JAMA

Zoonotic Virus Linked to Severe Encephalitis in Southern Germany

18-02-2020 – Kuehn BM.

A recent study suggested that Borna disease virus 1 (Bo
DV-1), which is carried by wild shrews in Germany, Austria, Switzerland, and Liechtenstein, could be a more common cause of severe or fatal encephalitis among people in endemic areas than previously realized.

Poor Infection Control Led to Child HIV Outbreak in Pakistan

18-02-2020 – Kuehn BM.

Poor infection control practices led to an unprecedented HIV outbreak among hundreds of children in Pakistan, according to a recent study.

Dial-In Mobile Service Enables Patient Feedback on Community Health Care

18-02-2020 – Kuehn BM.

A simple mobile phone–based technology could enable patients in rural Africa to provide valuable feedback about the care they receive from community health workers, according to a study presented at the recent Association for Computing Machinery conference on computer-supported cooperative work and social computing.

JAMA

18-02-2020 –

Finding Faith—Religion, Prayer, Spirituality, and Medicine

18-02-2020 – Kaye EC.

In this narrative medicine essay, a pediatric palliative oncologist meditates on the intersection of faith and medicine and of varying expressions of spirituality in the face of abject pain and suffering among her pediatric patients with cancer.

He Who Keeps Going

18-02-2020 – Pucciani D.

for Peter You sail into the garage on your bike, report on the miles wheeled in the woods, on the serpent that crossed your path, a turtle bobbing its head amid puddles, and all the creatures bounding away from your human scent.

Aspirin for Prevention of Cardiovascular Disease

18-02-2020 – Peters AT, Mutharasan R.

This JAMA Patient Page describes new guideline recommendations on the use of aspirin for primary and secondary prevention of cardiovascular disease.

Association Between Genetically Proxied Inhibition of HMG-CoA Reductase and Epithelial Ovarian Cancer

18-02-2020 – Yarmolinsky J, Bull CJ, Vincent EE, et al.

This study uses mendelian randomization to estimate the associations between genetic variants related to reduced HMG-Co
A reductase activity and epithelial ovarian cancer in the general population and in BRCA1/2 mutation carriers.

Change in Accuracy From Adding Polygenic Risk Information to a Clinical Risk Prediction Score for CAD

18-02-2020 – Elliott J, Bodinier B, Bond TA, et al.

This study uses UK Biobank data to examine whether adding polygenic risk information to the pooled cohort equations improves the accuracy of risk prediction for coronary artery disease (CAD).

Predictive Accuracy of a Polygenic Risk Score Compared With a Clinical Risk Score for Incident Coronary Heart Disease

18-02-2020 – Mosley JD, Gupta DK, Tan J, et al.

This pooled cohort involving US adults with white European ancestry compares the accuracy of a polygenic risk score vs 2013 ACC/AHA pooled cohort equations for predicting 10-year risk of coronary heart disease.

Risk of Offspring Birth Defects in Women After Bariatric Surgery—Reply

18-02-2020 – Neovius M, Johansson K, Stephansson O.

In Reply We agree with Dr Auger and colleagues that there are several effects of gastric bypass surgery that may influence the risk of birth defects, including positive effects from weight loss and improved glucose control, as well as negative effects such as nutrient deficiencies and increased risk of substance abuse.

Selepressin for Patients With Septic Shock—Reply

18-02-2020 – Angus DC, Laterre P, Lewis RJ, et al.

In Reply We agree with Dr Rehberg and colleagues that our study demonstrated that selepressin had a number of advantageous physiologic effects on blood pressure, urine output, and other features associated with septic shock. In this way, as the authors suggest, it appears that selepressin shares a set of properties similar to that of other agents used for cardiovascular support in septic shock, including the recently approved angiotensin II. In contrast to the study on which angiotensin II was approved, we chose a primary outcome designed to determine whether care with selepressin improved downstream patient-centered outcomes, and, at least in this setting, we were unable to demonstrate any such improvement. That said, we were reassured that there was no obvious sign that care with selepressin was associated with more adverse events than care with norepinephrine alone. Rehberg and colleagues note there are limited data suggesting that any vasopressor improves downstream patient-centered outcomes compared with any other and therefore imply that if selepressin appears to work as well as other vasopressors, surely it should be added to the armamentarium of vasopressors for the care of septic shock, or at least be available for further evaluation. This line of reasoning represents one side of an old argument, namely, is there value in providing clinicians with a larger number of agents with clinically similar effects? Rehberg and colleagues, at least in this instance, seem to think so, and either way, we agree this is an important question to consider.

Unmeasured Confounding in Observational Studies of Management of Cerebellar Intracranial Hemorrhage—Reply

18-02-2020 – Kuramatsu JB, Sheth KN, Huttner HB.

In Reply We agree with Dr van Essen and colleagues that observational studies harbor the risk of unmeasured confounding. Treatment of patients with intracerebral hemorrhage has been studied in only a few trials with considerable variance in management protocols. Hence, large multicenter observational studies must be relied on to provide treatment estimates. To address the limitation of unmeasured confounding, we compared our study results (propensity score–matched analysis) with instrumental variable analysis, which is potentially more resilient to unmeasured confounding, as suggested by van Essen and colleagues.

Error in USPSTF Report on Statin Use

18-02-2020 – Chou R.

The 2016 review for the US Preventive Services Task Force on statins for prevention of cardiovascular disease in adults had errors in the analysis of statins vs placebo and cardiovascular mortality. For the JUPITER trial, we interpreted “MI, stroke or cardiovascular death” as reported in the main trial publication as “myocardial death, stroke death, or cardiovascular death,” when it meant “nonfatal myocardial infarction, nonfatal stroke, or cardiovascular death.” Therefore, the analysis erroneously included nonfatal myocardial infarction and stroke events (83/8901 vs 157/8901 in the rosuvastatin vs placebo groups, respectively) in the analysis of cardiovascular mortality (Figure 3, panel B in the evidence review). The US Food and Drug Administration (FDA) review of atorvastatin reported 29 vs 37 cardiovascular mortality events in the rosuvastatin vs placebo groups, respectively, in JUPITER. However, a subsequent publication from 2 of the original JUPITER authors reported numbers of confirmed cardiovascular deaths of 35 vs 43 (not including 16 vs 25 cases of sudden death) in the rosuvastatin vs placebo groups. For the ASTRONOMER trial, data for cardiovascular deaths were transposed from another trial (2/103 vs 12/79 for statins vs placebo); the correct data are 2/134 vs 5/135.

Risk of Offspring Birth Defects in Women After Bariatric Surgery

18-02-2020 – Auger N, Bilodeau-Bertrand M, Arbour L.

To the Editor In a Research Letter, Dr Neovius and colleagues investigated the association between gastric bypass surgery and risk of birth defects in offspring. The authors found that bariatric surgery was protective against birth defects.

Unmeasured Confounding in Observational Studies of Management of Cerebellar Intracranial Hemorrhage

18-02-2020 – van Essen TA, Menon DK, Lingsma HF.

To the Editor In a propensity score–matched cohort of 578 patients from 4 observational cohort studies, Dr Kuramatsu and colleagues showed that evacuation of medium-sized intracerebellar hematomas (approximate volume, 20 cm3) was not associated with better functional outcome. Assessing treatment effectiveness in observational data is challenging because treatment decisions are based on patient characteristics that also are typically predictive of outcome, causing confounding by indication. Although the authors addressed this potential bias with propensity scores, we would like to emphasize the possibility of residual confounding.

Selepressin for Patients With Septic Shock

18-02-2020 – Rehberg S, Morelli A, Jansen G.

To the Editor Compared with placebo, the nonadrenergic vasopressor angiotensin II was shown to increase mean arterial pressure after 3 hours in patients with vasodilatory shock in the Angiotensin II for the Treatment of High-Output Shock (ATHOS-3) trial (primary end point). In addition, angiotensin II also reached the secondary goal of a greater reduction in the cardiovascular Sequential Organ Failure Assessment (SOFA) score after 48 hours vs placebo. As a consequence, research with angiotensin II continued and it was approved by the US Food and Drug Administration.

Private Equity Acquisitions of Physician Medical Groups Across Specialties, 2013-2016

18-02-2020 – Zhu JM, Hua LM, Polsky D.

This study characterizes practice characteristics and specialties of physicians and medical groups acquired by private equity firms between 2013 and 2016.

Book Notices

18-02-2020 –

Contributions to Medical and Biological Research. Dedicated to Sir William Osler, Bart., M.
D., F.
R.
S., in honor of his seventieth birthday, July 12, 1919, by his pupils and co-workers. Two volumes. Pp. 1268. Paul B. Hoeber, New York. Edition limited to 1,600 copies.

Audio Highlights

18-02-2020 –

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.

FDA Assesses Potential Cancer Risk Associated With Weight Loss Drug

18-02-2020 – Voelker R.

A recent drug safety communication alerted health professionals and the public about a potential increased risk of cancer associated with the weight management medication lorcaserin. The FDA has advised clinicians to consider whether the drug’s benefits outweigh its potential risks when deciding to prescribe or continue prescribing it.

FDA Says It Supports Cannabis Drug Development via Regulatory Pathways

18-02-2020 – Voelker R.

A key FDA official told members of Congress last month that the agency supports the development of new drugs that contain cannabis or are derived from the plant.

Drug Approved for Rare Mutation in Gastrointestinal Tumor

18-02-2020 – Voelker R.

The FDA has approved a tyrosine kinase inhibitor to treat adults with an unresectable or metastatic gastrointestinal stromal tumor (GIST) that has a specific genetic mutation.

Polygenic Risk Scores for Coronary Artery Disease?

18-02-2020 – Khan SS, Cooper R, Greenland P.

A risk-based prevention strategy is the most widely accepted approach to guide clinician-patient decision-making for prevention of coronary artery disease (CAD). According to this approach, the intensity of prevention efforts is matched to the estimated risk of the individual. American College of Cardiology/American Heart Association guidelines currently recommend pooled cohort equations for initial risk assessment, which integrate age, systolic blood pressure, total cholesterol, high-density lipoprotein cholesterol, smoking status, and treatment for hypertension and diabetes to provide race- and sex-specific estimates of a broadly relevant end point of atherosclerotic cardiovascular risk (myocardial infarction, death from coronary heart disease, and fatal or nonfatal stroke). While risk assessment for CAD is known to be an imprecise estimate, no other tests of cardiovascular risk are uniformly agreed to enhance risk stratification. Thus, the search for additional and better risk markers continues to be a focus of cardiovascular research.

Incorrect Percent Values Reported in Text and Table 1

18-02-2020 –

In the Research Letter entitled “Change in Prevalence of Disabilities and Accommodation Practices Among US Medical Schools, 2016 vs 2019” published in the November 26, 2019, issue of JAMA, incorrect percent values were reported in the text and in Table 1. A sentence in the Results should have read: “Of the 64 schools that responded in both years, the total number of students reporting disabilities increased from 1142 (2.9%) in 2016 to 2028 (4.9%) in 2019 (difference, 1.9% 95% CI, 1.8%-2.3%; relative increase, 69%) (Table 1).” In Table 1, the overall percent of students with disability in 2016 should have been reported as 2.9%, and in 2019, the overall percent should have been reported as 4.9%. Correction of these values does not affect the results, which remain as a 69% relative increase. This article was corrected online.

Incorrect Data in Text

18-02-2020 –

In the Editorial entitled “Statins for Primary Prevention: The Debate Is Intense, but the Data Are Weak” published in the November 15, 2016, issue of JAMA, incorrect data were reported in the text. In the first sentence of the second paragraph on the first page, the absolute benefit for use of statins should have been reported as 0.20%, rather than 0.43%, for cardiovascular mortality. This article was corrected online.

Incorrect Data in Text, Table, Figure, and Supplement

18-02-2020 –

In the US Preventive Services Task Force Evidence Report entitled “Statins for Prevention of Cardiovascular Disease in Adults: Evidence Report and Systematic Review for the US Preventive Services Task Force” published in the November 15, 2016, issue of JAMA, incorrect data were reported. In the abstract Results, the data reported for cardiovascular mortality should have read “RR, 0.82 95% CI, 0.71 to 0.94; I2 = 0%; ARD, –0.20% 95% CI, –0.35% to –0.05%; I2 = 11%.” In the second paragraph of the “Benefits of Statin Treatment” subsection in the text, the data reported for cardiovascular mortality should have read “RR, 0.82 95% CI, 0.71 to 0.94; I2 = 0%; ARD, –0.20% 95% CI, –0.35% to –0.05%; I2 = 11%”; 2 paragraphs later, the sentence “For cardiovascular mortality, statistical heterogeneity was present (I2 = 54%), but the estimate was similar using the profile likelihood method (RR, 0.71 95% CI, 0.55 to 0.88)” should have been deleted; and the text 2 paragraphs later should have read “Funnel plot asymmetry was not observed for outcomes reported in at least 10 trials, except for cardiovascular mortality (P = .049 for Egger test).” In the first paragraph of the Discussion, the data reported for cardiovascular mortality should have read “RR, 0.82 after 2-6 years 95% CI, 0.71 to 0.94; I2 = 0%; ARD, –0.20% 95% CI, –0.35% to –0.05%,” and the NNT for cardiovascular death should have been reported as 500. In Table 3, “Key Question 1a” section, “Summary of Findings” column, the data reported for cardiovascular mortality should have read “RR, 0.82 95% CI, 0.71-0.94; I2 = 0%; ARD, –0.20%; NNT, 500.” Incorrect data also appeared in Figure 3 and the online supplement. This article was corrected online.

Incorrect Data in Text

18-02-2020 –

In the US Preventive Services Task Force (USPSTF) Recommendation Statement entitled “Statin Use for the Primary Prevention of Cardiovascular Disease in Adults: US Preventive Services Task Force Recommendation Statement” published in the November 15, 2016, issue of JAMA, incorrect data were reported in the text. In the first paragraph of the “Statin Use in Adults Aged 40 to 75 Years” subsection and in the third paragraph of the “Benefits of Statin Use” subsection, the text “RR, 0.69 95% CI, 0.54-0.88” should have read “RR, 0.82 95% CI, 0.71-0.94.” The certainty, magnitude of net benefit, and grades of the USPSTF recommendation remain the same. This article was corrected online.

Dysphagia in a 34-Year-Old Woman

18-02-2020 – Posner S, Boyd A, Patel A.

Journal Article

A 34-year-old woman had worsening intermittent retrosternal dysphagia but no heartburn, nausea, vomiting, abdominal pain, weight loss, or changes in bowel habits; ranitidine (150 mg twice daily) provided no relief. CBC results were normal; esophagogastroduodenoscopy showed esophageal furrows and rings, and esophageal biopsy showed intraepithelial eosinophils. What is the diagnosis and what would you do next?

First-Line Psychotherapies for Military-Related PTSD

18-02-2020 – Steenkamp MM, Litz BT, Marmar CR.

Journal Article

This JAMA Insights Clinical Update reviews psychotherapy treatments for military-related posttraumatic stress disorder (PTSD) and discusses that psychotherapies do not outperform non–trauma-focused interventions and that attention should be paid to managing nonresponse to treatment, addressing posttreatment residual symptoms, and identifying patients with complex presentations who likely require individualized treatment.

Trauma-Informed Care May Ease Patient Fear, Clinician Burnout

18-02-2020 – Kuehn BM.

Journal Article

This Medical News article discusses how physicians can take an empathetic approach to caring for patients with a history of trauma.

Concussions Linked With Erectile Dysfunction in Football Player Study

18-02-2020 – Abbasi J.

Journal Article

This Medical News article discusses a recent JAMA Neurology study that found an association between concussion symptoms and later indicators of erectile dysfunction and low testosterone in former National Football League players.

Recurrent Urinary Tract Infections in Adult Women

18-02-2020 – Aslam S, Albo M, Brubaker L.

Journal Article

This JAMA Insights summarizes prevention and management recommendations for women with recurrent urinary tract infections (UTIs) and proposes individualizing approaches by age and menopausal status, underlying conditions (eg, diabetes), risk of pyelonephritis/sepsis, and patient preferences.

Evolving Issues in Oxygen Therapy in Acute Care Medicine

18-02-2020 – Munshi L, Ferguson ND.

Journal Article

This Viewpoint reviews the accumulating evidence about the harms of hypoxia and hyperoxemia and cautions against indiscriminate oxygen use for most acute conditions.

Ethical and Legal Aspects of Ambient Intelligence in Hospitals

18-02-2020 – Gerke S, Yeung S, Cohen I.

Journal Article

This Viewpoint reviews the ethical and legal implications of using ambient intelligence, the use of artificial intelligence–based technologies to monitor health care and quality measures like handwashing and patient falls in health care setting.

Effect of Stress Ulcer Prophylaxis With PPIs vs H 2 RBs on ICU Mortality

18-02-2020 – , Young PJ, Bagshaw SM, et al.

Journal Article

This cluster randomized trial compares the effects of proton pump inhibitors (PPIs) vs histamine-2 receptor blockers (H2RBs) on 90-day mortality among patients requiring invasive mechanical ventilation within 24 hours of admission to the intensive care unit (ICU).

Proton Pump Inhibitors vs Histamine-2 Receptor Blockers for Stress Ulcer Prophylaxis in ICU Patients

18-02-2020 – Rice TW, Kripalani S, Lindsell CJ.

Journal Article

Among critically ill patients in the intensive care unit (ICU), complications are frequent, including stress ulcers in the upper gastrointestinal tract. To help prevent the development of ulcers, antagonism of gastric acid (with antacids historically) or inhibition of the production of acid (with histamine-2 receptor blockers more recently) were implemented as part of routine critical care. The introduction of proton pump inhibitors, with data demonstrating improved ulcer prevention and recovery compared with histamine-2 receptor blockers in non–critically ill patients, led many physicians who provide care for critically ill patients to incorporate proton pump inhibitors for routine stress ulcer prophylaxis. However, the lack of randomized clinical trials (RCTs) that directly compared histamine-2 receptor blockers with proton pump inhibitors for stress ulcer prophylaxis in critically ill patients, combined with decreasing incidence of significant gastrointestinal bleeding in these patients and emerging evidence of an association between proton pump inhibitor use and adverse events, including Clostridioides difficile (Clostridium difficile) infection, cognitive decline, and nosocomial pneumonia, made the optimal choice of routine stress ulcer prophylaxis less clear.

The Use and Misuse of Transparency in Research—Science and Rulemaking at the EPA

18-02-2020 – Fineberg HV, Allison DB.

Journal Article

This Viewpoint discusses the 2019 proposed rule at the Environmental Protection Agency (EPA) requiring data underlying regulations to be publicly available for independent validation in the context of 2019 NASEM standards for reproducibility, suggesting that the proposal misinterprets those standards to give policy opponents greater latitude to question the EPA’s rationale for new rules and thereby hamper rulemaking.

Incidental Imaging Findings in Clinical Trials

18-02-2020 – Oren O, Blankstein R, Bhatt DL.

Journal Article

This Viewpoint characterizes incidental radiographic findings from clinical trial–related imaging as an underrecognized potential harm of trial participation and proposes practices and standards to more systematically include them as a trial safety end point.