Potential Adverse Financial Implications of the Medicare Merit-Based Incentive Payment System
Health care payment design requires careful monitoring and evaluation to understand and avoid unintended adverse consequences. In 2019, US clinicians began to be rewarded or penalized up to 4% of revenue under the Centers for Medicare& Medicaid Services Merit-based Incentive Payment System (MIPS). Clinicians can choose measures for evaluation from 3 categories: quality, meaningful use, and improvement activities. (Source: JAMA)
Source: JAMA - September 8, 2020 Category: General Medicine Source Type: research

Audio Highlights
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. (Source: JAMA)
Source: JAMA - September 8, 2020 Category: General Medicine Source Type: research

Polymyalgia Rheumatica and Giant Cell Arteritis
This JAMA Insights Clinical Update reviews the diagnosis and management of polymyalgia rheumatica and giant cell arteritis and provides a suggested treatment algorithm for giant cell arteritis. (Source: JAMA)
Source: JAMA - September 8, 2020 Category: General Medicine Source Type: research

The President Outlines a Program
On September 6 President Harry S. Truman sent to the Congress an outline of the executive and legislative program which he considered desirable. He concluded his presentation: (Source: JAMA)
Source: JAMA - September 8, 2020 Category: General Medicine Source Type: research

Hepatitis C –Related Hepatocellular Carcinoma Incidence After Introduction of Direct-Acting Antivirals
This study describes trends in the incidence of hepatocellular carcinoma within the Veterans Health Administration from 2002 to 2018 before and after widespread direct-acting anti –hepatitis C virus (HCV) treatment. (Source: JAMA)
Source: JAMA - September 8, 2020 Category: General Medicine Source Type: research

Allocation of COVID-19 Relief Funding to Disproportionately Black Counties
This study describes correlations between the dollar amount of relief funding authorized by the US Congress to fund prevention, diagnosis, and treatment of coronavirus disease 2019 (COVID-19) and to reimburse health care entities for lost revenues, and county-level Black population fraction accounting for county COVID-19 burden, comorbidity, and hospital financial health. (Source: JAMA)
Source: JAMA - September 8, 2020 Category: General Medicine Source Type: research

Reconfiguring Medical Education
To the Editor As a current medical student, I agree with Dr Emanuel on the increasing trend of using technology for medical education. Technology is readily used by most medical students, and it is arguably a more effective, flexible method of learning. However, preclinical medical education is more than just learning a base of knowledge. Medical school is a place where students go to make personal connections and develop life experience. I do not believe an exclusively online education can provide that human experience. What happens to the comradery and friendships developed between peers? What happens to the inspiration ...
Source: JAMA - September 8, 2020 Category: General Medicine Source Type: research

Reconfiguring Medical Education
To the Editor As a professional educator, I received multiple copies of the Viewpoint by Dr Emanuel, forwarded to me by various colleagues. Each expected that the ideas of “transformation” and “reimagination” would be of interest to me, so they were a bit disappointed by my ennui. (Source: JAMA)
Source: JAMA - September 8, 2020 Category: General Medicine Source Type: research

Reconfiguring Medical Education
To the Editor Dr Emanuel ’s discussion of the inevitable changes to medical education came at a pivotal moment. On March 11, coronavirus disease 2019 (COVID-19) was declared a global pandemic by the World Health Organization. Medical schools scrambled to comply with university mandates to discontinue in-person classes, al ong with government recommendations for “social distancing.” This required the rapid deployment of virtual learning modalities to replace the existing preclinical curriculum. (Source: JAMA)
Source: JAMA - September 8, 2020 Category: General Medicine Source Type: research

Reconfiguring Medical Education
To the Editor Dr Emanuel predicted that basic science education could be completed almost entirely before medical school, which then would meld with residency as purely clinical entities. (Source: JAMA)
Source: JAMA - September 8, 2020 Category: General Medicine Source Type: research

Chikungunya Virus –Like Particle Vaccine
To the Editor The chikungunya virus –like particle (CHIKV VLP) vaccine described in a recent article by Dr Chen and colleagues is one of several chikungunya vaccines that have completed either phase 1 or preclinical phases. The phase 2 randomized clinical trial reported focuses on pertinent clinical questions of safety and tolerabil ity of the vaccine in a chikungunya-endemic area. The trial enrolled healthy adults aged 18 through 60 years who had tested negative for chikungunya virus IgM/IgG and randomized them to receive 20 μg of the vaccine or a placebo. Both safety and tolerability were demonstrated. (Source: JAMA)
Source: JAMA - September 8, 2020 Category: General Medicine Source Type: research

Reconfiguring Medical Education —Reply
In Reply My Viewpoint argued that all preclinical medical education courses will be conducted online. I predicted it would take years. Just weeks later, COVID-19 mandated online preclinical education. (Source: JAMA)
Source: JAMA - September 8, 2020 Category: General Medicine Source Type: research

Chikungunya Virus –Like Particle Vaccine—Reply
We described the results of a phase 2 clinical trial demonstrating the safety, tolerability, and durable immunogenicity of a CHIKV VLP vaccine at 6 chikungunya-endemic sites in the Caribbean. Dr Jaiswal and colleagues highlight the favorable safety profile of the vaccine and inquire as to the reason for the study participant withdrawals described as “investigator or study decision” and requested the genotype-specific neutralization assay results. (Source: JAMA)
Source: JAMA - September 8, 2020 Category: General Medicine Source Type: research

Effect of Tranexamic Acid vs Placebo on Neurologic Outcomes in Patients With Traumatic Brain Injury
This randomized clinical trial compares the effects of an out-of-hospital tranexamic acid bolus vs placebo within 2 hours of traumatic brain injury (TBI) on 6-month functional neurologic outcome (Glasgow Coma Scale-Extended score>4) in patients with moderate or severe TBI. (Source: JAMA)
Source: JAMA - September 8, 2020 Category: General Medicine Source Type: research

Patient Social Risk and Physician Performance Scores in the First Year of the Merit-based Incentive Payment System
This study uses data from the Medicare Physician Compare database to assess associations between patient social risk, defined as dual eligibility for Medicare and Medicaid, and physicians ’ Merit-based Incentive Payment System (MIPS) data scores, a proxy for patient outcomes and care value. (Source: JAMA)
Source: JAMA - September 8, 2020 Category: General Medicine Source Type: research

Association Between Clinician Health System Affiliation and Outpatient MIPS Performance
This study uses data from the Medicare Physician Compare database to assess associations between clinician affiliation with health systems and performance scores and value-based reimbursement under the 2019 Merit-based Incentive Payment System (MIPS). (Source: JAMA)
Source: JAMA - September 8, 2020 Category: General Medicine Source Type: research

Patient Information: Caring for Someone With COVID-19
This JAMA Patient Page reviews the symptoms and signs of COVID-19, at-home management of the infection, and precautions to take while caring for someone with it. (Source: JAMA)
Source: JAMA - September 8, 2020 Category: General Medicine Source Type: research

Moving Back To The Marriage Bed
A month since my mastectomy, I ’ve slept in the spare room, which is closer to a toilet, and because my left side ached where a surgeon grafted back skin and muscle over my heart. I joked, “Tonight don’t be scared if you wake to find a balding white-haired lady in your bed.” Some men leave women when they hear the word ca ncer. True, we lose the parts that once defined us, wrongly or not, our hair, a breast or two, our libido. Maybe such partners fear costs of a consuming process of surgery, radiation and chemo, in my case, a stubborn tumor that returned too quickly. I had to remind myself I am more...
Source: JAMA - September 8, 2020 Category: General Medicine Source Type: research

The Silence and Sorrow of Miscarriage
In this narrative medicine essay, a neurologist relates the story of her miscarriage while touring immigration detention centers in Texas documenting medical care and human rights violations and shares her deep sorrow for the women who lost children either by force or miscarriages while incarcerated. (Source: JAMA)
Source: JAMA - September 8, 2020 Category: General Medicine Source Type: research

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(Source: JAMA)
Source: JAMA - September 8, 2020 Category: General Medicine Source Type: research

Cascading Risks of COVID-19 Resurgence During an Active 2020 Atlantic Hurricane Season
This Viewpoint discusses the prospects for exacerbation of the coronavirus disease 2019 (COVID-19) pandemic during hurricane season in the US, and proposes reinforcement of public health measures, clear communication, and learning from each experience to reduce the risks of hurricane-related harms and increases in COVID-19 cases. (Source: JAMA)
Source: JAMA - September 8, 2020 Category: General Medicine Source Type: research

TB Control Suffers During Pandemic
Extraordinary demands during the coronavirus disease 2019 (COVID-19) pandemic have diminished efforts to diagnose and treat people with tuberculosis (TB) at half of US public health departments, according to a report by the CDC and the National TB Controllers Association. (Source: JAMA)
Source: JAMA - September 8, 2020 Category: General Medicine Source Type: research

COVID-19 Precautions Helped Limit Cases Linked to Milwaukee Primary
High rates of voting by mail and other prevention strategies during Milwaukee ’s April primary limited the election-related spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), according to a report by CDC and City of Milwaukee Health Department researchers. (Source: JAMA)
Source: JAMA - September 8, 2020 Category: General Medicine Source Type: research

Prevalence of SARS-CoV-2 Antibodies in Health Care Personnel in the New York City Area
This seroprevalence survey study describes severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) seropositivity among health care workers at a New York City –based health system by age, sex, race, county of residence, and prior PCR-confirmed viral exposure. (Source: JAMA)
Source: JAMA - September 1, 2020 Category: General Medicine Source Type: research

Universal Masking in the United States: the Role of Mandates, Health Education, and the CDC
This Viewpoint proposes legal and policy options for promoting universal face mask wearing in the US and, recognizing the limits of state-by-state implementation, proposes strengthening the authority, independence, and funding of the CDC to enact responses to this and future comparable public health emergencies. (Source: JAMA)
Source: JAMA - September 1, 2020 Category: General Medicine Source Type: research

RNA Aptamers Deliver Chemotherapy Directly to Tumors
Scientists have harnessed synthetic RNA molecules that behave like antibodies —with high affinity and specificity for a target—to shuttle chemotherapy agents directly into tumors. (Source: JAMA)
Source: JAMA - September 1, 2020 Category: General Medicine Source Type: research

CAR-T Therapy Is Approved for Mantle Cell Lymphoma
The first cell-based gene therapy for adults with mantle cell lymphoma (MCL) has received FDA approval. (Source: JAMA)
Source: JAMA - September 1, 2020 Category: General Medicine Source Type: research

New FDA-EPA Protocol Covers Agricultural Water Safety
The FDA and the US Environmental Protection Agency (EPA) have developed a new protocol that may help farmers protect produce such as romaine lettuce and other leafy greens from contamination that can cause foodborne illnesses. (Source: JAMA)
Source: JAMA - September 1, 2020 Category: General Medicine Source Type: research

FDA Targets Illegal Hangover Relief
Forget the Happy Hour Vitamins, milk thistle, and prickly pear. Not only will they fail to prevent or cure a hangover, the FDA said they ’re illegally being marketed as remedies for having one too many. (Source: JAMA)
Source: JAMA - September 1, 2020 Category: General Medicine Source Type: research

Audio Highlights
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. (Source: JAMA)
Source: JAMA - September 1, 2020 Category: General Medicine Source Type: research

Treatment of Patients Following Bariatric Surgery in 2020-2021
This JAMA Insights Clinical Update reviews long-term complications of bariatric surgery, including GERD, gallstones, hypoglycemia, substance use disorder, and vitamin and other nutritional deficiencies, and proposes a schedule of testing and management strategies for each. (Source: JAMA)
Source: JAMA - September 1, 2020 Category: General Medicine Source Type: research

The Importance of Reestablishing a Pandemic Preparedness Office at the White House
As the country tries to make sense of all that has happened during the coronavirus disease 2019 (COVID-19) pandemic, one idea that should cause little controversy is the importance of health to the security of the US, to its economy, and to the well-being of its citizenry. Given health ’s fundamental importance to national security, a disaster preparedness and response unit should be reestablished as part of the National Security Council (NSC) and remain there on a permanent basis. This response unit would be in addition to, not a replacement for, the Office of Pandemics and Eme rging Threats. The latter currently re...
Source: JAMA - September 1, 2020 Category: General Medicine Source Type: research

Rambling Notes of a Roving Doctor
Paris, August, 1900. (Source: JAMA)
Source: JAMA - September 1, 2020 Category: General Medicine Source Type: research

Incidence of Malformations After Early Pregnancy Exposure to Modafinil in Sweden and Norway
This pharmacoepidemiology study uses Scandinavian birth registry data to estimate the association between modafinil use during early pregnancy and major congenital malformations among infants born in Norway and Sweden between 2005-2006 and 2016-2017. (Source: JAMA)
Source: JAMA - September 1, 2020 Category: General Medicine Source Type: research

Reducing Vasopressor Exposure in Patients With Vasodilatory Hypotension
To the Editor A clinical trial by Dr Lamontagne and colleagues showed that reducing exposure to vasopressors through a lower mean arterial pressure (MAP) target during resuscitation in older patients with vasodilatory hypotension decreased 90-day mortality, although it did not reach statistical significance. Three large randomized clinical trials also showed that early goal-directed therapy did not improve outcomes in patients with septic shock. (Source: JAMA)
Source: JAMA - September 1, 2020 Category: General Medicine Source Type: research

Nonalcoholic Steatohepatitis
To the Editor The Review by Dr Sheka and colleagues omitted 2 important facts: (1) nonalcoholic fatty liver disease (NAFLD) is an independent cardiovascular risk factor, increasing the risk of a cardiovascular event by nearly 2-fold and (2) an individual with metabolic syndrome and NAFLD has a 2- to 5-fold increased risk of progressing to diabetes compared with someone without NAFLD. (Source: JAMA)
Source: JAMA - September 1, 2020 Category: General Medicine Source Type: research

Payer Mix Among Patients Receiving Dialysis
To the Editor The Research Letter by Ms Hoffman and colleagues described trends in payer mix among patients receiving dialysis in the United States. We share the authors ’ concerns that shifting patients from publicly funded insurance to commercial insurance could increase the overall cost of dialysis care. Although the Affordable Care Act increased access to the commercial insurance market through the creation of health insurance exchanges, we were surprised by t he magnitude of non-Medicare coverage reported. (Source: JAMA)
Source: JAMA - September 1, 2020 Category: General Medicine Source Type: research

Reducing Vasopressor Exposure in Patients With Vasodilatory Hypotension —Reply
In Reply Dr Das and colleagues raise a number of concerns about the 65 Trial. The explanation for the median blood pressure being higher than the MAP target relates, in part, to the protocol. When MAP values were above 65 mm Hg, the protocol stipulated that vasopressor dose rates should be reduced until, if possible, they were stopped. As such, it was possible to adhere to the protocol by continuously reducing vasopressor doses and still record MAP values above 65 mm Hg until stopping the medication, at which time MAP values were not recorded. MAP values without vasopressor dose rates are not good indicators of protocol ad...
Source: JAMA - September 1, 2020 Category: General Medicine Source Type: research

Nonalcoholic Steatohepatitis —Reply
In Reply We agree with Dr Grajower that addressing cardiovascular risk is important in treating patients with NAFLD and NASH, as mentioned in the article. As he points out, NAFLD, NASH, and metabolic syndrome are closely related, and treatment is therefore also interrelated. It was simply not feasible to address all components of cardiovascular risk reduction in the Review, which was focused on NASH specifically. Similarly, we did not address screening and treatment for hepatocellular carcinoma, varices, and end-stage liver disease, although these are closely related to NASH. We did think it was important to mention statin...
Source: JAMA - September 1, 2020 Category: General Medicine Source Type: research

Payer Mix Among Patients Receiving Dialysis —Reply
In Reply We agree with Drs Lin and Erickson on the importance of using patient-level data to corroborate facility-level trends in payer mix for ESKD. Significant changes were shown in facility-reported Medicare and non-Medicare enrollment in our study, but the patient-level statistics that Lin and Erickson provide from the USRDS Annual Data Reports showed almost no change in Medicare and non-Medicare enrollment. (Source: JAMA)
Source: JAMA - September 1, 2020 Category: General Medicine Source Type: research

Rimegepant (Nurtec ODT) for Acute Treatment of Migraine
This Medical Letter review summarizes evidence supporting the use of rimegepant (Nurtec), a small-molecule calcitonin gene-related peptide receptor antagonist, for acute treatment of migraine with or without aura in adults. (Source: JAMA)
Source: JAMA - September 1, 2020 Category: General Medicine Source Type: research

Association Between New-Onset Atrial Fibrillation After Noncardiac Surgery and Subsequent Stroke and TIA
This retrospective study compared the rate of ischemic stroke or transient ischemic attack among Olmstead County, Minnesota, residents with vs without new-onset postoperative atrial fibrillation after undergoing noncardiac surgery. (Source: JAMA)
Source: JAMA - September 1, 2020 Category: General Medicine Source Type: research

Effect of Intraoperative Low vs Conventional Tidal Volume on Postoperative Pulmonary Complications After Major Surgery
This randomized clinical trial compares the effect of intraoperative ventilation with low vs conventional tidal volume (6 vs 10 mL/kg predicted body weight) on pulmonary complications in the first 7 postoperative days among patients undergoing major surgery lasting longer than 2 hours. (Source: JAMA)
Source: JAMA - September 1, 2020 Category: General Medicine Source Type: research

Patient Information: Sleeve Gastrectomy
This JAMA Patient Page explains who should undergo gastric sleeve procedure, a type of obesity surgery; how to prepare for it; and what to expect afterward. (Source: JAMA)
Source: JAMA - September 1, 2020 Category: General Medicine Source Type: research

The Nerve
I took a trip to death one day, a boat to carry all my pain. The captain said I wouldn ’t need to bring my shoes or coat, but I should lie here quietly till dead. The waves revolted every nerve. I stood and took my pain and wrecked it shore to shore, my inner artists weaving what they could. I didn’t want to die. I wanted more of air in leaves, the loving wind, the crow shining he r velvet feathers on my face. I told the captain that I wouldn’t go and struggled through a fog to leave that place. But clouds and sea turned into hopeless rain. What little raft I had sank in the pain. (Source: JAMA)
Source: JAMA - September 1, 2020 Category: General Medicine Source Type: research

Benefits and Risks of Bariatric Surgery in Adults: A Review
Precis This narrative review summarizes the efficacy and safety of bariatric surgery, mainly sleeve gastrectomy and the Roux-en-Y procedure, in assisting weight loss and in patients with type 2 diabetes and other obesity-related comorbidities. (Source: JAMA)
Source: JAMA - September 1, 2020 Category: General Medicine Source Type: research

Jama
(Source: JAMA)
Source: JAMA - September 1, 2020 Category: General Medicine Source Type: research

Postexercise Ankle-Brachial Index Testing
A 61-year-old woman with a history of hypertension presented for evaluation of exertional left calf discomfort. Her lower extremity systolic blood pressure and ankle-brachial index (ABI) measures declined after treadmill testing. What would you do next? (Source: JAMA)
Source: JAMA - August 25, 2020 Category: General Medicine Source Type: research

From Auto Mechanic to Emergency Medicine Resident: Inspiring Young Blacks to Become Physicians
This Medical News article discusses the circuitous path Carl Allamby, MD, traveled from auto repair shop owner to emergency medicine resident. (Source: JAMA)
Source: JAMA - August 25, 2020 Category: General Medicine Source Type: research

Management of Age-Related Macular Degeneration in 2020-2021
This JAMA Insights Clinical Update reviews the epidemiology, clinical manifestations, classification, diagnosis, prevention, and approved and investigational treatment of age-related macular degeneration in older adults. (Source: JAMA)
Source: JAMA - August 25, 2020 Category: General Medicine Source Type: research