JAMA

JAMA

Fighting Epilepsy Stigma

20-08-2019 – Kuehn B.

Greater efforts are needed worldwide to combat stigma and discrimination against patients with epilepsy, according to a World Health Organization report.

Viruses Drive Children’s Pneumonia

20-08-2019 – Kuehn B.

Respiratory syncytial virus and other viruses have replaced bacteria as the leading cause of severe childhood pneumonia in low- and middle-income countries, according to a study in The Lancet that examined childhood pneumonia in 7 Asian and African countries.

Gag Rule May Increase Abortions

20-08-2019 – Kuehn B.

Abortion rates in some sub-Saharan African countries increased by 40% when a US policy that pulled federal funding from overseas organizations that performed or discussed abortion was in effect, according to a study in The Lancet Global Health.

USPSTF Recommendation: Assessment, Counseling, and Testing for BRCA -Related Cancer

20-08-2019 – , Owens DK, Davidson KW, et al.

This 2019 Recommendation Statement from the US Preventive Services Task Force recommends that women with a family or personal history associated with increased risk for harmful mutations in the BRCA1/2 genes and with a positive result on a brief familial risk assessment tool should receive genetic counseling and, if indicated, genetic testing (B recommendation) and recommends against routine risk assessment, genetic counseling, or genetic testing for women whose personal or family history is not associated with potentially harmful BRCA1/2 gene mutations (D recommendation).

USPSTF Report: Risk Assessment, Genetic Counseling, and Testing for BRCA- Related Cancer

20-08-2019 – Nelson HD, Pappas M, Cantor A, et al.

This systematic review to support the 2019 US Preventive Services Task Force Recommendation Statement on risk assessment, genetic counseling, and genetic testing for BRCA-related cancer summarizes published evidence on the benefits and harms of assessment, counseling, and testing in women without recently diagnosed BRCA1/2-related cancer.

JAMA

20-08-2019 –

A Tale of Two Lungs: Helping Patients Make Decisions

20-08-2019 – Hensley MK.

In this narrative medicine essay, a critical care physician works through lessons he learned from his experience with a man with end-stage lung disease going into terminal respiratory failure who consented to intubation only if he had a chance for a lung transplant and considers how to balance patient autonomy with medical paternalism when good outcomes are unlikely and the best decisions are uncertain.

Playing Word Games

20-08-2019 – Martinello S.

I sprinkle hints, seeds in the withering garden of your brain, hope words will sprout, blossom on your lips. But deep in the gray matter, atrophy spreads like a biblical pestilence. In that un-Eden, hummingbirds dart, like crazed syllables, scatter alphabets like fallen petals amid stems of thought— bare, but pretending to be bright. Colors for flowers, all I could expect.

Testing for BRCA Mutations

20-08-2019 – Jin J.

This JAMA Patient Page describes the US Preventive Services Task Force’s recently published recommendations on risk assessment and genetic counseling and testing for BRCA mutations and BRCA-related cancers.

Association of Thyroid Function Test Abnormalities and Thyroid Autoimmunity With Preterm Birth

20-08-2019 – , Korevaar TM, Derakhshan A, et al.

This individual participant data meta-analysis pooled data from 19 cohort studies to assess whether maternal thyroid function test abnormalities and thyroid autoimmunity are risk factors for preterm birth among pregnant women without overt thyroid disease.

Effect of Continuing Olanzapine vs Placebo on Relapse Among Patients With Psychotic Depression in Remission

20-08-2019 – Flint AJ, Meyers BS, Rothschild AJ, et al.

This randomized clinical trial compares the effect on relapse of continuing olanzapine vs placebo among patients with psychotic depression who achieved remission of psychosis and depressive symptoms while taking olanzapine and sertraline.

Association of Smoking Cessation With Subsequent Risk of Cardiovascular Disease

20-08-2019 – Duncan MS, Freiberg MS, Greevy RA, Jr, et al.

This cohort study uses Framingham Heart Study data to assess the association between years since smoking cessation and incident cardiovascular disease (CVD), compared with current and never smoking, among participants without baseline CVD over a median follow-up of 26 years.

Treating Hypercholesterolemia in Older Adults—Reply

20-08-2019 – Skolnik N.

In Reply Dr Forman and colleagues, in a response to my Viewpoint, provide clarification regarding the IIb grade of the recommendation for management of hypercholesterolemia in older adults. A IIb recommendation indicates that a recommendation is based on weak evidence that the benefit is greater than the risk. The fact that clinical judgment should be used in carrying out a IIb recommendation is true but not distinct to IIb recommendations. Clinical judgment needs to be used for all recommendations.

Resuming Anticoagulation After Cerebral Intraparenchymal Hemorrhage—Reply

20-08-2019 – Gross BA, Jankowitz BT, Friedlander RM.

In Reply We agree with Ms Leasure and Dr Sheth that there is no firm evidence to support timing of restarting anticoagulation therapy following IPH, particularly for new-generation anticoagulants. We stated in our review that restarting anticoagulation therapy should be delayed by 1 to 2 months in patients with nonlobar IPH unrelated to amyloid angiopathy, but we did not state that anticoagulation therapy must be restarted in all cases at this time. In patients with a correctable etiologic cause of IPH and stronger indications for anticoagulation therapy, such as mechanical heart valves, anticoagulation therapy may need to be restarted even sooner. As Leasure and Sheth acknowledge, we summarized the available evidence to date, including a meta-analysis reinforcing the intuitive reduction of thromboembolic complications in patients resuming anticoagulation therapy. We agree that results of forthcoming trials will prove particularly useful in providing more rigorous evidence for future guidelines.

Monitoring Adherence to Inhaled Medications—Reply

20-08-2019 – Hew M, Reddel HK.

In Reply While we agree with the important points that Dr Bryant and colleagues have made about the role of multidisciplinary teams in improving adherence, we believe they may have misinterpreted our main thesis by inadvertently conflating adherence monitoring with adherence management. We have argued that input from pharmaceutical companies is essential to rectify the current lack of adherence monitoring. We do not, however, equate this with delivering overall adherence management, which is a far broader endeavor, needing to take into account multiple contributory factors and requiring an adequately resourced multidisciplinary approach, beyond the remit of any pharmaceutical company.

Treating Hypercholesterolemia in Older Adults

20-08-2019 – Forman DE, Stone NJ, Grundy SM.

To the Editor In his Viewpoint, Dr Skolnik discussed the 2018 American College of Cardiology (ACC)/American Heart Association (AHA) guideline on the management of blood cholesterol and its implications for older adults. We would like to highlight relevant features of the guidelines that merit greater recognition.

Resuming Anticoagulation After Cerebral Intraparenchymal Hemorrhage

20-08-2019 – Leasure AC, Sheth KN.

To the Editor Dr Gross and colleagues reviewed the management options for cerebral intraparenchymal hemorrhage (IPH) to help guide clinical decision-making. The review captured the most up-to-date evidence for clinical management of IPH; however, the authors’ suggestion to resume oral anticoagulation therapy 1 to 2 months after deep IPH unrelated to cerebral amyloid angiopathy may not be supported by firm evidence. We believe the recommendations should be more cautious. The 2015 American Heart Association guidelines do not provide a definitive recommendation for resumption of anticoagulation therapy after nonlobar IPH. In the absence of results from randomized clinical trials, the safety and optimal timing of restarting oral anticoagulation therapy in patients with IPH remains unknown.

Monitoring Adherence to Inhaled Medications

20-08-2019 – Bryant GA, Dy-Boarman EA, Kassel LE.

To the Editor Drs Hew and Reddel highlighted the importance of adherence to inhaled controller medications in the treatment of chronic respiratory conditions. Some of their claims regarding adherence monitoring systems for inhalers lacked a balanced perspective.

The Relation of Pathology to Practice

20-08-2019 –

With the swinging of the pendulum in the science of medicine has come the fashion of neglecting pathology, the pathology of the type called, in the olden days, morbid anatomy. This neglect is shown in many ways: in a diminution in the volume of published work; in the lessened number of necropsies performed, and in the smaller number of men who are actively interested in the subject. It may be that the great days of Rokitansky, of Virchow and of Cohnheim have passed never to return; but it is more likely that the next swing of the pendulum will bring with it a renewed interest in the study of the anatomic changes which accompany disease.

Averting Alert Fatigue to Prevent Adverse Drug Reactions

20-08-2019 – Carroll AE.

Although various electronic health records (EHRs) have different features, nearly all seem to have alerts for potential problems with drug prescribing. It’s one thing that many believe that EHRs do very well. However, a recent study warns that when it comes to opioids and benzodiazepines, we shouldn’t always assume that such alerts work as intended.

Catheter Ablation for Atrial Fibrillation in 2019

20-08-2019 – Upadhyay GA, Alenghat FJ.

This JAMA Insights Clinical Update reviews management approaches to atrial fibrillation (AF), including assessment of the need for anticoagulation, and controversies over the need for rhythm control and the role of catheter ablation for maintaining sinus rhythm and reducing AF-associated symptoms.

Highlights for August 20, 2019

20-08-2019 –

Prevalence and Treatment of Chronic Obstructive Pulmonary Disease (COPD) in the United States

20-08-2019 – Biener AI, Decker SL, Rohde F.

First Treatment for Rare Autoimmune Neuromyelitis

20-08-2019 – Sancar F.

The humanized monocolonal antibody eculizumab has been approved for adults with neuromyelitis optica spectrum disorder (NMOSD), a rare autoimmune inflammatory condition of the central nervous system (CNS). The disorder causes recurrent optic neuritis and myelitis, which may lead to permanent vision loss and paralysis.

Ventilator Recall

20-08-2019 – Sancar F.

More than 4000 Hamilton-G5 ventilators have been recalled due to a sporadic error message that can cause it to stop working, the FDA recently announced. The device provides breathing support for adult, pediatric, infant, and neonatal patients in intensive care.

Another Option for Hypoactive Sexual Desire

20-08-2019 – Sancar F.

The FDA recently approved bremelanotide for acquired generalized hypoactive sexual desire disorder (HSDD) in premenopausal women. It’s the first “as-needed” treatment for HSDD, a common condition characterized by low libido that causes distress or interpersonal difficulty and isn’t attributed to a coexisting medical or psychiatric condition, relationship problems, or medications.

Smoking Cessation and Reduction of Cardiovascular Disease Risk

20-08-2019 – Cole TB.

Smoking cessation improves cardiovascular health, but not right away. Studies have come to different conclusions about how long it takes for the excess risk associated with smoking to subside to the level of a never smoker, with estimates varying widely, from 2 to 20 years. The study by Duncan et al, which was based on repeated assessments of tobacco exposure, other risk factors, and cardiovascular disease (CVD) outcomes, provides estimates of cardiovascular risk among former smokers that are likely to be more precise and accurate than those of previous studies. This information is important for clinicians and patients. According to these new analyses, a former smoker’s risk of CVD does not approximate the risk of a never smoker until 10 to 15 years have elapsed since cessation. The risk of CVD does appear to decline substantially within the first 5 years, and smokers who are contemplating quitting may take some encouragement from this finding. On a population level, the implications of this study are sobering: reductions in CVD associated with declining smoking rates in countries such as Japan and the United States can be expected to lag quit rates by 10 to 15 years, and in countries where smoking rates appear to be increasing, such as China and Indonesia, rates of CVD are likely to increase for decades into the future. To counter these trends, all countries, particularly those most vulnerable to tobacco marketing, should implement tobacco control strategies to prevent smoking initiation and motivate current smokers to quit.

Thyroid Function Test Abnormalities During Pregnancy

20-08-2019 – Cappola AR, Casey BM.

Thyroid hormones affect the growth, metabolism, and function of multiple organs in the body. If adaptive mechanisms were not in place during pregnancy, physiological increases in the quantity of circulating thyroid hormone–binding proteins would result in lower concentrations of unbound (free) thyroid hormones and subsequent adverse maternal and fetal consequences. Fortunately, the hypothalamic-pituitary-thyroid axis compensates, matching thyroidal output to maternal requirements, and, as long as the thyroid has adequate reserves, thyrotropin (often referred to as thyroid-stimulating hormone or TSH) and free thyroxine are maintained at normal concentrations.

Broadening Criteria for BRCA1/2 Evaluation

20-08-2019 – Domchek S, Robson M.

Pathogenic variants (ie, mutations) in the breast cancer susceptibility 1 and 2 (BRCA1/2) genes are associated with a high risk of ovarian and female breast cancer as well as, particularly for BRCA2, elevated risks of male breast cancer, aggressive prostate cancer, and pancreatic cancer. The risks of ovarian cancer and breast cancer are as high as 45% and 70%, respectively. The detection of a BRCA1/2 pathogenic variant can significantly alter medical management (by early detection or risk reduction strategies) and improve outcomes.

Maintenance Treatment for Psychotic Depressive Disorders

20-08-2019 – Coryell WH.

Psychotic features, such as delusions of guilt or persecution, in major depressive disorder (MDD) attracted little research interest before the observation that patients with psychotic depression responded poorly to tricyclic antidepressants. Subsequent work showed that other depressive symptoms, particularly those of the melancholic subtype, are substantially more severe in this condition than they are in MDD without psychotic features. Second only to those with catatonic features, patients with psychotic features are most likely to experience hyperactivity of the hypothalamic-pituitary-adrenal axis and are much less likely than those without psychotic features to respond to placebo or to hospitalization alone.

Numbers of Patients Transposed in Text

20-08-2019 –

In the Original Investigation entitled “Effect of Pressure Support vs T-Piece Ventilation Strategies During Spontaneous Breathing Trials on Successful Extubation Among Patients Receiving Mechanical Ventilation: A Randomized Clinical Trial,” published in the June 11, 2019, issue of JAMA, patient numbers were transposed in a sentence in the Results section of the text. The first sentence in the Secondary Outcomes subsection on page 2178 should have read “After the first SBT, 532 patients (92.5%) undergoing the 30-minute PSV SBT and 486 patients (84.1%) undergoing the 2-hour T-piece SBT were extubated (difference, 8.4%; 95% CI, 4.7%-12.1%; P < .001).” This article was corrected online.

ECG Diagnosis of Atrial Arrythmias

20-08-2019 – Soliman EZ, Bhave PD, Chen LY.

This Clinical Challenge reviews ways to distinguish atrial ectopy, AV block, multifocal atrial tachycardia, and other supraventricular tachycardias from atrial fibrillation in patients with absent P waves, irregularly irregular R-R intervals, and f waves on electrocardiography.

Getting Social: Physicians Can Counteract Misinformation With an Online Presence

20-08-2019 – Rubin R.

Journal Article

This Medical News interview discusses the value of social media for health care.

Weighing the Risks and Rewards of Peanut Oral Immunotherapy

20-08-2019 – Abbasi J.

Journal Article

This Medical News article discusses a recent meta-analysis of oral immunotherapy trials for people with peanut allergies.

Implications of the United States Medical Licensing Examination (USMLE) Score Reporting Structure

20-08-2019 – Swails JL, Aibana O, Stoll BJ.

Journal Article

In the context of joint preliminary recommendations from the Federation of State Medical Boards and the National Board of Medical Examiners to consider moving the USMLE examination to pass-fail score reporting, this Viewpoint discusses how the current 3-digit score reporting structure is used by residency program directors and medical schools, how it may distract students from developing qualities of innovation and humanism important to medicine, and how it may facilitate workforce underrepresentation of some student groups.

Electronic Fetal Monitoring to Prevent Fetal Brain Injury—Ubiquitous But Flawed

20-08-2019 – Hirsch E.

Journal Article

This Viewpoint argues that the near-universal adoption of electronic fetal monitoring (EFM) in labor and delivery units has occurred without evidence that it has reduced adverse neurological events and has contributed to an increase in US cesarean delivery rates, and calls for the education of physicians and the public about EFM’s demonstrated reliability and value.

Clarification of Reporting of Potential Conflicts of Interest in JAMA Articles

20-08-2019 – Dzau VJ.

Journal Article

To the Editor I am writing to provide additional information to clarify conflict of interest disclosures in articles I published in JAMA in 2014, 2016, and 2019.

Clarification of Reporting of Potential Conflicts of Interest

20-08-2019 –

Journal Article

In 3 Viewpoints published in JAMA, additional information was needed to clarify the conflict of interest disclosures. The Conflict of Interest Disclosures statements in 2 of the Viewpoints should have read as follows: “Dr Dzau reports having served previously as a member of the board of Medtronic Inc ending in June 2014 and receiving compensation from that company.” For the third Viewpoint, the disclosure statement should have read as follows: “Dr Dzau reports having served previously as a member of the board of Alnylam Pharmaceuticals ending in June 2014 and receiving compensation from that company.” These articles have been corrected online and a letter of explanation has also been published for further clarification.

Protecting Pregnant Women With Opioid and Substance Use Disorders Participating in Research

20-08-2019 – Davis JM, Yao L, Bierer BE.

Journal Article

This Viewpoint discusses the potential risks faced by pregnant women with substance use disorders who participate in clinical research, including criminal prosecution for drug use while pregnant and custody loss of their children, and proposes changes to research procedures and disclosure provisions to encourage their participation so the evidence base informing their care and addressing the opioid epidemic more generally can advance.

The 2019 Supreme Court Ruling on Merck’s Liability for Bisphosphonate-Related Atypical Femoral Fractures

20-08-2019 – Johnston MC, Boumil MM, Curfman G.

Journal Article

In May 2019 the US Supreme Court sent back to lower courts the question of whether Merck Sharpe & Dohme Corp was liable for atypical fractures from its osteoporosis drug alendronate because it did not identify the adverse effect in the product’s label. This Viewpoint discusses the legal questions of liability raised by the case and the implication of the decision for the pharmaceutical industry and for patients alleging harmed from prescription drugs.

Prevalence and Characteristics of Virginia Hospitals Suing Patients and Garnishing Wages for Unpaid Bills

20-08-2019 – Bruhn WE, Rutkow L, Wang P, et al.

Journal Article

This study uses 2017 court records to characterize how frequently Virginia hospitals take legal action to garnish patients’ wages to recover unpaid medical expenses, and the characteristics of hospitals and patient employers associated with the actions.