Household transmission of SARS-CoV-2 and risk factors for susceptibility and infectivity in Wuhan: a retrospective observational study
Dentro das famílias, crianças e adolescentes foram menos suscetíveis à infecção por SARS-CoV-2, mas revelaram ser mais infecciosos do que indivíduos mais velhos. Os casos pré-sintomáticos foram mais infecciosos e os indivíduos com infecção assintomática menos infecciosos do que os sintomáticos.Verificou-se ainda que após o isolamento em massa de casos, quarentena de contatos domiciliares e políticas de restrição de movimento, os números reprodutivos domiciliares diminuíram.
Fang Li, et al. january 2021
Interleukin-6 Receptor Antagonists in Critically Ill Patients with Covid-19 – Preliminary report
Em pacientes gravemente doentes com Covid-19 admitidos em UCI a recever suporte respiratório ou cardiovascular, o tratamento com antagonistas do receptor de IL-6, tocilizumab e sarilumab associa-se a melhores resultados, incluindo menor mortalidade.
The REMAP-CAP investigatorsjanuary 2021
Association between palliative care and healthcare outcomes among adults with terminal non-cancer illness: population based matched cohort study
Haverá correlação entre cuidados paliativos e melhor saúde em adultos com doença terminal não oncológica? \n Cuidados paliativos em adultos com doenças terminais não oncológicas (insuf. cardíaca, DPOC, DRC, cirrose, AVC ou fragilidade/demência) associam-se a menos episódios de urgência, menos admissões hospitalares e menos admissões em UCI, maior probabilidade de morte em casa ou casa de repouso em vez de no hospital. É razoável admitir que acesso a cuidados paliativos provoque maior qualidade de vida no final da mesma e as políticas de saúde devem promover maior desenvolvimento desta oferta.
Quinn, Kieran L, Stukel, Therese, Stall, Nathan M, et al.july 2020
Vegetable Consumption and Progression of Prostate Cancer—Reply
In Reply Dr Kerley raises 4 concerns with the design and conduct of the MEAL trial: (1) evidence of dietary changes in the control group; (2) a potential placebo effect in the control group; (3) an inability to achieve predefined dietary targets in the intervention group; and (4) a failure of the intervention to incorporate fat intake. We believe these issues do not change the validity of our conclusions.
Parsons J, Pierce JP, Marshall JR. june 2020
Feasibility of Ultra-Rapid Exome Sequencing in Critically Ill Infants and Children With Suspected Monogenic Conditions
This descriptive study characterizes time from sample receipt to sequence report as a measure of the feasibility of ultra-rapid genomic diagnosis of critically ill pediatric patients with suspected monogenic conditions in an Australian public health care system.
, Lunke S, Eggers S, et al. june 2020
Potential Implications of Lowering the Medicare Eligibility Age to 60
This Viewpoint discusses the possible effects of former US Vice President and 2020 Presidential candidate Joe Biden’s proposal to lower Medicare eligibility age to 60 years on private insurance, Medicare, and Social Security coverage and spending, and the political and financial implications for US states struggling with health care costs and the economic downturn of the COVID-19 pandemic.
Song Z. june 2020
Clinical Genomics in Critically Ill Infants and Children
Increasing evidence indicates that many children who require neonatal or pediatric intensive care have an underlying genetic disease. However, until recently, many of these children did not receive sufficiently comprehensive or rapid genetic testing to be relevant to their acute care. With the increasing availability and affordability of whole exome or genome sequencing technology and the ability to interrogate the genome at scale within a short time frame, a number of rapid diagnostic genomic programs for critically ill infants and children have been developed and implemented, and the concomitant emerging evidence suggests that genomic data are increasingly useful for clinical decision-making in the acute care setting.
Raymond F. june 2020
Government Not Doing All It Could to Recruit and Retain Scientists
The US Department of Health and Human Services (HHS) hasn’t yet used the authority it was given more than 3 years ago to recruit and retain biomedical research scientists, according to a recent Government Accountability Office (GAO) report.
Rubin R. june 2020
Smoking Cessation—Progress, Barriers, and New Opportunities
This Viewpoint summarizes the 2020 report from the US Surgeon General, summarizing updated scientific evidence on the benefits of smoking cessation and individual, health systems, and population strategies that can facilitate smoking cessation.
Adams JM. june 2020
Clopidogrel Noninferior to Ticagrelor With Less Bleeding
Among older patients with acute coronary syndrome, platelet inhibition with clopidogrel significantly reduced bleeding risk without increasing thrombotic events compared with ticagrelor, a noninferiority trial in The Lancet reported.
Slomski A. june 2020
Planning for a COVID-19 Vaccination Program
This Viewpoint describes the categories of concerns underlying vaccine hesitancy (necessity, safety, and freedom of choice), and proposes ways to educate the public now about the public health and individual benefits of a COVID-19 vaccine to enhance its rapid, widespread uptake when it becomes available.
Schaffer DeRoo S, Pudalov NJ, Fu LY. june 2020
Association of Stay-at-Home Orders With COVID-19 Hospitalizations in 4 States
This study uses state public health department data to describe trends in COVID-19 hospitalizations before and after state executive stay-at-home orders issued in March and April 2020 in Colorado, Minnesota, Ohio, and Virginia, and compares projected vs observed admissions to estimate associations between the orders and hospital admissions.
Sen S, Karaca-Mandic P, Georgiou A. june 2020
Rushing a SARS-CoV-2 Vaccine: Potential for Harm
This Viewpoint discusses the importance of carefully evaluating SARS-CoV-2 vaccine candidates for safety and efficacy in the context of political pressure to accelerate the process, widespread vaccine hesitancy and refusal, and distrust of science.
Trogen B, Oshinsky D, Caplan A. june 2020
Effect of Intraoperative Dexamethasone on Major Complications and Mortality Among Infants Undergoing Cardiac Surgery
This randomized trial compares the effect of intravenous dexamethasone vs saline on death, need for ECMO or CPR, and other complications among infants younger than 12 months undergoing cardiac surgery with cardiopulmonary bypass.
Lomivorotov V, Kornilov I, Boboshko V, et al. june 2020
Labor and Delivery Visitor Policies During the COVID-19 Pandemic
This Viewpoint reviews the policies, challenges, and ethics of allowing visitors of women while laboring in a hospital from the perspective of the woman, the visitor, the hospital staff, the community, and the infant.
Arora K, Mauch JT, Gibson K. june 2020
Physical Therapy Outperforms Injections for Knee Osteoarthritis
Physical therapy reduced pain and functional disability more effectively than glucocorticoid injections among patients with osteoarthritis of the knee, a trial in the New England Journal of Medicine reported.
Slomski A. june 2020
Cautious and Fearful Infants Grow Into Cautious and Fearful Adults
Infants’ temperament can help predict who they’ll become as young adults, suggests a recent study from researchers at the National Institute of Mental Health, the University of Maryland, and the Catholic University of America.
Rubin R. june 2020
COVID-19 and Racial/Ethnic Disparities
This Viewpoint reviews possible reasons for reported excess mortality and poor outcomes in racial/ethnic minority populations with COVID-19 and proposes research, public health, and clinical interventions to decrease health inequities in and beyond the pandemic.
Webb Hooper M, Nápoles A, Pérez-Stable EJ. june 2020
Pandemic Highlights Behavioral Health Disparities
Lower access to behavioral health care is among the racial and ethnic disparities highlighted by the coronavirus disease 2019 (COVID-19) pandemic, according to a recent report from the Substance Abuse and Mental Health Services Administration (SAMHSA).
Rubin R. june 2020
Prevalence of SARS-CoV-2 Among Patients Admitted for Childbirth in Southern Connecticut
This study describes the prevalence of positive SARS-CoV-2 test results among asymptomatic pregnant women presenting for labor and delivery at Yale New Haven health system hospitals.
Campbell KH, Tornatore JM, Lawrence KE, et al. june 2020
After COVID-19: Thinking Differently About Running the Health Care System
Wars and other national crises force society to act differently for a while. But in doing so, they highlight organizational actions and innovations that should not end with the crisis and should be allowed to play a greater role in the future. The coronavirus disease 2019 (COVID-19) pandemic has similar features, and it should spur policy makers who shape the US health care system, to—as Apple Computer cofounder Steve Jobs often urged—“think different.”
Butler SM. june 2020
Cultivating Laughter as an Antidote to COVID-19
In this narrative medicine essay, a physician reviews the science supporting the beneficial health effects of humor and offers tips on how to bring humor into one’s everyday personal and professional life during and after the COVID-19 pandemic.
Fessell D. june 2020
Vegetable Consumption and Progression of Prostate Cancer
To the Editor Dr Parsons and colleagues conducted a phase 3 nutrition intervention trial among 443 men with prostate cancer. The intervention group was encouraged to consume at least 7 servings of vegetables and fruits daily, including at least 2 servings each of tomatoes and cruciferous vegetables.
Kerley CP. june 2020
Translating Science on COVID-19 to Clinical Care and Public Health
This Viewpoint reviews progress to date on drug and vaccine development for COVID-19, antibody testing for demonstration of immunity and seroprevalence, and the continuing need for testing capacity to more precisely manage the public’s health as mitigation restrictions loosen during summer 2020.
del Rio C, Malani P. june 2020
Accelerating COVID-19 Therapeutic Interventions and Vaccines (ACTIV)
This Viewpoint describes how the National Institutes of Health is partnering with more than a dozen biopharmaceutical companies and multiple other agencies to develop an international strategy for a coordinated research response to the COVID-19 pandemic, including prioritizing vaccine and drug candidates.
Collins FS, Stoffels P. june 2020
Treatment With Hydroxychloroquine or Azithromycin and In-Hospital Mortality in Patients With COVID-19
This study examines associations between use of hydroxychloroquine, azithromycin, or both and in-hospital mortality, ECG changes, and cardiac arrest among patients with COVID-19 hospitalized in the metropolitan New York area in March 2020.
Rosenberg ES, Dufort EM, Udo T, et al. june 2020
The Medical News and Perspectives article “Coconut Oil’s Health Halo a Mirage, Clinical Trials Suggest,” published in the April 28, 2020, issue of JAMA, included a quote that did not accurately explain how medium-chain fatty acids (MCFAs) are absorbed by humans. This article was corrected online.
C-Reactive Protein Test Reduces Antibiotics for COPD Flare-ups
In a recent UK trial, use of a C-reactive protein (CRP) point-of-care test to guide treatment decisions reduced antibiotic use among patients with acute exacerbations of chronic obstructive pulmonary disease (AECOPD). Previous research suggests that CRP levels correlate with antibiotic efficacy among patients with AECOPD.
Slomski A. june 2020
Artificial Intelligence: Promise, Pitfalls, and Perspective
In this Medical News article, JAMA Fishbein Fellow Angel N. Desai, MD, MPH, speaks with scientist and entrepreneur Gary Marcus, PhD, about the potential of artificial intelligence in health care and the current coronavirus pandemic.
Desai AN. june 2020
Postmortem Examination of Patients With COVID-19
This case series describes autopsy findings in 10 patients with proven severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection who died at a university medical center in Germany.
Schaller T, Hirschbühl K, Burkhardt K, et al. june 2020
Payment Reforms to Incentivize Innovations in Home-Based Care
This Viewpoint discusses the need for new payment models to incentivize innovations in personalized home care and facilitate transitions already occurring in response to the COVID-19 pandemic, and to develop lower-cost higher-quality approaches to home-based management of chronic illnesses such as heart failure and Parkinson disease.
Volpp KG, Diamond SM, Shrank WH. june 2020
Reevaluation of the Frequent Use of PD-1 Checkpoint Inhibitors for Treatment of Glioblastoma
Glioblastoma is the most common malignant primary brain tumor in adults and affects approximately 3 per 100 000 persons in the US annually. The standard of care is surgical resection followed by radiotherapy and chemotherapy. This combination has been used since 1978 and was updated to include temozolomide in 2005, which modestly increased median overall survival from 12.1 to 14.6 months and increased 5-year survival from 2% to 10%. Most patients with glioblastoma experience disease progression, and the average survival is less than 9 months after relapse.
Miller AM, DeAngelis LM. june 2020
Modeling Epidemics With Compartmental Models
This JAMA Guide to Statistics and Methods reviews the susceptible-infected-recovered (SIR) model for predicting the course of infectious disease outbreaks, which describes the transition of individuals from susceptible to infected and from infected to recovered, and discusses the model’s limitations, including oversimplification of complex disease processes.
Tolles J, Luong T. june 2020
Health Equity—A New Kind of “Herd Immunity”
Three articles recently published in JAMA provide insight into the large racial/ethnic differences associated with coronavirus disease 2019 (COVID-19) and highlight the need for, and potential opportunity to, redouble efforts in the US to develop strategies that would enable society to slow and ultimately eliminate the spread of inequities in health. COVID-19 is a magnifying glass that has highlighted the larger pandemic of racial/ethnic disparities in health. For more than 100 years research has documented that African American and Native American individuals have shorter life spans and more illness than white persons. Hispanic immigrants initially tend to have a relatively healthy profile but with increasing length of stay in the US, their health tends to decline. A black infant born in the US is more than twice as likely to die before his or her first birthday compared with a white infant. In adulthood, black individuals have higher death rates than white persons for most of the leading causes of death.
Williams DR, Cooper LA. june 2020
Vegetable Consumption and Progression of Prostate Cancer
To the Editor In the Men’s Eating and Living (MEAL) randomized clinical trial, men with early-stage prostate cancer were randomized to receive counseling to increase vegetable consumption to 7 servings per day or more vs the control group receiving written dietary information. We would caution that the generalizability of the findings may be limited to men with the baseline dietary habits of those recruited to the study. At baseline, the mean total vegetable intake was 3.38 servings per day, an amount twice the mean intake of US men (1.5 servings per day). Hence, most men in the US are likely to have lower vegetable intake than the amounts consumed at baseline by participants in this trial.
Csizmadi I, Lin P, Freedland SJ. june 2020
Diagnosis and Management of Olfactory Dysfunction in COVID-19
This JAMA Insights Clinical Update discusses the presumed mechanism of COVID-19–related olfactory dysfunction and proposes assessment and management strategies, including olfactory training and adjuvant medication treatments.
Whitcroft K, Hummel T. june 2020
Clearness in Medical Speech
When Polonius asked Hamlet, “What do you read, my lord?” Hamlet replied, “Words, words, words.” Any one who has served for five years as an officer of this section cannot fail to recall a great deal that was brilliantly conceived and skilfully presented; but if his memory is good he will not have forgotten the occasional paper which, because of its structure and the manner of its presentation, represented to the audience little more than words.
The Equitable Distribution of COVID-19 Therapeutics and Vaccines
This Viewpoint proposes a framework for international cooperation among governments and organizations to replace competition and hoarding with equitable global distribution of COVID-19 therapeutics and vaccines as they are developed.
Bollyky TJ, Gostin LO, Hamburg MA. june 2020
Chest Pain and a Cavitary Lung Mass in a Woman With Diabetes
A woman from the Southeastern US with a history of smoking, poorly controlled diabetes, and inhalational medical marijuana use had 4 months of productive cough, weight loss, subjective fevers, 3 days of worsening chest pain, and a large right upper lobe cavitary mass on chest CT unresponsive to antibiotics. AFB smear and GeneXpert MTB/RIF testing were negative; she developed a right-sided tension pneumothorax after intubation for hypoxemia, and chest tube placement yielded charcoal-colored pleural fluid. What is the diagnosis and what would you do next?
Koff A, Malinis M. june 2020
COVID-19 Reveals Urgent Need to Strengthen the World Health Organization
From the time China reported a novel coronavirus to the World Health Organization (WHO) on December 31, 2019, it took barely 4 months to become a pandemic, killing hundreds of thousands, and growing daily. It is now clear that the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) had been circulating in Wuhan, China, for weeks before China reported it to the WHO, and that authorities hid information. China maintained SARS-CoV-2 was not readily transmissible between humans. The WHO published China’s data, but without independently verifying their accuracy.
Gostin LO. june 2020
Digital Smartphone Tracking for COVID-19—Balancing Public Health and Civil Liberties
This Viewpoint compares manual and digital strategies for coronavirus disease 2019 (COVID-19) contact tracing, describes how countries in Asia and Europe have used smartphone tracking, and discusses privacy and discrimination concerns and strategies for balancing public health and civil liberties in the US.
Cohen I, Gostin LO, Weitzner DJ. june 2020
Genetic Analysis Tracks SARS-CoV-2 Mutations in Human Hosts
An analysis of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) genomes collected from more than 7500 patients worldwide has identified mutations in the virus that could aid in drug and vaccine development.
Kuehn BM. june 2020
Asymptomatic SARS-CoV-2 Seroconversion of Health Care Workers and Patients in a Pediatric Dialysis Unit
This case series describes subclinical development of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) antibodies in some patients and health care workers in a pediatric dialysis unit after contact with a seropositive patient.
Hains DS, Schwaderer AL, Carroll AE, et al. june 2020
Emergency Use Authorization of Remdesivir
This Viewpoint reviews the FDA’s May 2020 Emergency Use Authorization of the antiviral drug remdesivir for treatment of COVID-19 and discusses the need for a transparent distribution plan of a drug not otherwise available in the US and for which demand will likely exceed supply.
Ison MG, Wolfe C, Boucher HW. june 2020
Physician Notification Regarding Nonadherence to Colorectal Cancer Screening and Cancer Detection
This cluster randomized clinical trial compares the effect of physician notification for colorectal cancer screening and cancer detection on patients who were in a patient-specific reminders group in which physicians received a list of nonadherent patients, in a generic reminders group in which physicians received general information about regional screening adherence, or in a usual care group in which physicians received no reminders.
Schmeltz H, Rat C, Pogu C, et al. june 2020
Nasal ACE2 Levels and COVID-19 in Children
Coronavirus disease 2019 (COVID-19) has disproportionately affected certain vulnerable populations. Studies noted higher rates of certain comorbidities such as hypertension, diabetes mellitus, and chronic obstructive pulmonary disease in patients infected with COVID-19 with severe disease. Additionally, areas with more racial/ethnic minorities and higher rates of poverty have been shown to have higher rates of COVID-19 hospitalization and death. After adjustment for comorbidities, age has been independently associated with increased mortality due to COVID-19. However, limited attention has been given to children, who appear to have lower risk of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and mortality.
Patel AB, Verma A. june 2020
An Ethical Framework for Allocating Scarce Inpatient Medications for COVID-19 in the US
This Viewpoint proposes ethical principles to guide allocation of scarce inpatient therapies for hospitalized COVID-19 patients to maximize patient benefit, mitigate disparities, and minimize clinician burden.
DeJong C, Chen A, Lo B. june 2020
Overlap Weighting—A Propensity Score Method That Mimics Attributes of a Randomized Clinical Trial
This JAMA Guide to Statistics and Methods reviews overlap weighting, a technique to reduce the influence of patients who are nearly always treated or never treated on propensity score estimates, when attempting to reduce bias associated with nonrandomized treatment in observational study populations.
Thomas LE, Li F, Pencina MJ. june 2020
Home Noninvasive Positive Pressure Ventilation for Chronic Obstructive Pulmonary Disease—Reply
In Reply The issue of combining randomized clinical trials and nonrandomized studies in a meta-analysis is a common challenge faced during evidence synthesis. When an abundance of well-done randomized clinical trials does not exist, clinical decision-making has to proceed based on the available evidence. In our systematic review about home noninvasive positive pressure ventilation (NIPPV) in COPD, we judged that combining these 2 types of studies was appropriate. For transparency purposes, we presented estimates separately from each study design. When examining the 2 designs, we observed similar trends, consistent results (overlapping CIs of relative estimates of mortality, need for intubation, and hospitalization), and no significant heterogeneity. A methodology study by the Cochrane Collaboration that examined 1583 meta-analyses covering 228 different medical conditions concluded that there was little evidence for significant effect estimate differences between observational studies and randomized clinical trials (ratio of odds ratios, 1.08; 95% CI, 0.96-1.22). This should not be interpreted as equating inferences from the 2 designs, and there are many examples of misleading observational studies. It simply means that the totality of evidence needs to be considered when not enough trials are available.
Wilson ME, Murad M, Wang Z. june 2020
Home Noninvasive Positive Pressure Ventilation for Chronic Obstructive Pulmonary Disease
To the Editor Dr Wilson and colleagues reviewed bilevel positive airway pressure (BPAP) and home mechanical ventilation for chronic obstructive pulmonary disease (COPD). We are concerned about certain issues related to their methodology.
Owens RL, Oczkowski S, Rochwerg B. june 2020
How Academic Health Systems Can Move Forward Once COVID-19 Wanes
This Viewpoint discusses the role academic health systems can play in response to public health deficiencies identified in the coronavirus disease 2019 (COVID-19) pandemic, including developing early warning systems to identify future outbreaks, addressing community mental health needs more broadly, and working to reduce structural health inequities.
Shapiro SD, Rothman PB. june 2020
Nasal Gene Expression of Angiotensin-Converting Enzyme 2 in Children and Adults
This study compares angiotensin-converting enzyme 2 (ACE2) gene expression, which has been associated with SARS-CoV-2 cell entry, in the nasal epithelium of children vs adults.
Bunyavanich S, Do A, Vicencio A. june 2020
Ticagrelor Monotherapy vs Ticagrelor With Aspirin and Adverse Events in Acute Coronary Syndrome
This randomized trial compares the effects of ticagrelor-based 12-month dual antiplatelet therapy (DAPT) vs 3-month DAPT switching to 9-month ticagrelor monotherapy on rates of major bleeding and cardiovascular events in patients with acute coronary syndromes (ACS) undergoing PCI with drug-eluting stent (DES) placement.
Kim B, Hong S, Cho Y, et al. june 2020
Targeted Therapy and Diagnostic Test For Non–Small -Cell Lung Cancer
The FDA has approved a targeted therapy for certain adults with metastatic non–small cell lung cancer (NSCLC) as well as an in vitro diagnostic test to detect genetic alterations in their cancer.
Voelker R. june 2020
COVID-19 and the Need for a National Health Information Technology Infrastructure
This Viewpoint emphasizes the need for efficient and accurate data collection, aggregation, and analysis at the national level to properly manage the coronavirus pandemic, and proposes responses to the legal, ethical, and financial barriers that have historically delayed development of a national HIT infrastructure.
Sittig DF, Singh H. june 2020
Fourth-Line Treatment Approved For Gastrointestinal Tumor
The kinase inhibitor ripretinib has received approval as a fourth-line treatment for adults with advanced gastrointestinal stromal tumor (GIST) who already have been treated with 3 or more kinase inhibitors.
Voelker R. june 2020
Treating Type 2 Diabetes With Insulin
This JAMA Insights Clinical Update reviews indications and timing of insulin therapy for management of type 2 diabetes, emphasizing the likely benefit of its use as first-line therapy in patients with HbA1c levels less than 9.0%.
Hirsch IB, Gaudiani LM. june 2020
Digital Health Equity as a Necessity in the 21st Century Cures Act Era
This Viewpoint discusses inequities in broadband access and digital health literacy in the US, and proposes policies and actions to bring equity to patient-facing digital health tools, in the context of a 2020 final rule release giving patients more control of their health data from the US Office of the National Coordinator (ONC) for Health Information Technology’s Cures (HI-TEC) Act.
Rodriguez JA, Clark CR, Bates DW. june 2020
Seroprevalence of SARS-CoV-2–Specific Antibodies in Los Angeles County, California
This population epidemiology study investigates the prevalence of IgG and IgM antibodies to SARS-CoV-2 in Los Angeles County, California, as a marker of both active and past infections.
Sood N, Simon P, Ebner P, et al. june 2020
Screening for Adverse Childhood Experiences in Primary Care
This Viewpoint discusses the effects that adverse childhood experiences (ACEs) can have on long-term mental and physical health and reviews the potential benefits and harms of screening for ACEs in primary care settings.
Campbell TL. june 2020
Continuous Glucose Monitoring in Adolescent, Young Adult, and Older Patients With Type 1 Diabetes
The advent of continuous glucose monitoring (CGM) technology has revolutionized outpatient diabetes care in the past decade. A CGM device consists of a sensor that continuously measures subcutaneous glucose and sends data wirelessly to a display device through a transmitter. CGM offers real-time blood glucose monitoring (BGM) with alerts for trends in blood glucose levels and decreases the need for fingerstick glucose monitoring for people with diabetes. Studies of CGM have shown improvement in glycemic control in adults and children with type 1 diabetes and equivalence to glucometers for self-monitoring of blood glucose. Coupled with recent advances in CGM technology to improve accuracy and ease of use, CGM has become a vital tool for glycemic management in individuals with type 1 diabetes.
Agarwal S, Cappola AR. june 2020
Telehealth in a Postpandemic Future—Regulatory Changes and Opportunities
This Viewpoint describes changes in reimbursement standards, patient privacy (HIPAA) regulations, and licensing requirements that have occurred around provision of telehealth in the US in response to the COVID-19 pandemic and highlights opportunities to further standardize regulations and facilitate use of telehealth after the pandemic.
Shachar C, Engel J, Elwyn G. june 2020
Pulse Pressure and Isolated Diastolic Hypertension
To the Editor Dr McEvoy and colleagues performed cross-sectional analyses of several large databases to investigate clinical outcomes related to isolated diastolic hypertension (IDH) based on the 2017 hypertension guidelines of a diastolic blood pressure of 80 mm Hg or greater. They found no associations and implied that clinicians need not be clinically concerned by IDH. I disagree.
Anstadt GW. june 2020
Pulse Pressure and Isolated Diastolic Hypertension—Reply
In Reply We agree with Dr Anstadt about the tetrad linking systolic and diastolic blood pressure and that pulse pressure is a critically important consideration in any analysis of the relationship between blood pressure and CVD outcomes. Pulse pressure adds prognostic information to systolic or diastolic blood pressure values because pulse pressure, which is calculated as the absolute difference between systolic and diastolic blood pressure, is related to both stroke volume and the compliance of large arteries (with the latter influencing vascular resistance). Therefore, pulse pressure can be an important surrogate marker for the health of large arteries. Indeed, our group has published related studies from the Atherosclerosis Risk in Communities (ARIC) Study that highlight the importance of pulse pressure in analyses of diastolic blood pressure in particular.
McEvoy JW, Selvin E. june 2020
Effect of Continuous Glucose Monitoring on Hypoglycemia in Older Adults With Type 1 Diabetes
This randomized clinical trial compares the effect of continuous glucose monitoring vs standard blood glucose monitoring on percentage of time spent with hypoglycemia (glucose <70 mg/dL) among older adults with type 1 diabetes.
Pratley RE, Kanapka LG, Rickels MR, et al. june 2020
Using Controlled Trials to Resolve Key Unknowns About Policy During the COVID-19 Pandemic
This Viewpoint proposes implementing comparison groups for policy decisions, for example assessing disease transmission with alternative housing vs in-home isolation of individuals who test positive for coronavirus disease 2019 (COVID-19), or with different durations or cycles of school openings, to gather data that could make broader and future policy implementations more informed and effective.
Starr P. june 2020
The “Sense” of Humor—Art & Science
In the undefined Good Old Days, a quality known as the “bedside manner” was held to be important to the success of a physician. Then, the good doctor was knowing, sensitive, and, perhaps above all, good-humored. Time, in its march, has heeled good humor in deference to the advances of knowledge, including the important “know-how.” But what of the “know-why”?
Effect of Continuous Glucose Monitoring on Glycemic Control in Adolescents and Young Adults With Type 1 Diabetes
This randomized clinical trial examines the effect of continuous glucose monitoring vs standard blood glucose monitoring on glycemic outcomes among adolescents and adults with type 1 diabetes and suboptimal glycemic control.
Laffel LM, Kanapka LG, Beck RW, et al. june 2020
Telemonitoring at scale for hypertension in primary care: An implementation study
Este estudo avalia se a tele-monitorização de doentes hipertensos é exequível. Conclui que sim, que para doentes com hipertensão a mesma pode ser implementada em cuidados primários de rotina em escala, com relativo pouco incremento na carga de trabalho do clínico e resulta em reduções na PA semelhantes às de grandes ensaios no Reino Unido. A integração das leituras de telemonitorização no workflow rotineiro diário dos clínicos foi crucial para o sucesso dessa iniciativa. Os resultados sugerem que a introdução do telemonitorização na prática de rotina em escala é viável. Embora não sejam definitivos, os resultados garantem que a intervenção não aumentou a carga de trabalho da prática e que as melhorias no controlo da PA foram semelhantes às de ensaios controlados. No entanto, as pessoas que participaram não eram inteiramente típicas da população em geral, sendo, em média, mais jovens e com mais recursos sociais.
Vicky Hammersley, Richard Parker, Mary Paterson, et al.june 2020
Surgery in a Time of Uncertainty—The Need for Universal Respiratory Precautions in the Operating Room
This Viewpoint proposes that universal respiratory precautions in the operating room—use of respirators with face masks and eye protection—could protect staff from possible coronavirus disease 2019 (COVID-19) infection and facilitate resumption of elective surgeries canceled during the first wave of the pandemic.
Livingston EH. june 2020
How Will COVID-19 Affect the Health Care Economy?
Coronavirus disease 2019 (COVID-19) has created an economic crisis alongside a health care crisis. During the 2 weeks ending on March 28, nearly 10 million people filed for unemployment insurance, dwarfing any previous monthly numbers. Estimates suggest that the US economy will contract by 10% to 25% during the second quarter. The US has entered a COVID-19 recession.
Cutler D. june 2020
When Should Physicians Act on Non–Statistically Significant Results From Clinical Trials?
This Viewpoint discusses considerations that might lead physicians to change their practice based on RCTs reporting non–statistically significant differences in primary outcomes, including trial methodology, totality of evidence, cost, invasiveness, and labor-intensiveness of the interventions being compared.
Young PJ, Nickson CP, Perner A. june 2020
Prone Positioning in Nonintubated Patients With COVID-19 and Hypoxemic Acute Respiratory Failure
This case series describes the proportion of awake, nonintubated inpatients with COVID-19 and hypoxemic respiratory failure requiring oxygen supplementation whose Pao2 increased ≥20% with prone positioning, and their respiratory status after resuming supine positioning.
Elharrar X, Trigui Y, Dols A, et al. june 2020
USPSTF Recommendation: Screening for Unhealthy Drug Use
This 2020 US Preventive Services Task Force Recommendation Statement recommends screening for unhealthy drug use in adults 18 years or older when services for diagnosis, treatment, and care can be offered or referred (B recommendation) and concludes that evidence is insufficient to assess the balance of benefits and harms of screening for unhealthy drug use in adolescents (I statement).
, Krist AH, Davidson KW, et al. june 2020
Spike in Poison Control Calls Related to Disinfectant Exposures
Calls to US poison control centers regarding exposures to cleaning products and disinfectants increased by more than 20% during the first quarter of 2020 compared with 2019, according to a CDC analysis posted online on April 20.
Kuehn BM. june 2020
The Spectrum of Deaths Encountered by a Young Learner
In this narrative medicine essay, a medical student describes 3 patient deaths whose care she was involved in and expresses her hopes that what she learned will ground her professional course in compassion and patient care.
Hawes A. june 2020
Community Use of Face Shields to Contain COVID-19
This Viewpoint discusses the prospect that face shields might be more effective than face masks at reducing community SARS-CoV-2 transmission and calls for rapid adoption of face shield-wearing by the public as an infection control strategy.
Perencevich EN, Diekema DJ, Edmond MB. june 2020
Effect of Noninvasive Ventilation in the Prone Position for Patients With COVID-19
This study measured respiratory parameters of 15 non-ICU patients before, during, and after receiving noninvasive ventilation in the prone position.
Sartini C, Tresoldi M, Scarpellini P, et al. june 2020
Homeless Shelters Face High COVID-19 Risks
The CDC has recommended steps that homeless shelters should take to prevent severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission after studying outbreaks at several facilities across the United States.
Kuehn BM. june 2020
Association of Migraine With Aura and Other Risk Factors With Cardiovascular Disease in Women
This cohort study uses Women’s Health Study data to compare the association of migraine with aura vs other major vascular risk factors (diabetes, hypertension, dyslipidemia, smoking, BMI, CVD family history) with incidence of cardiovascular disease.
Kurth T, Rist PM, Ridker P, et al. june 2020
An Early Result Acceptance Program for Residency Application
To the Editor Although the residency match system has become increasingly complicated and has a number of problems, the implementation of an early result acceptance program (ERAP), as suggested by Dr Hammoud and colleagues, raises a number of concerns.
Adler C. june 2020
Incisional Negative Pressure Wound Therapy After Surgery for Major Trauma–Related Fractures—Reply
In Reply We agree with Mr Zwanenburg and colleagues that the duration of application of the incisional negative pressure wound therapy dressing after surgery is an important variable. Based on their meta-analysis, they suggest that “it is essential to provide incisional negative pressure wound therapy for a sufficient amount of time for the therapy to be effective (eg, for 7 days).”
Costa ML, . june 2020
Accuracy of the PHQ-2 Alone and in Combination With the PHQ-9 for Screening to Detect Major Depression
This meta-analysis uses individual participant data from diagnostic accuracy studies to estimate the accuracy of the Patient Health Questionnaire–2 (PHQ-2) alone and combined with the PHQ-9 for detecting major depression.
Levis B, Sun Y, He C, et al. june 2020
Association of Dysanapsis With COPD Among Older Adults
This study used pooled cohort data to estimate the association between CT-assessed dysanapsis—a mismatch between airway tree caliber and lung size—and incident COPD in adults aged 60 years and older.
Smith BM, Kirby M, Hoffman EA, et al. june 2020
Randomized Clinical Trials and COVID-19
Despite the millions of cases and hundreds of thousands of deaths that have occurred in this devastating coronavirus disease 2019 (COVID-19) pandemic, no peer-reviewed studies of specific therapies proven to be effective in reducing mortality have been published and a vaccine is many months to years away. To date, more than 1000 studies addressing various aspects of COVID-19 are registered on ClinicalTrials.gov, including more than 600 interventional studies and randomized clinical trials (RCTs). During the next few weeks and months, the results of numerous RCTs involving therapies for COVID-19 will be reported. Indeed, preliminary results from some studies have already been reported in social media and the popular press. How will clinicians, the public, and politicians understand the results of these much-anticipated and critically needed clinical trials?
Bauchner H, Fontanarosa PB. june 2020
SARS-CoV-2 Rates in BCG-Vaccinated vs Unvaccinated Young Adults
This cohort study compares rates of coronavirus PCR test positivity among Israelis with symptoms suspicious for COVID-19 who did and did not receive BCG vaccination as part of routine childhood immunization in the early 1980s.
Hamiel U, Kozer E, Youngster I. june 2020
Immunization Against Plague
The reiterated plea of scientists for accurately controlled experiments in the determination of the value of measures adopted against disease may seem to some physicians to be somewhat too emphatic. Again and again, however, the disinterested scientist is compelled to protest against the use of statistics and experiments by those commercially interested and by overenthusiastic advocates of the prophylactic use of certain products. How difficult it really is to arrive at definite conclusions relative to the efficacy of many such preventive measures is pointed out by Flu, in a recent discussion of experiments on immunization against plague. The reports concerning the results of vaccination against this disease have been contradictory. Haffkine believed that he had demonstrated statistically that his vaccine was effectual in creating immunity. Bitter and other observers, analyzing the work of Haffkine, concluded that the immunity acquired was not of high degree and that it did not last more than six months. That opinions based on statistics may not be reliable, Flu illustrates by the recital of an incident occurring in the Division of Malang in Java:
Reopening Society and the Need for Real-Time Assessment of COVID-19 at the Community Level
This Viewpoint discusses the need for population COVID-19 PCR and antibody surveys to better understand where communities are on the continuum of COVID-19 incidence and prevalence, to determine the effectiveness of mitigation strategies, and to plan for future mitigation strategies and development of vaccines and therapeutics.
Angulo FJ, Finelli L, Swerdlow DL. june 2020
Ethics of COVID-19 Immunity-Based Licenses
This Viewpoint explains the ethics of implementing licensing or certification of coronavirus immunity as basis for permitting public activities, anticipates challenges to effectively implementing such a system, and proposes potential policy solutions.
Hall MA, Studdert DM. june 2020
Trends in SARS-CoV-2 PCR Test Positivity Among Outpatients in Seattle and Washington State
This population epidemiology study characterizes trends in polymerase chain reaction (PCR) test positivity for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in Washington State and the Seattle area between March 1 and April 16, 2020, before and after statewide physical distancing guidelines and stay-at-home orders.
Randhawa A, Fisher LH, Greninger AL, et al. june 2020
Is the Prone Position Helpful During Spontaneous Breathing?
A substantial proportion of patients with coronavirus disease 19 (COVID-19) develop severe respiratory failure and require mechanical ventilation, most often fulfilling criteria for acute respiratory distress syndrome (ARDS). The characteristics of these patients are heterogeneous, consistent with what is known about ARDS. Inflammatory edema leads to varying degrees of lung collapse resulting in ventilation perfusion ratio (V̇/Q̇) mismatching, including a significant shunt fraction. Additionally, lung microthrombi are suspected and result in different levels of dead space and inefficient ventilation. In sedated patients, gravitational forces lead to lung atelectasis occurs in the dependent lung regions, and the remaining aerated lung available for gas exchange becomes small. Insufficient hypoxic vasoconstriction, another feature of ARDS that contributes to V̇/Q̇ mismatch, is suggested by the finding of hypoxemia with relatively preserved compliance in some patients.
Telias I, Katira BH, Brochard L. june 2020
Bionic Arm With Sensation Tested in Multiyear Study
Researchers recently reported that 4 men with transhumeral amputations have used a self-contained robotic arm with sensory feedback in daily life for several years. The prosthetic’s hand has sensation, allowing the men to do complex tasks such as ski, repair cars, and canoe. One man became employed full-time thanks to the arm’s improved functionality, and patients also reported complete relief of phantom limb pain.
Abbasi J. june 2020
Ventilator Management of Patients With COVID-19
This JAMA Insights Clinical Update discusses the pathophysiology of SARS-CoV-2–related respiratory failure, distinguishing unique L and H phenotypes and their implications for ventilator strategies and settings.
Marini JJ, Gattinoni L. june 2020
Oedipus and the Coronavirus Pandemic
This Arts and Medicine feature draws lessons from Sophocles’ classic tragedies Oedipus Rex and Oedipus at Colonus about the limits of medicine and the importance of community in the midst of the coronavirus (COVID-19) pandemic.
Antiel RM. june 2020
Incisional Negative Pressure Wound Therapy After Surgery for Major Trauma–Related Fractures
To the Editor The results of the Wound Healing in Surgery for Trauma (WHIST) trial by Dr Costa and colleagues should be interpreted with caution until the authors provide information regarding the actual duration of the incisional negative pressure wound therapy because duration is associated with effectiveness.
Zwanenburg PR, Timmer AS, Boermeester MA. june 2020
Updated CDC Recommendations for Universal HCV Screening—Implications for Clinical Practice
This Viewpoint discusses the clinical implications of the US Centers for Disease Control and Prevention’s (CDC’s) 2020 recommendation to screen all adults for hepatitis C virus (HCV) infection at least once and pregnant women during each pregnancy, including the need to offer substance use disorder referral and testing protocols for diagnosing perinatal HCV infection in newborns.
Havens PL, Anderson JR. june 2020
Blood Test Flags Multiple Cancers in Large Study
A recent study in Science suggests that a blood test to detect different types of cancer is safe when used with positron emission tomography–computed tomography (PET-CT) to confirm the results. The researchers emphasized that, if approved for use, multicancer blood tests should be used alongside standard-of-care screenings to increase detection.
Abbasi J. june 2020
USPSTF Report: Screening for Unhealthy Drug Use
This systematic review to support the 2020 US Preventive Services Task Force Recommendation Statement on screening for unhealthy drug use including nonmedical use of prescription drugs in adolescents and adults summarizes published evidence on the benefits and harms of primary care–based screening.
Patnode CD, Perdue LA, Rushkin M, et al. june 2020
An Early Result Acceptance Program for Residency Application—Reply
In Reply We agree with Dr Adler that it is important to think critically about any proposed changes to the current residency selection process, such as an ERAP discussed in our Viewpoint.
Hammoud MM, Andrews JS, Skochelak SE. june 2020
Prioritizing Physician Mental Health as COVID-19 Marches On
This Medical News article is an interview with the University of New Mexico’s Eileen Barrett, MD, MPH, about the pandemic’s mental toll on health care workers—and how they and their employers can safeguard their emotional well-being.
Abbasi J. june 2020
Revisiting Leonardo da Vinci’s Vitruvian Man
This study uses 3D body scanner measurements of US Air Force recruits to compare ideal body proportions represented by Leonardo da Vinci’s Vitruvian Man with contemporary body proportions in young adult men and women.
Thomas DM, Galbreath D, Boucher M, et al. june 2020
The Ethics of COVID-19 Immunity-Based Licenses (“Immunity Passports”)
This Viewpoint explains the ethical basis for implementing immunity-based licensing—certification of coronavirus immunity as a basis for permitting public activities—and anticipates challenges to effective implementing such a system, and potential solutions.
Persad G, Emanuel EJ. june 2020
Screening for Unhealthy Drug Use
In this issue of JAMA, the US Preventive Services Task Force (USPSTF) presents a Recommendation Statement and an accompanying Evidence Review on screening for unhealthy drug use. “Unhealthy drug use” refers to drugs that are illegal or medications not used for medical purposes, including cannabis, but not including alcohol, nicotine, or tobacco. Unlike alcohol screening, drug screening approaches aim to capture any drug use and are not restricted to a specific substance; they capture the full spectrum of unhealthy use, from any use through a drug use disorder.
Saitz R. june 2020
Prevalence of Asymptomatic SARS-CoV-2 Infection - A Narrative Review
Revisão narrativa - desenho com limitações metodológicas, da evidência disponível sobre a infecção assintomática por SARS-CoV-2. Concluem que as pessoas assintomáticas parecem ser responsáveis por aproximadamente 40% a 45% das infecções por SARS-CoV-2 e podem transmitir o vírus a outras pessoas por um período prolongado, talvez por mais de 14 dias. A infecção assintomática pode estar associada a alterações subclínicas do pulmão, detectadas pela TAC. Propõem que pelo elevado risco de disseminação por pessoas assintomáticas, os programas de teste incluam aqueles sem sintomas. Para complementar o teste de diagnóstico convencional, que é limitado pela capacidade, custo e sua natureza única, táticas inovadoras para a vigilância em saúde pública, como crowdsourcing de dados digitais monitorização de sistemas públicos de esgotos sejam potencialmente úteis. \n \n Notas: \n - há estudos em águas residuais a serem feitos em Portugal. \n - É discutível a proposta dos autores de alargar para rastreio populacional pois os testes apresentam baixa sensibilidade e especificidade para serem úteis nesse contexto. \n - não surpreende a taxa de assintomáticos encontrada. Faz sentido numa doença que rapidamente se tornou pandemia.
Oran D. P., Topol E. J. june 2020
I Remember Wells of Nausea Worse Than Pain
Trying to decide if we should get our son a phone— my belly button still popped out forever because of him— seems like all sixth graders get one by Christmas, but we were going to hold out until seventh at least, maybe when his voice begins to crack open his childhood like split wood, grinning. His dad says, Why buy him a ticket to misery? Everyone we know wants to shoot themselves— I remember the cool flavor and smell of the ceramic sink as I pressed my palms on it during a contraction. Always on, selfies, the endless texting and commenting and liking and congratulating. The porn and the paroxetine. How young should he start shutting down his ability to speak to another person? I remember when I got my own phone, in seventh, talked every afternoon to Sara and Jane and Michael, an imprint of buttons on my cheek, twirling the cord around my fingers, all the way down the hall.
Akresh-Gonzales J. june 2020
Twentieth-Century Lessons for a Modern Coronavirus Pandemic
In this Medical News article, Howard Markel, MD, PhD, director of the Center for the History of Medicine at the University of Michigan, speaks about nonpharmaceutical interventions during the 1918-1919 influenza pandemic and their lessons for today.
Desai A. june 2020
COVID-19 and the Financial Health of US Hospitals
This Viewpoint reviews the revenue sources and financial liquidity of nonfederal US general hospitals to estimate the economic effects pandemic-related reductions in elective procedures and outpatient revenues might have, and argues for targeted government financial support for smaller, independent, and more rural institutions.
Khullar D, Bond AM, Schpero WL. june 2020
COVID-19 and 6 Dimensions of Health Care Poised for a “New Normal”
In this Viewpoint, Donald Berwick summarizes the rapid changes the COVID-19 pandemic has wrought on the pace, scientific standards, delivery mechanisms, and working conditions of health care and how it has sharply increased awareness of the societal costs of poor public health preparedness and health inequities.
Berwick DM. june 2020
Surgery vs Endoscopy for Early Treatment of Chronic Pancreatitis
To the Editor In the ESCAPE randomized clinical trial, Dr Issa and colleagues concluded that early surgery compared with an endoscopy-first approach resulted in significantly less pain over 18 months among patients with chronic pancreatitis. We are concerned about the generalizability of the finding.
Qian Y, Hu L, Liao Z. june 2020
Second-Trimester Miscarriage in a Pregnant Woman With COVID-19
This case report describes a pregnant woman with symptomatic coronavirus disease who experienced a second-trimester miscarriage in association with documented placental SARS-CoV-2 infection.
Baud D, Greub G, Favre G, et al. june 2020
Patient and Study Participant Rights to Privacy in Journal Publication
Personal health information is defined as identifiable data related to the past, present, or future health status of an individual. Personal health information has been considered protected health information, which is governed by ethical principles and laws to shield against intrusions into an individual’s rights to privacy. However, rapid growth in the volume of electronic health records, access to other health information, and increasing use of personal health data by artificial intelligence, social media, technology, and other companies are threatening the traditional tenets of privacy protections for personal health information. As Gostin and colleagues have warned, “Individuals’ health data are now solicited, aggregated, analyzed, shared, and sold in ways poorly understood and largely unregulated.” Clearly, new or enhanced legislative privacy safeguards are needed to protect personal health information.
Flanagin A, Bauchner H, Fontanarosa PB. june 2020
Vitamin C, Hydrocortisone, and Thiamine for Septic Shock—In Reply
In Reply We agree with Dr Long and colleagues that the timing of interventions is important in the management of sepsis. They suggest that early administration of vitamin C is essential for the intervention to have beneficial effects, even though no data on the timing of intervention were reported in the study by Marik et al. In the VITAMINS trial, an elevated lactate level was required to meet the consensus definition of septic shock. During the study period, sepsis resuscitation in Australasian emergency departments for patients with suspected septic shock was administration of 27 mL/kg of intravenous fluids before starting vasopressors, which were commenced a median of 3.5 hours after triage. Moreover, given that patients in the trial were randomized and that vitamin C concentrations in the intervention group increased from low to supraphysiological levels, it is unlikely that the volume and duration of fluid resuscitation affected the results.
Fujii T, Udy AA, Bellomo R. june 2020
Privacy Controversies Around Information Technology–Based COVID-19 Tracing in South Korea
This Viewpoint discusses legal and privacy concerns raised by South Korea’s information technology (IT)–based containment of the COVID-19 pandemic and proposes use of aggregated rather than person-level data to protect the privacy of individuals while maintaining the effectiveness of public health measures.
Park S, Choi G, Ko H. june 2020
Medical Student Education in the Time of COVID-19
This Viewpoint discusses ways the coronavirus pandemic is forcing change onto graduate medical education, including online implementation of preclerkship curricula and alternatives to in-person patient experiences in clinical clerkship rotations.
Rose S. june 2020
Association Between Thrombolytic Door-to-Needle Times and Ischemic Stroke Outcomes
This cohort study estimates associations between intravenous tissue plasminogen activator (tPA) door-to-needle times of less than 4.5 hours for acute ischemic stroke and 1-year mortality or readmission among Medicare beneficiaries aged 65 years or older.
Man S, Xian Y, Holmes DN, et al. june 2020
Characteristics of Hospitalized Adults With COVID-19 in an Integrated Health Care System in California
This case series characterizes the demographics, health services use, and vital status and discharge dispositions of patients with polymerase chain reaction–confirmed coronavirus disease 2019 (COVID-19) hospitalized in the Kaiser Permanente Northern California health system in March 2020.
Myers LC, Parodi SM, Escobar GJ, et al. june 2020
A Structured, Electronic Approach to Shared Decision-making and Attempted Trial of Labor
In 2018, more than 1.2 million pregnant women in the US underwent a cesarean delivery as part of their birth experience. Maternal indications for cesarean delivery include a lack of progress during labor, placental abnormalities, and complex medical conditions. Fetal conditions include multifetal gestation, fetal malpresentation (breech), congenital anomalies, and fetal intolerance of labor. Although generally safe for mother and fetus, cesarean deliveries are associated with significantly higher risk of maternal morbidity, including maternal transfusion, surgical injury, unplanned hysterectomy, intensive care unit admission, and complications with subsequent pregnancies. Thus, vaginal delivery remains the default delivery method.
Swamy GK, Grotegut CA. june 2020
Vitamin C, Hydrocortisone, and Thiamine for Septic Shock
To the Editor The Vitamin C, Hydrocortisone, and Thiamine in Patients With Septic Shock (VITAMINS) trial found that vitamin C, hydrocortisone, and thiamine, compared with hydrocortisone alone, did not improve outcomes in patients with septic shock.
Long MT, Kory P, Marik P. june 2020
Preserving Clinical Trial Integrity During the Coronavirus Pandemic
This Viewpoint discusses ways the coronavirus pandemic is threatening clinical trial conduct and enrollment, and suggests ways to adapt, including changes to how outcomes data are collected and how interventions are delivered and monitored, to minimize trial disruption, maximize trial benefit, and ensure patient health and safety during the pandemic.
McDermott MM, Newman AB. june 2020
Effect of C-Reactive Protein–Guided or Fixed Antibiotic Duration on Clinical Failure in Patients With Gram-Negative Bacteremia
This randomized trial compares the effects of C-reactive protein (CRP)–guided antibiotic duration (discontinuation once CRP declined by 75% of peak value) vs fixed 7- vs 14-day durations on 30-day clinical failure rate among patients with gram-negative bacteremia.
von Dach E, Albrich WC, Brunel A, et al. june 2020
Determining How Public Health Measures Might Be Slowing COVID-19 Using the Reproduction Number ( R t )
This JAMA Insights review explains the use of the effective reproduction number (Rt) as a measure of the number of secondary infectious disease cases spread from an initial case, and how this number is used to assess the effects of public containment and mitigation efforts to control SARS-CoV-2 transmission.
Inglesby TV. june 2020
Transcutaneous Magnetic Stimulation for Ventricular Tachycardia (VT) Storm
This case series describes outcomes for 5 patients with VT storm refractory to drug therapy treated with left stellate ganglion transcutaneous magnetic stimulation (TCMS) to reduce cardiac sympathetic input.
Markman TM, Hamilton RH, Marchlinski FE, et al. june 2020
Fact and Opinion on the Present Epidemic
The recent meeting of the American Public Health Association in Chicago was devoted largely to the present epidemic of influenza. An abstract of the proceedings of the sessions devoted to this subject appears in this issue of The Journal. This abstract is not, of course, a verbatim report of the proceedings, but represents that which seems of permanent value, eliminating a large mass of discussion that was argumentative rather than of the nature of scientific evidence. There are certain large phases of the subject on which much evidence was presented leading to what might be expressed as a consensus of opinion. It must be borne in mind that this organization consists primarily of public health officials, though it includes many research workers and physicians engaged in medical practice and investigation.
Understanding Brain Death
This Viewpoint examines the need to reconcile discrepancies between the definition of brain death in the 1981 Uniform Determination of Death Act and current diagnostic standards in the US given legal challenges arising from the differences.
Truog RD, Paquette E, Tasker RC. june 2020
Do Gut Bacteria Play a Role in Preeclampsia?
As investigators from diverse biomedical fields continue to study gut microbes’ widespread effects on health and disease, 1 group is homing in on preeclampsia. Gut microbiota imbalances have been linked to conditions like obesity and the metabolic syndrome, which can contribute to pregnancy complications. Researchers recently questioned whether these imbalances also might be associated with preeclampsia, a condition that lacks reliable prediction methods and can lead to serious and even fatal complications for both mother and baby.
Hampton T. june 2020
Surgery vs Endoscopy for Early Treatment of Chronic Pancreatitis—Reply
In Reply Dr Qian and colleagues are concerned about the generalizability of the ESCAPE trial and call for a standardized endoscopy strategy for better control of painful chronic pancreatitis.
Kempeneers MA, Bruno MJ, Boermeester MA. june 2020
Prevalence of SARS-CoV-2 Infection in a Large Homeless Shelter in Boston
This study characterizes the prevalence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection detected on polymerase chain reaction (PCR) screening of a large homeless shelter population in Boston prompted by an outbreak of COVID-19 cases among shelter residents.
Baggett TP, Keyes H, Sporn N, et al. june 2020
Governmental Public Health Powers in the COVID-19 Pandemic—Stay-at-home Orders and Business Closures
This Viewpoint provides historical and legal context for governmental directives to close schools and businesses, ban public gatherings, impose curfews, issue stay-at-home orders, require quarantines for travelers, and impose travel restrictions during the COVID-19 pandemic, urging transparent evidence-based processes to ensure equity and social justice.
Gostin LO, Wiley LF. june 2020
Action-Informed Artificial Intelligence—Matching the Algorithm to the Problem
This Viewpoint discusses ways in which artificial intelligence (AI) methods can enhance the use of health care data in detection, prognostication, and prediction; suggests ways in which AI tools might be better developed and deployed; and calls for increased focus on anticipated changes that will be made in the health care system to better benefit from the use of AI.
Lindsell CJ, Stead WW, Johnson KB. june 2020
Variation in COVID-19 Hospitalizations and Deaths Across New York City Boroughs
This study describes demographic characteristics and hospital bed capacities of the 5 New York City boroughs, and evaluates whether differences in testing for coronavirus disease 2019 (COVID-19), hospitalizations, and deaths have emerged as a signal of racial, ethnic, and financial disparities.
Wadhera RK, Wadhera P, Gaba P, et al. june 2020
Long-term Outcomes After Thrombolytic Therapy for Acute Ischemic Stroke
The role of intravenous thrombolytic therapy in the management of acute ischemic stroke is well established, and faster administration of intravenous tissue plasminogen activator (tPA) has been associated with better short-term outcomes in clinical practice.
Muth CC. june 2020
Effect of a Patient-Centered Decision Support Tool on Rates of Trial of Labor After Previous Cesarean Delivery
This randomized clinical trial compares the effect of a patient-centered decision support tool vs usual care on rates of trial of labor among women with a previous cesarean delivery.
Kuppermann M, Kaimal AJ, Blat C, et al. june 2020
Understanding and Addressing Anxiety Among Healthcare Professionals During the COVID-19 Pandemic
This Viewpoint discusses sources of anxiety revealed in conversations with health care workers (HCWs) in the early weeks of the coronavirus disease 2019 (COVID-19) pandemic, and the importance of expressions of gratitude from leadership for HCWs’ commitment and willingness to put themselves in harm’s way as a means to ameliorate that anxiety.
Shanafelt T, Ripp J, Trockel M. june 2020
Ondansetron Use in Pregnancy and Congenital Malformations—Reply
In Reply Ms Saban and colleagues raise questions about treatment with intravenous ondansetron in our cohort study of congenital malformations. We reported an adjusted relative risk (RR) of oral clefts of 0.95 (95% CI, 0.63-1.43) for intravenous ondansetron and 1.24 (95% CI, 1.03-1.48) for oral ondansetron in an earlier publication. Although the point estimate is lower for intravenous ondansetron compared with oral ondansetron, the 95% CI was wide, with an upper limit similar to that for oral ondansetron. Although the increase in risk was statistically significant for oral ondansetron and was not for intravenous ondansetron, interpretation of risk estimates from epidemiological studies should focus on the magnitude of the observed increase in risk and the precision of the estimate and not on statistical significance alone. Based on our analyses, given the width of the 95% CIs, there is insufficient evidence to conclude that the observed risks are different for intravenous vs oral ondansetron.
Huybrechts KF, Hernandez-Diaz S, Bateman BT. may 2020
Genital Powder Use and Ovarian Cancer
To the Editor We disagree with the analysis and interpretation of the findings presented by Dr O’Brien and colleagues. The increased risk of ovarian cancer in women with intact genital tracts exposed to powder (HR, 1.13) is actually greater than the estimated 10% increased incidence of ovarian cancer attributable to cumulative talc exposure with 10 000 or more applications previously reported in women with intact genital tracts. The lack of association in women without an intact genital tract is consistent with their curtailed exposure. O’Brien and colleagues discounted the results because their statistical test for heterogeneity was not statistically significant. No statistical test is needed to know that women without an intact genital tract face a different risk of ovarian cancer than women whose genital tract is intact.
Harlow BL, Murray EJ, Rothman KJ. may 2020
Deprescribing Antihypertensive Medications for Patients Aged 80 or Older
The treatment of hypertension in older adults is a major public health concern. Among the nearly 13 million persons in the United States aged 80 years or older, approximately 80% have high blood pressure (BP). Hypertension is the most potent modifiable risk factor for cardiovascular disease in older adults and has been strongly associated with stroke, myocardial infarction, heart failure, peripheral artery disease, kidney failure, and dementia. Thus, defining optimal strategies for managing elevated BP in older individuals is a high priority.
Peterson ED, Rich MW. may 2020
COVID-19 and Risks Posed to Personnel During Endotracheal Intubation
Health care personnel who care for critically ill patients with suspected or confirmed novel coronavirus disease 2019 (COVID-19) routinely participate in procedures, such as endotracheal intubation, that may create infectious aerosols. Among persons infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes COVID-19, approximately 8% will require endotracheal intubation and mechanical ventilation.
Weissman DN, de Perio MA, Radonovich LJ, Jr. may 2020
Diagnosis and Treatment of Opioid Use Disorder in 2020
This JAMA Insights Clinical Update reviews current approaches to screening for and managing opioid use disorder, summarizing available screening instruments, diagnostic criteria, and appropriate use of medication-assisted treatment (MAT), including methadone, buprenorphine, and naltrexone.
Wakeman SE. may 2020
The etiology of pellagra has attracted the consideration of a number of investigators who have been able to study it on an unusually large scale and with exceptional facilities. In this country the zeist theory, which related pellagra in some way to the dietary use of maize and maize products, has been finally abandoned. An exclusive diet of corn is unquestionably inadequate; and corn damaged by microbiotic changes may well be harmful at times to persons ingesting it. But no adequate review of the actual incidence of pellagra, as it has occurred in different places and among different peoples, will any longer justify the assumption that the pathogenesis of the disease is concerned primarily with a corn factor. Pellagra may occur without the use of corn.
Health Care Heroes of the COVID-19 Pandemic
The COVID-19 pandemic has accounted for tens of thousands of deaths and ultimately will affect millions more people who will survive. There will be time to mourn the victims and care for the survivors. But it is also time to recognize and thank some of the heroes who have emerged so far.
Bauchner H, Easley TJ, . may 2020
Emerging Lessons From COVID-19 Response in New York City
In a little more than 1 month, US society and its hospitals were transformed by coronavirus disease 2019 (COVID-19). The once-boisterous streets of New York City became quiet, while the hospital wards reverberated with the swooshes and beeps usually heard in intensive care units (ICUs). COVID-19 echoed that duality. There are so many outside the hospital who were silently infected, while so many fought for their lives in the hospital, struggling just to breathe.
Chokshi DA, Katz MH. may 2020
Interventions to Prevent Illicit Drug Use in Children, Adolescents, and Young Adults
This JAMA Patient Page summarizes the 2020 US Preventive Services Task Force recommendation concluding that evidence is insufficient to assess the balance of benefits and harms of primary care–based behavioral counseling interventions to prevent illicit drug use in children, adolescents, and young adults.
Jin J. may 2020
Effect of Doxycycline on Aneurysm Growth of Small Infrarenal Abdominal Aortic Aneurysms
This randomized trial compares the effect of doxycycline with placebo on reducing CT-measured abdominal aortic aneurysms over 2 years among patients with small infrarenal abdominal aortic aneurysms.
Baxter B, Matsumura J, Curci JA, et al. may 2020
Lost Space and Lost Connection With Noninfected Patients
In this narrative medicine essay, an internist considers the effects of the coronavirus disease 2019 pandemic on noninfected patients whose access to care may be blocked by fear, economic loss, or an overwhelmed health care system.
Thronson R. may 2020
The Pass/Fail Decision for USMLE Step 1—Next Steps
On February 12, 2020, the Federation of State Medical Boards and the National Board of Medical Examiners announced a change in score reporting of Step 1 of the United States Medical Licensing Examination (USMLE) from a 3-digit numerical score to pass/fail. As explained in the Viewpoint by Chaudhry et al, 3-digit numerical scoring is perceived to have had deleterious effects on student well-being and the medical education learning environment.
Humphrey HJ, Woodruff JN. may 2020
Reporting USMLE Step 1 Scores as Pass/Fail: An Opportunity for Medical Education and Training
This Viewpoint discusses the rationale for the announced 2022 change in USMLE Step 1 examination scoring from a 3-digit score to a pass/fail designation, addressing concerns that the change might lead to a shift in the importance of Step 2 Clinical Knowledge scores and emphasizing it as one part of a process to improve students’ transition into graduate medical education (GME) training programs.
Chaudhry HJ, Katsufrakis PJ, Tallia AF. may 2020
Antihypertensive Medication Reduction vs Usual Care in Short-term Blood Pressure Control
This randomized clinical trial compares the effects of antihypertensive medication withdrawal vs usual care on systolic blood pressure (SBP) among adults ≥80 years with SBP <150 mm Hg receiving ≥2 blood pressure–lowering drugs.
Sheppard JP, Burt J, Lown M, et al. may 2020
Psoriasis Drug Guselkumab Improved Psoriatic Arthritis Symptoms
Guselkumab, a biologic drug approved to treat patients with moderate or severe psoriasis, significantly and safely improved psoriatic arthritis, a phase 3 trial in The Lancet concluded. Guselkumab is a human monoclonal antibody that inhibits interleukin-23.
Slomski A. may 2020
Daily Aspirin Not Neuroprotective in ASPREE Trial
Daily low-dose aspirin does not reduce the risk of dementia, mild cognitive impairment (MCI), or cognitive decline, according to a secondary analysis of the Aspirin in Reducing Events in the Elderly (ASPREE) trial, published in Neurology.
Slomski A. may 2020
Prevalence, Types, and Sources of Bullying Reported by US General Surgery Residents in 2019
This survey study describes surgical trainees’ self-reported experiences of bullying and symptoms of burnout and suicidality assessed at the time of their board certification examination.
Zhang LM, Ellis RJ, Ma M, et al. may 2020
USPSTF Recommendation: Interventions to Prevent Illicit Drug Use in Children and Young Adults
This 2020 Recommendation Statement from the US Preventive Services Task Force concludes that the current evidence is insufficient to assess the balance of benefits and harms of primary care–based behavioral counseling interventions to prevent illicit drug use, including nonmedical use of prescription drugs, in children, adolescents, and young adults (I statement).
, Krist AH, Davidson KW, et al. may 2020
Clarification of Mortality Rate and Data in Abstract, Results, and Table 2
In the Original Investigation titled “Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area” published online April 22, 2020, in JAMA, clarification and correction of data were required. In the Abstract, Results paragraph, the sentence reporting mortality for patients receiving mechanical ventilation should read, “As of April 4, 2020, for patients requiring mechanical ventilation (n = 1151, 20.2%), 38 (3.3%) were discharged alive, 282 (24.5%) died, and 831 (72.2%) remained in hospital.” This same sentence was added to the second paragraph of the Results section in the text. In the first paragraph of the text Results, the sentence about test results should read, “The first test for COVID-19 was positive in 5517 patients (96.8%), while 183 patients (3.2%) had a negative first test and positive repeat test.” In the Discussion, a paragraph was added to clarify the calculation of mortality rates. In Table 2, the number (%) of patients with concurrent entero/rhinovirus infection should be “22 (52.4).” This article has been corrected online.
Symptoms at COVID-19 Onset Among Health Care Workers in Washington State
This study assessed the spectrum of initial symptoms at the onset of polymerase chain reaction–confirmed coronavirus disease 2019 (COVID-19) among health care personnel in King County, Washington.
Chow EJ, Schwartz NG, Tobolowsky FA, et al. may 2020
Medicaid’s Response to COVID-19: Securing the Safety Net and Protecting Public Health
This Viewpoint reviews options legally available to state Medicaid programs to respond to the COVID-19 pandemic, including increasing coverage of the uninsured, expanding telehealth capabilities, removing financial barriers to testing and treatment, and easing limits on drug prescriptions.
Bachireddy C, Chen C, Dar M. may 2020
Social Media and Emergency Preparedness for the Coronavirus 2019 (COVID-19) Pandemic
This Viewpoint discusses the ways social media can be used as a critical tool in managing the COVID-19 outbreak, such as by directing users to trusted sources and counteracting misinformation, and how it can transform aspects of preparedness and response for the future.
Merchant RM, Lurie N. may 2020
Rates of Co-infection of SARS-CoV-2 With Other Respiratory Pathogens
This study describes the prevalence of SARS-CoV-2 co-infection with noncoronavirus respiratory pathogens in a sample of symptomatic patients undergoing PCR testing in March 2020.
Kim D, Quinn J, Pinsky B, et al. may 2020
Ondansetron Use in Pregnancy and Congenital Malformations
To the Editor Dr Huybrechts and colleagues conducted a population-based cohort study of intravenous ondansetron use during pregnancy and congenital malformations and found no association.
Saban A, Deruelle P, Boisrame T. may 2020
Simulated Coronavirus Contamination of Health Care Workers After Endotracheal Intubation of Manikins
This study uses an atomizer and fluorescent markers to simulate contamination of uncovered skin and hair of health care workers wearing personal protective equipment after intubating patient manikins under emergency conditions.
Feldman O, Meir M, Shavit D, et al. may 2020
The Business of Medicine in the Era of COVID-19
This Viewpoint discusses the shifting landscape of health care financing, regulation, and delivery as a result of the coronavirus pandemic, and discusses regulatory and other changes that need to be in place if telehealth and physician practice and hospital mergers become the “new normal” once the pandemic is controlled.
Cutler DM, Nikpay S, Huckman RS. may 2020
Reporting USMLE Step 1 Scores as Pass/Fail: Implications for International Medical Graduates
This Viewpoint reviews the roles international medical graduates (IMGs) play in US health care systems and discusses the potential challenges that the announced 2022 change in USMLE Step 1 examination scoring from a 3-digit score to a pass/fail designation will pose for this workforce segment.
Desai A, Hegde A, Das D. may 2020
Reporting USMLE Step 1 Scores as Pass/Fail: Where Does It Leave Students?
This Viewpoint discusses possible unforeseen consequences of the announced 2022 change to USMLE Step 1 licensure examination results reporting from a 3-digit score to a pass/fail designation, including increased emphasis by programs on the scored Step 2 Clinical Knowledge examination and increased reliance on institutional reputations as criteria to recruit trainees.
Crane MA, Chang HA, Azamfirei R. may 2020
Oncology Practice During the COVID-19 Pandemic
This Viewpoint proposes a framework for modifying cancer care in the midst of the COVID-19 pandemic that balances considerations about the time-sensitivity of patient need for visits and treatment, risk of infectious exposure, and hospital and staff capacity and stress.
Schrag D, Hershman DL, Basch E. may 2020
Disposing of Controlled Substances After Home Hospice Deaths
Patients who die while receiving hospice care at home often leave behind unused controlled substances that aren’t disposed of properly and could be diverted or misused, according to a recent US Government Accountability Office (GAO) report.
Rubin R. may 2020
Genital Powder Use and Ovarian Cancer
To the Editor Dr O’Brien and colleagues combined data on powder use in the genital area and ovarian cancer from 4 cohort studies and reported an overall hazard ratio (HR) of 1.08 (95% CI, 0.99-1.17). Except for data from the Nurses’ Health Study II and additional follow-up, little new information was presented. Previously, combined data from 3 of the cohorts showed an odds ratio (OR) for perineal powder use and ovarian cancer of 1.06 (95% CI, 0.90-1.25). In the latter study, the cohort data did not outweigh the evidence from 24 case-control studies, with a combined OR of 1.31 (95% CI, 1.24-1.39).
Cramer DW. may 2020
Integrated Care Cut Mortality in Patients With Atrial Fibrillation
An integrated-care intervention conducted in primary care practices reduced all-cause mortality among elderly patients with atrial fibrillation (AF), a noninferiority trial in the European Heart Journal demonstrated.
Slomski A. may 2020
USPSTF Report: Interventions to Prevent Drug Use in Children, Adolescents, and Young Adults
This systematic review to support the 2020 US Preventive Services Task Force Recommendation Statement on interventions to prevent illicit and nonmedical drug use summarizes published evidence on the benefits and harms of primary care–based interventions to prevent illicit and nonmedical drug use in children, adolescents, and young adults.
O’Connor E, Thomas R, Senger CA, et al. may 2020
Mother is less noun than predicate in the daily liturgy of care for a second body, childhood’s parade of sensation as in tickle here come the monkeys, now elephants, the clown of a graham cracker bobbing in its dunk-tank of milk, trapeze act of noodles sidling down the tines.
Treseler H. may 2020
Genital Powder Use and Ovarian Cancer—Reply
In Reply As pointed out by Dr Cramer, the cohorts in our pooled analysis assessed powder use with less detail compared with prior case-control studies. He is also correct that most participants were postmenopausal at enrollment, although ever use included premenopausal time and we considered menopausal status and hormone use as effect modifiers. We noted that genital powder exposure was likely misclassified for some individuals, especially with regard to frequency and duration, and we did not have data on changes in use over time, use during specific exposure windows, or use of different types of powder. This lack of detail may have biased our effect estimates toward the null.
O’Brien KM, Sandler DP, Wentzensen N. may 2020
Postacute Care Preparedness for COVID-19
This Viewpoint discusses the second surge of COVID-19 patients on postacute care facilities and offers suggestions on how the medical community and policy makers should prepare by ensuring adequate infrastructure, staff training, and protective equipment.
Grabowski DC, Joynt Maddox KE. may 2020
No Benefit for Lopinavir–Ritonavir in Severe COVID-19
Treatment with the HIV combination drug lopinavir-ritonavir did not accelerate recovery or improve mortality rates among hospitalized patients with severe coronavirus disease 2019 (COVID-19), a trial in the New England Journal of Medicine reported.
Slomski A. may 2020
From Mitigation to Containment of the COVID-19 Pandemic
This Viewpoint discusses public health strategies necessary for the US to relax its mitigation strategies—most notably expanded testing, isolation, and contact-tracing in ways that avoid stigmatization of vulnerable populations—and proposes investing returns from a reopened economy to finance testing and public health infrastructure.
Walensky RP, del Rio C. may 2020
Sample Pooling as a Strategy to Detect Community Transmission of SARS-CoV-2
This study describes findings of novel coronavirus testing on pooled nasopharyngeal and bronchoalveolar lavage samples taken from patients who had negative results by routine respiratory virus testing to see if pooling samples could increase testing throughput and efficiency and facilitate early detection of community COVID-19 transmission.
Hogan CA, Sahoo MK, Pinsky BA. may 2020
Testing Individuals for COVID-19
This JAMA Patient Page describes the test for coronavirus disease 2019 (COVID-19), current guidelines for determining who should be tested, reasons for slow adoption of testing in the US, and potential drawbacks of alternate tests.
Hadaya J, Schumm M, Livingston EH. may 2020
Balancing Past vs Future Values in Decision-making
To the Editor For 30 years, philosophers and legal scholars have pondered the possible disconnect when a person dictates treatment preferences in advance directives for their future self. Psychologists and disability scholars followed, demonstrating that individuals are poor predictors of how they will feel in the future, potentially locking themselves into unwelcome commitments.
Shapiro SP. may 2020
Food Safety and COVID-19
This JAMA Patient Page describes how the novel coronavirus that causes COVID-19 is transmitted and provides measures people can take while grocery shopping, unpacking groceries, and preparing food to minimize the risk of being infected.
Desai AN, Aronoff DM. may 2020
Cognitive Screening of Older Practitioners
To the Editor Drs Cooney and Balcezak described an innovative and well-intentioned effort at Yale New Haven Hospital to assess the cognitive ability and professional competency of aging clinicians. However, the understandably benevolent procedure of allowing older physicians whose safety to treat patients has been called into question to subsequently retire or limit their practice voluntarily raises real questions of compliance with federal law. It is important that physicians who sit on hospital peer review committees be apprised of this issue because failure on the part of the hospital to make mandatory reports may compromise the liability protections afforded to participants in the professional review process.
Kels CG. may 2020
Conserving Supply of Personal Protective Equipment—A Call for Ideas
The editors of JAMA recognize the challenges, concerns, and frustration about the shortage of personal protective equipment (PPE) that is affecting the care of patients and safety of health care workers in the US and around the world. We seek creative immediate solutions for how to maximize the use of PPE, to conserve the supply of PPE, and to identify new sources of PPE. We are interested in suggestions, recommendations, and potential actions from individuals who have relevant experience, especially from physicians, other health care professionals, and administrators in hospitals and other clinical settings. JAMA is inviting immediate suggestions, which can be added as online comments to this article.
Bauchner H, Fontanarosa PB, Livingston EH. may 2020
COVID-19—Looking Beyond Tomorrow for Health Care and Society
Just 6 months ago, the novel coronavirus now known as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and COVID-19, the severe disease it causes, were unheard of. Today, this highly contagious and dangerous virus and the widespread virulent disease it causes have resulted in major disruptions of business, education, and transportation, and have permeated and interrupted virtually every aspect of daily life. Millions of people have been affected by COVID-19, hundreds of thousands have experienced critical illness, and tens of thousands have died. Physicians, other health care professionals, and health care systems around the world have been challenged like never before in recent history.
Fontanarosa PB, Bauchner H. may 2020
Ensuring Scientific Integrity and Public Confidence in the Search for Effective COVID-19 Treatment
This Viewpoint discusses the risks to patients and public health posed by the FDA’s politically pressured Emergency Use Authorization (EUA) of chloroquine and hydroxychloroquine for COVID-19 treatment, and proposes principles to follow to ensure new therapies are studied properly and quickly to maximize benefits and minimize risks to patients.
Goodman JL, Borio L. may 2020
The Sound of Grief
I watch in silence as another boy lies still upon this shrouded cot. Garnet jelly pools beside his chest and bubbles seep from holes torn in the pale soft skin. A sigh escapes the room as if the air has been released and all the noise replaced by softer sounds, the closing up of drawers the final keyboard clicks the wide broom brushes on the trash strewn floor the contents to be bagged and tied for homicide or simply thrown away.
Mitchell EL. may 2020
Sourcing Personal Protective Equipment During the COVID-19 Pandemic
As the coronavirus disease 2019 (COVID-19) pandemic accelerates, global health care systems have become overwhelmed with potentially infectious patients seeking testing and care. Preventing spread of infection to and from health care workers (HCWs) and patients relies on effective use of personal protective equipment (PPE)—gloves, face masks, air-purifying respirators, goggles, face shields, respirators, and gowns. A critical shortage of all of these is projected to develop or has already developed in areas of high demand. PPE, formerly ubiquitous and disposable in the hospital environment, is now a scarce and precious commodity in many locations when it is needed most to care for highly infectious patients. An increase in PPE supply in response to this new demand will require a large increase in PPE manufacturing, a process that will take time many health care systems do not have, given the rapid increase in ill COVID-19 patients.
Livingston E, Desai A, Berkwits M. may 2020
Risk of Legal Liability for Withdrawing or Withholding Ventilators From COVID-19 Patients
This Viewpoint discusses the legal risks to health care workers and hospital systems from withdrawing or withholding ventilation from COVID-19 patients and cites a Maryland statute that offers legal immunity to clinicians making good faith decisions under emergency conditions as an example for other states to follow.
Cohen I, Crespo AM, White DB. may 2020
Study Suggests a Second Patient Has Been Cured of HIV
For only the second time, a patient with HIV who received an allogeneic hematopoietic stem cell transplant from a donor with an HIV resistance gene appears to have been cured of the disease, according to a recent study.
Kuehn BM. may 2020
Seasonal Influenza Activity During the SARS-CoV-2 Outbreak in Japan
This study uses data from the National Institutes of Infectious Diseases Japan to compare weekly influenza activity in the 2019/2020 vs the 2014-2019 seasons given mitigation strategies taken in 2020 to limit the spread of COVID-19.
Sakamoto H, Ishikane M, Ueda P. may 2020
Cognitive Screening of Older Practitioners—Reply
In Reply We agree with Dr Wijeratne that more information on the results of cognitive testing of older physicians would be helpful, including the optimal age at which to start testing. The screening test created domain-specific results for executive function and other domains, and we did evaluate individuals who were impaired in 1 or more specific domains despite an overall passing score. We extended our screening process in these domains for these clinicians. We proceeded with full neuropsychological testing for individuals with worrisome results in specific domains.
Cooney LM, Jr, Balcezak T. may 2020
Failing Another National Stress Test on Health Disparities
This narrative medicine essay emphasizes the undue disease burden carried by minority populations in the COVID-19 pandemic and proposes collection and reporting of data by race/ethnicity and multilingual targeted educational efforts delivered by celebrities or faith leaders as first steps to reduce the imbalance.
Owen WF, Jr, Carmona R, Pomeroy C. may 2020
Treating COVID-19—Off-Label and Compassionate Use and Clinical Trials During Pandemics
This Viewpoint uses the absence of known effective treatment for Ebola virus disease to emphasize the costs of off-label and compassionate drug use during an infectious disease outbreak and the importance of establishing the efficacy and safety of promising drug leads in randomized trials to inform their clinical use.
Kalil AC. may 2020
SARS-CoV-2 Among Patients Presenting With Influenzalike Illnesses to a Los Angeles Medical Center
This study characterizes the prevalence of reverse-transcriptase polymerase chain reaction results positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) among patients presenting with influenzalike illness who underwent nasopharyngeal swab testing for influenza and respiratory syncytial virus over 4 days in March 2020.
Spellberg B, Haddix M, Lee R, et al. may 2020
Cognitive Screening of Older Practitioners
To the Editor A JAMA Performance Improvement article reported the use of a cognitive screening battery as the primary basis of recredentialing older practitioners by Yale New Haven Hospital. Some modifications and caveats would enhance this program and those at other centers for testing the cognition of physicians.
Wijeratne C. may 2020
Generic Albuterol Inhaler Approved
The FDA has approved the first generic version of Proventil HFA Metered Dose Inhaler, 90 μg per inhalation, to treat or prevent bronchospasm in patients aged 4 years or older who have reversible obstructive airway disease. The generic albuterol sulfate inhaler also is indicated for exercise-induced bronchospasm prevention in the same age group.
Voelker R. may 2020
Antenatal corticosteroids, when administered to a pregnant woman before delivery of a very premature infant, accelerate fetal lung maturation and prevent neonatal mortality, respiratory distress syndrome, and brain injury. Even though the first trial to demonstrate benefits of antenatal corticosteroid exposure was published in 1972, widespread use of this therapy did not occur until 20 years later. The first systematic review of antenatal corticosteroid therapy was so influential in the obstetric and neonatal care communities that a forest plot from this study is depicted in the logo for the Cochrane Database of Systematic Reviews. Antenatal corticosteroid therapy has been one of the most important advances in perinatal care.
DeMauro SB. may 2020
The Bubonic Plague in San Francisco
We have always regarded the plague as something very distant and impossible, and have read of its ravages in India and China with much the same feeling of composure and security that we read about an uprising of the natives in Madagascar. Or perhaps we have considered it as a matter of historic interest on account of the fearful epidemics which in pre-sanitary days used to sweep over Europe, devastating countries and hardly leaving enough people behind to keep up the archives and records of the state. Even now that it is among us, and in America for the first time, there seems to be a tendency to underrate its importance and dismiss it without a thought, as a scare designed for base political motives.
Association Between Antenatal Maternal Corticosteroid Treatment and Mental/Behavioral Disorders in Children
This population cohort study uses national Finnish birth registry data to assess associations between antenatal corticosteroid treatment to accelerate fetal maturation and mental and behavioral disorders in term and preterm children.
Räikkönen K, Gissler M, Kajantie E. may 2020
WHO: Strengthen Nurse Workforce
An urgent global effort is needed to bolster the nurse workforce, according to a report from the World Health Organization (WHO), the International Council of Nurses, and Nursing Now, an international campaign to raise nurses’ status.
Kuehn BM. may 2020
Optimizing the Trade-off Between Learning and Doing in the COVID-19 Pandemic
This Viewpoint discusses the tensions between evaluating treatments (learning) and just treating patients (doing) during the coronavirus disease 2019 (COVID-19) pandemic, and proposes actions the clinical research and practice communities can take to support each other’s imperatives so that both can “learn from doing” in a more integrated patient care approach.
Angus DC. may 2020
COVID-19, African Americans, and Health Disparities
This Viewpoint discusses the long history of racial inequities that cause black populations in US cities to bear a disproportionate burden of COVID-19 illness and mortality and calls for a renewed commitment to eliminating disparities that have been made so starkly visible by the pandemic.
Yancy CW. may 2020
Studies Explore HIV Treatment and Prevention in Pregnant Women
Taking dolutegravir along with a single pill containing emtricitabine (FTC) and tenofovir alafenamide fumarate (TAF) is the safest, most effective option for pregnant women with HIV and their infants, according to a large international study presented recently at the Conference on Retroviruses and Opportunistic Infections (CROI).
Kuehn BM. may 2020
Public Health Interventions and Epidemiology of the COVID-19 Outbreak in Wuhan, China
This population epidemiology study examines associations between phases of nonpharmaceutical public health interventions (social distancing, centralized quarantine, home confinement, and others) and rates of laboratory-confirmed COVID-19 infection in Wuhan, China, between December 2019 and early March 2020.
Pan A, Liu L, Wang C, et al. may 2020
Mathematical Models Predicting the COVID-19 Pandemic
This Viewpoint discusses the challenges of accurately modeling the COVID-19 pandemic and reviews principles that will make some models more useful than others, such as use of granular local data when available, regular updating and revision, and specification of uncertainty around estimates.
Jewell NP, Lewnard JA, Jewell BL. may 2020
Public Health Interventions for COVID-19
For decades, leading scientists and influential professional societies have warned of the dangers of emerging infections and the specter of a global pandemic. The emergence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and its subsequent spread has lived up to and surpassed many of the warnings and has caused an evolving global public health and economic crisis. Significantly, no pharmaceutical agents are known to be safe and effective at preventing or treating coronavirus disease 2019 (COVID-19), the resulting illness. This leaves the medical and public health community with only nonpharmaceutical interventions (NPIs) to rely on for reducing the burden of COVID-19. These measures aim to reduce disease transmission both locally and globally and include bans on public gatherings, compulsory stay-at-home policies, mandating closures of schools and nonessential businesses, face mask ordinances, quarantine and cordon sanitaire (ie, a defined quarantine area from which those inside are not allowed to leave), among others. The effectiveness of NPIs has been studied theoretically, especially within the context of pandemic influenza, and also through analysis of historical observational data. A common finding of these studies is that implementing NPIs, especially when done rapidly after initial detection of a new contagious pathogen, can reduce transmission.
Hartley DM, Perencevich EN. may 2020
FDA Site Inspection Reports on RCT Irregularities and Misconduct—The Case For Transparency
This Viewpoint reviews notable examples of clinical trial misconduct identified by routine US Food and Drug Administration (FDA) clinical trial site inspections and argues that making inspection reports publicly available on the agency’s and trial registry websites is important to maintaining the integrity of clinical research.
Dal-Ré R, Kesselheim AS, Bourgeois FT. may 2020
Balancing Past vs Future Values in Decision-Making—Reply
In Reply Dr Shapiro comments on our Viewpoint on improving conversations regarding treatment decisions in the intensive care unit. To accomplish truly informed, patient-centered treatment decisions, be it with would-be patients in advance of a crisis (advance care planning) or with the family members of incapacitated patients in the intensive care unit, sensitive, skillful, and honest communication is key.
Creutzfeldt CJ, Holloway RG. may 2020
Time to Consider a New Look at Physician-Owned Hospitals to Increase Competition in Health Care?
In most sectors of the economy, competition is regarded as the way to improve quality and efficiency, lower costs, and increase innovations. Whether competition effectively achieves these improvements in health care, particularly with respect to hospital services, which remains the largest sector of spending for health care, is open to debate. Also debated, at least among some physicians, is whether functionally banning new physician-owned hospitals by prohibiting their participation in Medicare under the Affordable Care Act (ACA) was too blunt an instrument to correct a problem that could have been fixed with a more nuanced regulatory solution, needlessly limiting a potential source of competition for hospital services.
Wilensky G, Miller B. may 2020
Infectious Disease Outbreaks, Pandemics, and Hollywood—Hope and Fear Across a Century of Cinema
This Arts and Medicine feature tallies the appearance of infectious disease outbreaks in cinema since 1914, and identifies common themes, such as stigmatization and physician heroism, that characterize the films.
Dehority W. may 2020
ACEI/ARB Use and Risk of Infection or Severity or Mortality of COVID-19: A Systematic Review and Meta-analysis
Meta-análise de estudos observacionais que não confirma preocupações anteriores sobre um risco maior de infecção, maior gravidade e mortalidade em pacientes com COVID-19 que fazem IECA ou ARA. Pelo contrário, um menor risco de mortalidade foi observado quando limitando análise a pacientes com hipertensão (análise com elevado risco de viés). Parece-nos no entando seguro afirmar que os doentes não devem descontinuar estes fármacos.
Xue Zhang, Jiong Yu, Li-ya Pan, Hai-yin Jiangmay 2020
Hydroxychloroquine in patients with mainly mild to moderate coronavirus disease 2019: open label, randomised controlled trial
Ensaio clínico open label o que pode induzir viezes relevantes. Amostra pequena. Hidroxicloroquina não resultou numa probabilidade significativamente maior de conversão negativa do que os cuidados habituais em doentes com COVID19 leve a moderada. Os eventos adversos foram maiores nos doentes a fazer hidroxicloroquina do que nos que não a fizeram.
Tang, Wei and Cao, Zhujun and Han, Mingfeng and Wang, Zhengyan, et al. may 2020
Clinical and Epidemiological Characteristics of 1,420 European Patients with mild‐to‐moderate Coronavirus Disease 2019
Os sintomas mais frequentemente reportados em doentes com formas ligeiras a moderadas de infeção por COVID-19 foram cefaleia, anósmia, obstrução nasal, tosse, astenia, mialgias, rinorreia, alterações do paladar e odinofagia. É um estudo realizado numa população europeia, com características semelhantes aos nossos doentes. Sendo um estudo transversal, descritivo permite ter uma ideia das prevalências de cada um dos sintomas mas, para a decisão clínica, seria útil um estudo de acuidade diagnóstica para determinar LRs de certos sintomas (anosmia, por exemplo). Apesar de os autores terem recorrido a modelos preditivos, este é um estudo exploratório. Através da metodologia usada não é possível estabelecer relações causais e é difícil perceber a força de cada correlação.
Jerome R. Lechien, Carlos M. Chiesa‐Estomba, Sammy Place, et al.may 2020
Training and Fitting Health Care Personnel for Elastomeric Half-Mask vs N95 Respirators
This study examines the feasibility of rapidly training and fit testing health care workers to use elastomeric half-mask respirators (EHMRs), widely used in construction and manufacturing, as an alternative to N95 respirators during periods of shortage.
Pompeii LA, Kraft CS, Brownsword EA, et al. may 2020
Cultivating Hope Through Advocacy, Love, and Resilience
In this narrative medicine essay, a pediatric psychiatrist relates how her younger sister with Down syndrome and congenital heart disease has lived well beyond expectation inspired her to help children cultivate hope through love and resilience.
Singh MK. may 2020
Delivery of Talc for Pleurodesis of Malignant Pleural Effusions
To the Editor Dr Bhatnagar and colleagues examined the effect of thoracoscopic talc poudrage vs talc slurry on pleurodesis in individuals with malignant pleural effusions and found no significant differences between the procedures. We have a number of concerns about the study.
Wollbrett C, Seitlinger J, Renaud S. may 2020
Medical Students and Public Health Service for the COVID-19 Pandemic
Over the next few months it is likely that the coronavirus disease 2019 (COVID-19) pandemic that has surged in New York City, Seattle, New Orleans, and Detroit will move from city to city and state to state. After the initial peak, absent highly effective medical interventions, the US will likely experience outbreaks of lingering disease for months and potentially years to come. As the US enters the next phase of COVID-19, critical questions will involve the nation’s capacity to respond to outbreaks, protect high-risk populations, and limit community spread.
Bauchner H, Sharfstein J. may 2020
Safety of ACEIs and ARBs in Patients With COVID-19—What Is the Evidence?
This Viewpoint reviews the pathophysiological and observational basis for speculating that angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) might worsen clinical outcomes for patients with COVID-19, and summarizes guidance from specialty societies to continue the drugs in patients who need them pending more definitive evidence of harm.
Patel AB, Verma A. may 2020
Serums and Vaccines in Influenza
With respect to serums and vaccines in influenza, there are certain simple facts and considerations that physicians will do well to keep in mind at this time. The main point to keep always in sight is that unfortunately we as yet have no specific serum or other specific means for the cure of influenza, and no specific vaccine or vaccines for its prevention. Such is the fact, all claims and propagandist statements in the newspapers and elsewhere to the contrary notwithstanding. This being the case, efforts at treatment and prevention by serums and vaccines, now hurriedly undertaken, are simply experiments in a new field, and the true value of the results cannot be predicted by any one. Indeed, the exact results can be determined if at all only after a time, in most cases probably not until the epidemic is past and all the returns fully canvassed. Consequently the physician must keep his head level and not allow himself to be led into making more promises than the facts warrant. This warning applies especially to health officers in their public relations.
Advanced Care Planning and Decisions About DNR Orders During COVID-19
This Viewpoint emphasizes the importance of advanced care planning and goals-of-care discussions with older patients and those with chronic disease during the spread of coronavirus disease (COVID-19), given the likelihood these patients could become critically ill and require resuscitation and advanced life support if they became infected with SARS-CoV-2.
Curtis J, Kross EK, Stapleton RD. may 2020
Discovering Why Some Infants Have Delayed Hearing Loss Detection
Several socioeconomic factors were linked in a recent study with delayed hearing loss diagnoses in Minnesota infants. Launching initiatives to pinpoint these populations and identify infants with hearing loss more quickly could help reduce their risk of delayed speech and language development, the study’s authors noted.
Kuehn BM. may 2020
Delivery of Talc for Pleurodesis of Malignant Pleural Effusions—Reply
In Reply The methods for our study were fully detailed in the eAppendix in the Supplement and included a comprehensive, 28-step recommended approach to performing medical thoracoscopy. One of these steps was ensuring even pleural coverage of talc. The article also made clear that procedures were performed while individuals were under local anesthesia and moderate sedation rather than general anesthetic.
Bhatnagar R, Maskell NA. may 2020
Association Between Pulmonary Rehabilitation After Hospitalization for COPD and 1-Year Survival
This inception cohort study uses Medicare fee-for-service claims data to assess the association between initiation of pulmonary rehabilitation within 90 days of hospital discharge and 1-year survival among US patients hospitalized for chronic obstructive pulmonary disease in 2014.
Lindenauer PK, Stefan MS, Pekow PS, et al. may 2020
Delayed Antibiotic Prescriptions in Ambulatory Care—Reconsidering a Problematic Practice
This Viewpoint discusses the unintended adverse consequences of delayed antibiotic prescribing—provision of an antibiotic prescription to be filled at a later date if a patient’s condition has not improved—and calls on clinicians to avoid the practice in patients who have self-limited conditions with likely viral etiologies.
Rowe TA, Linder JA. may 2020
A Framework for Rationing Scarce Ventilators and Critical Care Beds During the COVID-19 Pandemic
This Viewpoint describes a framework for rationing ventilators during the COVID-19 pandemic should intensive care units find themselves with more patients than they can care for, using a score-based system that incorporates patients’ likelihood of surviving to hospital discharge and beyond and their role in the public health response to the outbreak.
White DB, Lo B. may 2020
Toward Universal Deployable Guidelines for the Care of Patients With COVID-19
Guidelines are developed for various reasons, including the emergence of new, potentially practice-changing evidence or a perceived need for guidance in times of uncertainty. The COVID-19 pandemic presents an almost unparalleled example of the latter, prompting the Surviving Sepsis Campaign (SSC) Task Force to rapidly produce Guidelines on the Management of Critically Ill Adults With Coronavirus Disease 2019 (COVID-19). These guidelines are adapted from the well-known 2016 SSC guidelines, and highlights are excerpted in this issue of JAMA. In a brief amount of time, the authors have produced an impressively thorough and expansive set of guidelines, organized as more than 50 recommendations under 4 domains. The intended goal is to reduce unwanted practice variation and provide a focused and informed distillation of the existing evidence in a manner that will be practical for, and accessible to, clinicians in a wide variety of settings around the world. Because COVID-19 is a new disease, the SSC Task Force relied on the expert interpretation of available evidence from analogous conditions, such as sepsis, when generating its recommendation. The intent of the guideline committee is to update the guidelines as evidence specific to the care of patients with COVID-19 emerges.
Lamontagne F, Angus DC. may 2020
Ankle Robots Could Make Running Easier, Encourage Exercise
Stanford University’s Steven Collins, PhD, spends much of his time developing prostheses and exoskeletons to help people with disabilities walk more easily. Now he and his collaborators are designing a wearable ankle robot to aid in running. In treadmill tests, an exoskeleton emulator tethered to a power source decreased competitive runners’ net metabolic rate by 15% on average compared with jogging in normal shoes.
Abbasi J. may 2020
Effect of Surgery vs Functional Bracing on Functional Outcome for Closed Displaced Humeral Shaft Fractures
This randomized trial compares the effects of open reduction and internal fixation vs functional bracing for treating patients with closed displaced humeral shaft fractures.
Rämö L, Sumrein BO, Lepola V, et al. may 2020
Rural-Urban Differences in Cardiovascular Mortality in the United States, 1999-2017
This study used data from the US Centers for Disease Control and Prevention WONDER database to examined temporal trends in cardiovascular disease age-adjusted mortality rates overall and across subgroups stratified by rural-urban area designation in the US.
Cross SH, Mehra MR, Bhatt DL, et al. may 2020
Older Clinicians and the Surge in Novel Coronavirus Disease (COVID-19) Hospitalization
This Viewpoint summarizes the distribution of physicians and registered nurses aged 55 years and older in US cities caring for COVID-19 patients and proposes roles they can play in health systems that preserve their ability to apply their experience over the long-term course of the pandemic.
Buerhaus PI, Auerbach DI, Staiger DO. may 2020
Ethics Committee Reviews of Research Applications in China for COVID-19
This study reviews research ethics committee applications for COVID-19–related research at a Chinese hospital in February 2020 to characterize study type, approval rate and review time, reason for revision or denial, and issues with informed consent.
Zhang H, Shao F, Gu J, et al. may 2020
PET-CT Improved High-risk Prostate Cancer Staging in Trial
In a recent phase 3 trial, a novel imaging technique that identifies prostate-specific membrane antigen (PSMA) on tumor cells was more accurate than the scans typically used to stage high-risk prostate cancer before surgery or radiotherapy. The crossover study compared a combination of PSMA positron emission tomography (PET) and computed tomography (CT)—or PSMA PET-CT—with conventional imaging using CT and bone scans.
Abbasi J. may 2020
Pulmonary Rehabilitation and Improved Survival for Patients With COPD
Chronic obstructive pulmonary disease (COPD) is highly prevalent worldwide, is estimated to affect more than 16 million people in the US, and is the fourth leading cause of death in the US. COPD causes disabling physical and psychosocial symptoms for patients and adversely affects caregivers. Hospitalizations for COPD exacerbations are a key contributor to morbidity, mortality, and health care costs for individuals with COPD. Evidence-based interventions that reduce mortality are needed and would be welcomed by patients with COPD and clinicians alike.
Rochester CL, Holland AE. may 2020
Pharmacologic Treatments for Coronavirus Disease 2019 (COVID-19)
This narrative review summarizes what is currently known about how SARS-CoV-2 infects cells and causes disease as a basis for considering whether chloroquine, remdisivir and other antivirals, or other existing drugs might be effective treatment for coronavirus disease 2019 (COVID-19).
Sanders JM, Monogue ML, Jodlowski TZ, et al. may 2020
COVID-19 Case-Fatality Rate and Characteristics of Patients Dying in Italy
This Viewpoint from physicians with the Italian National Institute of Health confirms a higher case-fatality rate from coronavirus disease 2019 (COVID-19) in Italy compared with China and explains possible reasons, including age, cause of death definitions, and testing strategy.
Onder G, Rezza G, Brusaferro S. may 2020
Turbulent Gas Clouds and Respiratory Pathogen Emissions
This JAMA Insights Clinical Update discusses the need to better understand the dynamics of respiratory disease transmission by better characterizing transmission routes, the role of patient physiology in shaping them, and best approaches for source control in the context of the COVID-19 outbreak.
Bourouiba L. may 2020
Can SARS-CoV-2 Infection Be Acquired In Utero?
Two articles reported in this issue of JAMA from separate research teams in China present details of 3 neonates who may have been infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in utero from mothers with coronavirus disease 2019 (COVID-19). Evidence for such transmission is based on elevated IgM antibody values in blood drawn from the neonates following birth. All infants also had elevated IgG antibody values and cytokine levels, although these may have crossed the placenta from the mother to the infant. No infant specimen had a positive reverse transcriptase–polymerase chain reaction test result, so there is not virologic evidence for congenital infection in these cases to support the serologic suggestion of in utero transmission. Nevertheless, the serologic data are provocative for a virus that is believed to be spread by respiratory secretions and—given the modeling showing that a significant percentage of the world’s population, many of them pregnant women, will be infected over the next weeks or months—it is one that deserves careful consideration. However, at this time, these data are not conclusive and do not prove in utero transmission.
Kimberlin DW, Stagno S. may 2020
The COVID-19 Pandemic in the US: A Clinical Update
This Viewpoint provides a summary update of coronavirus disease 2019 (COVID-19) in the US, discussing case-fatality rates, interpretation of polymerase chain reaction test results, duration of immunity, reinfection, and more.
Omer SB, Malani P, del Rio C. may 2020
Effect of Biomechanical Footwear on Knee Pain in People With Knee Osteoarthritis
This randomized trial compares the effect of shoes with adjustable external convex pods attached to the outsole vs usual footwear on knee pain over 24 weeks in patients with symptomatic, radiologically confirmed knee osteoarthritis.
Reichenbach S, Felson DT, Hincapié CA, et al. may 2020
Interpreting a covid-19 test result
A interpretação do resultado de um teste para o covid-19 depende de duas coisas: a precisão do teste e a probabilidade pré-teste ou risco estimado de doença antes do teste; Um teste de RT-PCR positivo para o teste covid-19 tem mais peso do que um teste negativo devido à alta especificidade do teste, mas com sensibilidade moderada; Um único teste covid-19 negativo negativo não deve ser usado como regra em pacientes com sintomas fortemente sugestivos; Os médicos devem compartilhar informações com os pacientes sobre a precisão dos testes covid-19.
Watson J., Whiting P. F., Brush J. E.may 2020
Real-time tracking of self-reported symptoms to predict potential COVID-19
A partir de uma aplicação móvel de auto-relato de sintomas, apurou-se que parece existir uma associação entre sintomas como anósmia e disgeusia e o diagnóstico de COVID-19 (OR 6.74 [IC 95% 6.31-7.21]). A presença destes sintomas associada a outros já relatados anteriormente, como febre e tosse persistente, é fortemente sugestiva da presença da doença COVID-19.
Menni C., Valdes A.M., Freidin M.B., et al.may 2020
Interpreting Diagnostic Tests for SARS-CoV-2
A evidência actual revela que temos marcadores de diagnóstico para a detecção de COVID-19 úteis mas com aplicações temporais diferentes (ver figura). A maioria dos dados disponíveis referem-se a para populações adultas que não são imunocomprometidas. O curso temporal da positividade da PCR e de anticorpos IgM e IgG pode variar em crianças e outros grupos de doentes, incluindo a grande população de indivíduos assintomáticos que não são diagnosticados sem vigilância ativa. Muitas perguntas permanecem, particularmente quanto tempo dura a imunidade potencial em indivíduos, assintomáticos e sintomáticos, infectados com SARS-CoV-2.
Sethuraman N, Jeremiah SS, Ryo A.may 2020
The Incubation Period of Coronavirus Disease 2019 (COVID-19) From Publicly Reported Confirmed Cases: Estimation and Application
Em doentes por COVID-19 sintomáticos, estimou-se que o tempo médio de incubação para foi de 5.1 dias após a exposição, sendo que nas estimativas mais conservadoras, os primeiros sintomas poderiam ocorrer em média até 11.5 dias após a exposição. Através desta análise torna-se muito pouco provável que doentes de alto risco de contágio venham a ter um resultado positivo após o período de 14 dias de isolamento (1 em 10 000 pessoas). Ainda assim, este estudo não integrou doentes infectados por SARS-CoV-2 que permanecem sempre assintomáticos, pelo que a sua aplicabilidade nesse grupo é limitada.
Lauer SA, Grantz KH, Bi Q, et al.may 2020
The $50 000 Physical
In this narrative medicine essay, a physician reflects on his father’s experience, at the age of 85 years, of getting a physical examination from a new primary care physician that ended up setting off a cascade of examinations and treatments.
Rothberg MB. may 2020
Learning to Talk: Speaking the Language of Patients
In this narrative medicine essay, a resident physician recalls the joy she felt while learning the formal language of medicine as a student and anticipates the lifelong joy of learning to interpret that language in ways most helpful for her patients.
Landrey A. may 2020
The Environment: People Pollution
Meeting basic food and shelter needs of a growing population and catering to the insatiable consumer demands of people profoundly influences the quality of our environment. President Nixon observed that many of our present social problems may be related to the fact that we have had only 50 years in which to accommodate the second 100 million Americans. To provide for the increasing needs and demands of people, we are polluting our air, soil, and water. Unchecked population growth, people pollution, is not merely a problem, it is a paradox. It is an issue that is intimately private and yet inescapably public.
Moral Choices for Today’s Physician
In this essay, Don Berwick considers moral choices physicians face personally, organizationally, and globally and exhorts them to understand that the health of humanity depends on their speaking out against the social injustice of overpricing drugs and services, mass incarceration, and the lack of environmental responsibility.
Berwick DM. may 2020
Full Circle: How Medicine Enabled Avoidance and Acceptance
In this narrative medicine essay, a psychiatrist used her residency to avoid grieving the loss of her brother to suicide but through participation in a grief support group during training she began to thaw enough to remember her brother, watch videos of ephemeral moments like celebrating his fourth birthday, an act that allowed her to see him and her family again.
Abu-Libdeh RA. may 2020
John Lennon’s Elbow: The Long, Winding Road of the EMR Progress Note
In this narrative medicine essay, an attending physician shares his observations of how the changing nature of electronic medical record (EMR) hospital progress notes—often entered out of sequence and becoming ever longer and more unreadable—can hamper interacting with patients and providing patient care.
Hirschtick RE. may 2020
The Road Back to the Bedside
In this narrative medicine essay, a group of physicians from an academic program in bedside medicine offer their observations on deficiencies in the assessment of US medical residents’ clinical skills and suggest principles for enhancing the teaching and high-stakes assessment of these skills to improve diagnostic accuracy and achieve truly patient-centered care.
Elder A, Chi J, Ozdalga E, et al. may 2020
Mentoring in the #MeToo Era
In this narrative essay, the author wonders what effect the #metoo phenomenon will have on mentoring between male mentors and junior female trainees and faculty and recalls male mentors who were supportive of her and other women colleagues’ professional development in a plea for diversity and inclusion among leaders in medicine that supports the entire academic medical community.
Byerley J. may 2020
Advice for Starting Medical School
In this narrative medical essay, an internist offers three basic lessons not taught in medical school that he learned about practicing medicine based on his experiences from a patient with whom he has built a trusting relationship over the years.
Cifu AS. may 2020
The Quick Physical Exam
In this narrative medicine essay, a teaching physician uses the fictitious characters Holmes and Watson to dispell the belief held by many physicians—that a thorough physical examination is an unnecessary art of the past. His emphasis: taking time to gather data and observe can avoid unneeded tests and guide accurate diagnosis.
Hirschtick RE. may 2020
My first glimpse into the craft of physician-writers did not come through Anton Chekhov, Walker Percy, or William Carlos Williams, whose works I only came to after medical school. As a schoolboy, I loved W. Somerset Maugham, although he never practiced medicine, and his craft had little to do with his medical degree. My introduction to physicians as writers came through my textbooks. Boyd’s Pathology made me aware of literary voice, the ability of authors to place themselves in the text, let their personality come through, and subtly become a character in the reading experience. On the topic of defining the moment of death, Boyd in his single-author text wrote, “It was the author of the book of Ecclesiastes who said, ‘There is a time to be born, and a time to die.’ Fortunately it is the clinician, not the pathologist, who has to make this difficult decision. Sometimes, however, the kindly doctor may find himself murmuring those moving lines from the last act of King Lear: O let him pass! He hates him/That would upon the rack of this tough world/Stretch him out longer.”
Verghese A. may 2020
The Unreasonable Patient
In this narrative medicine essay, the author describes his experience with a patient referred to as “unreasonable,” and what the experience taught him about the need for physicians to perhaps improve their communication skills with patients rather than jump to labelling them.
Thurston A. may 2020
A Silent Curriculum
In this narrative medicine essay, a medical student reflects on the ways in which she has seen racism and implicit bias affect clinical practice and emphasizes the importance of examining and challenging these biases to address health inequalities.
Brooks KC. may 2020
My Name Is Not “Interpreter”
In this essay, the author relays his personal experience with ethnicity-based discrimination and discusses the “microaggressions” that medical trainees from underrepresented groups based on race/ethnicity, gender, or sexual orientation experience.
Montenegro RE. may 2020
In this narrative medicine essay, an African American physician reflects on her experience one day with a white member of her ward team made up of two interns, three medical students, and a senior resident that sparked cultural and racial discussions throughout their month together that usually do not occur in such a diverse group.
Manning KD. may 2020
Doppelgänger—Parallel Struggles to Lose Weight
In this narrative medicine essay, a primary care physician describes his patient’s struggle with obesity, sees himself in his patient, and wonders if his own struggles with weight loss impede his patient’s efforts to lose weight.
Kapur N. may 2020
Crossing Boundaries—Violation or Obligation?
In this narrative medicine essay, a physician reflects on the rise of professional boundaries; on the ways in which such boundaries can in some instances foster uncaring patient-physician relationships; and on ways physicians might balance providing objective medical care and addressing social and economic injustices in the lives of their patients.
Schiff GD. may 2020
EBM’s Six Dangerous Words
In this narrative medicine essay, a physician shares his thoughts about how the phrase “there is no evidence to suggest,” commonly used in the medical literature, can lead to false inferences and suppression of clinical intuition, and suggests four alternative phrases for clarifying inferences and improving shared decision-making.
Braithwaite R. may 2020
The Cost of Technology—Patient-Centered Care
In this narrative medicine essay, a primary care physician describes a drawing by a 7-year-old patient who is sitting on an examination table with her mother cradling her baby sister with the physician’s back to them entering data in the computer as an example of a system that is sacrificing human contact for electronics.
Toll E. may 2020
Miles Together—A Patient-Physician Journey
In this narrative medicine essay, a family physician shares the beginning and ending of a near 12-year journey with a patient, helping him reach sobriety that led to a full though short life and feeling humbled to have been so entrusted to travel with him.
Denniston CR. may 2020
Forty Years of A Piece of My Mind
Forty years ago, in 1980, Jimmy Carter was president. Pac-Man debuted. In medicine, smallpox was declared to be eradicated. Additionally, on May 9, 1980, A Piece of My Mind was inaugurated in JAMA. The first essay, “Tuna on Rye, 1984,” was written by then–senior editor Samuel Vaisrub under the pen name Sam Vee. He introduced the column with an editorial entitled “For the Peace of Your Mind.”
Malani PN, Zylke JW. may 2020
How to Mentor Millennials
In this narrative medical essay, the authors present 3 scenarios exemplifying the collision between mentoring expectations among millennials and older generation faculty and proposes strategies to bridge generational divides and engage the next generation of physicians.
Waljee JF, Chopra V, Saint S. may 2020
Friendships Across Cultural Barriers—We Are All the Same
In this narrative medicine essay, a family practitioner tells the story of how her relationship with an old-order Mennonite woman whose newborn son she examined and took to the hospital for cardiac surgery one Christmas day turns to friendship and a relationship with her broader community when the woman stays with her during her newborn daughter’s cardiac surgery.
Maneval ML. may 2020
What Would You Do, Doctor?
In this narrative medicine essay, an emergency medicine physician recalls an encounter early in her career when she was asked by parents to make a recommendation regarding ending life support for a young child, reflects on the way practice has changed from physician-centric to patient-involved decision-making, and discusses how her husband’s pancreatic cancer diagnosis brought up a different perspective.
Mannix R. may 2020
A Death in the Family
In this narrative medicine essay, an anesthesia resident describes his feelings of loss and unease when a coresident is admitted as a patient and dies of an overdose of fentanyl; this article emphasizes the importance of prioritizing physician wellness programs to help avoid burnout and substance use disorder.
Khan A. may 2020
For the Peace of Your Mind
We hasten to assure our readers that a piece of my mind...is not intended as a sounding board for peevish gripes, nit-picking beefs, or sundry assortments of righteous indignation, which are usually prefaced by an angry “let me give you a piece of my mind.” Nor is this section of The Journal meant to be a podium for pompous preachments and ex cathedra pronouncements. Nor again is it designed to be a forum for half-baked speculations and warmed-over hypotheses. Least of all is a piece of my mind envisaged as a jamboree of jokes and a shivaree of limericks.
The Sound of Silence—When There Are No Words
In this narrative medicine essay, a surgeon and palliative care physician describes the isolating silence that she felt her after the slaying of her father in Egypt when she was 18 years old and how that lingering silence has come to guide her when sitting with patients, when there are no words.
Hoffman M. may 2020
What Gets Measured Gets (Micro)managed
In this narrative medicine essay, an attending physician reflects on the evolution of the role of the attending physician from a supervisor in the background to a micromanaging supervisor to ensure that the proper steps are followed to meet the quality metrics in place in the current health system.
Ranji SR. may 2020
Questioning a Taboo
This narrative medicine essay summarizes ways in which physicians can use polite and scripted interruption to help patients effectively communicate their medical concerns, encourage further details, improve accuracy of the diagnosis, and set the agenda for the medical visit.
Mauksch LB. may 2020
To Isaiah, a Casualty of a Fractured System
In this narrative medicine essay, Donald M. Berwick shares the story of his patient Isaiah with the 2012 Harvard Medical School graduating class as an example of a patient who deserved the treatment that cured him of leukemia but whose life was lost to poverty and exhorts them to regard health care as human right that must be preserved in the clinic and in public.
Berwick DM. may 2020
Reflections on Women in Leadership—Holding up Half
In this narrative medicine essay, a medical school dean talks about the reticence most women feel when considering leadership roles and urges women to work out of their comfort zones, seize diverse opportunities, and step into leadership roles.
Stoll BJ. may 2020
Physician-Parents Whose Children Have Rare Diseases
In this essay, a critical care pediatric hospitalist finds herself on the other side of the office table advocating for the specific medical care needed to address her son’s rare skeletal dysplasia and her search for a pediatric specialist with whom to travel on this quest.
Rule AL. may 2020
The Changing of the Seasons
In this narrative medicine essay, a level-one trauma nurse compares Arizona’s 2 seasons with the waning and the waxing of patient admissions and with the cycle of grief for loss of her mother and son, realizing how much their deaths have affected her nursing.
Ratner TJ. may 2020
Patient’s Sister, Seeking Job: Toward More Patient-Centered Care
In this narrative medicine essay, the sister of a young man with Gardner syndrome reflects on the care her brother received over his nearly three decades of life and offers her observations on several things physicians and other members of health care teams can do to achieve true patient-centered care.
Zimmerman B. may 2020
You Did Not Teach Me What You Thought You Did
In this narrative medicine essay, a clinical educator uses her experiences enduring the aftermath of treatment for acute myeloid leukemia to reflect on the difference between physician-teachers and patients’ experience of illness and to locate meaning in what she can offer her colleagues and trainees despite persistent disability.
Archambault Carlson M. may 2020
Guidelines on the Treatment and Management of Patients with COVID-19
Estas guidelines baseada na metodologia GRADE, evidenciam a falta de evidência existente até à data, relativamente a várias propostas terapêuticas para a COVID-19. À excepção da recomendação contra a utilização de corticoterapia em doentes internados por pneumonia a COVID-19, ainda que com nível de certeza muito baixo, a IDSA admite a utilização das restantes terapêuticas em doentes internados e inclusivé corticoterapia em casos de ARDS, em contexto de ensaio clínico. A CMA adota uma postura mais conservadora, sugerindo contra a utilização de fármacos ainda sem evidência comprovada, à excepção da corticoterapia em contexto de ARDS, cuja recomendação é condicional a favor. Veja todas as recomendações no link para análise.
Bhimraj A, Morgan RL, Shumaker AH, et al.april 2020
Critical Illness in Patients With COVID-19
Dedicated, impassioned, and exhausted clinicians the world over are collaborating to report the emerging profile of the coronavirus disease 2019 (COVID-19) pandemic. The unparalleled need for intensive care during this period challenges clinicians to bring their best efforts to the bedside, while advising health care leaders on the optimal management of resources to deliver that care in each jurisdiction. A renewed sense of community is avowed among critical care clinicians who share their early observations through traditional and social media, such that learnings from one group of patients can inform the care of the next.
Cook DJ, Marshall JC, Fowler RA. april 2020
Premature Menopause and Risk for Cardiovascular Disease
To the Editor The cohort study by Dr Honigberg and colleagues found that natural and surgical premature menopause were associated with increased risks of cardiovascular diseases among postmenopausal women. Some important issues were not addressed.
Zhou X, Tang G. april 2020
Thangkhali Hospital at Night II
I was lying in bed swaddled in synthetic blankets in the on-call room. But what does it really mean to be “on-call”’ in a place like this? Really, everyone here is kind of “on-call”— ready to leave at a moment’s notice to somewhere better.
Dimitri A. april 2020
Using 2 Prostate Biopsy Techniques Optimizes Cancer Diagnosis
Combining a traditional biopsy with a magnetic resonance imaging (MRI)–targeted biopsy more accurately diagnoses clinically significant prostate cancer than either technique alone, according to a recent study by National Institutes of Health (NIH) researchers.
Rubin R. april 2020
USPSTF Recommendations for Prevention and Cessation of Tobacco Use in Children and Adolescents
In this issue of JAMA, the US Preventive Services Task Force (USPSTF) presents updated recommendations on prevention and cessation of tobacco use among children and adolescents seen in primary care settings. The USPSTF recommends education and brief counseling with a clinician to prevent initiation of tobacco use (B recommendation). The USPSTF also concludes that evidence is insufficient to assess the balance of benefits and harms of primary care–feasible interventions for the cessation of tobacco use among school-aged children and adolescents (I statement). These recommendations reflect the accompanying Evidence Review.
Sargent JD, Unger JB, Leventhal AM. april 2020
Treatment of Critically Ill Patients With COVID-19 With Convalescent Plasma
This case series describes clinical outcomes in 5 Chinese patients with laboratory-confirmed COVID-19, ARDS, and high viral loads despite antiviral treatment who were given human plasma with SARS-CoV-2 antibodies obtained from previously infected and recovered patients.
Shen C, Wang Z, Zhao F, et al. april 2020
Characteristics and Outcomes of Critically Ill Patients With COVID-19 in Washington State
This case series describes the clinical presentation, characteristics, and outcomes of patients with coronavirus disease 2019 (COVID-19) admitted to the intensive care unit at a public hospital in Washington State in February 2020, including initial reports of cardiomyopathy in one-third of the patients.
Arentz M, Yim E, Klaff L, et al. april 2020
Methotrexate and Adverse Events in CIRT Secondary Analysis
Although low-dose methotrexate has long been the first-line treatment for rheumatoid arthritis, the drug’s safety is based on inconclusive and contradictory case reports and observational studies. The drug was associated with a small to modest increase in adverse events (AEs) among patients at high cardiovascular risk in a study in the Annals of Internal Medicine.
Slomski A. april 2020
The Role of Physicians in Addressing Social Determinants of Health
This Viewpoint acknowledges that physicians in clinical roles may be limited in their ability to influence social determinants of patients’ health but proposes they have a role to play in educating others of its importance through teaching and training, diverse student and workforce recruitment, and activism.
Maani N, Galea S. april 2020
Addressing Social Determinants of Health: Time for a Polysocial Risk Score
This Viewpoint introduces the notion of a polysocial risk score, much like a polygenic risk score, which might help predict the risk that varying combinations of social conditions contribute to specific health outcomes.
Figueroa JF, Frakt AB, Jha AK. april 2020
Apabetalone and Major Adverse Cardiovascular Events in Patients With Acute Coronary Syndrome and Diabetes
This randomized trial compares the effects of apabetalone (an inhibitor of bromodomain 2 and extraterminal protein, 2 epigenetic “readers”) vs placebo on major adverse cardiovascular events in patients with acute coronary syndrome (ACS), type 2 diabetes, and low HDL cholesterol level.
Ray KK, Nicholls SJ, Buhr KA, et al. april 2020
Epigenetic Therapeutics for Cardiovascular Disease
Cells, and hence organisms, have biological memory, recording prior exposures to facilitate future responses. By linking this recall to gene expression, coordinated transcriptional programs are triggered that define normal function and adaptive responses. Efficient, integrated gene expression is essential, as evident with inflammatory responses to infection or tissue repair after injury. Cellular memory may also promote chronic disease states, such as atherosclerosis, with risk factors propagating maladaptive responses, including those involving inflammation and injury.
Plutzky J. april 2020
Convalescent Plasma to Treat COVID-19
In this issue of JAMA, Shen et al report findings from a preliminary study of 5 severely ill patients with coronavirus disease 2019 (COVID-19) who were treated in the Shenzhen Third People's Hospital, China, using plasma from recovered individuals. All patients had severe respiratory failure and were receiving mechanical ventilation; 1 needed extracorporeal membrane oxygenation (ECMO) and 2 had bacterial and/or fungal pneumonia. Four patients without coexisting diseases received convalescent plasma around hospital day 20, and a patient with hypertension and mitral valve insufficiency received the plasma transfusion at day 10. The donor plasma had demonstrable IgG and IgM anti–SARS-CoV-19 antibodies and neutralized the virus in in vitro cultures. Although these patients continued to receive antiviral treatment primarily with lopinavir/ritonavir and interferon, the use of convalescent plasma may have contributed to their recovery because the clinical status of all patients had improvement approximately 1 week after transfusion, as evidenced by normalization of body temperature as well as improvements in Sequential Organ Failure Assessment scores and Pao2/Fio2 ratio. In addition, the patients’ neutralizing antibody titers increased and respiratory samples tested negative for SARS-CoV-2 between 1 and 12 days after transfusion.
Roback JD, Guarner J. april 2020
Coconut Oil Raises LDL, Does Not Improve Weight, Inflammation, or Blood Sugar in Review Clinical Trials
This Medical News article discusses a recent review of 17 clinical trials comparing the effects of coconut oil and other vegetable oils on cardiovascular disease risk factors.
Abbasi J. april 2020
Data Error in Viewpoint on COVID-19 in Italy
In the Viewpoint titled “Case-Fatality Rate and Characteristics of Patients Dying in Relation to COVID-19 in Italy” published online March 23, 2020, in JAMA, a data error appeared in the eighth paragraph. The number of women included in the chart review of 355 patients should have been reported as 106 (not 601). This article has been corrected online.
The Influenza Outbreak
As set forth elsewhere in this issue, widespread outbreaks of acute respiratory infection have occurred at irregular intervals for many centuries. The general clinical manifestations and the complications have been always practically the same. Owing to conditions that are far from being adequately understood, such infection now and again spreads over the world with great rapidity and in a manner that was altogether mysterious and disconcerting until we learned that it never spreads faster than human travel. It seems as if in the course of evolutionary processes there suddenly is liberated a form of infectious agent against which large numbers of people offer little or no resistance and which is transmitted readily from person to person under the most diverse hygienic and geographic circumstances. That the peculiarly subtile nature of these outbreaks was recognized long before the bacteriologic era is indicated by the introduction of the name influenza, which means, literally, influence. The question as to the real nature of this “influence,” it must be acknowledged, is not settled definitely. The discovery by Pfeiffer in 1890, at the time of the last pandemic, of the influenza bacillus (B. influenzae) in the sputum and respiratory tract of influenza patients seemed, it is true, to have settled the matter. At any rate, Pfeiffer’s claim that he had discovered the cause of influenza secured fairly general acceptance except possibly in France.
Personal Risk and Societal Obligation Amidst COVID-19
In this narrative medicine essay, a resident physician with asthma describes her internal deliberations about public vs private good after a decision to retreat from direct-patient care to telemedicine to protect her health during the coronavirus pandemic.
Tsai C. april 2020
USPSTF Review: Tobacco and Nicotine Use Prevention and Cessation in Children and Adolescents
This systematic review to support the 2020 US Preventive Services Task Force Recommendation Statement on interventions for prevention and cessation of tobacco and nicotine use summarizes published evidence on the benefits and harms of primary care–relevant interventions for tobacco and nicotine use prevention and cessation in children and adolescents.
Selph S, Patnode C, Bailey SR, et al. april 2020
Quality Measure Development and Associated Spending by the Centers for Medicare & Medicaid Services
This study uses data from the publicly available Centers for Medicare & Medicaid Services (CMS) Inventory Tool to determine the proportion of CMS quality measures that are used or finalized for use in a CMS program, under development or consideration for use, or not in use.
Wadhera RK, Figueroa JF, Joynt Maddox KE, et al. april 2020
Characteristics and Outcomes of Patients Infected With SARS-CoV-2 Admitted to ICUs in Italy
This case series describes the demographics, comorbidities, ventilation requirements, dispositions, and mortality of patients with PCR-confirmed SARS-CoV-2 infection admitted to northern Italy ICUs in February-March 2020..
Grasselli G, Zangrillo A, Zanella A, et al. april 2020
Presidential Powers and Response to COVID-19
This Viewpoint reviews legal powers the US president and state governors have to implement travel and other restrictions to control the spread of coronavirus, and discusses the need to balance rights to privacy and liberty with public health in ways that do not disadvantage already vulnerable populations.
Gostin LO, Hodge JG, Jr, Wiley LF. april 2020
SARS-CoV-2 Contamination of Air, Environmental Surfaces, and Personal Protective Equipment
This study documents results of SARS-CoV-2 polymerase chain reaction (PCR) testing of environmental surfaces and personal protective equipment surrounding 3 COVID-19 patients in isolation rooms in a Singapore hospital.
Ong S, Tan Y, Chia P, et al. april 2020
Health Outcomes With Vitamin D Supplementation—Reply
In Reply Our Editorial accompanied the report of the VITAL-DKD trial. The focus of that article and our Editorial was the lack of benefit of vitamin D supplementation over placebo for prevention of chronic kidney disease end points. We concluded that the VITAL-DKD and D2d trials “provide strong clinical trial–grade evidence against … kidney-protective effects of routine vitamin D3 supplementation in the vast majority of patients with prediabetes or established type 2 diabetes,” and emphasized the discrepancy between the “negative” results of these trials relative to previous observational studies that suggested benefits of higher vitamin D levels.
Lucas A, Wolf M. april 2020
Premature Menopause and Risk for Cardiovascular Disease
To the Editor Venous thromboembolism (VTE) is a global health concern because of its significant morbidity and mortality. To our knowledge, few studies have investigated the associations of reproductive life characteristics with VTE risk in women. Analysis of UK Biobank data by Dr Honigberg and colleagues highlights the role of premature natural or surgical menopause in increasing both atherosclerotic and nonatherosclerotic cardiovascular risk, including VTE risk.
Scarabin P. april 2020
In the Clinical Review titled “Nonalcoholic Steatohepatitis: A Review,” published in the March 24, 2020, issue of JAMA, the legend for Figure 1 had a typographical error. The sentence describing stenosis with hepatocyte ballooning and lobular inflammation should have read that such “patients are considered to have NASH.” This article was corrected online.
USPSTF Recommendation: Tobacco Use Prevention and Cessation in Children and Adolescents
This 2020 Recommendation Statement from the US Preventive Services Task Force recommends that primary care clinicians provide interventions, including education or brief counseling, to prevent initiation of tobacco use among school-aged children and adolescents (B recommendation) and concludes that current evidence is insufficient to assess the benefits and harms of primary care interventions for cessation of tobacco use among school-aged children and adolescents (I statement).
, Owens DK, Davidson KW, et al. april 2020
Health Outcomes With Vitamin D Supplementation
To the Editor In an Editorial, Drs Lucas and Wolf stated that randomized clinical trials (RCTs) of vitamin D and health outcomes have failed to confirm observational study findings. However, that is not the case for several health outcomes. Secondary analyses of the Vitamin D and Omega-3 Trial (VITAL) revealed significant reductions in overall cancer incidence with supplementation with 2000 IU/d of vitamin D3 in participants with a body mass index (BMI) of less than 25 and in black individuals and reduced overall cancer mortality when the first 1 or 2 years of data were omitted. Secondary analyses of the Vitamin D and Type 2 Diabetes (D2d) trial showed significant reductions in progression from prediabetes to type 2 diabetes with 4000 IU/d of vitamin D3 supplementation in participants with a BMI less than 30, in those not taking calcium supplements, in males, in those older than 60.9 years, and in non-Hispanic individuals. Most such findings can be explained by vitamin D axis effects. For example, those with higher BMI have smaller increases in serum 25-hydroxyvitamin D (25[OH]D) concentration with supplementation than individuals with comparable supplementation and lower BMI.
Grant WB, Boucher BJ. april 2020
Long-Acting Injectable HIV Therapy Noninferior to Daily Pills
A pair of trials in the New England Journal of Medicine found that long-acting monthly injectable therapy for HIV-1 infection was noninferior to standard daily oral regimens for maintaining viral suppression.
Slomski A. april 2020
Alteplase Inhibits Nerinetide, a Novel Stroke Drug
The investigational neuroprotectant nerinetide did not reduce disability in all patients with ischemic stroke who were treated with endovascular thrombectomy, a trial in The Lancet reported. However, patients who were not concurrently treated with alteplase had a large benefit from nerinetide.
Slomski A. april 2020
Premature Menopause and Risk for Cardiovascular Disease—Reply
In Reply Dr Scarabin highlights our finding that menopausal hormone therapy use at study enrollment was not associated with incident VTE. At enrollment, women in the UK Biobank reported whether they had ever used menopausal hormone therapy, the age at which they started and (if applicable) stopped using therapy, and whether they were currently using hormones. In our postmenopausal cohort, it is unlikely that women who were never users of menopausal hormone therapy at enrollment subsequently started using it after the study began—particularly in the era following publication of the Women’s Health Initiative results. Women with any prevalent cardiovascular disease diagnoses at baseline, including VTE, were excluded from the analysis, and a secondary analysis evaluated development of a first VTE event.
Honigberg MC, Natarajan P. april 2020
Managing COVID-19 in Low- and Middle-Income Countries
This Viewpoint discusses challenges to managing a COVID-19 outbreak in low- and middle-income countries (LMICs), reviewing how absence of testing, critical care capacity, climate, war, distrust, and large refugee populations could complicate implementation of proven infection prevention and control measures.
Hopman J, Allegranzi B, Mehtar S. april 2020
Treatment of patients with nonsevere and severe coronavirus disease 2019: an evidence- based guideline
Estas guidelines baseada na metodologia GRADE, evidenciam a falta de evidência existente até à data, relativamente a várias propostas terapêuticas para a COVID-19. À excepção da recomendação contra a utilização de corticoterapia em doentes internados por pneumonia a COVID-19, ainda que com nível de certeza muito baixo, a IDSA admite a utilização das restantes terapêuticas em doentes internados e inclusivé corticoterapia em casos de ARDS, em contexto de ensaio clínico. A CMA adota uma postura mais conservadora, sugerindo contra a utilização de fármacos ainda sem evidência comprovada, à excepção da corticoterapia em contexto de ARDS, cuja recomendação é condicional a favor. Veja todas as recomendações no link para análise.
Zhikang Ye, Bram Rochwerg, Ying Wang, Neill K. Adhikari, et al. april 2020
Use of Frozen Embryo Transfer During Fertility Treatment and Risk of Childhood Cancer—Reply
In Reply Drs Parmegiani and Vajta note recent changes in the cryopreservation method from the traditional slow-rate freezing to cryopreservation by vitrification and suggest this may be relevant for the interpretation of our study.
Hargreave M, Jensen A, Kjaer SK. april 2020
Prevalence and Outcomes of Infection Among Patients in Intensive Care Units in 2017
This study characterizes the point prevalence and outcomes of infection among adult patients treated at international intensive care units during a 24-hour period.
Vincent J, Sakr Y, Singer M, et al. april 2020
RT-PCR Test Results in Patients Recovered From COVID-19
This case series describes reverse transcriptase–polymerase chain reaction (RT-PCR) test results in 4 health professionals discharged from hospitalization or quarantine after 2 negative RT-PCR test results and resolution of clinical COVID-19 infection.
Lan L, Xu D, Ye G, et al. april 2020
Consumer Genomic Testing in 2020
This Viewpoint discusses gaps between the growth of direct-to-consumer genomic testing and knowledge about how best to use the information, highlighting the absence of diversity in genetic databases, the scarcity of accompanying genetic counseling, and data security and privacy concerns.
Feero W, Wicklund CA. april 2020
Empathy Revisited—Understanding Patients’ Pain From Experienced Pain
In this narrative medicine essay, a cardiologist recalls the effects his wife’s death had on his young family and the humility he brings to being with patients in their traumas as a result.
Gubernikoff G. april 2020
The Menopause Transition and Cognition
This JAMA Insights article summarizes the subjective cognitive problems experienced by some women during perimenopause (menopausal transition) and provides guidance to physicians on how to effectively answer patients’ questions and recognize when these symptoms may require clinical intervention.
Greendale GA, Karlamangla AS, Maki PM. april 2020
Characteristics of Faculty Accused of Academic Sexual Misconduct in the Biomedical and Health Sciences
This study uses internet search data to identify and characterize biomedical and health sciences faculty at US higher education institutions who had sexual misconduct accusations against them between 1982 and 2019 that led to institutional or legal actions proving or supporting guilt.
Espinoza M, Hsiehchen D. april 2020
HCV Drug Used in Adults Receives Approval for Pediatric Patients
A combination drug used to treat hepatitis C virus (HCV) infection in adults has been approved for pediatric patients 6 years or older or those who weigh at least 37 lb and don’t have cirrhosis or only a mild case.
Voelker R. april 2020
Paralytic Agents for Intubation in the Out-of-Hospital Setting
To the Editor The study by Dr Guihard and colleagues is one of the few trials to use endotracheal intubation success as an outcome when comparing rocuronium and succinylcholine for rapid sequence intubation. With the exception of a few observational studies that evaluated intubation success, previous investigations only measured intubation conditions as an outcome.
Patanwala AE. april 2020
Paralytic Agents for Intubation in the Out-of-Hospital Setting—Reply
In Reply Dr Patanwala raises the possibility that our results could be misinterpreted due to inappropriate use of terms related to the interpretation of noninferiority trials. However, as Patanwala points out, the description of our results in the article is correct. Nevertheless, we agree that the term inconclusive could have been used and the figure could have been revised for consistency. We fully agree that failure to demonstrate the noninferiority of rocuronium should not be interpreted as the superiority of succinylcholine.
Guihard B, Combes X. april 2020
Errors in Text, Figure, and End Matter
In the Original Contribution entitled “Epidemiologic Features and Clinical Course of Patients Infected With SARS-CoV-2 in Singapore” published online in JAMA on March 3, 2020, there were errors in the text, a figure, and the end matter. In the second paragraph of the “Case Management” section in the text, the dose for coformulated lopinavir-ritonavir reported as 200 mg/100 mg should have been reported as 400 mg/100 mg. At the top right of Figure 1, “February 202” should have read “February 2020.” In the author affiliations, coauthor Kalimuddin should have appeared with coauthors Low, Anderson, T. Y. Tan, and Wang (all with Duke-NUS Medical School, Singapore). This article was corrected online.
Pulse Oximetry Monitoring in Hospitalized Children With Bronchiolitis Not Requiring Supplemental Oxygen
This study characterizes use of continuous pulse oximetry monitoring in hospitalized children with bronchiolitis who do not require supplemental oxygen in Canadian and US hospitals.
Bonafide CP, Xiao R, Brady PW, et al. april 2020
Sexual Misconduct in Academic Medicine
The Me Too movement began in 2006 but was popularized in 2017 by women in Hollywood who had been sexually harassed. Since then, the pervasiveness of sexual misconduct across many segments of society has become apparent, and medicine has not been exempt. Although many studies have described sexual misconduct from the point of view of the person who was the target of the sexual misconduct, few studies have focused on the perpetrators.
Freischlag J, Files K. april 2020
Boosting Rwanda’s Health Workforce
Rwanda’s physician specialist workforce tripled and the ranks of nurses and midwives grew substantially as a result of the country’s Human Resources for Health (HRH) Program, according to an evaluation by the National Academies of Science, Engineering, and Medicine.
Kuehn BM. april 2020
Correcting the Scientific Record—Retraction and Replacement of a Report on Dialysis Ownership and Access to Kidney Transplantation
The September 10, 2019, issue of JAMA included an Original Investigation titled “Association Between Dialysis Facility Ownership and Access to Kidney Transplantation” by Gander and colleagues, and an accompanying Editorial by Boulware and colleagues. The authors of the research report subsequently notified the editors that a major coding error had occurred in their data management and analyses, and that they discovered these errors had resulted in incorrect data in their published article. As reported in their letter of explanation, the authors performed a thorough reanalysis of their data to address these errors and found that the main findings and overall conclusion were consistent with the main findings and conclusion reported in the published article, although the corrected analysis revealed important differences in effect size and strength of the associations.
Bauchner H, Flanagin A, Fontanarosa PB. april 2020
Graphic Health Images Are Coming to Cigarette Packaging
Beginning in June 2021, people who buy cigarettes will get their tobacco fix from packages with stark images that depict lesser-known smoking risks such as stunted fetal growth or increased odds of developing bladder cancer.
Voelker R. april 2020
Paralytic Agents for Intubation in the Out-of-Hospital Setting
To the Editor Dr Guihard and colleagues investigated 1248 patients requiring out-of-hospital rapid sequence tracheal intubation in a multicenter, single-blind, noninferiority randomized clinical trial comparing 1.2 mg/kg of rocuronium with 1 mg/kg of succinylcholine. The authors stated that rocuronium, compared with succinylcholine, failed to demonstrate noninferiority with regard to first-attempt intubation success rate.
Drexler B, Grasshoff C. april 2020
Wilhelm Konrad Roentgen—The Centennial of His Birth
On March 27, 1845 Wilhelm Konrad Roentgen was born in Lennep, Germany. He received his early education in the Netherlands and then studied under Clausius, teacher of Willard Gibbs, in Zurich, Switzerland. At Würzburg he became assistant to Kundt. In 1874 he became privatdozent at Strasbourg University. In 1875 Roentgen was made professor of mathematics and physics at the Agricultural Academy of Hohenheim. He returned to Strasbourg in 1876, where he became extraordinary professor. In 1879 he was appointed ordinary professor of physics and director of the Physical Institute of Giessen, and in 1885 he became professor at Würzburg. Here in 1895, at the age of 50, Roentgen discovered the x-rays.
Infection, Antibiotics, and Patient Outcomes in the Intensive Care Unit
Infection is a major cause of admissions and prolonged stays in intensive care units (ICUs). Epidemiological information on the underlying source of infections, associated microorganisms, treatment, and eventual outcomes is essential for identifying gaps and opportunities to optimize patient management. Systematic and harmonized data collection across institutions allows for geographical comparisons and tracking of temporal trends and also enhances the generalizability of findings. However, such large-scale patient-level data are scarce, likely due to the immense logistical demands for coordinating such a study.
Yin M, Tambyah P, Perencevich EN. april 2020
Management of Tinnitus in 2020
This JAMA Clinical Insights article reviews the diagnosis and treatment of chronic tinnitus based on current understanding of symptom mechanisms and emphasizes the importance of behavioral therapies (tinnitus retraining) and personalized treatment whenever possible.
Piccirillo JF, Rodebaugh TL, Lenze EJ. april 2020
Medicaid Work Requirements Shift to New Terrain
State policies requiring low-income adults to work to maintain Medicaid coverage have been gaining traction and sparking debate. With encouragement from the Centers for Medicare & Medicaid Services (CMS), 20 states have proposed some form of “community engagement” requirements. These proposals typically involve mandating Medicaid beneficiaries to work a certain number of hours (usually 20 hours per week), engage in job training or community service, or obtain an exemption (such as having children with disabilities or being family caregivers).
Sommers BD, Allen HL. april 2020
Overuse of Continuous Pulse Oximetry for Bronchiolitis
Bronchiolitis, a viral infection of the lower respiratory tract, is the most common cause of hospitalization among children younger than 2 years, and generated estimated direct hospital costs of $734 million in 2016. Clinical practice recommendations from the Choosing Wisely campaign and the American Academy of Pediatrics (AAP) specifically target medical overuse for children with bronchiolitis in an effort to improve value of medical care for the approximately 130 000 infants admitted each year with this disease. Amid recommendations related to prevention, diagnosis, and management of bronchiolitis, these guidelines recommend restricting the use of continuous pulse oximetry for hospitalized children receiving supplemental oxygen. Despite data suggesting that continuous pulse oximetry is associated with increased length of stay (LOS), health care costs, and patient harm, little is known about the prevalence of or contextual factors associated with continuous pulse oximetry use for patients admitted with bronchiolitis.
Cheston CC, Vinci RJ. april 2020
Use of Frozen Embryo Transfer During Fertility Treatment and Risk of Childhood Cancer
To the Editor Dr Hargreave and colleagues examined the association between fertility treatment and cancer risk in children. They found that the use of frozen embryo transfer was associated with a small increased risk of childhood cancer compared with children born to fertile women. We would like to raise an important technical consideration regarding the cryopreservation method.
Parmegiani L, Vajta G. april 2020
Supporting the Health Care Workforce During the COVID-19 Global Epidemic
This Viewpoint discusses the importance of protecting health care workers caring for patients with coronavirus disease 2019 (COVID-19) and measures that can be taken in and out of the hospital to prevent their and their families’ exposure to SARS-CoV-2.
Adams JG, Walls RM. april 2020
Effect of Zoledronic Acid on Tibiofemoral Cartilage Volume in Knee Osteoarthritis With Bone Marrow Lesions
This randomized trial compares the effects of intravenous zoledronic acid vs placebo on magnetic resonance imaging–assessed knee cartilage volume loss in patients with symptomatic knee osteoarthritis and subchondral bone marrow lesions.
Cai G, Aitken D, Laslett LL, et al. april 2020
Techniques for Treatment of Carotid Stenosis—Reply
In Reply In response to Dr Sharma and colleagues, we used propensity score matching methods to account for baseline characteristic differences found between patients undergoing transfemoral carotid artery stenting and transcarotid artery revascularization. Although this led to a 50% exclusion of patients from the transfemoral carotid stenting cohort and a 37% exclusion of patients from the transcarotid artery revascularization cohort, these matching methods are important for controlling intrinsic biases found in observational studies. However, we provided unadjusted complete raw data outcomes in eTable 1 in the supplemental material. These unmatched outcomes also show a higher rate of stroke or death in patients undergoing transfemoral carotid artery stenting compared with transcarotid artery revascularization (3.2% vs 1.5%, respectively; P < .001).
Schermerhorn ML, Liang P. april 2020
Epidemiologic Features and Clinical Course of Patients Infected With SARS-CoV-2 in Singapore
This case series describes the epidemiologic features, clinical presentation, treatment, and outcomes of the first 18 patients with confirmed coronavirus disease 2019 (COVID-19) in Singapore
Young B, Ong S, Kalimuddin S, et al. april 2020
Techniques for Treatment of Carotid Stenosis
To the Editor Dr Schermerhorn and colleagues compared transcarotid artery revascularization with transfemoral carotid stenting for treatment of carotid stenosis and found that transcarotid artery revascularization was associated with a lower risk of stroke or death. However, 37% of the patients (n = 1965) were excluded from the transcarotid artery revascularization group and 50% (n = 3354) from the transfemoral carotid stenting group. When such a large percentage of the registry data are excluded, it becomes difficult to make a fair comparison without eliminating selection bias. The authors should have reported the complete raw data from all patients in the registry or suggested a randomized clinical trial.
Sharma S, Bhambi N, Bhambi B. april 2020
Corrections to Address Revised Analysis in Related Study
In the Editorial entitled “Improving Access to Kidney Transplantation: Business as Usual or New Ways of Doing Business?” published in the September 10, 2019, issue of JAMA, has been corrected to address coding errors in the related study, which has been retracted and replaced. This Editorial was corrected online.
The Need to Improve the Clinical Utility of Direct-to-Consumer Genetic Tests: Either Too Narrow or Too Broad
This Viewpoint summarizes current shortcomings in direct-to-consumer genetic tests, which often lack clinical utility for consumers, and explains how tests that encompass entire genes and include only genes with well-established risk estimates and medical management guidelines could provide more valuable insight into their disease risk.
Kilbride MK, Bradbury AR. april 2020
Meeting the Care Needs of Older Adults Isolated at Home During the COVID-19 Pandemic
Embora os idosos que vivem na comunidade sejam altamente suscetíveis a mortalidade por COVID-19, os seus cuidados de saúde não-COVID-19 não devem ser esquecidos. O distanciamento físico e o isolamento social podem ter um grande impacto não apenas em sua saúde mental, mas também na sua saúde e funcionamento físicos. Para responder à pandemia, é essencial estar atento aos desafios que o distanciamento físico provova para os idosos vulneráveis e enfrentar esses desafios. São propostas algumas dicas para que tal aconteça.
Steinman MA, Perry L, Perissinotto CMapril 2020
Clinician Education and Adoption of Preventive Measures for COVID-19: A Survey of a Convenience Sample of General Practitioners in Lombardy, Italy
Os Médicos de Família apresentam alto risco de contrair e disseminar a infeção por COVID-19, existindo necessidade de os testar e isolar, de forma a diminuir a disseminação na comunidade. É fulcral existirem medidas preventivas e EPIs adequadas, bem como orientações claras dos órgãos de saúde pública sobre como gerir doentes durante o surto de COVID-19.
Fiorino G, Colombo M, Natale C, et al. april 2020
An Update of the Diagnosis and Treatment of Clostridioides difficile Infection in Adults
This JAMA Insights Clinical Update summarizes updated evidence regarding diagnosis and management of Clostridioides (formerly Clostridium) difficile infection (CDI) in adults, including review of new toxin detection assays and biologic treatments.
Rao K, Malani PN. april 2020
Why Test for Proportional Hazards?
This JAMA Guide to Statistics and Methods explains the meaning underlying the proportional hazards (PH) assumption underlying Cox regression and survival analyses, and proposes that reports of survival differences might replace statistical tests of the PH assumption because they are more meaningful.
Stensrud MJ, Hernán MA. april 2020
Listless—A Mother Struggles With Her Son’s Constipation
In this narrative medicine essay, a neonatologist struggles with the perfectionism she cultivated during her pediatric training in knowing how to help her son’s constipation and in the process learns true compassion for patients’ families.
Fleishman R. april 2020
The Prevailing Pandemic of Influenza
During the past two weeks, August 28 to September 11, there has begun a severe and rapidly spreading epidemic of influenza in the First Naval District. More than 2,000 cases have been reported in these two weeks, and there are indications of a rapid spread of the infection. This is undoubtedly the same disease which, first heard of in Spain last spring, and hence called Spanish influenza, has in recent months spread over nearly all of Europe, including Germany, Italy, France, England and Ireland, attacking from 30 to 40 per cent. of the people. The outstanding feature of this epidemic is its high degree of communicability; in fact, in pandemics of this nature, influenza is the most contagious of all infections. The last pandemic (1889-1890) also moved from east to west along the lines of travel. We, therefore, have every indication that this outbreak will soon spread all over the United States. It doubtless has been carried to this country by patients or carriers aboard vessels. In fact, definite histories to this effect have been obtained from officers aboard vessels.
When Guidelines Recommend Shared Decision-making
This Viewpoint discusses the importance of shared decision-making (SDM) for providing care that takes into account the experience, expertise, and specific situations of patients; and stresses the importance of developing clinical practice guidelines that consider known barriers and costs of SDM implementation and when SDM is most relevant and useful.
Rabi DM, Kunneman M, Montori VM. april 2020
Effect of Dapagliflozin on Patients With Heart Failure With and Without Diabetes
This exploratory analysis of a randomized trial examined the effect of dapagliflozin on a composite of worsening heart failure or cardiovascular death on individuals with heart failure with reduced ejection fraction with and without diabetes.
Petrie MC, Verma S, Docherty KF, et al. april 2020
Alzheimer Disease Blood Test in Development
Two recent studies suggest that a simple blood test can distinguish Alzheimer disease (AD) from other neurodegenerative diseases and predict which patients may develop AD regardless of their cognitive status when they’re tested.
Abbasi J. april 2020
Diagnosis and Management of Obstructive Sleep Apnea
This review provides an update on the epidemiology, pathophysiology, diagnosis, and management of obstructive sleep apnea, including the incorporation of questions regarding snoring, breathing pauses at night, and excessive fatigue or sleepiness during the day at routine clinician visits and the increased use of home sleep apnea testing rather than in-hospital testing for diagnostic purposes.
Gottlieb DJ, Punjabi NM. april 2020
COVID-19—New Insights on a Rapidly Changing Epidemic
This Viewpoint provides an update on what’s known and not yet known about the coronavirus disease 2019 (COVID-19) epidemic, reviewing advances over the initial weeks of the outbreak in understanding the epidemiology and clinical spectrum of the illness and in approaches to diagnosis, management, and infection control.
del Rio C, Malani PN. april 2020
Suicides Among Opioid Overdose Deaths
To the Editor Dr Olfson and colleagues examined trends in the rates of opioid-related mortality, stratified by intentionality. Concerns about whether a significant proportion of opioid overdose suicides have been misclassified, and therefore that the suicide component of the opioid epidemic is underestimated, cannot be answered with death certificate data.
Nestadt PS. april 2020
Kidney Function in Patients With Type 2 Diabetes After Vitamin D Supplementation—Reply
In Reply Dr Peiris suggests that 25(OH)D concentrations, adherence, or vitamin D3 dose may have limited testing the effects of vitamin D3 on change in eGFR in our study.
de Boer IH, Zelnick LR, Manson JE. april 2020
Presumed Asymptomatic Carrier Transmission of COVID-19
This study describes possible transmission of novel coronavirus disease 2019 (COVID-19) from an asymptomatic Wuhan resident to 5 family members in Anyang, a Chinese city in the neighboring province of Hubei.
Bai Y, Yao L, Wei T, et al. april 2020
Preemptive Therapy vs Antiviral Prophylaxis and CMV in Seronegative Liver Transplant Recipients With Seropositive Donors
This randomized trial compares preemptive therapy vs antiviral prophylaxis with valganciclovir in cytomegalovirus (CMV)-seronegative liver transplant recipients with seropositive donors for the prevention of CMV disease.
Singh N, Winston DJ, Razonable RR, et al. april 2020
Preventing Cytomegalovirus Infection After Liver Transplant: An Evolving Approach
Despite recent advances in the management of patients following liver transplant, cytomegalovirus (CMV) infection remains a substantial cause of morbidity and mortality among this population. Clinicians and transplant centers have adopted varying approaches to managing CMV-seronegative liver transplant recipients with CMV-seropositive donors, a recipient group that is at highest risk for developing CMV-associated complications. Antiviral prophylaxis is typically initiated soon after transplant for a period of several months. Although the most widely used strategy, prophylaxis is limited by the incidence of delayed-onset CMV disease that can occur long after antivirals are completed. In contrast, preemptive therapy involves monitoring patients for CMV viremia and beginning antivirals only after CMV replication is detected by polymerase chain reaction testing. Small, observational studies have suggested that preemptive therapy in this high-risk population may be associated with lower rates of CMV disease.
Desai AN, Malani PN. april 2020
Kidney Function in Patients With Type 2 Diabetes After Vitamin D Supplementation
To the Editor Dr de Boer and colleagues reported that vitamin D3 and/or omega-3 fatty acids compared with placebo did not result in any significant difference in change in estimated glomerular filtration rate (eGFR) in patients with type 2 diabetes at 5 years. There are multiple study limitations that were not discussed.
Peiris AN. april 2020
Priorities for the US Health Community Responding to COVID-19
This Viewpoint discusses the preparedness plans that need to be implemented in the US to combat the SARS-CoV-2 virus (the cause of COVID-19 disease), including shoring up resources in hospitals and clinics, updating of triage and isolation protocols, expanding PCR manufacturing and patient testing, and communicating to the public with unified public health messages.
Adalja AA, Toner E, Inglesby TV. april 2020
A Novel Cardioprotective Therapy That Also Improves Glycemia
The profound effects of sodium-glucose transporter 2 (SGLT2) inhibition on the risks of cardiovascular complications in patients with hyperglycemia have provided for rapid and substantive changes to diabetes guidelines from various countries. In this issue of JAMA, Petrie and colleagues report findings from a highly informative exploratory analysis of the most recent large-scale clinical trial of an SGLT2 inhibitor that may suggest the next chapter for this drug class—the transition from a glucose-lowering therapy that provides cardioprotection to a cardioprotective agent that happens to lower blood glucose.
Neal B, Arnott C. april 2020
Association Between Nocturnist Supervision and Perceived Overnight Supervision Adequacy in the US
This cross-sectional study uses data from a voluntary survey that was administered during the American College of Physicians Internal Medicine In-Training Examination to assess whether residents in programs with nocturnists perceived nighttime supervision differently than those in programs without nocturnists.
Catalanotti JS, O’Connor AB, Kisielewski M, et al. april 2020
A New Vaccine for Chikungunya Virus
Arboviruses (arthropod-borne) are a group of viruses that encompass hundreds of members and span multiple viral families making it one of the most genetically diverse, widespread, and dangerous groups of viruses on earth. Arboviruses are transmitted to humans by a variety of geographically widespread arthropod vectors (most commonly, mosquitoes and ticks) so that these viruses can change location with human hosts or arthropod vectors, with potential for rapid spread wherever these vectors are present. Past outbreaks of West Nile virus and recent outbreaks of eastern equine encephalitis virus, Zika virus, and chikungunya virus (CHIKV) in the Americas highlight that these viruses can move rapidly through new populations and may cause outbreaks associated with substantial morbidity and mortality.
Stapleford KA, Mulligan MJ. april 2020
Universal Flu Vaccine Candidate Advances
A broad-spectrum influenza vaccine candidate is poised for larger phase 3 trials after demonstrating immunogenicity and safety in a recent phase 2b study. The findings could bring a long-awaited universal influenza vaccine one step closer to reality.
Abbasi J. april 2020
Suicides Among Opioid Overdose Deaths—Reply
In Reply Dr Nestadt raises 3 concerns regarding our analysis of trends in the intent of overdose deaths involving opioids. His first concern is that suicides may have been misclassified. A prior estimate assumed that because 26.5% of opioid overdose visits to the emergency department were classified as intentional, 20% to 30% of opioid overdose deaths were also intentional. Our findings, which were based on the National Vital Statistics System, revealed that in 2017, 4.0% of overdose deaths involving opioids were certified as suicides, 5.4% were certified as undetermined intent, and 90.6% were unintentional. One reason that a larger percentage of nonfatal than fatal opioid overdoses are intentional may be that intentional opioid overdoses are less often fatal than unintentional opioid overdoses.
Olfson M, Wall MM, Blanco C. april 2020
Response to COVID-19 in Taiwan: Big Data Analytics, New Technology, and Proactive Testing
This Viewpoint describes the outbreak response infrastructure developed by the Taiwanese government following the SARS epidemic in 2003 and actions in response to COVID-19, including dedicated hotlines for symptom reporting, mobile phone messaging and case tracking, and the ramping up of facemask production.
Wang C, Ng CY, Brook RH. april 2020
Skin Cancer Detection Apps Unreliable
Smartphone apps that use artificial intelligence to assess skin cancer risk based on images of suspicious moles aren’t ready for prime time, a recent systematic review in the BMJ suggests. The 9 studies included in the review “showed variable and unreliable test accuracy” for 6 such apps, 2 of which are approved by European regulators as medical devices.
Abbasi J. april 2020
In the Original Investigation entitled “Effect of Ubrogepant vs Placebo on Pain and the Most Bothersome Associated Symptom in the Acute Treatment of Migraine: The ACHIEVE II Randomized Clinical Trial” published in the November 19, 2019, issue of JAMA, imprecise language was used in the Discussion section and a typographical error occurred in Figure 2. In the second full paragraph on page 1896, the penultimate sentence should have read, “These results were obtained in a population sample older than the US population and may therefore be overestimates.” In Figure 2, the word optimal should have read optional. This article was corrected online.
Clinician Burnout and Professional Well-being
To the Editor Our experiences from clinical practice improvement projects suggest very different approaches to resolving physician burnout from those advanced by Dr Carayon and colleagues. Their stated purpose to “…encourage health care leaders to prioritize the actions, procedures, and policies that deliver the greatest value to direct patient care…” implies that clinicians should continue trusting their future well-being to those who have been responsible for the “industrialization of health care delivery.” Furthermore, the authors’ proposals do not reflect our understanding of the root causes of physician burnout, and they would appear to only increase clinicians’ administrative burdens and costly health system bureaucracies.
Arnold EL, Sikes DH, Harrington J. april 2020
In the Original Investigation titled “Association of Initial Disease-Modifying Therapy With Later Conversion to Secondary Progressive Multiple Sclerosis,” published in the January 15, 2019, issue of JAMA, the institutional affiliation for Dr Lugaresi was incorrectly presented. This article was corrected online.
Warning About Cleaning CPAP Devices With Ozone Gas, UV Light
A recent FDA safety communication has warned patients and health professionals that the agency has not cleared any devices that use ozone gas or UV light to clean, sanitize, or disinfect continuous positive airway pressure (CPAP) devices.
Voelker R. april 2020
Novel Coronavirus Infection in Hospitalized Infants Under 1 Year of Age in China
This study characterizes the demographic, epidemiologic, and clinical characteristics of hospitalized infants diagnosed with coronavirus disease 2019 infection between December 8, 2019, and February 6, 2020, in China.
Wei M, Yuan J, Liu Y, et al. april 2020
Treatment for Advanced Soft Tissue Sarcoma
The treatment of soft tissue sarcomas (STSs), which encompass a group of more than 70 histologically and biologically distinct subtypes of cancer, is emblematic of an orphan disease. About 13 000 patients are diagnosed as having STS in the United States every year, survival rates are poor and have not changed in the last 40 years, and there is little funding to support scientific discovery of disease biology to improve treatment regimens. Clinical presentation and prognosis are influenced not only by the extent of disease and histological subtypes, but by tumor location as well. There is a significant unmet need for improved systemic therapies in the treatment of patients with STS.
Roland CL, Wong SL. april 2020
The Environment: A Death of Air
During recent months, if it wasn’t in the air (and it was) it was surely in the news—pollution. Of course there is nothing new about air pollution in the United States. For years residents and visitors in Los Angeles have complained about that city’s eye-smarting smog. And in 1948 Donora, Pa, lay under a five-day poisonous fog labeled “the brown plague.” As a result, 22 people died and 5,910 became ill.
Effect of Intravenous Tenecteplase Dose on Cerebral Reperfusion Before Thrombectomy in Patients With Ischemic Stroke
This randomized clinical trial compares the effects of 2 tenecteplase doses (0.40 vs 0.25 mg/kg) prior to endovascular thrombectomy on blood flow restoration to brain ischemic territory in patients with large vessel occlusion ischemic stroke.
Campbell BV, Mitchell PJ, Churilov L, et al. april 2020
Editorial Concern—Possible Reporting of the Same Patients With COVID-19 in Different Reports
Since January 1, 2020, JAMA and the JAMA Network journals have received hundreds of manuscripts and direct queries related to coronavirus disease 2019 (COVID-19), including research reports, case series and case reports, and opinion pieces. The editors have become aware that some of the patients described in some of these manuscripts, sometimes with overlapping authorship, have been reported in more than 1 submission. This inclusion of the same patients in more than 1 report has not been clearly indicated in the submitted manuscripts. This is of concern and may represent a lapse in ethical standards of scientific reporting.
Bauchner H, Golub RM, Zylke J. april 2020
Clinician Burnout and Professional Well-being—Reply
In Reply Our Viewpoint was a summary of a comprehensive National Academies of Sciences, Engineering, and Medicine (NASEM) report. Time pressure and high workload are work system factors that contribute to clinician burnout and affect patient care; however, many other work system factors can also increase clinician burnout. The review of the evidence in the NASEM report showed that there is not a single root cause of burnout among clinicians, including physicians, nurses, pharmacists, dentists, and other health care professionals who provide direct care to patients.
Carayon P, Cassel C, Dzau VJ. april 2020
USPSTF 2020 Recommendations on Screening for Asymptomatic Bacterial Vaginosis in Pregnancy
Bacterial vaginosis during pregnancy is associated with higher risks of pregnancy complications, including preterm birth, whether or not symptoms are reported. Bacterial vaginosis is currently considered to be a microbial imbalance of the lower genital tract characterized by low levels of “healthy” Lactobacillus and overgrowth of a mixed population of other bacterial genera, including Gardnerella, Atopobium, Prevotella, Mobiluncus, Sneathia, and other taxa. Many of these microbes are also common isolates from sites of intrauterine infection, including the placenta and amniotic fluid. These findings have motivated investigators to conduct clinical trials to examine the potential benefits and harms associated with screening and treatment of asymptomatic bacterial vaginosis in pregnant women, either applied to a general obstetric population or targeting women at increased risk for preterm delivery, such as those with prior preterm birth. This is particularly important in light of growing concerns about the effects of antibiotic use on long-term maternal and child health because of effects on their microbiomes.
Lewis AL, Laurent LC. april 2020
USPSTF Report: Screening for Bacterial Vaginosis in Pregnant Adolescents and Women
This systematic review to support the 2020 US Preventive Services Task Force Recommendation Statement on screening for bacterial vaginosis (BV) summarizes published evidence on the benefits and harms of BV screening and treatment in pregnant adolescents and adults to prevent preterm delivery.
Kahwati LC, Clark R, Berkman N, et al. april 2020
USPSTF Recommendation: Screening for Bacterial Vaginosis to Prevent Preterm Delivery
This 2020 Recommendation Statement from the US Preventive Services Task Force recommends against screening for bacterial vaginosis (BV) in pregnant persons not at increased risk for preterm delivery (D recommendation) and concludes that current evidence is insufficient to assess the balance of benefits and harms of screening for BV in pregnant persons at increased risk for preterm delivery (I statement).
, Owens DK, Davidson KW, et al. april 2020
Cardiac Resynchronization Therapy for Chemotherapy-Induced Cardiomyopathy—Reply
In Reply We agree with Dr Schwartz and colleagues that it would be worthwhile examining the time from the last anthracycline dose on the extent of CRT benefit. However, for CRT to work, there needed to have been concomitant conduction tissue disease because all the patients in our study had an accompanying LBBB contributing to the mechanical dyssynchrony that was corrected with CRT. The temporal relationship of the LBBB to the development of cardiomyopathy could influence the degree of response. We do not have data to examine the relationship between the last dose of anthracycline, the development of LBBB, and the onset of cardiomyopathy.
Singh JP, Fradley MG, Kutyifa V. april 2020
Preparing for the Most Critically Ill Patients With COVID-19: The Potential Role of ECMO
This Viewpoint discusses the potential role of ECMO (extracorporeal membrane oxygenation) in the management of novel coronavirus disease 2019 (COVID-19) and cautions about the risk of overuse and the shortage of ECMO capability given the numbers of people infected if the technology is not appropriately utilized.
MacLaren G, Fisher D, Brodie D. april 2020
Cardiac Resynchronization Therapy for Chemotherapy-Induced Cardiomyopathy
To the Editor Dr Singh and colleagues reported that patients with chemotherapy-induced cardiomyopathy (CHIC) who met class I or II indications for cardiac resynchronization therapy (CRT) showed improvement in left ventricular ejection fraction (LVEF) and heart failure symptoms by 6 months following CRT implantation. We would like to raise a few points for consideration.
Schwartz AM, Westerman S, Mandawat A. april 2020
Incorrect Data and Presentation in Abstract and Figures
In the US Preventive Services Task Force Evidence Report titled “Screening for Hepatitis C Virus Infection in Adolescents and Adults: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force” published online in JAMA on March 2, 2020, data and presentation were incorrect in the abstract and figures. In the abstract Conclusions, the value reported as 5% should have been reported as 95%. In Figure 1, the blue circle indicating key question 3 should have been presented on the first horizontal line at the left of the figure, just before the branch. In Figure 3, several percentages in the “Women” column were incorrect. This article was corrected online.
After Heart Attack, Growth Factor Improves Scar Quality and Heart Function in Pig Study
Composed primarily of collagen and strengthened with cross-linked fibers, scar tissue that forms after a heart attack doesn’t contract as well as healthy muscle tissue. It can therefore compromise the organ’s ability to pump blood, which may lead to heart failure, arrhythmias, and sudden cardiac death. Scientists who developed a therapy that targets such scar formation, or fibrosis, recently brought their strategy a step closer to the clinic. After demonstrating its effectiveness in rodents, their latest work—a randomized, double-blinded pig study—validates the approach in a large-animal model.
Hampton T. april 2020
Careful readers will notice a 2-year-old girl, Charlotte, named in the A Piece of My Mind essay (“The Peekaboo Visit)” and the poem (“The Key”) in this JAMA issue. They are the same child. Charlotte is a patient, a daughter, and for a too-brief period a twin sister, and submissions from her pediatrician and mother offered JAMA a rare opportunity to represent a family’s story from 2 perspectives. We hear much about shared decision-making, perhaps even shared story-telling, but the attempts of a physician and a mother to express their feelings of guilt and loss in poetic language, to find the words Charlotte was too young to have to grieve for her brother, helps us accompany them in their search for meaning. Poetry leaves us less alone in our private struggles with the limits of medicine’s magic, psychiatrist Jed Myers has written in these pages, and these 2 contributions demonstrate what that feels like. Writing doesn’t reverse loss or take away pain but it honors both, making them mean something. Hopefully, that’s a comfort to the writers and a lesson in empathy and in healing for readers.
Berkwits M. april 2020
A Low-Carbon Future Could Improve Global Health and Save Money
This Viewpoint proposes that framing climate change as a human health crisis could accelerate climate action, and reviews evidence pointing toward the health benefits of transitioning to renewable energy, plant-based diets, and a global lower carbon footprint.
Patz JA, Stull VJ, Limaye VS. april 2020
Boxed Warning for Allergy Drug
The FDA is requiring that the allergy and asthma medication montelukast carry a boxed warning—its most prominent type of alert—to caution consumers and clinicians about the risk of neuropsychiatric events associated with the drug. Montelukast is marketed as Singulair and in generic form.
Voelker R. april 2020
The Coronavirus Disease 2019 (COVID-19) Outbreak in China—Summary of a China CDC Report
This Viewpoint summarizes key epidemiologic and clinical findings from all cases of coronavirus disease 2019 (COVID-19) reported through February 11, 2020, in mainland China, and case trends in response to government attempts to control and contain the infection.
Wu Z, McGoogan JM. april 2020
Medicare Enrollment Among Patients With End-Stage Kidney Disease Receiving Dialysis in Outpatient Facilities Between 2005 and 2016
This study characterizes annual changes in enrollment of Medicare and non-Medicare patients treated at dialysis facilities before and after 2011 payment reforms and 2014 Affordable Care Act changes that influenced reimbursements.
Hoffman A, Sloan CE, Maciejewski ML, et al. april 2020
Effect of Doxorubicin Plus Olaratumab vs Doxorubicin Plus Placebo on Survival in Advanced Soft Tissue Sarcomas
This randomized trial compares the effect of doxorubicin plus olaratumab vs doxorubicin plus placebo on overall survival in patients with advanced/metastatic soft tissue sarcoma and leiomyosarcoma.
Tap WD, Wagner AJ, Schöffski P, et al. april 2020
COVID-19 in Singapore—Experience and Critical Issues That Require Attention and Action
This Viewpoint discusses public health measures implemented in Singapore to manage potential COVID-19 infection based on the country’s experience with SARS in 2003 and reviews critical information gaps necessary to help manage the outbreak, such as viral shedding patterns and optimal timing of antiviral treatment after exposure.
Wong JL, Leo Y, Tan C. april 2020
What Other Countries Can Learn From Italy During the COVID-19 Pandemic
As lições relevantes para outros países são a necessidade de \n 1 - evitar levar pacientes com suspeita de infecção por SARS-CoV-2 para o hospital, excepto quando eles claramente exigem cuidados hospitalares; \n 2 - manter procedimentos rigorosos de higiene no ambiente hospitalar; e \n 3 - agir rapidamente em caso de exposição do pessoal médico para evitar perda de capacidade do pessoal.
Boccia S, Ricciardi W, Ioannidis JPAapril 2020
Report 14: Online Community Involvement in COVID-19 Research & Outbreak Response: Early Insights from a UK Perspective
A população tem medo e está confusa sobre o que pensar e fazer. Propõe-se que as autoridades apoiem a coordenação rápida de grupos comunitários de ajuda mútua já existentes e/ ou estabelecimento de uma nova rede de "campeões da comunidade" e “explicadores” para apoiar a distribuição de mensagens de saúde pública e agir como porta-voz da comunidade de forma a recolher preocupações e necessidades não atendidas e orientar a respostas. Essa abordagem também garantiria chegar a pessoas que não podem aceder ou participar nas atividades on-line disponíveis.
Philippa Pristerà, Vasiliki Papageorgiou, Meerat Kaur, Christina Atchison, et al.april 2020
White Blood Cells Might Provide Clues to Breast Cancer Risk
The proportions of certain white blood cell types in a woman’s blood might predict her risk of being diagnosed with breast cancer in the short-term and in the long-term, according to a recent study in JAMA Network Open by researchers from the National Institute of Environmental Health Sciences (NIEHS).
Rubin R. march 2020
Accuracy of Newborn Screening for Biliary Atresia Using Direct or Conjugated Bilirubin Measurements
This cross-sectional study characterizes the diagnostic accuracy of direct or conjugated bilirubin measurements for identifying newborns with biliary atresia and the associations between screening and age of therapeutic surgery.
Harpavat S, Garcia-Prats JA, Anaya C, et al. march 2020
US Emergency Legal Responses to Novel Coronavirus—Balancing Public Health and Civil Liberties
This Viewpoint discusses the policy and legal ramifications of the national public health emergency declared by the US government in response the coronavirus disease 2019 (COVID-19) outbreak, and examines the lawfulness of quarantine and other compulsory measures.
Gostin LO, Hodge JG, Jr. march 2020
Spirits and the Medical Mind
The linguistic devices by which we distinguish between a specialist in the laws of the behavior of matter, one who deals with the functions of the body, and still another who ministers to the body diseased, indicate that for human ends we must divide what in nature is joined. We call the one man a physicist, the second a physiologist, the third a physician. The names, like the pursuits, all begin alike, for they are but phases of a common nature. So when any doctrines come forward that threaten to overturn the common foundation of science, physicist, physiologist and physician are equally concerned, and with them in these days the psychologist, who shares somewhat of the habit of mind of all three. But so far as the psychologist has a special warrant to consider belief in spirit-agency or in telepathic or other unrecognized forces, he approaches the matter with the clinical sense congenial to the medical mind.
New Resource for Managing Patients Receiving Long-term Opioid Therapy
The Agency for Healthcare Research and Quality (AHRQ) recently updated a toolkit for primary care practices who treat patients with chronic pain who take opioids. As AHRQ noted, most patients taking opioids for chronic pain are managed by primary care practitioners and their staffs.
Rubin R. march 2020
Hotspotting Doesn’t Prevent Hospital Readmissions in Study
An intensive “hotspotting” program designed to reduce unnecessary medical care by so-called superutilizer patients while improving their health failed to prevent hospital readmissions, a trial in the New England Journal of Medicine reported.
Slomski A. march 2020
Cultural Influences in Psychiatry
To the Editor In a Viewpoint, Dr Guinart et al highlighted the need for fuller consideration of transcultural psychiatry to better explain cultural variation in clinical trials of psychotropic medicines. As the article suggested, such research is bedeviled by questions of interrater reliability, variations in the expression of stigmatizing emotional experience, and capacity for measuring treatment response. Neglecting cultural contexts distorts the results of clinical trials. Such concerns about cultural validity for effective clinical practice, in fact, motivated formulation of the “new cross-cultural psychiatry” as an upgrade for transcultural psychiatry more than 4 decades ago.
Deshmukh A, Sarmukaddam SB, Paralikar VP. march 2020
In the Rational Clinical Examination entitled “Will This Patient Be Difficult to Intubate? The Rational Clinical Examination Systematic Review” published in the February 5, 2019, issue of JAMA, an incorrect percentage was reported. In the “Scenario Resolution, Case 2” section, second sentence, the first percentage should have been 20% so that the sentence reads “Based on the cursory physical examination (obese; positive LR, 2.2) and retrognathia (positive LR, 6.0), it was estimated that her posttest probability of a difficult intubation was between 20% and 40%.” This article was corrected online.
Enhancing Private Sector Health System Preparedness for 21st-Century Health Threats
This Viewpoint summarizes recommendations made by National Academies of Sciences, Engineering, and Medicine (NASEM) experts to address the US health system’s preparedness for major threats, highlighting 5 principles to help regions prepare for specific threats as a prelude to partnerships that would facilitate more comprehensive national preparedness.
Berwick DM, Shine K. march 2020
Confirming Point-of-Care INR Test Results
To the Editor The authors of the JAMA Diagnostic Test Interpretation article on point-of-care (POC) testing for vitamin K antagonist monitoring suggested confirming POC international normalized ratio (INR) test results greater than 3.5. There are numerous INR tests cleared by the US Food and Drug Administration (FDA), and the FDA recommends confirming all POC test results with an INR value greater than 4.5. Variation between whole blood POC and citrated plasma-based laboratory methods can be expected. One significant source of variation between INR testing methods is the animal source of thromboplastin. The authors did not mention which specific POC and laboratory assays were used, and therefore it is difficult to know whether the difference observed between the POC and laboratory tests was expected based on differences in thromboplastin.
Fantz CR. march 2020
The Inevitable Reimagining of Medical Education
This Viewpoint summarizes trends in preclinical medical education away from in-person classroom experiences toward online learning, and imagines the transformation of medical schools into programs that provide clinical rotations and residency training only.
Emanuel EJ. march 2020
When Can Intermediate Outcomes Be Used in Clinical Trials?
This JAMA Guide to Statistics and Methods reviews how and under what conditions surrogate outcomes can replace patient-centered outcomes in randomized trials and stresses the importance of properly validating outcomes as surrogates for direct measures of patient experiences.
DeMets DL, Psaty BM, Fleming TR. march 2020
Adults Are Making It Easier for Children to Ingest Dangerous Drugs
When children accidentally swallow prescription drugs, more than half the time it’s because an adult has removed the medication from child-safe packaging, according to a CDC study in the Journal of Pediatrics.
Kuehn BM. march 2020
Online Mindfulness Therapy Improves Residual Depression
Patients whose depression lingered after treatment had less severe residual symptoms, higher rates of remission, and lower rates of relapse following online mindfulness-based cognitive therapy, a trial in JAMA Psychiatry reported.
Slomski A. march 2020
Thank You to JAMA Peer Reviewers, Authors, and Readers
In this issue of JAMA, we are pleased to publish the names of the 2816 reviewers who completed reviews of manuscripts for JAMA in 2019. The thoughtful comments and recommendations of each reviewer for each manuscript are carefully considered in the editorial evaluation and are exceedingly helpful in assessing the novelty and importance of submitted manuscripts and in improving the presentation and quality of published articles. JAMA could not be successful without the efforts of the reviewers. We extend our appreciation to all reviewers for their service to the journal and hope that publishing your names in this issue provides recognition of the critical importance of the often underrecognized and underappreciated academic activity of scholarly peer review.
Golub RM, Bauchner H, Fontanarosa PB. march 2020
For days, the silver sprinkler high on the wall is a mouse poking its head out. The tangle of tubing draped over the circulation-boot pump is a Medusa-woman’s hair. You watch a battle rage on the blank TV screen; outside the hospital room window, the white-washed high-rise makes you think you’re in Miami, though you’ve never been. Then again, you’ve never died before either, never come back like Lazarus to this same old unfamiliar world.
McAbee D. march 2020
“Superdonor” Fecal Microbiota Transplant Effective for IBS
Fecal microbiota transplant (FMT) using a single “superdonor” produced high rates of clinical response in patients with irritable bowel syndrome (IBS) in a trial published in Gut. Two previous randomized clinical trials of FMT for IBS had conflicting results.
Slomski A. march 2020
Association of Daily Step Count and Step Intensity With Mortality Among US Adults
This study uses National Health and Nutrition Examination Survey data to examine the dose-response relationships between step count (steps/d) and step intensity (steps/min) and mortality in a representative sample of US adults aged 40 years or older.
Saint-Maurice PF, Troiano RP, Bassett DR, Jr, et al. march 2020
The Other Side
In this narrative medical essay, a medicine resident describes her father’s vegetative state following a cardiac arrest and finds herself identifying with families who don’t want limitations on medical care for their loved ones in conflict with her identity as an internist.
Song A. march 2020
Nonalcoholic Steatohepatitis—A Review
This narrative review summarizes the epidemiology of nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH), proposes a diagnostic algorithm for distinguishing the 2, and reviews management options.
Sheka AC, Adeyi O, Thompson J, et al. march 2020
Leading HIV Vaccine Trial Stopped for Ineffectiveness
The National Institute of Allergy and Infectious Diseases last month halted a highly anticipated clinical trial testing an investigational HIV vaccine regimen. After an interim review, a data and safety monitoring board found that the 2 experimental vaccines in the regimen were ineffective against HIV, although there were no safety concerns.
Slomski A. march 2020
Government Cites California for Violating Federal Conscience Laws
The US Department of Health and Human Services (HHS) recently issued a Notice of Violation of federal conscience laws to the state of California because it mandated that all health insurance plans provide coverage for abortions.
Rubin R. march 2020
Errors in Author Affiliations
In the Original Investigation entitled “Comparison of Abbreviated Breast MRI vs Digital Breast Tomosynthesis for Breast Cancer Detection Among Women With Dense Breasts Undergoing Screening” published in the February 25, 2020, issue of JAMA, the Department of Radiology, University of Rochester, Rochester, New York, affiliation that was given for Gillian M. Newstead, MD, should have instead been given for Jennifer A. Harvey, MD. This article was corrected online.
Preparation for Possible Sustained Transmission of 2019 Novel Coronavirus
This Viewpoint discusses the concepts of transmissibility and severity as the critical factors that determine the extent of an epidemic, drawing on the previous pandemic of influenza A(H1N1) and epidemics of SARS and MERS to consider what the scope, morbidity, and mortality of the 2019 novel coronavirus (2019-nCoV) epidemic might be.
Swerdlow DL, Finelli L. march 2020
Newborn Screening for Biliary Atresia
Biliary atresia is a serious pediatric liver disease. It is among the leading causes of newborn cholestasis, the foremost reason for cirrhosis and liver-related death in children, and the most frequent indication for liver transplant in the pediatric population. The condition results from an idiopathic, rapidly progressive, fibrosclerosing obliterative injury to large bile ducts during the first months of life. Although not an inherited disease, biliary atresia is a rare orphan liver disease that occurs in 1:15 000 to 1:20 000 live births in North America and Western Europe, with the highest incidence rates in Asia (1:6000 to 1:9000) and French Polynesia (1:3000).
Schreiber RA. march 2020
Medical Exemption From Disconnection of Utilities in Connecticut
This study uses data from the Connecticut Public Utilities Regulatory Authority to describe trends in medical exemptions from utility disconnection and characteristics and health care use of adults applying for such exemptions at a Yale New Haven Hospital care practice between 2011 and 2017.
Kahn PA, Daggula KR, Teng W, et al. march 2020
Two Rows Transposed in Table 1
In the Original Investigation entitled “Effect of Folic Acid and Zinc Supplementation in Men on Semen Quality and Live Birth Among Couples Undergoing Infertility Treatment: A Randomized Clinical Trial” published in the January 7, 2020, issue of JAMA, the data for 2 rows were transposed in Table 1. Under the row labeled “Taking multivitamin within past 3 mo,” the data for “Yes” are 298/751 (40) for the folic acid and zinc group and 284/752 (38) for the placebo group. In the next row, the data for “No” are 453/751 (60) for the folic acid and zinc group and 468/752 (62) for the placebo group. This article was corrected online.
Confirming Point-of-Care INR Test Results—Reply
In Reply We agree with Dr Fantz and the FDA guidance that confirmation venipuncture INR testing should be performed, at minimum, for all patients with POC INR testing results of 4.5 or greater. However, we recommend that each institution examine whether a lower threshold for performing POC INR testing (such as >3.5) would better meet patient safety goals. Donaldson et al conducted a single-institution study comparing POC INR values using 2 different POC devices (CoaguChek XS Plus and i-STAT) vs venipuncture INR (Stago). Based on prior studies, the authors defined a clinically significant INR difference (one that would result in differing dosing plans) as when the INR measurement was within therapeutic range on one device and out of therapeutic range on the other device or when both device INR measurements were out of range with an INR difference of 0.5 or greater. They also assessed the percentage of times that the device INR values differed by 0.4 INR units or more. The CoaguChek POC INR values were significantly different, with at least a 0.4-unit difference, from the venipuncture INR values in 33% of cases and the i-STAT POC INR values were significantly different, with at least a 0.4-unit difference, than the venipuncture INR values in 54% of cases.
Anderson I, Wool GD, Madden W. march 2020
Public health medicine
Novel Coronavirus Infection (COVID-19) in Humans: A Scoping Reviewand Meta-Analysis
Primeira análise sistemática da evidência disponível até 24/02/2020, metodologicamente bem feita mas baseada em estudos de baixo grau de evidência (relatos de caso e séries de casos). Relembra os sintomas mais comuns, achados radiológicos característicos e o quanto ainda não se conhece da doença, alertando que a maioria das mortes ocorreu em pessoas com mais de 60 anos, nas quais o diagnóstico precoce podefazer a diferença. A suspeita clínica deve ser acompanhada de uma história epidemiológica relevante, seguida por exames virológicos e de imagem precoces. A maioria dos sintomas clínicos e achados imagiológicos são inespecíficos, sendo os mais comuns febre e tosse, opacidades em vidro fosco e consolidações. A mortalidade foi maior em doentes de sexo masculino e mais idosos.
Israel Júnior Borges do Nascimento, Nensi Cacic, Hebatullah M. Abdulazeem, et al.march 2020
Healthcare Is a Right and Not a Privilege
The US will elect a new president in 8 months. Voters in the election will need to consider many issues in selecting their preferred candidate. Among the most important issues is the future of the US health care system. Several options have been proposed as part of the current political landscape, including expand the current system, adopt a single-payer model, or retreat from recent reforms, once again leaving more individuals without health coverage. Embedded in these discussions is the cost of care, which increased to an estimated $3.6 trillion in the US in 2018, about $11 000 per person, with increasing amounts of administrative complexity, out-of-pocket spending, surprise billing, high-deductible health care plans, the relentless increase in the cost of drugs, and concerns about waste in the health care system. At the same time, life expectancy in the US has declined and concerns have been raised about how to maintain innovation and the extraordinary advances of care that have occurred in the last decade.
Bauchner H, Fontanarosa PB. march 2020
Randomized Clinical Trials of Artificial Intelligence
As patient data are increasingly captured digitally, the opportunities to deploy artificial intelligence (AI), especially machine learning, are increasing rapidly. Machine learning is automated learning by computers using tools such as artificial neural networks to search data iteratively for optimal solutions. Typical applications include searching for novel patterns (eg, latent cancer subtypes), making a diagnosis or outcome prediction (eg, diabetic retinopathy), and optimizing treatment decisions (eg, fluid and vasopressor titration for septic shock). Although many express excitement regarding the promise of AI, others express concern about adverse consequences, such as loss of physician and patient autonomy or unintended bias, and still others claim that the entire endeavor is largely hype, with virtually no data that actual patient outcomes have improved.
Angus DC. march 2020
What Does It Mean to Be a Physician?
This Viewpoint provides a historical perspective on the evolution of the roles and responsibilities of physicians and proposes a response to the trends in dysfunctional health care systems, lifestyle changes that favor distancing from patients, disruptions in care continuity, and expectations that doctors manage social determinants of health that threaten physician identity.
Schwenk TL. march 2020
Healthy Tensions in the Evolution of Schools of Thought in Medicine
This Viewpoint reviews the modern evolution of medicine, from William Osler’s efforts to systematize practice through evidence-based and precision medicine, and highlights unifying themes in the continued fracturing of scientific approaches to medicine, including the need for medical care to stay patient-centered despite advances in medical science and technology.
Naylor C. march 2020
Guided Self-help Program May Help Refugees in Distress
A guided self-help program that uses audio courses and an illustrated book helped reduce psychological distress and improve functioning among female South Sudanese refugees in Uganda, according to the results of a cluster randomized trial.
Kuehn BM. march 2020
Clinical Characteristics of Patients With 2019 Novel Coronavirus (2019-nCoV)–Infected Pneumonia in Wuhan, China
This single-center case series describes the demographics, symptoms, laboratory and imaging findings, treatment, and clinical course of 138 patients hospitalized with 2019 novel coronavirus (2019-nCoV)–infected pneumonia (NCIP) in Wuhan, China, highlighting presumed human-to-human hospital-associated transmission in many cases.
Wang D, Hu B, Hu C, et al. march 2020
FDA Takes on Agricultural Biotech
A new pilot program from the FDA’s Center for Veterinary Medicine is intended to facilitate the development of genetically altered animal products and clarify the regulatory process involved in bringing those products to market. The Veterinary Innovation Program covers “intentional genomic alterations in animals and animal cells, tissues, and cell- or tissue-based products seeking FDA approval.”
Voelker R, Voelker R. march 2020
Errors in Text
In the Special Communication entitled “Practices to Foster Physician Presence and Connection With Patients in the Clinical Encounter” published in the January 7, 2020, issue of JAMA, errors occurred in the text. On page 72, in the Delphi section, “a nurse” should not have been included in the sentence that stated “Individual panelists included physicians, a nurse, health system leaders, patient and caregiver advocates, and researchers with expertise in physician communication and behavior, implementation of physician-patient interpersonal interventions, and medical education.” On page 73, in the Clinical Observations and Interviews With Physicians and Patients section, the information on patients who spoke a second language at home should have reported that patients spoke “Hindi” instead of “Hindu.” A number of minor typographical errors were also corrected. This article was corrected online.
Treatment of Older Adults With Subclinical Hypothyroidism
To the Editor In the study by Dr Mooijaart and colleagues of adults aged 80 years and older with subclinical hypothyroidism, treatment with levothyroxine vs placebo was not associated with improvement in symptoms. The lack of subjective benefit of therapy was not surprising because at least half of the participants did not qualify for the diagnosis of subclinical hypothyroidism. The study did not use the age-adjusted criteria for the upper limit of normal serum thyrotropin in individuals older than 80 years of 7.5 mIU/L based on an analysis of 924 disease-free participants older than 80 years in the National Health and Nutrition Examination Survey (NHANES) III study. The mean thyrotropin level for the patients in the study by Mooijaart and colleagues before thyroxine therapy was 6.5 mIU/L. Inclusion of a high proportion of euthyroid participants based on age-adjusted thyrotropin levels biased the study against detection of any improvement in thyroid-related symptoms.
Hershman JM. march 2020
How Not to Spend an Opioid Settlement
With fatal overdose numbers remaining unacceptably high in 2019, an important story in 2020 will be the outcome of litigation against opioid manufacturers and distributors. Signs point to settlements in lawsuits brought by cities, counties, and states as well as to distributions from the bankruptcy case of Purdue Pharma. Billions of dollars are at stake.
Sharfstein JM, Olsen Y. march 2020
Preventing Surgical Site Infections—Looking Beyond the Current Guidelines
This JAMA Insights Clinical Update summarizes current guidelines for prevention of surgical site infections and discusses emerging prevention strategies, such as preoperative bowel preparation and negative-pressure wound therapy, that are challenging longstanding surgical practices.
Fields AC, Pradarelli JC, Itani KF. march 2020
ICMJE Proposal for Disclosure Form
Many factors, including professional and personal relationships and activities, can influence the design, conduct, and reporting of the clinical science that informs health care decisions. The potential for conflict of interest exists when these relationships and activities may bias judgment. Many stakeholders—editors, peer reviewers, clinicians, educators, policy makers, patients, and the public—rely on the disclosure of authors’ relationships and activities to inform their assessments. Trust in the transparency, consistency, and completeness of these disclosures is essential.
Taichman DB, Backus J, Baethge C, et al. march 2020
Clinical Characteristics of Patients With Novel Coronavirus (2019-nCoV) Infection Hospitalized in Beijing, China
This case series uses patient hospital data to summarize the clinical presentation and laboratory and imaging findings of 13 patients with confirmed 2019-nCoV infection admitted to hospitals in Beijing in January 2020.
Chang D, Lin M, Wei L, et al. march 2020
Hong Kong Unrest Contributes to Increased Mental Health Care Burden
An observational study has linked the social unrest roiling Hong Kong since June 2019 with a 5-fold increase in probable depression and a 6-fold increase in posttraumatic stress disorder (PTSD) symptoms.
Kuehn BM. march 2020
Physiologic Significance of Record Aeroplane Flight
A few days ago an aeroplane carrying Major R. W. Schroeder of the American army aviation service reached an altitude of 36,020 feet, about 5,000 feet higher than the previous world’s record for such a mode of flight. Only a few years ago this marvelous performance would have been rated as virtually impossible because of the limitations of the human organism at great heights. In the oft quoted balloon ascension of the meteorologist Glaisher, in 1862, an altitude of about 30,000 feet was reached. When the balloonist attained a height of 26,000 feet, he first noticed that he could not read his instruments properly. Shortly after this his legs became paralyzed, and then his arms, though he could still move his head. Then his sight failed entirely, afterward his hearing, and he became unconscious. Glaisher’s companion, Coxwell, likewise incapacitated in the upper air, managed to open a valve which permitted the balloon to descend, and thus saved the lives of the men. Another historic instance of a record balloon ascension concerns the experience of Tissandier, the sole survivor of a party of three in the fatal trip of 1875.…
How Becoming a Doctor Made Me a Worse Listener
In this narrative medicine essay, a former National Public Radio reporter turned neurologist regrets time and attention she once had to show interest in and learn about people and tells how she’s adapted to retain a small measure of that reporter’s curiosity in her interactions with patients.
Goss AL. march 2020
Return on Investment From Co-Locating Tax Assistance for Low-Income Persons at Clinical Sites
This study characterizes net dollars low-income persons received from participation in tax preparation services co-located at clinical sites in New York City intended to maximize credits and reduce poverty.
Black S, Sisco S, Williams T, et al. march 2020
Genetic Ancestry Testing: What Is It and Why Is It Important?
This Genomics and Precision Health article explains how genetic testing is used to identify the probable geographic origins of one’s ancestors and how it can aid in risk assessment for some heritable conditions, and summarizes the contexts in which its information provides clinically relevant information.
Jorde LB, Bamshad MJ. march 2020
Controversies in Hip Arthroplasty—Using Registries to Answer Difficult Questions
The advent of hip arthroplasty to treat hip fractures and hip degeneration has been an extraordinary achievement that has significantly changed the lives of millions of people. Hip hemiarthroplasty involves replacement of the femoral head and neck. Modern total hip arthroplasty (replacement of both the femoral head and acetabulum) was developed by Charnley in the 1960s and has allowed generations of surgeons to treat previously disabling hip disease, keeping patients active, productive, and independent. Since the development of these procedures, there has been debate about the techniques used for both fixation and surgical approach, resulting in substantial changes in clinical practice and major differences in technique both locally and internationally.
Hallstrom BR, Hughes RE. march 2020
Measuring vs Estimating LDL-C Levels in a Clinical Trial of Bempedoic Acid
To the Editor Dr Goldberg and colleagues reported that bempedoic acid compared with placebo provided additional lowering of low-density lipoprotein cholesterol (LDL-C) levels in patients who did not achieve an adequate response to standard lipid-lowering therapy. We are concerned that the patients’ LDL-C levels used in this study were not directly measured but were estimated by the Friedewald equation.
Xu H, Pan S. march 2020
Bisphosphonates for Osteopenia in Postmenopausal Women—Reply
In Reply The topic addressed by our article was the efficacy and safety of bisphosphonate treatment for women with postmenopausal osteoporosis, not osteopenia. Dr Snyder comments that we stated that no clinical trials have assessed the benefit of treatment with bisphosphonates in women with osteopenia. However, our article instead stated that while some organizations recommend treatment initiation in postmenopausal women with osteopenia who have a 10-year fracture probability (calculated using the FRAX tool) at or above intervention thresholds proposed by the National Osteoporosis Foundation, the benefit of treatment in patients selected on the basis of these criteria has not been assessed in clinical trials. Snyder refers to a trial of intravenous zoledronate vs placebo in 2000 women aged 65 years and older (mean age, 71 years) with osteopenia defined by at least 1 BMD T score between −1.0 and −2.5 at the hip (total hip or femoral neck) on either side that reported a reduction in clinical fracture (but not hip fracture) risk with zoledronate treatment.
Ensrud KE, Crandall CJ. march 2020
Association Between Surgical Approach and Major Surgical Complications in Patients Undergoing Total Hip Arthroplasty
This cohort study uses Ontario administrative data to estimate the risk of complications associated with posterior or lateral vs anterior surgical approaches to total hip replacement arthroplasty.
Pincus D, Jenkinson R, Paterson M, et al. march 2020
Effect of a Machine Learning–Derived Early Warning System vs Standard Care on Hypotension During Noncardiac Surgery
This unblinded randomized trial compares the effect of a machine learning–derived system that uses arterial waveform information to predict cardiovascular decompensation vs standard monitoring by anesthesiologists on the depth and duration of intraoperative hypotension in patients undergoing elective noncardiac surgery.
Wijnberge M, Geerts BF, Hol L, et al. march 2020
Errors in Table 1, Figure 3, and Results Section
In the Original Investigation entitled “Effect of Sunscreen Application on Plasma Concentration of Sunscreen Active Ingredients: A Randomized Clinical Trial” published in the January 21, 2020, issue of JAMA, there were errors in Table 1, Figure 3, and the Results section. In Table 1, the number of participants in the nonaerosol spray group with Fitzpatrick skin type IV should have been listed as 3 (25%). In Figure 3, the unit of measure should have been listed as hours, not days, so that the x-axis labels read “Time, h” for all panels. And at the end of the first paragraph of the Post Hoc Assessments subsection of the Results section, the Figure 3 callout should have been for Figure 2. This article was corrected online.
Measuring vs Estimating LDL-C Levels in a Clinical Trial of Bempedoic Acid—Reply
In Reply Drs Xu and Pan comment that the Friedewald formula used for calculating LDL-C levels is not as accurate as direct LDL-C measurement and that our study should have used the latter methodology. Although it is true that methodology improves over time and that there are new methods under exploration that may be more sensitive, those methods have not yet been widely adopted in clinical practice or investigational research. The methods used in our study were consistent with the current gold standard and with the way clinical trial data are typically reported.
Goldberg A, Hanselman JC, Duell P. march 2020
Bisphosphonates for Osteopenia in Postmenopausal Women
To the Editor The JAMA Insights article on bisphosphonates for postmenopausal osteoporosis commented that no clinical trials have assessed benefit of treatment with bisphosphonates in women with osteopenia. I disagree. A double-blind, randomized, placebo-controlled trial of nearly 2000 older women with osteopenia with average bone mineral density (BMD) T scores between −0.91 at the lumbar spine and −1.67 at the femoral neck showed a fracture reduction rate at 6 years of at least 33% from intravenous zoledronate given at 18-month intervals. The reduction in hip fracture rates did not achieve statistical significance; however, the fracture reduction rates outside the hip occurred without the adverse effects of jaw osteonecrosis or atypical hip fractures. The results held true even when data from a subset of 163 women with osteoporosis who were included in the study were later excluded from statistical analysis. The results are remarkable given that 62 of the 954 women (6.4%) in the treatment group received only 1 infusion of zoledronate because of acute phase reactions or iritis and that 115 women (12.2%) in the placebo group vs 33 (3.5%) in the treatment group received bisphophonates outside the study. In addition, the benefits of zoledronate were sustained in women with or without 10-year baseline fracture risks of greater than 3% for hip fractures and 20% for any fracture as determined by the Fracture Risk Assessment Tool (FRAX) calculator proposed by the National Osteoporosis Foundation and in individuals with a history of a nonvertebral fracture after 45 years of age. These data are consistent with the reduction in bone turnover markers, procollagen type 1 N-terminal propeptide and carboxy-terminal collagen crosslinks by 37% to 50% at the end of the study. Similar data have shown bone turnover markers that are suppressed nearly 50% and significant increases in bone mineral density apparent 5 years after a single infusion of zoledronate.
Snyder S. march 2020
Explaining Health State Utility Assessment
This JAMA Guide to Statistics and Methods reviews how health state utility assessment can be used to calculate quality-adjusted life-years, a patient-specific measure of preference for health outcomes that incorporates quantity and quality of life.
Chang EM, Saigal CS, Raldow AC. march 2020
Treatment of Older Adults With Subclinical Hypothyroidism—Reply
In Reply The population distribution of thyrotropin across the human life span has been reported in multiple studies with ambiguous results: both increase and decrease with increasing age have been reported. These inconsistencies may reflect differences in iodine intake across cohorts or age categories and underscore that population distributions alone are unfit to determine reference ranges. Other observational studies of subclinical hypothyroidism, including the NHANES study mentioned by Dr Hershman as well as an individual patient data meta-analysis by Rodondi et al, showed no association of subclinical hypothyroidism with mortality and cardiovascular events in individuals aged 80 years and older. However, because these data have all been observational, they are not suitable to definitely establish or rule out causality. Therefore, until now, existing studies have not justified age-specific reference ranges and guidelines currently do not support them.
Mooijaart SP, Du Puy RS. march 2020
Association Between Uncemented vs Cemented Hemiarthroplasty and Revision Surgery in Hip Fracture
This cohort study compares the rate of aseptic revision among patients with hip fracture undergoing cemented vs uncemented hemiarthroplasty in a large US integrated health care system.
Okike K, Chan PH, Prentice HA, et al. march 2020
Public health medicine
Risk Factors Associated With Acute Respiratory Distress Syndrome and Death in Patients With Coronavirus Disease 2019 Pneumonia in Wuhan, China
Importance: Coronavirus disease 2019 (COVID-19) is an emerging infectious disease that was first reported in Wuhan, China, and has subsequently spread worldwide. Risk factors for the clinical outcomes of COVID-19 pneumonia have not yet been well delineated. Objective: To describe the clinical characteristics and outcomes in patients with COVID-19 pneumonia who developed acute respiratory distress syndrome (ARDS) or died. Design, Setting, and Participants: Retrospective cohort study of 201 patients with confirmed COVID-19 pneumonia admitted to Wuhan Jinyintan Hospital in China between December 25, 2019, and January 26, 2020. The final date of follow-up was February 13, 2020. Exposures: Confirmed COVID-19 pneumonia.Main Outcomes and Measures: The development of ARDS and death. Epidemiological, demographic, clinical, laboratory, management, treatment, and outcome data were also collected and analyzed. Results: Of 201 patients, the median age was 51 years (interquartile range, 43-60 years), and 128 (63.7%) patients were men. Eighty-four patients (41.8%) developed ARDS, and of those 84 patients, 44 (52.4%) died. In those who developed ARDS, compared with those who did not, more patients presented with dyspnea (50 of 84 [59.5%] patients and 30 of 117 [25.6%] patients, respectively [difference, 33.9%; 95% CI, 19.7%-48.1%]) and had comorbidities such as hypertension (23 of 84 [27.4%] patients and 16 of 117 [13.7%] patients, respectively [difference, 13.7%; 95% CI, 1.3%-26.1%]) and diabetes (16 of 84 [19.0%] patients and 6 of 117 [5.1%] patients, respectively [difference, 13.9%; 95% CI, 3.6%-24.2%]). In bivariate Cox regression analysis, risk factors associated with the development of ARDS and progression from ARDS to death included older age (hazard ratio [HR], 3.26; 95% CI 2.08-5.11; and HR, 6.17; 95% CI, 3.26-11.67, respectively), neutrophilia (HR, 1.14; 95% CI, 1.09-1.19; and HR, 1.08; 95% CI, 1.01-1.17, respectively), and organ and coagulation dysfunction (eg, higher lactate dehydrogenase [HR, 1.61; 95% CI, 1.44-1.79; and HR, 1.30; 95% CI, 1.11-1.52, respectively] and D-dimer [HR, 1.03; 95% CI, 1.01-1.04; and HR, 1.02; 95% CI, 1.01-1.04, respectively]). High fever (≥39 °C) was associated with higher likelihood of ARDS development (HR, 1.77; 95% CI, 1.11-2.84) and lower likelihood of death (HR, 0.41; 95% CI, 0.21-0.82). Among patients with ARDS, treatment with methylprednisolone decreased the risk of death (HR, 0.38; 95% CI, 0.20-0.72). Conclusions and Relevance: Older age was associated with greater risk of development of ARDS and death likely owing to less rigorous immune response. Although high fever was associated with the development of ARDS, it was also associated with better outcomes among patients with ARDS. Moreover, treatment with methylprednisolone may be beneficial for patients who develop ARDS.
Chaomin Wu, Xiaoyan Chen, Yanping Cai, et al.march 2020
Public health medicine
How Should U.S. Hospitals Prepare for Coronavirus Disease 2019 (COVID-19)?
Coronavirus disease 2019 (COVID-19) is on the verge of being declared a pandemic. As of 7 March 2020, a total of 423 cases and 19 deaths, including several non–travel-related cases, areas of sustained community transmission, and a nursing home outbreak, have been reported (1). Best-case estimates suggest that COVID-19 will stress bed capacity, equipment, and health care personnel in U.S. hospitals in ways not previously experienced (2). How can health systems prepare to care for a large influx of patients with this disease?
LVineet Chopra, Eric Toner, Richard Waldhorn, Laraine Washermarch 2020
Prevalence of Pathogenic Variants in Cancer Susceptibility Genes Among Women With Postmenopausal Breast Cancer
This study uses Women’s Health Initiative data to compare the prevalence of pathogenic variants (PVs) in breast cancer susceptibility genes in postmenopausal women with vs without breast cancer to guide decisions about who should undergo PV testing.
Kurian AW, Bernhisel R, Larson K, et al. march 2020
Association of Physician Orders for Life-Sustaining Treatment With ICU Admission Near the End of Life
This cohort study uses electronic health record (EHR) data to evaluate the association between Physician Orders for Life-Sustaining Treatment (POLST) and intensive care unit (ICU) admission and the incidence of and risk factors for POLST-discordant intensive care among adult patients hospitalized 6 months or less before death.
Lee RY, Brumback LC, Sathitratanacheewin S, et al. march 2020
The Need to Incorporate Additional Patient Information Into Risk Adjustment for Medicare Beneficiaries
This Viewpoint discusses concern that current risk adjustment models used by CMS to tie payment to performance do not account for dementia, frailty, and social risk, and proposes ways to add reliable measures of each to the agency’s CMS-HCC model to more equitably reimburse clinicians and facilities caring for patients with challenging conditions.
Johnston KJ, Bynum JW, Joynt Maddox KE. march 2020
Mortality and Hospitalizations for Dually and Nondually Enrolled Medicare Beneficiaries, 2004-2017
This population epidemiology study compares annual changes in all-cause mortality, hospitalization rates, and hospitalization-related mortality among beneficiaries aged 65 years or older dually enrolled in Medicare fee-for-service and Medicaid vs those nondually enrolled (Medicare only).
Wadhera RK, Wang Y, Figueroa JF, et al. march 2020
Diagnostic Testing for Acute Hepatitis
An 18-year-old man who recently emigrated from India presented with fever, malaise, and anorexia for 4 days. He was afebrile with scleral icterus and a palpable liver edge; had a white blood cell count of 3.9 × 103/μL with elevations in total and direct bilirubin, alkaline phosphatase, and liver enzymes; and laboratory test results were positive for HBsAg and HBV core IgG. What is the cause of his hepatitis, and what would you do next?
Mikolajczyk AE, Chung NL. march 2020
Special Needs Plans for People Experiencing Homelessness
This Viewpoint proposes the creation of a homelessness-focused special needs plan, a Medicare Advantage insurance plan aimed at meeting the unique care needs of specific populations, to help offer the intensive case management and care coordination necessary for providing health care to homeless individuals.
Jain SH, Baackes J, O’Connell JJ. march 2020
23andMe Develops First Drug Compound Using Consumer Data
Direct-to-consumer genetic testing company 23andMe has developed an antibody aimed at treating inflammatory skin conditions. The DNA testing and research outfit licensed the compound to Barcelona-based pharmaceutical firm Almirall in January, its first such deal for a drug compound developed in-house using consumer data.
Abbasi J. march 2020
Discussing the ABCs of Health Security—Antibiotic Resistance, Biothreats, and Coronavirus
In this Medical News article, Tom Inglesby, MD, director of the Center for Health Security at the Johns Hopkins Bloomberg School of Public Health, speaks about natural and deliberate biological threats to US national security.
Desai AN. march 2020
CAR Natural Killer-Cell Therapy Safe and Effective in First Trial
A variation on chimeric antigen receptor (CAR) T-cell therapy that instead modifies natural killer (NK) immune cells appeared to be safe and effective in an ongoing phase 1 and 2 trial of patients with CD19-positive blood cancers.
Abbasi J. march 2020
Physician Orders for Life-Sustaining Treatment and Limiting Overtreatment at the End of Life
In this issue of JAMA, Lee and colleagues examine the association between Physician Orders for Life-Sustaining Treatment (POLST), which involve portable medical orders that document treatment limitations for out-of-hospital emergency care and for limiting overtreatment at the end of life. The authors studied adults with chronic life-limiting illnesses who were hospitalized within the last 6 months of life and who had completed a POLST before their last inpatient admission. Among 1818 patients enrolled, 656 (36%) had POLST orders for “full treatment” and 1162 had orders for either “limited additional interventions” (761 [42%]) or “comfort measures only” (401 [22%]). Among the combined latter 2 groups, 472 (41%) were admitted to the intensive care unit (ICU), 436 (38%) received POLST-discordant intensive care, and 204 (18%) received POLST-discordant life-sustaining treatments, defined as mechanical ventilation, vasoactive infusions, new renal replacement therapy, or cardiopulmonary resuscitation. Patients with cancer or dementia were less likely to receive POLST-discordant intensive care, whereas patients hospitalized for traumatic injuries were more likely to receive POLST-discordant intensive care. These results are sobering.
Truog RD, Fried TR. march 2020
Oral Injections Tested in Proof-of-Concept Trial
A microneedle-containing pill safely injected an oral version of a biologic drug directly into the intestinal wall in a first-in-human phase 1 trial, Rani Therapeutics recently announced. The drug, octreotide, is a subcutaneous injection used to treat acromegaly and neuroendocrine disorders. The San Jose–based startup is also developing orally administered injections for diabetes, rheumatoid arthritis, and cardiovascular disease biologics, among others.
Abbasi J. march 2020
USPSTF Recommendation: Screening for Hepatitis C Virus Infection in Adolescents and Adults
This 2020 Recommendation Statement from the US Preventive Services Task Force recommends screening for hepatitis C virus infection in adults aged 18 to 79 years (B recommendation).
, Owens DK, Davidson KW, et al. march 2020
Clarifying the Language of Clinician Distress
This Viewpoint argues that moral dilemma, moral distress, and moral injury more accurately and etiologically characterize what most people refer to as physician burnout, and proposes that this reconception can lead to more effective prevention strategies and targeted solutions to address physician stress, frustration, dissatisfaction, and depression.
Dean W, Talbot SG, Caplan A. march 2020
Radiation Oncology Alternative Payment Model
To the Editor Drs Howard and Torres provided a synopsis of the alternative payment model for radiation oncology proposed by the Centers for Medicare & Medicaid Services (CMS). Four points deserve further consideration.
Royce TJ, Thaker NG, Agarwal A. march 2020
Dissenting Opinions in Nutrition Research
To the Editor In a Viewpoint on the public focus on minor lifestyle issues, Dr Ioannidis illustrated his claim that “[a]dvocacy may even lead to bullying of dissenters” by mentioning an occasion in which “collection of signatures in a petition was orchestrated to request retraction of a dissenter’s article.”
Liebman BF. march 2020
Rising Emergency Department Visits for Suicidal Ideation and Self-harm
Emergency departments have seen a 25.5% increase the past 2 years in patients who’ve had suicidal thoughts, harmed themselves, or both, according to a CDC report. It’s the latest article to raise alarm about rising suicide rates, which have increased by 40% in US working-aged adults in less than 2 decades, according to the agency.
Kuehn BM. march 2020
Measles as Metaphor—What Resurgence Means for the Future of Immunization
With the call for a vaccine to prevent the spread of the newly identified coronavirus (COVID-19), we should not lose sight of a virus we know, for which there has been a vaccine in use for more than 50 years: measles. Measles, one of the most contagious infectious diseases, is the canary in the immunization coal mine. Previously a near rite of passage, annually infecting 3 million to 4 million US children and causing 400 to 500 deaths, measles steadily declined after the 1968 introduction of a safe, highly effective vaccine to the point of declared national elimination (in 2000).
Koh HK, Gellin BG. march 2020
Choosing the Best Blood Pressure Target for Vasopressor Therapy
Medical research drives innovation and improves outcomes. In cardiology, advances in diagnosis, prevention, and treatment reduced the 30-day mortality from acute myocardial infarction from 20% to 12.4% between 1995 and 2014. Similarly, for women diagnosed with breast cancer, 5-year survival has increased from 74% to 88.5% over the past 4 decades in parallel with advances in diagnosis and targeted therapy, including chemotherapeutic regimens such as cyclophosphamide, methotrexate, and fluorouracil (CMF), trastuzumab, and aromatase inhibitors.
Marshall JC. march 2020
Radiation Oncology Alternative Payment Model—Reply
In Reply We agree with Dr Royce and colleagues that mandatory participation in the Radiation Oncology Model will add an additional layer of administrative burden and cost that could be disruptive to clinicians in the assigned regions. But voluntary enrollment is also problematic. Low and selective enrollment in voluntary alternative payment models has made them difficult to evaluate. The enrollment target for the Radiation Oncology Model (40% of episodes) is based on statistical power calculations.
Howard DH, Torres MA. march 2020
Dissenting Opinions in Nutrition Research—Reply
In Reply Ms Liebman comments on a statement in my Viewpoint but provides an incomplete presentation of the lengthy reevaluation process of the article by Teicholz published in the BMJ. The outcome was summarized by Fiona Godlee, the BMJ’s editor in chief, as follows: “We stand by Teicholz’s article and its critique of this highly influential advisory committee’s processes for reviewing the evidence, and we echo her conclusion” and “The current state of nutrition research should be a matter of grave concern to those attempting to develop evidence based health and economic policies that truly serve the public interests.”
Ioannidis JA. march 2020
Universal Screening for Hepatitis C
In this issue of JAMA, the US Preventive Services Task Force (USPSTF) has issued new recommendations for hepatitis C virus (HCV) infection screening in the asymptomatic US population. Based on an updated review of the evidence, the task force now “recommends screening for HCV infection in adults aged 18 to 79 years (B recommendation),” regardless of known risk factors. Adolescents who engage in injection drug use or other behaviors associated with acquisition of HCV should also be screened. Screening all adults has been shown to be cost-effective, and a B recommendation means that insurance companies will provide reimbursement for hepatitis C testing without cost-sharing by patients.
Graham CS, Trooskin S. march 2020
Alcohol and School Physiologies
In a number of states, at the instance of active temperance workers, laws have been passed prescribing instruction in the public schools as to the toxic action of alcohol. It is charged by some, and very recently by Professor Atwater, whose experiments—previously noted in The Journal—are known throughout the world, that the text-books used contain errors, notably in denying absolutely any food value to alcohol, with other inaccurate statements. He is reported as saying: “There are many errors in these text-books, sometimes the error consists in stating doubtful theories as attested facts; in other cases the principles laid down are partly true and partly false; in still others the statements are squarely opposed to all the latest and most accurate scientific research.” He proceeds to say, further, that the impression these text-books convey—as the facts—is “that science teaches that alcohol even in moderate quantities is always harmful and never useful. This is untrue.”
Data Errors in Table 3 and Figure 1
In the Original Investigation titled “Effect of Early Surgery vs Physical Therapy on Knee Function Among Patients With Nonobstructive Meniscal Tears: The ESCAPE Randomized Clinical Trial,” published in the October 2, 2018, issue, the number of available participants for primary analysis for the physical therapy group should have been listed as 148 instead of 141. In addition, the upper limits of 95% CIs were incorrectly reported as positive rather than negative numbers in Table 3. The between-group differences for the arthroscopic partial meniscectomy vs physical therapy groups overall, at 6 months, and at 24 months should have been reported as −5.9 (95% CI, −10.3 to −1.4), −8.2 (95% CI, −14.1 to −2.3), and −7.7 (95% CI, −14.0 to −1.3) points, respectively. Also, the P values for the between-group difference for the delayed arthroscopic partial meniscectomy vs physical therapy group at 6 months and 24 months should have been .009 and .01, respectively. This article was corrected online.
USPSTF Report: Screening for Hepatitis C Virus Infection in Adolescents and Adults
This systematic review to support the 2020 US Preventive Services Task Force Recommendation Statement on screening for hepatitis C virus (HCV) infection summarizes published evidence on the benefits and harms of HCV screening and treatment in adolescents and adults.
Chou R, Dana T, Fu R, et al. march 2020
US Zika-Related Birth Defects in High-Transmission Areas
In US regions with widespread Zika virus transmission, birth defects that possibly were virus-related increased about 4-fold, from 1.3 per 1000 live births between January and March 2016 to 5.6 per 1000 live births in January to March 2017, according to a CDC report.
Kuehn BM. march 2020
Potential Consequences of Changing Disease Classifications
This Viewpoint discusses the potential harms that can emerge from changing disease classifications, generally to broaden criteria for diagnosing greater numbers of patients, and calls for a balanced and systematic evaluation of the benefits and risks of shifting illness thresholds before formalizing changes.
Doust JA, Bell KL, Glasziou PP. march 2020
Prophylaxis, Invasive Fungal Disease, and Neutropenic Children and Young Adults
To the Editor Dr Fisher and colleagues examined prevention of invasive fungal infections in neutropenic patients aged 3 months to 30 years with acute myeloid leukemia with caspofungin vs fluconazole. Caspofungin resulted in a statistically significant lower incidence of invasive fungal disease. However, prophylaxis depends on appropriateness and adequacy of the antifungal medication.
de Lange DW, Brüggemann RM. march 2020
Trauma Surgery for Psychic Damage
In this narrative medicine essay a psychiatrist finds parallels between his attempts to locate the source of a patient’s psychological trauma and those of trauma surgeons opening up patients to reveal their injuries and shares how a successful connection heals both doctor and patient.
Loper PL, Jr. march 2020
Effect of Reduced Exposure to Vasopressors on 90-Day Mortality in Older Critically Ill Patients With Vasodilatory Hypotension
This randomized clinical trial compares the effect of vasopressors guided by a mean arterial pressure (MAP) target of 60 to 65 mm Hg with a MAP level determined by the treating physician on 90-day mortality among critically ill older patients with vasodilatory hypotension.
Lamontagne F, Richards-Belle A, Thomas K, et al. march 2020
Prophylaxis, Invasive Fungal Disease, and Neutropenic Children and Young Adults
In Reply We agree with Drs de Lange and Brüggemann that results of a randomized clinical trial comparing prophylaxis therapies need to be interpreted in the context of the target population and the chosen comparator agents.
Fisher BT, Sung L. march 2020
Sponsorship and Funding for Gene Therapy Trials in the United States
This study characterizes government, academia, and private funding for gene therapy trials in the United States by technology type and therapeutic and disease area.
Kassir Z, Sarpatwari A, Kocak B, et al. march 2020
Affording Medicines for Today’s Patients and Sustaining Innovation for Tomorrow
This is a time of unprecedented medical progress. Breakthrough science is transforming patient outcomes and enabling clinicians to treat—and sometimes cure—diseases that previously posed insurmountable challenges to people’s health. However, many individuals in the United States are increasingly concerned about the out-of-pocket expenses they face in gaining access to the care they need. Escalating insurance premiums, co-insurance expenses, and co-payments can be financially devastating for individuals and families. Many patients with private insurance are shocked to learn that, even when they received care at a network facility, large balance bills—“surprise” medical bills for noncovered clinicians, ambulances, and other services—can amount to thousands of dollars. But perhaps nothing has galvanized the current groundswell of populist outrage more than the money patients must pay for their prescription drugs in retail pharmacies. As a result, many patients skip doses because they simply cannot afford to pay for their medications or do not fill their prescriptions. This should not be.
Frazier KC. march 2020
Changes in List Prices, Net Prices, and Discounts for Branded Drugs in the US, 2007-2018
This study describes changes in list prices, net prices, and discounts for branded pharmaceutical products in the US between 2007 and 2018 and estimates the extent to which list price increases were offset by increases in discounts.
Hernandez I, San-Juan-Rodriguez A, Good CB, et al. march 2020
In the Original Investigation titled “Effect of Renal Denervation and Catheter Ablation vs Catheter Ablation Alone on Atrial Fibrillation Recurrence Among Patients With Paroxysmal Atrial Fibrillation and Hypertension: The ERADICATE-AF Randomized Clinical Trial” published in the January 21, 2020, issue of JAMA, there was incorrect wording in Table 2. The first row in the first column should have read “Primary end point of atrial fibrillation, flutter, or tachycardia.” This article was corrected online.
Diagnosis and Treatment of Adults With Community-Acquired Pneumonia
This JAMA Guidelines Synopsis summarizes the American Thoracic Society (ATS)/Infectious Diseases Society of America (IDSA) 2019 recommendations on diagnosis and treatment of adults with community-acquired pneumonia.
Olson G, Davis AM. march 2020
Strategies to Avoid Extubation Failure Among ICU Patients
To the Editor Dr Thille and colleagues reported that the combination of noninvasive ventilation (NIV) and high-flow nasal oxygen decreased the reintubation rate in patients at high risk of extubation failure compared with high-flow nasal oxygen alone. Before postextubation practice is changed, and given the burden on staff and costs of NIV, the settings in which this strategy is beneficial should be considered.
Matsuda W. march 2020
Relentless Prescription Drug Price Increases
One in 4 people in the US has difficulty paying the cost of their prescription medications. This stark fact was recently reported in a 2019 Kaiser Family Foundation public opinion poll among a nationally representative random sample of 1205 adults. Persons who reported having the greatest difficulty affording their prescription drugs were those who most needed them, including those who took 4 or more prescription drugs, spent $100 or more per month on their drugs, and reported being in fair or poor health.
Deb C, Curfman G. march 2020
Corticosteroids in Community-Acquired Pneumonia
This Medical Letter review summarizes evidence underlying American Thoracic Society and Infectious Diseases Society of America guideline recommendations on the use of corticosteroids as an adjunct to antimicrobials for the treatment of community-acquired pneumonia
Informed Consent for Stem Cell–Based Interventions—Reply
In Reply There are a variety of promising ways to help steer patients away from unsafe or fraudulent stem cell therapies; all may be worth pursuing as long as these inappropriate practices persist. That said, there is nothing wrong with announcing broadly that patients should be given the information necessary for them to be able to give informed consent for any intervention, even if this is not a complete solution to the problem. Dr Master and colleagues agree that such standards are a start toward helping patients make informed decisions. We also note the recent actions by the US Food and Drug Administration to step up enforcement of its regulations and shut down clinics engaged in illegal, often dangerous, or entirely fraudulent practices.
Charo R, Barker RA, Sugarman J. march 2020
Are Pharmaceutical Companies Earning Too Much?
Some of the most valuable innovations known to medicine have come from the pharmaceutical industry. Yet, the cost of those innovations places new drugs out of reach for many patients and significantly burdens others. Are pharmaceutical companies earning too much? Deciding whether pharmaceutical companies earn too much money is complicated.
Cutler DM. march 2020
Wasteful Health Care Spending in the United States—Reply
In Reply As we stated in our article on waste in the US health care system, our review was necessarily broad. We believe our results are conservative and imprecise, limited by existing published data. Our goal was to assess sources of waste broadly, using previously defined categories, and to update perceived areas of opportunity and directions for future improvement.
Shrank WH, Parekh N. march 2020
A poison is a substance, which when taken into the system is either absorbed or by its thermal action on the parts with which it is in contact produces deleterious effects. It may seem strange that almost all toxics are innocent, until they reach the circulation of the blood. Their slow or rapid absorption largely determines their deleterious effects upon the system. In our observations we are reminded from time to time of the idiosyncrasies of individuals and we seldom inquire into the causes of these peculiar conditions. It is generally attributed to a perversion of the nervous system, but in truth is caused by a rapid absorption of the poison and is modified by the power of resistance inherent in the individual. Hereditary predispositions and peculiar cachexias in persons are dissimilar conditions, and are in no sense identical. Heredity has not been defined satisfactorily, but the conditions of progenitors are transmitted in an attenuated form, which underlies their maladies.
US Health Care Spending by Payer and Health Condition, 1996-2016
This study estimates health care spending for the most common health conditions in the United States, including low back pain and musculoskeletal disorders, diabetes, and ischemic heart disease, between 1996 and 2016.
Dieleman JL, Cao J, Chapin A, et al. march 2020
The Probiotic Conundrum—Regulatory Confusion, Conflicting Studies, and Safety Concerns
This Viewpoint characterizes reasons for the lack of evidence about the health effects of probiotic supplements and cautions against a “can’t hurt, can’t help” presumption made by consumers and clinicians.
Freedman SB, Schnadower D, Tarr PI. march 2020
Wasteful Health Care Spending in the United States
To the Editor Dr Shrank and colleagues reported on “the sources of waste in health care spending” in the United States. Although we agree with the authors that an understanding of wasteful spending and overtreatment is important, we are concerned about their use of the term end-of-life care.
Martin EW, Murphy JB, Besdine RW. march 2020
New Insight on Preventing EGFR Inhibitor–Induced Adverse Effects
Targeted drugs that bind to and inhibit the epidermal growth factor receptor (EGFR) profoundly benefit many patients with solid tumors without the severe adverse effects associated with chemotherapy and radiation. But the agents can cause stigmatizing facial rashes and other cutaneous symptoms that may decrease cancer treatment adherence and effectiveness. Now, new research published in Science Translational Medicine reveals the mechanisms behind these adverse effects and points to an add-on treatment that might help to prevent them.
Hampton T. march 2020
Informed Consent for Stem Cell–Based Interventions
To the Editor Dr Sugarman and colleagues reported on the professional standards for informed consent for patients seeking stem cell interventions outside a clinical trial from the International Society for Stem Cell Research. We agree that informed consent is the cornerstone of ethical clinical practice and that patients need accurate information to make a reasonable choice when considering a stem cell intervention. These standards will aid the efforts of those engaged in responsibly advancing stem cell medicine.
Master Z, Smith C, Tilburt JC. march 2020
Strategies to Avoid Extubation Failure Among ICU Patients—Reply
In Reply Our clinical trial demonstrated that NIV alternating with high-flow nasal oxygen between NIV sessions applied after extubation of at-risk patients in the intensive care unit (ICU) significantly decreased reintubation rates compared with high-flow nasal oxygen alone. We agree with Dr Matsuda that NIV is a burden and that, consequently, this strategy must be well-justified before changing clinical practice. The trial was performed in 30 French ICUs and all centers had NIV experience, with a ratio of 2 nurses for 5 patients, and usually without a respiratory therapist. Although the protocol planned to apply NIV for a minimum period of 48 hours after extubation, in 23.2% of patients (149/641), the treatment was stopped and patients discharged from the ICU before 48 hours had elapsed. Conversely, NIV was continued beyond 48 hours in 25.4% of patients (86/339) because of incomplete recovery of respiratory status. Therefore, to reduce work overload, NIV might be applied for less than 48 hours according to patient respiratory status.
Thille AW, Ragot S, Frat J. march 2020
Expanding Access and Reducing Prices for Drugs to Prevent HIV
This Viewpoint considers the lawsuit United States v Gilead Sciences in the context of intellectual property rights and the patents held on medications for preexposure prophylaxis (PrEP) for HIV infection, leading to a trade-off between affordability and future pharmaceutical collaboration and innovation.
Gostin LO, Rai AK. march 2020
Profitability of Large Pharmaceutical Companies vs Other Large Public Companies
This study uses data from annual financial reports to compare the profitability of large pharmaceutical companies vs other large companies in the S&P 500 Index from 2000 to 2018, measured via gross profit; earnings before interest, taxes, depreciation, and amortization; and net income (earnings).
Ledley FD, McCoy S, Vaughan G, et al. march 2020
Drug Shortages in the United States—Are Some Prices Too Low?
This Viewpoint discusses underlying causes of generic drug shortages in the United States and proposes solutions to address those shortages, including financial incentives for manufacturers that provide a steady supply of high-quality products.
Hernandez I, Hershey T, Donohue JM. march 2020
Wasteful Health Care Spending in the United States
To the Editor Studying unnecessary spending in the US health care system, Dr Shrank and colleagues updated previous estimates of wasteful spending to between $760 billion and $935 billion per year, or approximately 25% of total US health care expenditures. However, we believe their estimates of wasteful spending are likely underestimated because they did not consider the effect of health behaviors.
Urwin JW, Pronovost PJ, Navathe AS. march 2020
Drug Approved to Aid Youths With Peanut Allergy
A newly approved drug is intended to lessen allergic reactions, including anaphylaxis, in children and adolescents who are allergic to peanuts. An FDA advisory committee supported approval of the treatment, Peanut (Arachis hypogaea) Allergen Powder-dnfp, during a September 2019 meeting.
Voelker R. march 2020
Rising Prices and Health Care “Empires”
The rate of growth of health care expenditures in the United States in 2018 vs 2017 was actually below the annual rate of growth of the US economy as a whole, according to the Centers for Medicare & Medicaid Services (CMS) Office of the Actuary. However, this is more of a reflection of the high annual rate of growth in the US economy in 2018 than a slowing in health care expenditures, which grew at an annual rate of growth of 4.6%.
Bindman AB. march 2020