JAMA

New Malaria Option

14-01-2020 – Kuehn B.

A newer antimalaria medication with a simplified dosing regimen may be useful in US patients as prophylaxis or as an antirelapse treatment, according to a review in the Morbidity and Mortality Weekly Report.

Pneumococcal Vaccine Recommendation

14-01-2020 – Kuehn B.

An updated recommendation from CDC’s Advisory Committee on Immunization Practices (ACIP) suggests adults aged 65 years or older should receive only the 23-valent pneumococcal polysaccharide vaccine (PPSV23) with a few exceptions.

JAMA

14-01-2020 –

FDA Approval and Regulation of Pharmaceuticals, 1983-2018

14-01-2020 – Darrow JJ, Avorn J, Kesselheim AS.

This study uses publicly available and FDA data to describe changes in drug testing laws and standards, the use of new FDA approval programs and standards, changes in the role and authority of the FDA, and changes in the number of drugs the FDA has approved from 1983 to 2018.

Doctoring and Deportation—Immigration Advocacy as Primary Care

14-01-2020 – Slavin SD.

In this narrative medicine essay, a resident physician shares the story of a young Haitian woman with cancer whose survival was threatened with deportation for having missed her residency application deadline and of his role in advocating for her care with US citizenship and immigration services.

One’s Self I Sing Too

14-01-2020 – Neilson S.

Cognitive Testing of Older Clinicians Prior to Recredentialing

14-01-2020 – Cooney L, Balcezak T.

This JAMA Performance Improvement article reports the methods and outcomes of a cognitive screening program implemented at a US hospital to assess medical staff aged 70 years or older for clinical competency every 2 years as a requirement for reappointment.

Periorbital and Orbital Cellulitis

14-01-2020 – Baiu I, Melendez E.

This JAMA Patient Page describes the causes, symptoms, diagnosis, and treatment of periorbital and orbital cellulitis.

Effect of Osocimab on Venous Thromboembolism Prevention Among Patients Undergoing Knee Arthroplasty

14-01-2020 – Weitz JI, Bauersachs R, Becker B, et al.

This phase 2 clinical noninferiority trial compared 4 doses of postoperative osocimab, a monoclonal antibody against factor XI, vs enoxaparin and apixiban on venous thromboembolism incidence among patients undergoing knee replacement.

Comparison of Functional Patient-Reported Outcomes 5 Years After Treatments for Localized Prostate Cancer

14-01-2020 – Hoffman KE, Penson DF, Zhao Z, et al.

This cohort study compares functional outcomes, including sexual and bowel function and urinary incontinence, associated with active surveillance, surgery, or radiation therapy 5 years after treatment.

Effect of a Behavioral Intervention to Increase Vegetable Consumption on Prostate Cancer Progression

14-01-2020 – Parsons J, Zahrieh D, Mohler JL, et al.

This randomized trial compares the effect of a counseling intervention to promote consumption of 7 or more daily vegetable servings vs an educational control on time to PSA- and biopsy-defined cancer progression in men with early-stage prostate cancer.

Recommendations Related to Genetic Testing for Breast Cancer—Reply

14-01-2020 – Krist AH, Owens DK, Mangione CM.

In Reply Dr Pinsky asks for more clarity on the USPSTF’s recent recommendation. The USPSTF found that women with a personal or family history of breast or ovarian cancer, or an ancestry associated with BRCA1/2 mutations, are at increased risk for having a BRCA1/2 mutation. For these women, the benefits of risk assessment and potentially counseling and testing outweigh the harms. Determining whether a woman may be a candidate for referral for counseling and possible genetic testing is a multistep process for primary care clinicians. The first step is to identify women with a personal or family history of breast or ovarian cancer or an ancestry associated with BRCA1/2 mutations (eg, Ashkenazi Jewish women). For these women, the next step is to perform a risk assessment using 1 of several brief risk assessment tools. Last, for women found to be at higher risk using these tools, clinicians should refer or provide genetic counseling. This includes more definitive risk assessment, counseling about genetic testing, shared decision-making about whether to be tested, and potentially genetic testing.

Reporting of the Medical Licensing Examination—Reply

14-01-2020 – Swails JL, Aibana O, Stoll BJ.

In Reply Based on the letters from Mr Schneider, Drs Everett and Isea, and Dr Battisti, we find 2 key issues to discuss—transparency and competency. We absolutely agree that increased transparency and access to data, both from medical schools and through ERAS, would facilitate holistic review. Program directors have been lamenting the erosion of meaningful performance measures for years as medical schools increasingly moved to pass-fail grading. We wonder what role the narrow focus on academic metrics in residency selection may have played during this transition. Broadening the selection criteria beyond academic metrics in true holistic review may be a more successful approach for encouraging data release than further demands for score details. Realistic solutions include use of additional information already collected by ERAS, such as student experiences (volunteer work, research productivity) and attributes (language skills, regional ties, distance traveled), to filter applicants for review. Once a reasonable number of applications is identified, each can be individually assessed for mission-specific factors including medical knowledge.

Recommendations Related to Genetic Testing for Breast Cancer

14-01-2020 – Pinsky PF.

To the Editor The recent Recommendation Statement by the US Preventive Services Task Force (USPSTF) on risk assessment, genetic counseling, and genetic testing for breast cancer susceptibility (BRCA) gene mutations seems to contain some internal inconsistencies. The Summary of Recommendations and Evidence section stated that women with either a personal or family history of BRCA-related cancers or an ancestry associated with BRCA mutations are recommended for risk assessment. However, in the USPSTF Assessment section, net benefit of the intervention was only ascribed to women with the relevant family or personal history, and it was stated that the harms of risk assessment outweigh the benefits “in women whose family or personal history is not associated with an increased risk” for harmful BRCA mutations. Therefore, the task force appears to be recommending intervention for women with a BRCA-associated ancestry but no personal or family history (since such women satisfy the “or” logic in the recommendation) but also stating that the harms outweigh the benefits for these women. Another sentence in the text, under Estimate of Magnitude of Net Benefit, excluded even personal history, stating that the harms of risk assessment outweigh the benefits for women without a BRCA-associated family history. Although readers could presume that the task force would consider these interventions to have net benefit in women with the requisite ancestry but no relevant family or personal history, it is curious that these direct statements would exclude mention of ancestry. It would be helpful if the task force could provide added clarity with regard to these net benefit statements and their relation to the overall recommendation.

Recommendations Related to Genetic Testing for Breast Cancer

14-01-2020 – Dörk T, Park-Simon T, Hillemanns P.

To the Editor The USPSTF found adequate evidence of moderate benefit for women whose family or personal history is associated with increased risk for BRCA1/BRCA2 mutations, whereas for women without such family history, it stated that the benefits are small to none. However, a BRCA1/BRCA2 mutation carrier without a positive family history still faces a substantial lifetime risk, with more than half the hazard of a BRCA1/BRCA2 mutation carrier with a positive family history. The proportion of these unsuspected mutation carriers is not negligibly small. In hospital-based settings at Hannover Medical School, current risk assessment tools miss about half of BRCA1/BRCA2 mutation carriers in breast cancer cohorts because of incomplete penetrance or small pedigrees. A recent population-based study reported that 49.4% of BRCA1/BRCA2 mutation carriers did not meet guidelines for clinical testing. Such women would, at their asymptomatic stage, be excluded from the possible benefits of counseling, preventive measures, and intensified surveillance.

Reporting of the Medical Licensing Examination

14-01-2020 – Everett G, Isea L.

To the Editor The Viewpoint by Dr Swails and colleagues concluded that “the current USMLE 3-digit scores may be distracting the medical education system from the goal of building an innovative, diverse, and resilient physician workforce.” Program directors of residency programs would likely disagree with these statements: “Changing the USMLE to a pass-fail format would require residency programs to find other, potentially more meaningful, ways of evaluating applicants”; “Medical knowledge may not be the most important skill required to meet the needs of patients and society”; and “Overemphasizing medical knowledge may limit the time focused on innovation, humanism, and wellness.”

Reporting of the Medical Licensing Examination

14-01-2020 – Battisti R.

To the Editor The proposed change to a pass-fail score reporting for the USLME Step 1 Examination from the Federation of State Medical Boards and the National Board of Medical Examiners was based on the recommendations from the Invitational Conference on USMLE Scoring. I am concerned that the authors made several claims either without evidence (or have not cited that evidence) or in direct contradiction to established evidence to advance their view. The authors stated “…the narrow differences in examination scores used by some programs to exclude many applicants are arbitrary with neither clinical, nor statistical meaning.” There is no way for the authors to know how other programs use cutoffs and whether those cutoffs have clinical or statistical meaning.

Reporting of the Medical Licensing Examination

14-01-2020 – Schneider TR.

To the Editor Dr Swails and colleagues argued that the current 3-digit scoring system for the United States Medical Licensing Examination (USMLE) is a broken metric for evaluating residency applicants. They suggested that a pass-fail licensing examination with “individual mission–based holistic criteria” would be more appropriate. I disagree with their suggestion for several reasons.

CLABSI Differences Based on Criteria Used to Count Central Line Days

14-01-2020 – Scheinker D, Ward A, Shin AY, et al.

This study uses electronic health record (EHR) data to evaluate differences in central line–associated bloodstream infection (CLABSI) rates by how central line days are counted: once a day at a fixed time for all patients; a sampling-based approximation; or a validated electronic count.

Incidence of Infectious Complications Following Cochlear Implantation in Children and Adults

14-01-2020 – Lander DP, Durakovic N, Kallogjeri D, et al.

This cohort study uses data from state health care databases to determine the incidence and timing of infectious complications following cochlear implant surgery among patients in 5 US states between 2006 and 2016.

The Patient Himself

14-01-2020 –

Among the vices of advancing years are carping criticism, garrulity and needless admonition. To all of these I plead guilty and so can only beg your indulgence while I say a few things that I think should be said, knowing that I say them poorly and that I add nothing to our store of knowledge.

Early Returns From the Era of Precision Medicine

14-01-2020 – Cutler DM.

The era of precision medicine has arrived. A large share of new pharmaceuticals are tested and approved on the basis of biomarkers. Pharmacogenetics—the tailoring of drugs to patients based on 1 or more biomarkers—is used in conditions as diverse as HIV and thromboembolism.

Audio Highlights

14-01-2020 –

Listen to the JAMA Editor’s Audio Summary for an overview and discussion of the important articles appearing in this week’s issue of JAMA.

How Effective and Safe Is Factor XI Inhibition in Preventing Venous Thrombosis?

14-01-2020 – Bauer KA.

The introduction of the direct oral anticoagulants for stroke prevention in atrial fibrillation and the management of thromboembolism has transformed the care of patients with these disorders. These drugs, which selectively and reversibly inhibit factor Xa or thrombin in the common pathway of the coagulation cascade, have a wide therapeutic window; this allows for simplified dosing regimens without laboratory monitoring of most adult patients as contrasted to vitamin K antagonists. This class of drug is also associated with a lower bleeding risk than vitamin K antagonists, which has been most clearly demonstrated by a 50% relative risk reduction in intracranial hemorrhage. Nevertheless, bleeding with the direct oral anticoagulants remains a clinically significant issue, particularly in vulnerable patient populations, such as older patients and those with renal dysfunction.

Reform at the FDA—In Need of Reform

14-01-2020 – Sharfstein JM.

On December 23, 2016, the US Food and Drug Administration (FDA) announced the approval of nusinersen, the first drug for the devastating disease spinal muscular atrophy. The approval was based on an interim analysis of 82 patients in a single randomized trial; 40% of treated children improved, compared with none in the control group. The FDA had requested that the interim analysis be conducted. A press release emphasized the speed of agency action, with the review division director saying, “We worked hard to review this application quickly.”

Best Practices in Assessing Aging Physicians for Professional Competency

14-01-2020 – Saver JL.

The unprecedented number and proportion of aging physicians in the workforce in both the United States and the world is a unique challenge of the current medical era. Fully 43% of all US physicians are aged 55 years or older, including 61% of psychiatrists, 52% of radiologists, 46% of general surgeons, and 44% of internists. Moreover, approximately 15% of practicing US physicians are older than 65 years, tripling from 23 000 in 1980 to 73 000 in 2012-2016. Every year, 20 000 more US physicians turn 65 years of age, and, even though half retire by age 65, many continue practicing for years and decades more. Indeed, US policy makers are counting on these older physicians to do so to help mitigate the nation’s growing physician shortage. Currently, an estimated 50 million to 70 million US office visits and 11 million to 20 million hospitalizations each year are overseen by physicians older than 65 years.

Opportunities and Challenges in Valuing and Evaluating Aging Physicians

14-01-2020 – Armstrong KA, Reynolds EE.

In 2017, more than 15% of practicing physicians were older than 65 years. Without a national mandatory retirement age, many physicians plan to practice until they are in their 70s or 80s. Cognitive decline often accompanies aging, and the prevalence of dementia increases rapidly after age 70 years. Thus, it is not surprising that the issue of screening aging physicians for cognitive deficits has gained attention over the last decade.

Testing Hypothermic Preservation for Trauma Patients

14-01-2020 – Abbasi J.

Only 1 in 20 patients survive cardiac arrest from trauma-related blood loss. “Surgeons don’t have time to stop the bleeding before irreversible damage occurs to the brain and other vital organs,” trauma surgeon Samuel A. Tisherman, MD, of the University of Maryland School of Medicine in Baltimore, said in an email.

Can Apple Watches Detect Atrial Fibrillation?

14-01-2020 – Abbasi J.

Researchers tested a smartwatch-based irregular pulse notification algorithm for suspected atrial fibrillation among more than 400 000 US participants in a recent trial. The findings, published in the New England Journal of Medicine, came from the Apple Heart Study, a collaboration between technology giant Apple and Stanford Medicine.

First US “Donation After Circulatory Death” Heart Transplant

14-01-2020 – Abbasi J.

An adult patient received a “donation after circulatory death” (DCD) heart transplant in the first such procedure to take place in the United States. Surgeons at Duke University Hospital in Durham, North Carolina, recently performed the operation as part of a clinical trial evaluating the Organ Care System (OCS) Heart, an investigational normothermic preservation system from Massachusetts-based Trans
Medics. An alternative to cold storage, the device keeps the donor heart pumping with warm oxygen- and nutrient-rich blood.

Treatment Decisions for a Future Self—Ethical Obligations to Guide Truly Informed Choices

14-01-2020 – Creutzfeldt CJ, Holloway RG.

Journal Article

This Viewpoint discusses the reality that most decisions about treatment for incapacitated patients involve surrogate assessments of patients’ past values at their baseline health, and it proposes that more ethical and informed decision-making would help surrogates consider the degree to which their loved one might be able to adapt to and value a future health state at what is a higher level of disability.

The Responsibility of Physicians to Maintain Competency

14-01-2020 – Santen SA, Hemphill RR, Pusic M.

Journal Article

This Viewpoint discusses 2 forces that can lead to the decline in competency in medicine over time, deterioration in ability with age and decrease in opportunities for maintenance and self-improvement, includes considerations that may be helpful to addressing competency decline.

Large-Capacity Magazine Bans Linked With Fewer Mass Shootings, Deaths

14-01-2020 – Abbasi J.

Journal Article

This Medical News article discusses a recent study of federal and state legislation restricting high-capacity ammunition-feeding devices.

Mild Traumatic Brain Injury in 2019-2020

14-01-2020 – Silverberg ND, Duhaime A, Iaccarino M.

Journal Article

This JAMA Insights Clinical Update reviews current practice for managing mild traumatic brain injury, which includes monitoring symptom resolution, counseling on return to activity, and timely specialty referral.