Primary Care for All
Democratic candidates for president have been actively debating the merits of “Medicare for all.” This term is used differently by the candidates, and what has been left unsaid is whether they endorse a particular model of care. Medicare for all would have enormous implications for how health care is financed, but ensuring that primary care is the foundation of the US hea lth care delivery system is what is needed to have a significant impact on the population’s health. (Source: JAMA)
Source: JAMA - November 5, 2019 Category: General Medicine Source Type: research

The Relationship Between Herpes Zoster, Syphilis and Chickenpox
The significance of herpes zoster is still a matter for speculation. While technically a disease of the skin, the condition is one that has always been of interest to the neurologist and to the general practitioner. Originally regarded as occurring along the distribution of peripheral nerves, it has been recognized, since the epoch-marking discoveries of Henry Head, as having a segmental distribution. Certain aspects of the disease, particularly its relationship to syphilis, have recently been discussed by Brown and Dujardin. These observers noted that herpes zoster was distinctly more prevalent among a group of soldiers u...
Source: JAMA - November 5, 2019 Category: General Medicine Source Type: research

Requests for Diagnoses of Sexually Transmitted Diseases on a Social Media Platform
This study monitored online posts from readers seeking specific health information on a social media platform to evaluate the volume of information requests, whether readers sought an initial or second opinion for diagnosis, and the amount of response time before a reply answer was sent. (Source: JAMA)
Source: JAMA - November 5, 2019 Category: General Medicine Source Type: research

Spontaneous Breathing Trials and Successful Extubation
To the Editor The results of the randomized clinical trial reported by Dr Subir à and colleagues compared a less demanding spontaneous breathing trial (SBT) of 30 minutes of pressure support ventilation (PSV) with a more demanding 2-hour T-piece SBT and showed a higher successful extubation rate favoring the less demanding test without a higher need for reintubation. In this t rial, clinicians, who were not blinded to treatment assignment, made greater use of prophylactic respiratory interventions in the PSV group (24.7%) (8.9% noninvasive ventilation [NIV] + 15.8% high-flow nasal cannula [HFNC]) compared with the T...
Source: JAMA - November 5, 2019 Category: General Medicine Source Type: research

Trends in Obesity Among Low-Income Young Children
To the Editor Using data from the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), Dr Pan and colleagues found that in low-income children aged 2 through 4 years, obesity declined from 15.9% to 13.9% between 2010 and 2016. These data are important because they suggest that, compared with the period between 1970 and 2010 during which the prevalence of childhood obesity increased in the US population, after 2010 there was a decrease in adiposity among low-income young children. (Source: JAMA)
Source: JAMA - November 5, 2019 Category: General Medicine Source Type: research

One vs 12 Months of Dual Antiplatelet Therapy for Patients After Percutaneous Coronary Intervention
To the Editor The STOPDAPT-2 (Short and Optimal Duration of Dual Antiplatelet Therapy After Everolimus-Eluting Cobalt-Chromium Stent 2) study reported noninferiority and superiority of 1 month vs 12 months of dual antiplatelet therapy (DAPT) on cardiovascular and bleeding events in patients receiving everolimus-eluting stents. (Source: JAMA)
Source: JAMA - November 5, 2019 Category: General Medicine Source Type: research

Spontaneous Breathing Trials and Successful Extubation
To the Editor Dr Subir à and colleagues evaluated 2 types of SBTs to evaluate readiness for extubation, a short-duration (30-minute) PSV strategy compared with a long-duration (2-hour) T-piece strategy, and found higher extubation rates with the PSV strategy (82.3% vs 74.0% at 72 hours; 92.5% vs 84.1% after the first SBT ), with no difference in reintubation rates within 72 hours of extubation (11.1% vs 11.9%). Surprisingly, patients underwent their first SBT when the pretest probability of successful separation from the ventilator was already extremely high (as indicated by the success rate of the trial). When the ...
Source: JAMA - November 5, 2019 Category: General Medicine Source Type: research

Spontaneous Breathing Trials and Successful Extubation —Reply
In Reply We agree with Drs Friedrich and Burns that prophylaxis against postextubation respiratory failure with NIV or HFNC was more common in the PSV group than in the T-piece group (24.7% vs 18.7%). However, the decision to apply prophylaxis was made before randomization, so this difference can only be attributed to chance. We would like to clarify that patients could receive prophylactic NIV or HFNC but not both. (Source: JAMA)
Source: JAMA - November 5, 2019 Category: General Medicine Source Type: research

Trends in Obesity Among Low-Income Young Children —Reply
In Reply We agree with Drs Stefan and Schulze that there are limitations of BMI as a surrogate of adiposity in our study of the prevalence of obesity among children aged 2 through 4 years enrolled in WIC. (Source: JAMA)
Source: JAMA - November 5, 2019 Category: General Medicine Source Type: research

1 vs 12 Months of Dual Antiplatelet Therapy for Patients After Percutaneous Coronary Intervention —Reply
In Reply In response to the 1-year primary analysis of the STOPDAPT-2 trial, Dr Tan commented on the appropriateness of the noninferiority margin and the actual timing of aspirin discontinuation in the 1-month DAPT group. (Source: JAMA)
Source: JAMA - November 5, 2019 Category: General Medicine Source Type: research

Lefamulin (Xenleta) for Community-Acquired Bacterial Pneumonia
This Medical Letter review summarizes the indications, adverse effects, and drug interactions of Lefamulin, a semisynthetic pleuromutilin antibiotic approved by the US Food and Drug Administration for intravenous and oral treatment of community-acquired bacterial pneumonia in adults. (Source: JAMA)
Source: JAMA - November 5, 2019 Category: General Medicine Source Type: research

Caspofungin vs Fluconazole for Invasive Fungal Disease Among Young Patients With Acute Myeloid Leukemia
This randomized trial compares the effect of prophylactic caspofungin vs fluconazole on invasive fungal disease among patients between the ages of 3 months to 30 years with acute myeloid leukemia. (Source: JAMA)
Source: JAMA - November 5, 2019 Category: General Medicine Source Type: research

Association of Genetic Variants With Primary Open-Angle Glaucoma Among Individuals With African Ancestry
This genome-wide association study (GWAS) investigates genetic loci associated with primary open-angle glaucoma in individuals in Africa and in the United States with African ancestry. (Source: JAMA)
Source: JAMA - November 5, 2019 Category: General Medicine Source Type: research

Dementia
This JAMA Patient Page describes the causes, symptoms, evaluation, and treatments for dementia. (Source: JAMA)
Source: JAMA - November 5, 2019 Category: General Medicine Source Type: research

The Hospital Mail
At no particular hour the door to my room snaps open to a snuffling yellow paper gown wearing an orange pleated mask (Source: JAMA)
Source: JAMA - November 5, 2019 Category: General Medicine Source Type: research

Resident Report —What a Physician With Cancer Needs From Her Doctors
In this narrative medicine essay, an internal medicine intern with metastatic osteosarcoma tells what it is like to be a patient facing a grave disease and explains that she needs commitment, empathy, and presence from her physicians. (Source: JAMA)
Source: JAMA - November 5, 2019 Category: General Medicine Source Type: research

Jama
(Source: JAMA)
Source: JAMA - November 5, 2019 Category: General Medicine Source Type: research

Heavy Hunger —Managing Weight and Obesity in Black American Communities
This Arts and Medicine feature reviews 2 memoirs by black Americans, Hunger by Roxane Gay, and Heavy by Kiese Laymon, that reveal how early-life trauma and adverse experiences contribute to eating disorders and obesity and complicate weight management in black Americans. (Source: JAMA)
Source: JAMA - October 22, 2019 Category: General Medicine Source Type: research

Fluoxetine and Repetitive Behaviors in Children and Adolescents With Autism Spectrum Disorder
The results of the multisite randomized clinical trial of fluoxetine in children and adolescents with autism spectrum disorder (ASD) reported by Reddihough and colleagues in this issue of JAMA will challenge the field to reconcile the limited performance of the drug with long-standing utilization patterns. Fluoxetine and other selective serotonin reuptake inhibitors (SSRIs) have been among the most widely prescribed medications for individuals with ASD for well over a decade. In 2008, when this trial was first registered with the Australian and New Zealand Clinical Trials Registry, there were few data to guide the field, a...
Source: JAMA - October 22, 2019 Category: General Medicine Source Type: research

Cervical Cancer as a Global Concern
Cancer of the uterine cervix is among the most preventable human malignancies, yet it remains a leading cause of death among women worldwide, accounting for more than 300  000 deaths annually. Well on its way to elimination in the global north, cervical cancer mostly affects women living in low- or middle-income countries (LMICs), where limited access to vaccination, screening, and therapy have made it overwhelmingly a disease of women who are poor and lack access to health care. Nowhere is this more evident than in sub-Saharan Africa, where HIV is endemic and where cervical cancer has surpassed breast cancer as the most...
Source: JAMA - October 22, 2019 Category: General Medicine Source Type: research

Many Children, Adolescents Not Getting Medicaid-Covered Screenings
Approximately 4 of 10 Medicaid beneficiaries younger than 21 years did not receive any recommended screenings in fiscal year 2017, according to a recent US Government Accountability Office (GAO) report. (Source: JAMA)
Source: JAMA - October 22, 2019 Category: General Medicine Source Type: research

Air Pollution and Preterm Birth Risk in Second Pregnancy
Among low-risk women, exposure to higher levels of air pollution during their second pregnancy, compared with the first, was associated with increased risk of preterm birth, according to a study by National Institutes of Health researchers. (Source: JAMA)
Source: JAMA - October 22, 2019 Category: General Medicine Source Type: research

Use of Illicit Drugs Continues to Rise
Marijuana continues to be the most widely used illicit drug in the United States, with 15.9% of people aged 12 years or older reporting that they had used it in the past year, higher than in 2002 to 2017, according to the recently released 2018 National Survey on Drug Use and Health (NSDUH). (Although medical marijuana is legal in most states, the federal government still considers cannabis to be illicit.) (Source: JAMA)
Source: JAMA - October 22, 2019 Category: General Medicine Source Type: research

Global Trends in Type 2 Diabetes, 2007-2017
(Source: JAMA)
Source: JAMA - October 22, 2019 Category: General Medicine Source Type: research

Highlights for October 22/29, 2019
(Source: JAMA)
Source: JAMA - October 22, 2019 Category: General Medicine Source Type: research

Tuberculosis in Health Resorts for the Tuberculous
The fear of infection from contact with tuberculous patients is still widely prevalent among the laity. This phthisiophobia has often presented an obstacle to the institution of desired relief measures in the management of the tuberculous. The “fear born of ignorance” is not directed to these unfortunates alone. Even today it is frequently a difficult task to secure a suitable site for any contagious disease hospital in the vicinity of human habitations. The dread with which such an institution is still contemplated cannot be dispelle d by exhortations or governmental edicts. The absence of special dangers in t...
Source: JAMA - October 22, 2019 Category: General Medicine Source Type: research

Industrial Tuberculosis Experience in 1918
The industrial department of the Metropolitan Life Insurance Company has recently published a report of the department ’s tuberculosis mortality experience for the year 1918. The death rate from tuberculosis (all forms) has decreased every year for the Metropolitan since 1911, when the rate was 224.6 per hundred thousand. In 1918 the death rate had fallen to 187.4, which is, however, only slightly lower than the r ate for 1917—188.9. With this experience rate of the Metropolitan company may be compared the general mortality rate for 1917 throughout the death registration area in continental United States, which...
Source: JAMA - October 22, 2019 Category: General Medicine Source Type: research

Association Between Limited English Proficiency and Revisits and Readmissions After Hospitalization in Toronto, Ontario, Canada
This study discusses observed associations between limited English proficiency, revisits, and readmissions to 2 Toronto hospitals. (Source: JAMA)
Source: JAMA - October 22, 2019 Category: General Medicine Source Type: research

P2Y12 Inhibitor Monotherapy vs Dual Antiplatelet Therapy After Percutaneous Coronary Intervention
To the Editor Dr Hahn and colleagues reported noninferiority of P2Y12 inhibitor monotherapy compared with dual antiplatelet therapy (DAPT) among patients receiving current-generation drug-eluting stents. The primary end point was major adverse cardiac and cerebrovascular events. Assuming a 12-month event rate of 4.0% for the DAPT group, the noninferiority margin for the event rate difference (monotherapy minus DAPT) was set at 1.8%. In the intention-to-treat analysis, the 12-month cumulative incidence of the primary outcome was 2.9% for monotherapy and 2.5% for DAPT. Since the upper bound of the confidence interval for the...
Source: JAMA - October 22, 2019 Category: General Medicine Source Type: research

FEV1:FVC Thresholds for Defining Chronic Obstructive Pulmonary Disease
To the Editor Dr Bhatt and colleagues compared the discriminative accuracy of airflow obstruction defined by thresholds for FEV1:FVC of 0.70 (fixed ratio) vs LLN. Discriminative accuracy was based on unadjusted C statistics and a composite outcome of COPD-related hospitalization and death. The fixed ratio for FEV1:FVC provided similar or more accurate discrimination, with a C statistic of 0.695 compared with a C statistic of 0.661 for the LLN. I do not believe this conclusion is warranted. (Source: JAMA)
Source: JAMA - October 22, 2019 Category: General Medicine Source Type: research

FEV1:FVC Thresholds for Defining Chronic Obstructive Pulmonary Disease
To the Editor A study examining the discriminatory accuracy of different thresholds of the ratio of forced expiratory volume in the first second to forced vital capacity (FEV1:FVC) to define chronic obstructive pulmonary disease (COPD) concluded that a fixed ratio of 0.7 best identified patients with COPD-related hospitalization or mortality. However, the conclusion from this work should be that the majority of clinicians caring for the patients in their study used the fixed ratio of 0.7 to diagnose COPD. The authors used International Classification of Diseases (ICD), Ninth Revision and Tenth Revision, codes for COPD as i...
Source: JAMA - October 22, 2019 Category: General Medicine Source Type: research

Antihypertensive Medication Use in Older Adults at Risk for Hip Fracture
To the Editor The recent Clinical Update on hip fractures in older adults included a figure on managing medications in older adults at risk for fracture. In the section on deprescribing fall-related medications, one item listed is “antihypertensives if blood pressure is below target or the patient has orthostatic hypotension.” This unreferenced recommendation does not reflect an evidence-based assessment of antihypertensive medication as a risk factor for falls and fractures. (Source: JAMA)
Source: JAMA - October 22, 2019 Category: General Medicine Source Type: research

FEV1:FVC Thresholds for Defining Chronic Obstructive Pulmonary Disease
To the Editor The discriminative accuracy of various FEV1:FVC fixed thresholds for predicting COPD-related hospitalization and mortality was evaluated using data from 4 US general population –based cohorts with a median follow-up of 15 years. The authors defined the optimal fixed FEV1:FVC threshold by the best discrimination for COPD-related events as indexed using the Harrell C statistic from unadjusted Cox proportional hazards models. The authors further determined the significance of differences in C statistics with respect to FEV1:FVC less than 0.70 and less than the LLN thresholds using a nonparametric approach,...
Source: JAMA - October 22, 2019 Category: General Medicine Source Type: research

P2Y12 Inhibitor Monotherapy vs Dual Antiplatelet Therapy After Percutaneous Coronary Intervention —Reply
In Reply We agree with Drs McCaw and Wei that the intention-to-treat analysis might dilute the true difference in the event rates between the P2Y12 inhibitor monotherapy group and the DAPT group in the SMART-CHOICE (Smart Angioplasty Research Team: Comparison Between P2Y12 Antagonist Monotherapy vs Dual Antiplatelet Therapy in Patients Undergoing Implantation of Coronary Drug-Eluting Stents) trial. Considering that 8.9% of patients in the P2Y12 inhibitor monotherapy group received aspirin at 1 year, to estimate the effects of treatment as received is of great importance. The most frequently used method for this purpose is ...
Source: JAMA - October 22, 2019 Category: General Medicine Source Type: research

Antihypertensive Medication Use in Older Adults at Risk for Hip Fracture —Reply
In Reply Conflicting data exist on the relationship between antihypertensive medications and falls, particularly among patients beyond the eighth decade of life and frail older adults. In a large observational study of Medicare beneficiaries with hypertension (mean age, 80 years), Tinetti et al used propensity scores to match patients according to the intensity of antihypertensive therapy. In the primary analysis, exposure to moderate- or high-dose antihypertensive drugs was associated with a 30% to 40% increased risk of injurious falls compared with no antihypertensive drug use. The association between antihypertensive me...
Source: JAMA - October 22, 2019 Category: General Medicine Source Type: research

FEV1:FVC Thresholds for Defining Chronic Obstructive Pulmonary Disease —Reply
In Reply We disagree with Drs Miller and Stanojevic that our results were mainly due to clinicians ’ use of the fixed ratio of 0.70 for the diagnosis of COPD. Clinicians were blinded to study spirometry, and spirometry is substantially underutilized in clinical care. Furthermore, in the context of substantial debate on optimal spirometric criteria, it is unknown which threshold may have been se lected by treating physicians. In a number of cases, it is possible that a clinical diagnosis of chronic bronchitis was made. A diagnostic threshold should have meaningful prognostic utility, and in the absence of a diagnostic...
Source: JAMA - October 22, 2019 Category: General Medicine Source Type: research

Experimental Chlamydia Vaccine Shows Promise
A novel chlamydia vaccine was shown to be safe and immunogenic, according to a phase 1 first-in-human trial published in The Lancet Infectious Diseases. (Source: JAMA)
Source: JAMA - October 22, 2019 Category: General Medicine Source Type: research

Counseling Reduces Physician Burnout
Physicians reported less burnout and emotional exhaustion after receiving short-term professional coaching, according to a pilot trial published in JAMA Internal Medicine. (Source: JAMA)
Source: JAMA - October 22, 2019 Category: General Medicine Source Type: research

Occupational Intervention Unnecessary to Treat Back Pain
Usual care in treating low back pain was just as effective in reducing disability and sick leave as a complex 3-month occupational intervention, found a trial in PLOS Medicine. (Source: JAMA)
Source: JAMA - October 22, 2019 Category: General Medicine Source Type: research

Esketamine Prevents Treatment-Resistant Depression Relapse
Long-term use of esketamine nasal spray in combination with an antidepressant was more effective than an oral antidepressant alone in preventing relapse in patients with treatment-resistant depression, found a trial in JAMA Psychiatry. (Source: JAMA)
Source: JAMA - October 22, 2019 Category: General Medicine Source Type: research

Diabetes, Prior PCI, and Dual Antiplatelet Therapy
Ticagrelor plus aspirin reduced ischemic events in patients with type 2 diabetes, stable coronary artery disease, and previous percutaneous coronary intervention (PCI), according to a trial published in The Lancet. (Source: JAMA)
Source: JAMA - October 22, 2019 Category: General Medicine Source Type: research

Cryotherapy vs LEEP and Cervical Disease Recurrence Among Women With HIV in Kenya
This randomized clinical trial compares the effect of cryotherapy vs loop electrosurgical excision procedure (LEEP) on disease recurrence (cervical intraepithelial neoplasia [CIN] grade 2 or higher or invasive cervical cancer) in women with HIV and CIN grade 2 or 3. (Source: JAMA)
Source: JAMA - October 22, 2019 Category: General Medicine Source Type: research

Prevalence of Survival Without Major Comorbidities Among Adults Born Prematurely
This cohort study uses data from the Swedish Birth Registry to determine the prevalence of survival without major comorbidities in adulthood among persons born preterm vs full-term in Sweden between 1973 and 1997. (Source: JAMA)
Source: JAMA - October 22, 2019 Category: General Medicine Source Type: research

Fluoxetine for Obsessive-Compulsive Behaviors in Children With Autism Spectrum Disorders
This randomized clinical trial compares the effects of fluoxetine vs placebo for obsessive-compulsive behaviors in children and adolescents with autism spectrum disorders. (Source: JAMA)
Source: JAMA - October 22, 2019 Category: General Medicine Source Type: research

Lactose Intolerance
This JAMA Patient Page describes lactose intolerance, its diagnosis, and its treatment. (Source: JAMA)
Source: JAMA - October 22, 2019 Category: General Medicine Source Type: research

After Aleppo
(Source: JAMA)
Source: JAMA - October 22, 2019 Category: General Medicine Source Type: research

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. (Source: JAMA)
Source: JAMA - October 22, 2019 Category: General Medicine Source Type: research

Diagnosis and Management of Dementia
This narrative review summarizes published evidence on the diagnosis and management of dementia, including criteria distinguishing mild cognitive impairment (MCI) from dementia, newer approaches to diagnostic testing and imaging, and nonpharmacologic and drug treatment approaches. (Source: JAMA)
Source: JAMA - October 22, 2019 Category: General Medicine Source Type: research

Jama
(Source: JAMA)
Source: JAMA - October 22, 2019 Category: General Medicine Source Type: research

Disparities in Maternal Mortality
Black and American Indian/Alaskan Native mothers in the United States were 2 to 3 times more likely to die from pregnancy-related causes between 2007 and 2016, according to a recent CDC report. Overall, pregnancy-related mortality in the United States rose from 15 to 17 per 100  000 live births during this period, while global rates have been decreasing. (Source: JAMA)
Source: JAMA - October 22, 2019 Category: General Medicine Source Type: research