A Nearly Stressful Situation —a Case of Wellens Syndrome
This case report presents the electrocardiographic findings of a man in his 70s with Wellens syndrome. (Source: JAMA Internal Medicine)
Source: JAMA Internal Medicine - March 18, 2019 Category: Internal Medicine Source Type: research

Aspirin Use and Risk of Hepatocellular Carcinoma in Hepatitis B
Liver cancer (hepatocellular carcinoma [HCC]) incidence and mortality rates have been increasing in most countries for several decades. Currently, HCC is the second most common cause of cancer-related death in the world and represents the fastest rising cause of cancer-related deaths in the United States. Chronic hepatitis B virus (HBV) and hepatitis C virus are the primary underlying causes of HCC, with contributions from alcohol, tobacco, aflatoxin, obesity, and metabolic syndrome. In patients with chronic hepatitis C virus, the risk of HCC can be reduced rapidly with short-term, direct-acting antiviral medications. In c...
Source: JAMA Internal Medicine - March 18, 2019 Category: Internal Medicine Source Type: research

Formulary Placement of Branded Drugs in Medicare Prescription Drug Plans When Generics Are Available
This study examines Medicare Part D prescription drug plans to assess how often branded products were given more favorable formulary placement than generic products. (Source: JAMA Internal Medicine)
Source: JAMA Internal Medicine - March 18, 2019 Category: Internal Medicine Source Type: research

Association of Daily Aspirin Therapy With Risk of Hepatocellular Carcinoma in Patients With Chronic Hepatitis B
This nationwide cohort study examines the risk of hepatocellular carcinoma in Taiwanese patients with chronic hepatitis B who are receiving daily aspirin therapy. (Source: JAMA Internal Medicine)
Source: JAMA Internal Medicine - March 18, 2019 Category: Internal Medicine Source Type: research

Screening Ultrasonography as Adjunct to Screening Mammography Across the Spectrum of Breast Cancer Risk
This cohort study investigates the performance of screening mammography plus screening ultrasonography compared with screening mammography alone among women at low, intermediate, and high risk for breast cancer. (Source: JAMA Internal Medicine)
Source: JAMA Internal Medicine - March 18, 2019 Category: Internal Medicine Source Type: research

What Should I Know About Opioids?
This Patient Page describes the symptoms and recommended treatment options for patients with opioid use dissorder. (Source: JAMA Internal Medicine)
Source: JAMA Internal Medicine - March 18, 2019 Category: Internal Medicine Source Type: research

Precision Preventive Medicine —Ready for Prime Time?
This Viewpoint discusses the potential overstatement of findings in 2 studies that used predictive risk scores to draw conclusions about precision preventive medicine and suggests that improvements to predictive methods are necessary before being more widely applied. (Source: JAMA Internal Medicine)
Source: JAMA Internal Medicine - March 18, 2019 Category: Internal Medicine Source Type: research

Effect of the Serious Illness Care Program in Outpatient Oncology
This cluster randomized clinical trial evaluates the effect of a communication quality-improvement intervention on a goal-concordant care and peacefulness at the end of life among oncology clinicians and patients with advanced cancer. (Source: JAMA Internal Medicine)
Source: JAMA Internal Medicine - March 14, 2019 Category: Internal Medicine Source Type: research

Dosage Error in the Figure Footnote
This article was corrected online. (Source: JAMA Internal Medicine)
Source: JAMA Internal Medicine - March 11, 2019 Category: Internal Medicine Source Type: research

The Need to Realign Health System Processes for Patients Discharged From the Hospital
Health Care Policy (Source: JAMA Internal Medicine)
Source: JAMA Internal Medicine - March 11, 2019 Category: Internal Medicine Source Type: research

Advance Care Planning Codes —Getting Paid for Quality Care
In 2017, Sudore et al(p14) developed a consensus definition of advance care planning (ACP) as “a process that supports adults at any age or stage of health in understanding and sharing their personal values, life goals, and preferences regarding future medical care. The goal of ACP is to help ensure that people receive medical care that is consistent with their values, goals, and preferenc es during serious and chronic illness.” The discussion around ACP has evolved for decades. Originally, efforts focused on documenting advance directives or surrogate decision makers, interventions that alone were not effectiv...
Source: JAMA Internal Medicine - March 11, 2019 Category: Internal Medicine Source Type: research

Assessment of First-Year Use of Medicare ’s Advance Care Planning Billing Codes
This observational analysis characterizes the first year of use of the Medicare code for advance care planning and describes beneficiaries most likely to receive advance care planning. (Source: JAMA Internal Medicine)
Source: JAMA Internal Medicine - March 11, 2019 Category: Internal Medicine Source Type: research

Early Utilization Patterns of the New Medicare Procedure Codes for Advance Care Planning
This study of Medicare claims analyzes utilization patterns for newCurrent Procedural Terminology codes for advance care planning visits. (Source: JAMA Internal Medicine)
Source: JAMA Internal Medicine - March 11, 2019 Category: Internal Medicine Source Type: research

Outcomes After Hospital Discharge to Home With Home Health Care vs to a Skilled Nursing Facility
This cohort study uses Medicare claims data to investigate the association of patient outcomes and Medicare costs of discharge to home with home health care vs discharge to a skilled nursing facility. (Source: JAMA Internal Medicine)
Source: JAMA Internal Medicine - March 11, 2019 Category: Internal Medicine Source Type: research

Journal Registration Policies and Prospective Registration of RCTs of Nonregulated Interventions
This study analyzes the prospective registration policies of specialty journals that publish randomized clinical trials of drugs, biologics, and medical devices not regulated by the US Food and Drug Administration. (Source: JAMA Internal Medicine)
Source: JAMA Internal Medicine - March 11, 2019 Category: Internal Medicine Source Type: research

Errors in Data Entry and Figures
This article has been corrected online. (Source: JAMA Internal Medicine)
Source: JAMA Internal Medicine - March 4, 2019 Category: Internal Medicine Source Type: research

Communicating, and Justifying, Nonefficacy Benefits for New Drugs Approved via Noninferiority Trials
Noninferiority clinical trials are designed to determine whether an intervention is not “unacceptably worse” than a comparator by more than a prespecified difference, known as the noninferiority margin. The US Food and Drug Administration (FDA) has established guidance for industry to clarify when a superiority study design does not need to be used to establish new drug effectivene ss, usually because it would not be ethical to use a placebo or “no-treatment” control. Other justifications for noninferiority-designed trials include testing interventions with more favorable safety profiles or more con...
Source: JAMA Internal Medicine - March 4, 2019 Category: Internal Medicine Source Type: research

Implications of Oxalate as a Novel Risk Factor for Chronic Kidney Disease
One in 7 Americans (approximately 30 million individuals) has chronic kidney disease (CKD). Beyond heightened risk of end-stage renal disease, these individuals are at high risk of cardiovascular disease, frailty, cognitive impairment, and premature death. Chronic kidney disease is widely recognized as a major public health concern in both the United States and worldwide. Diabetes is the most common cause of CKD, and most epidemiology texts list hypertension as the second most common cause. However, some experts believe that hypertension may in fact be the consequence rather than the cause of this large fraction of CKD, an...
Source: JAMA Internal Medicine - March 4, 2019 Category: Internal Medicine Source Type: research

Communication of Nonefficacy Benefits of New Drugs Approved on the Basis of Noninferiority Trials Alone
This cohort study of FDA- and drug sponsor –written communications evaluates the communication of nonefficacy benefits of new drugs approved on the basis of noninferiority trials alone. (Source: JAMA Internal Medicine)
Source: JAMA Internal Medicine - March 4, 2019 Category: Internal Medicine Source Type: research

Inclusion of Studies Identified by the FDA as Having Falsified Data in the Results of Meta-analyses
This study evaluates the inclusion of studies identified by the FDA as having falsified data in the results of meta-analyses. (Source: JAMA Internal Medicine)
Source: JAMA Internal Medicine - March 4, 2019 Category: Internal Medicine Source Type: research

Clarifications Needed on Study of Association Between Physician Burnout and Patient Safety
To the Editor The recently published meta-analysis by Panagioti and colleagues coincides with an increasing awareness of burnout among physicians. Almost half of all young physicians in Australia may be experiencing burnout, according to a major mental health survey. The implications of burnout have often been considered in terms of the personal consequences for the physician: relationship breakdowns, substance abuse, and suicidal ideation. As the study by Panagioti and colleagues demonstrates, there is growing recognition that burnout also results in loss of empathy, decreased productivity, and an increased likelihood of ...
Source: JAMA Internal Medicine - March 4, 2019 Category: Internal Medicine Source Type: research

Clarifications Needed on Study of Association Between Physician Burnout and Patient Safety
To the Editor The recently published Original Investigation by Dr Panagioti and colleagues provides supportive evidence for concerning associations between physician burnout and a number of outcomes, including patient safety, professionalism, and patient satisfaction. The review is compelling, but we believe several clarifications are needed. (Source: JAMA Internal Medicine)
Source: JAMA Internal Medicine - March 4, 2019 Category: Internal Medicine Source Type: research

Clarifications Needed on Study of Association Between Physician Burnout and Patient Safety —Reply
In Reply In response to the letter by Jansen, we acknowledge our study ’s limitations of pooling cross-sectional data, and we based our sensitivity analyses mostly on prospective studies. The assessment methods of patient safety outcomes were considered in the subgroup analyses. In most studies, physicians were asked to self-report patient safety incidents. A few stu dies used surveillance methods to assess whether patient safety incidents occurred. However, none of these studies had detailed case note reviews using standardized assessment protocols and independent reviewers, which is the gold-standard approach for i...
Source: JAMA Internal Medicine - March 4, 2019 Category: Internal Medicine Source Type: research

Association of Adding Aspirin to Warfarin Therapy With Bleeding and Other Adverse Events
This registry-based cohort study compares adverse event rates up to 3 years after initiation of treatment among patients receiving combination warfarin and aspirin therapy (without a therapeutic indication for aspirin use) vs those receiving warfarin monotherapy. (Source: JAMA Internal Medicine)
Source: JAMA Internal Medicine - March 4, 2019 Category: Internal Medicine Source Type: research

Association of Urinary Oxalate Excretion With the Risk of Chronic Kidney Disease Progression
This study assesses whether urinary oxalate excretion predisposes patients to more rapid progression of chronic kidney disease. (Source: JAMA Internal Medicine)
Source: JAMA Internal Medicine - March 4, 2019 Category: Internal Medicine Source Type: research

Arthritis of the Knees
Precis (Source: JAMA Internal Medicine)
Source: JAMA Internal Medicine - March 4, 2019 Category: Internal Medicine Source Type: research

Error in Axis in Figure 2B
This article was corr ected online. (Source: JAMA Internal Medicine)
Source: JAMA Internal Medicine - March 1, 2019 Category: Internal Medicine Source Type: research

Errors in Byline and Table and Omitted Conflict of Interest Disclosure
This article was corrected online. (Source: JAMA Internal Medicine)
Source: JAMA Internal Medicine - March 1, 2019 Category: Internal Medicine Source Type: research

Errors in Table 1
This article was corrected online. (Source: JAMA Internal Medicine)
Source: JAMA Internal Medicine - March 1, 2019 Category: Internal Medicine Source Type: research

Error in Figure Legend
This article has been corrected online. This article was also corrected on April 3, 2017, to fix errors in the conflict of interest disclosures and author affiliations. (Source: JAMA Internal Medicine)
Source: JAMA Internal Medicine - March 1, 2019 Category: Internal Medicine Source Type: research

March 2019 Issue Highlights
(Source: JAMA Internal Medicine)
Source: JAMA Internal Medicine - March 1, 2019 Category: Internal Medicine Source Type: research

Coney Island on a Foggy June Afternoon
Courtesy of: Thomas Ashley, MD, Gen Re, 120 Long Ridge Rd, Stamford, CT 06902 (Source: JAMA Internal Medicine)
Source: JAMA Internal Medicine - March 1, 2019 Category: Internal Medicine Source Type: research

A Case for n-of-1 Trials
To the Editor In a recent issue ofJAMA Internal Medicine, Kravitz and colleagues presented a randomized clinical trial comparing n-of-1 trials with usual care. Use of n-of-1 trials is highly relevant to recent emerging themes in health research, such as patient-centered research as well as personalized and precision medicine. Use of n-of-1 trials has been shown as useful across a broad range of health conditions and a diverse array of health interventions. The Oxford Centre for Evidence-Based Medicine considers n-of-1 trials level 1A evidence. (Source: JAMA Internal Medicine)
Source: JAMA Internal Medicine - March 1, 2019 Category: Internal Medicine Source Type: research

A Case for n-of-1 Trials
To the Editor Several months ago, I began experiencing dysphagia and solid food impaction. Findings from an esophagogastroduodenoscopy (EGD) with biopsy confirmed eosinophilic esophagitis. My gastroenterologist recommended the 6-food elimination diet to eliminate milk products, wheat, soy, eggs, seafood, or nuts from my diet for 6 to 8 weeks until my symptoms resolved, then add them back 2 at a time until symptoms recurred. (Source: JAMA Internal Medicine)
Source: JAMA Internal Medicine - March 1, 2019 Category: Internal Medicine Source Type: research

Sodium-Glucose Cotransporter 2 Inhibitors and Amputations
To the Editor In their recently published Original Investigation involving a population-based cohort trial, Chang and colleagues found a statistically significant increase in the risk of amputation among new users of sodium-glucose cotransporter 2 (SGLT-2) inhibitors when compared with use of oral antihyperglycemic agents. A risk of amputations and other vascular outcomes was not seen when use of SGLT-2 inhibitors was compared with use of dipeptidyl peptidase 4 inhibitors and glucagon-like peptide 1 agonists. The mechanism of SGLT-2 inhibitors can only be speculated as glucosuria and volume depletion, which leads to a high...
Source: JAMA Internal Medicine - March 1, 2019 Category: Internal Medicine Source Type: research

Low-Dose Amitriptyline for Chronic Low Back Pain
To the Editor We read the article “Efficacy of Low-Dose Amitriptyline for Chronic Low Back Pain: A Randomized Clinical Trial” by Urquhart and colleagues, in which the authors found a significant reduction in disability at 3 months following treatment with amitriptyline but not at 6 months. The other outcome parameters, such as p ain intensity and work absence and hindrance, were not significantly different between the amitriptyline and the control groups. Adverse effects of a drug are an important outcome measure. A drug may be effective but may not be used because of its severe adverse effects, such as reserpi...
Source: JAMA Internal Medicine - March 1, 2019 Category: Internal Medicine Source Type: research

Low-Dose Amitriptyline for Chronic Low Back Pain
To the Editor We thank Dr Urquhart and colleagues for their recent trial of low-dose amitriptyline in people with chronic low back pain. However, the interpretation of their findings —that amitriptyline may be an effective treatment for chronic low back pain and a possible strategy to avoid using opioid analgesics—is problematic as it is not supported by the data presented. (Source: JAMA Internal Medicine)
Source: JAMA Internal Medicine - March 1, 2019 Category: Internal Medicine Source Type: research

Delivery of Bottled Water to Women With Recurrent Urinary Tract Infections: Why in Bulgaria?
To the Editor The value of effective but simple measures in primary care with few or even no adverse events cannot be overestimated. The study conducted by Hooton and colleagues adds evidence that drinking more water may reduce the number of urinary tract infections in premenopausal, low-volume drinking women who have frequent urinary tract infections. (Source: JAMA Internal Medicine)
Source: JAMA Internal Medicine - March 1, 2019 Category: Internal Medicine Source Type: research

Finding Benefit in n-of-1 Trials
To the Editor The recent article by Kravitz and colleagues reporting the results of a randomized clinical trial comparing n-of-1 trials with standard care for treatment of chronic musculoskeletal pain raises a number of interesting issues that merit further examination. (Source: JAMA Internal Medicine)
Source: JAMA Internal Medicine - March 1, 2019 Category: Internal Medicine Source Type: research

Finding Benefit in n-of-1 Trials
To the Editor We read with interest the recent article by Kravitz and colleagues describing a randomized clinical trial comparing n-of-1 trials with standard care for treatment of chronic musculoskeletal pain. (Source: JAMA Internal Medicine)
Source: JAMA Internal Medicine - March 1, 2019 Category: Internal Medicine Source Type: research

Inconsistencies in Reporting Studies of Lactic Acidosis
To the Editor In their recently published Original Investigation regarding metformin use, renal function, and acidosis, Lazarus and colleagues explained why their findings were different than ours and wrote that our study “was limited by sparse [estimated glomerular filtration rate] data and did not account for changes in [estimated glomerular filtration rate] over time.”(909) This is not true. Table 2 in our article summarized that we were able to classify more than 90% of metformin exposure time to renal function. In addition, our methods section clearly stated that we determined renal function during follow-...
Source: JAMA Internal Medicine - March 1, 2019 Category: Internal Medicine Source Type: research

A Case for n-of-1 Trials —Reply
In Reply The letters from Vohra and Punja and Smith about our recent Original Investigation underscore the same crucial point: patients may vary not only in their response to treatment, but also in their response to n-of-1 trials. Vohra and Punja offer an ardent counterpoint to Mirza and Guyatt ’s conclusion that n-of-1 trials are a “beautiful idea being vanquished by cruel and ugly evidence.”(1379) Smith ’s story offers an inspiring example of how n-of-1 trials may be applied informally in the service of better, more patient-centered care. (Source: JAMA Internal Medicine)
Source: JAMA Internal Medicine - March 1, 2019 Category: Internal Medicine Source Type: research

Delivery of Bottled Water to Women With Recurrent Urinary Tract Infections: Why in Bulgaria? —Reply
In Reply We thank Dr Freitag for his thoughtful comments about our Original Investigation regarding increased hydration for prevention of recurrent urinary tract infections (UTIs). Danone, based in France, wanted the study to be performed in Europe. It was very difficult to recruit a population of premenopausal women meeting the rigorous eligibility criteria. Thus, a feasibility study of potential sites was performed to identify research centers that had adequate resources and experience with clinical trials, quality certifications, recruitment capabilities, and interest in conducting this trial. Of 6 sites queried, only C...
Source: JAMA Internal Medicine - March 1, 2019 Category: Internal Medicine Source Type: research

Low-Dose Amitriptyline for Chronic Low Back Pain —Reply
In Reply We would like to thank Kalita and Misra for their response. They suggest that the use of an active comparator may negate the difference in adverse events of amitriptyline. However, we found that more than 30% of participants in both groups had moderate and/or severe symptoms at baseline, similar to the adverse events associated with psychotropic medications, and that the proportion with these symptoms did not increase, with no difference between groups at 6 months. Moreover, 12% of participants withdrew from our trial due to adverse events, which is similar to the number reported by other trials. (Source: JAMA Internal Medicine)
Source: JAMA Internal Medicine - March 1, 2019 Category: Internal Medicine Source Type: research

Finding Benefit in n-of-1 Trials —Reply
In Reply Many of the questions raised by Chapple and Blackston and by McDonald and colleagues about our recent Original Investigation are addressed in Pocock and Stone ’s recent review on what to do when the primary outcome fails. Certainly, a trial in which the primary outcome falls short of statistical significance can be distressing to investigators. However, as highlighted by Chapple and Blackston, the interpretation of trial results may be colored by undue attention to a single primary outcome and arbitraryP value cut points. These constraints make sense in confirmatory studies of new drugs and devices (where th...
Source: JAMA Internal Medicine - March 1, 2019 Category: Internal Medicine Source Type: research

Inconsistencies in Reporting Studies of Lactic Acidosis —Reply
In Reply We thank Dr de Vries for his letter and, overall, agree with his comments. Limitations of diagnostic codes exist in both studies. In the future, we believe that advancements in the design and structure of electronic health records will allow for more sophisticated algorithms to accurately identify exposures and outcomes. Such advances will be fundamental to the assessment of the risks and benefits of medications and clinical care processes, and ultimately, improvement in patient outcomes. (Source: JAMA Internal Medicine)
Source: JAMA Internal Medicine - March 1, 2019 Category: Internal Medicine Source Type: research

JAMA Internal Medicine
Mission Statement: To promote the art and science of medicine and the betterment of human health by publishing manuscripts of interest and relevance to internists practicing as generalists or as medical subspecialists. (Source: JAMA Internal Medicine)
Source: JAMA Internal Medicine - March 1, 2019 Category: Internal Medicine Source Type: research

Evaluating Digital Health Tools
Digital health software tools (DHSTs) are becoming increasingly available to patients, health care systems, and other key stakeholders seeking to enhance patient-centered care with innovative apps, sensors, algorithms, and data visualization approaches. Broadly speaking, DHSTs seek to improve care by providing more informed treatment recommendations, clarifying and refining diagnoses, optimizing workflows and efficiency, and facilitating access to and use of complex health care data. However, even as these tools increase in use and popularity, real challenges exist to identify which DHSTs are appropriate for which patients...
Source: JAMA Internal Medicine - February 25, 2019 Category: Internal Medicine Source Type: research

Characteristics of Digital Health Studies Registered in ClinicalTrials.gov
This analysis of digital health studies in ClinicalTrials.gov examines the clinical evidence underlying digital health interventions. (Source: JAMA Internal Medicine)
Source: JAMA Internal Medicine - February 25, 2019 Category: Internal Medicine Source Type: research

Assessing Google Translate for Spanish and Chinese Translations of ED Discharge Instructions
This study assesses the use of Google Translate for Spanish and Chinese translations of emergency department discharge instructions. (Source: JAMA Internal Medicine)
Source: JAMA Internal Medicine - February 25, 2019 Category: Internal Medicine Source Type: research