shah DJ, Jena AB. — Wed, 22 May 2013 00:00:00 GMT

In Reply: Duty hour reforms in the United States and Europe have sparked vigorous debate about optimal trade-offs that must be made among the well-being of physicians in training, the continuity of care provided to patients, and the necessary experience required to prepare physicians for independent practice after completion of postgraduate medical training. Our description of the European Working Time Directive was intended to fuel further discussion and research into whether the pendulum has swung too far in Europe, where duty hour restrictions are greater than in the United States.

End Points in Trials of Treatments for Skin Infections

Spellberg B. — Wed, 22 May 2013 00:00:00 GMT

To the Editor: In accord with US Food and Drug Administration guidance for skin infection clinical trials, Dr Prokocimer and colleagues reported an early “cessation of lesion spread” analysis as their primary end point in a trial of tedizolid phosphate vs linezolid for acute bacterial skin and skin structure infections (ABSSSIs). Thus, patients with skin infections were deemed treatment successes if the skin infection did not worsen after receiving antibiotic therapy for 3 days.

End Points in Trials of Treatments for Skin Infections—Reply

Prokocimer P, Das A. — Wed, 22 May 2013 00:00:00 GMT

In Reply: Dr Spellberg raises the question of whether a cessation of lesion spread in ABSSSIs can be considered a cure of the disease. This issue was discussed by the Foundation for the National Institutes of Health working group on end points in ABSSSIs. The group's recommended end point is a 20% or greater decrease in lesion size at the 48- to 72-hour assessment rather than cessation of spread at this time point.

Residual Gastric Volume and Risk of Ventilator-Associated Pneumonia

Elke G, Heyland D. — Wed, 22 May 2013 00:00:00 GMT

To the Editor: Dr Reignier and colleagues provided evidence that not measuring residual gastric volume and adjusting enteral nutrition except in the case of vomiting or regurgitation (intervention group) did not negatively affect clinical outcomes compared with checking residual gastric volume 4 times per day and adjusting enteral feeding rates if the volume exceeded 250 mL (control group). The conclusion given by the authors that monitoring residual gastric volume should be discontinued in all patients receiving mechanical ventilation and early enteral nutrition is, in our opinion, an overstatement, because we believe that the external validity of the trial is limited.

Residual Gastric Volume and Risk of Ventilator-Associated Pneumonia—Reply

Reignier J, Lascarrou J. — Wed, 22 May 2013 00:00:00 GMT

In Reply: Despite the data obtained in our trial, Drs Elke and Heyland state that by continuously monitoring residual gastric volume, clinicians can detect more readily patients with delayed gastric emptying and intervene with strategies that minimize the risk of enteral nutrition. However, guidelines state that “residual gastric volumes in the range of 200-500 mL should raise concern and lead to the implementation of measures to reduce risk of aspiration” and acknowledge that “residual gastric volume does not correlate well to incidence of pneumonia, measures of gastric emptying, or incidence of regurgitation and aspiration.”

CDC: Use Antivirals Early, Aggressively for H7N9 Flu

Kuehn BM. — Wed, 22 May 2013 00:00:00 GMT

The US Centers for Disease Control and Prevention (CDC) is advising clinicians to begin antiviral treatment as soon as possible for individuals with suspected or confirmed H7N9 influenza infection, according to a guidance document issued by the agency in April (http://tinyurl.com/d4gzab7).

Growing Use of Genomic Data Reveals Need to Improve Consent and Privacy Standards

Kuehn BM. — Wed, 22 May 2013 00:00:00 GMT

In March, the publication of the complete genome sequence of cancer cells from a Maryland woman who died in 1951 ignited an ethical firestorm. These cells, called HeLa because they were derived from the cervical tumor of Henrietta Lacks, have been widely cultured in laboratories and used in research.

Physicians, Patients Not Following Advice From USPSTF on Mammography Screening

Mitka M. — Wed, 22 May 2013 00:00:00 GMT

In 2009, the US Preventive Services Task Force (USPSTF) recommended against routine screening mammography for women aged 40 to 49 years and advised biennial rather than annual screening for women aged 50 to 74 years. But it appears that women and physicians have ignored these recommendations.

Residencies Roll Out New Training System

Mitka M. — Wed, 22 May 2013 00:00:00 GMT

Medical residency programs are about to undergo substantial changes in the ways the physicians of tomorrow are trained.

From JAMA ’s Daily News Site

Wed, 22 May 2013 00:00:00 GMT

Exercise and Teen Smoking

Kuehn BM. — Wed, 22 May 2013 00:00:00 GMT

Increasing physical activity may help teens reduce or quit smoking, according to a study funded by the US Centers for Disease Control and Prevention.

Major Brain Research Program

Kuehn BM. — Wed, 22 May 2013 00:00:00 GMT

A new federally funded “big science” project will probe the inner workings of the brain. The initiative, announced by President Obama in April, will be funded by the Defense Advanced Research Projects Agency, the National Institutes of Health, and the National Science Foundation.

Neonatal Trial Criticized for Inadequate Consent

Kuehn BM. — Wed, 22 May 2013 00:00:00 GMT

The US Office for Human Research Protections (OHRP) has determined that a large multisite clinical trial comparing the effects of differing levels of oxygen supplementation for neonates failed to obtain proper consent from the parents of enrolled infants.

Safer Oxycodone

Kuehn BM. — Wed, 22 May 2013 00:00:00 GMT

Only an abuse-resistant name-brand formulation of oxycodone will be allowed to remain on the market, according to the US Food and Drug Administration (FDA). In April 2013, the agency withdrew approval of the original form of the drug and noted that it will not accept generic drug applications from companies seeking to reproduce the original formulation.

American Picnic

Cole TB. — Wed, 22 May 2013 00:00:00 GMT

Judging from their body language, the casually dressed women and men in Roland Petersen's American Picnic (cover) aren't having a pleasant afternoon. With the exception of two couples in conversation to pass the time, the picnickers don't seem to know one another or be making an effort to get acquainted. The ambience is obligatory, like a corporate function; if this scene had been painted from life, it would hardly seem worth commemorating. The painting is probably not based on a real event, but is rather a composite of views from the Sacramento Valley of California assembled by the painter to create a sense of rhythm and spatial recession. In this painting, the human figures are intentionally deanimated. Petersen said that he admired the rigidity and silence of Egyptian art and the stiff postures of the bourgeoisie in the pointillist paintings of Georges Seurat. Picnic scenes were particularly well suited to Petersen's artistic goal, which was to create a plausible composition of human figures and landscape features in a large, open-air still life. The figures and objects function as pictorial elements that mark intervals of color and geometric shapes.

Infinitive

McMahon T. — Wed, 22 May 2013 00:00:00 GMT

To walk is to fallwith every step, yettrust in the next.To love is to open, willingto give everything away.To comfort is to sharewhat cannot be changed.To grieve is to graspthe fullness of letting go.To live is to be presentin this step, this breath.To die? Finally to know.

THE OFFICE OF CORONER

Wed, 22 May 2013 00:00:00 GMT

May 24, 1913

CDC Offers Primer on Blast Injury Care

Wed, 22 May 2013 00:00:00 GMT

In the aftermath of bombings at the Boston marathon on April 15, the Centers for Disease Control and Prevention (CDC) has alerted health professionals that its website on mass casualty event preparedness and response contains extensive information for them, their patients, and the general public.

Nematode Infection Is Transmitted via Organ Transplants

Wed, 22 May 2013 00:00:00 GMT

Infection with an intestinal nematode transmitted via organ transplants may be more common than previously believed.

Ohio Varicella Death Is Vaccination Wake-up Call

Wed, 22 May 2013 00:00:00 GMT

The death of an Ohio teen from varicella should serve as a reminder that catch-up vaccination of older children and adolescents can prevent severe complications and death from infection with varicella-zoster virus.

US Infant Mortality Decreases but Still Ranks High Worldwide

Wed, 22 May 2013 00:00:00 GMT

After significant decreases throughout the 20th century, the US infant mortality rate plateaued from 2000 to 2005 and now is declining again. However, the US infant mortality rate still ranks 27th among the 34 countries of the Organization for Economic Cooperation and Development.

Conjunctivitis

Goodman DM, Rogers J, Livingston EH. — Wed, 22 May 2013 00:00:00 GMT

The conjunctiva is a thin membrane covering the inside of the eyelids and the white part of the eye (the sclera). Inflammation or infection of the conjunctiva is called conjunctivitis (“pink eye”). It can be caused by viruses, bacteria, or fungi; allergy; exposure to chemicals or irritants; or long-term presence of a foreign body, such as hard or rigid contact lenses.

About This Journal

Wed, 22 May 2013 00:00:00 GMT