Catheter Ablation for Atrial Fibrillation in 2019
This JAMA Insights Clinical Update reviews management approaches to atrial fibrillation (AF), including assessment of the need for anticoagulation, and controversies over the need for rhythm control and the role of catheter ablation for maintaining sinus rhythm and reducing AF-associated symptoms. (Source: JAMA)
Source: JAMA - August 20, 2019 Category: General Medicine Source Type: research

Averting Alert Fatigue to Prevent Adverse Drug Reactions
Although various electronic health records (EHRs) have different features, nearly all seem to have alerts for potential problems with drug prescribing. It ’s one thing that many believe that EHRs do very well. However, a recent study warns that when it comes to opioids and benzodiazepines, we shouldn’t always assume that such alerts work as intended. (Source: JAMA)
Source: JAMA - August 20, 2019 Category: General Medicine Source Type: research

The Relation of Pathology to Practice
With the swinging of the pendulum in the science of medicine has come the fashion of neglecting pathology, the pathology of the type called, in the olden days, morbid anatomy. This neglect is shown in many ways: in a diminution in the volume of published work; in the lessened number of necropsies performed, and in the smaller number of men who are actively interested in the subject. It may be that the great days of Rokitansky, of Virchow and of Cohnheim have passed never to return; but it is more likely that the next swing of the pendulum will bring with it a renewed interest in the study of the anatomic changes which acco...
Source: JAMA - August 20, 2019 Category: General Medicine Source Type: research

Monitoring Adherence to Inhaled Medications
To the Editor Drs Hew and Reddel highlighted the importance of adherence to inhaled controller medications in the treatment of chronic respiratory conditions. Some of their claims regarding adherence monitoring systems for inhalers lacked a balanced perspective. (Source: JAMA)
Source: JAMA - August 20, 2019 Category: General Medicine Source Type: research

Resuming Anticoagulation After Cerebral Intraparenchymal Hemorrhage
To the Editor Dr Gross and colleagues reviewed the management options for cerebral intraparenchymal hemorrhage (IPH) to help guide clinical decision-making. The review captured the most up-to-date evidence for clinical management of IPH; however, the authors ’ suggestion to resume oral anticoagulation therapy 1 to 2 months after deep IPH unrelated to cerebral amyloid angiopathy may not be supported by firm evidence. We believe the recommendations should be more cautious. The 2015 American Heart Association guidelines do not provide a definitive recomm endation for resumption of anticoagulation therapy after nonlobar ...
Source: JAMA - August 20, 2019 Category: General Medicine Source Type: research

Treating Hypercholesterolemia in Older Adults
To the Editor In his Viewpoint, Dr Skolnik discussed the 2018 American College of Cardiology (ACC)/American Heart Association (AHA) guideline on the management of blood cholesterol and its implications for older adults. We would like to highlight relevant features of the guidelines that merit greater recognition. (Source: JAMA)
Source: JAMA - August 20, 2019 Category: General Medicine Source Type: research

Monitoring Adherence to Inhaled Medications —Reply
In Reply While we agree with the important points that Dr Bryant and colleagues have made about the role of multidisciplinary teams in improving adherence, we believe they may have misinterpreted our main thesis by inadvertently conflating adherence monitoring with adherence management. We have argued that input from pharmaceutical companies is essential to rectify the current lack of adherence monitoring. We do not, however, equate this with delivering overall adherence management, which is a far broader endeavor, needing to take into account multiple contributory factors and requiring an adequately resourced multidiscipl...
Source: JAMA - August 20, 2019 Category: General Medicine Source Type: research

Resuming Anticoagulation After Cerebral Intraparenchymal Hemorrhage —Reply
In Reply We agree with Ms Leasure and Dr Sheth that there is no firm evidence to support timing of restarting anticoagulation therapy following IPH, particularly for new-generation anticoagulants. We stated in our review that restarting anticoagulation therapy should be delayed by 1 to 2 months in patients with nonlobar IPH unrelated to amyloid angiopathy, but we did not state that anticoagulation therapy must be restarted in all cases at this time. In patients with a correctable etiologic cause of IPH and stronger indications for anticoagulation therapy, such as mechanical heart valves, anticoagulation therapy may need to...
Source: JAMA - August 20, 2019 Category: General Medicine Source Type: research

Treating Hypercholesterolemia in Older Adults —Reply
In Reply Dr Forman and colleagues, in a response to my Viewpoint, provide clarification regarding the IIb grade of the recommendation for management of hypercholesterolemia in older adults. A IIb recommendation indicates that a recommendation is based on weak evidence that the benefit is greater than the risk. The fact that clinical judgment should be used in carrying out a IIb recommendation is true but not distinct to IIb recommendations. Clinical judgment needs to be used for all recommendations. (Source: JAMA)
Source: JAMA - August 20, 2019 Category: General Medicine Source Type: research

Association of Smoking Cessation With Subsequent Risk of Cardiovascular Disease
This cohort study uses Framingham Heart Study data to assess the association between years since smoking cessation and incident cardiovascular disease (CVD), compared with current and never smoking, among participants without baseline CVD over a median follow-up of 26 years. (Source: JAMA)
Source: JAMA - August 20, 2019 Category: General Medicine Source Type: research

Effect of Continuing Olanzapine vs Placebo on Relapse Among Patients With Psychotic Depression in Remission
This randomized clinical trial compares the effect on relapse of continuing olanzapine vs placebo among patients with psychotic depression who achieved remission of psychosis and depressive symptoms while taking olanzapine and sertraline. (Source: JAMA)
Source: JAMA - August 20, 2019 Category: General Medicine Source Type: research

Association of Thyroid Function Test Abnormalities and Thyroid Autoimmunity With Preterm Birth
This individual participant data meta-analysis pooled data from 19 cohort studies to assess whether maternal thyroid function test abnormalities and thyroid autoimmunity are risk factors for preterm birth among pregnant women without overt thyroid disease. (Source: JAMA)
Source: JAMA - August 20, 2019 Category: General Medicine Source Type: research

Testing for BRCA Mutations
This JAMA Patient Page describes the US Preventive Services Task Force ’s recently published recommendations on risk assessment and genetic counseling and testing for BRCA mutations and BRCA-related cancers. (Source: JAMA)
Source: JAMA - August 20, 2019 Category: General Medicine Source Type: research

Playing Word Games
I sprinkle hints, seeds in the withering garden of your brain, hope words will sprout, blossom on your lips. But deep in the gray matter, atrophy spreads like a biblical pestilence. In that un-Eden, hummingbirds dart, like crazed syllables, scatter alphabets like fallen petals amid stems of thought — bare, but pretending to be bright. Colors for flowers, all I could expect. (Source: JAMA)
Source: JAMA - August 20, 2019 Category: General Medicine Source Type: research

A Tale of Two Lungs: Helping Patients Make Decisions
In this narrative medicine essay, a critical care physician works through lessons he learned from his experience with a man with end-stage lung disease going into terminal respiratory failure who consented to intubation only if he had a chance for a lung transplant and considers how to balance patient autonomy with medical paternalism when good outcomes are unlikely and the best decisions are uncertain. (Source: JAMA)
Source: JAMA - August 20, 2019 Category: General Medicine Source Type: research

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(Source: JAMA)
Source: JAMA - August 20, 2019 Category: General Medicine Source Type: research

USPSTF Report: Risk Assessment, Genetic Counseling, and Testing for BRCA- Related Cancer
This systematic review to support the 2019 US Preventive Services Task Force Recommendation Statement on risk assessment, genetic counseling, and genetic testing for BRCA-related cancer summarizes published evidence on the benefits and harms of assessment, counseling, and testing in women without recently diagnosed BRCA1/2-related cancer. (Source: JAMA)
Source: JAMA - August 20, 2019 Category: General Medicine Source Type: research

USPSTF Recommendation: Assessment, Counseling, and Testing for BRCA -Related Cancer
This 2019 Recommendation Statement from the US Preventive Services Task Force recommends that women with a family or personal history associated with increased risk for harmful mutations in the BRCA1/2 genes and with a positive result on a brief familial risk assessment tool should receive genetic counseling and, if indicated, genetic testing (B recommendation) and recommends against routine risk assessment, genetic counseling, or genetic testing for women whose personal or family history is not associated with potentially harmful BRCA1/2 gene mutations (D recommendation). (Source: JAMA)
Source: JAMA - August 20, 2019 Category: General Medicine Source Type: research

Gag Rule May Increase Abortions
Abortion rates in some sub-Saharan African countries increased by 40% when a US policy that pulled federal funding from overseas organizations that performed or discussed abortion was in effect, according to a study in The Lancet Global Health. (Source: JAMA)
Source: JAMA - August 20, 2019 Category: General Medicine Source Type: research

Viruses Drive Children ’s Pneumonia
Respiratory syncytial virus and other viruses have replaced bacteria as the leading cause of severe childhood pneumonia in low- and middle-income countries, according to a study in The Lancet that examined childhood pneumonia in 7 Asian and African countries. (Source: JAMA)
Source: JAMA - August 20, 2019 Category: General Medicine Source Type: research

Fighting Epilepsy Stigma
Greater efforts are needed worldwide to combat stigma and discrimination against patients with epilepsy, according to a World Health Organization report. (Source: JAMA)
Source: JAMA - August 20, 2019 Category: General Medicine Source Type: research

Detecting Circulating Tumor Cells Through the Skin
Today ’s methods of detecting circulating tumor cells (CTCs) in blood are hampered by poor sensitivity, which limits the so-called liquid biopsies’ usefulness for catching low-level CTCs present before metastasis, when prognosis is better. A new photoacoustic liquid biopsy approach that peers through the skin was more sensitive than existing assays in detecting CTCs in patients with melanoma. (Source: JAMA)
Source: JAMA - August 13, 2019 Category: General Medicine Source Type: research

Smart Devices Detect Agonal Breathing in Cardiac Arrest
Roughly half of people who experience a cardiac arrest demonstrate agonal breathing, a brainstem reflex during severe hypoxia. Researchers at the University of Washington in Seattle are teaching smart devices to detect this audible biomarker, often described as gasping breaths. Agonal breathing sounds from Seattle-area 911 cardiac arrest calls were used to train and validate a detection system recently introduced in npj Digital Medicine. (Source: JAMA)
Source: JAMA - August 13, 2019 Category: General Medicine Source Type: research

Meditation App Improves Attention in Young Adults
Healthy young adults had significant improvements in sustained attention on cognitive tasks after using a meditation-inspired mobile app for 6 weeks in a recent randomized clinical trial, which appeared in Nature Human Behavior. (Source: JAMA)
Source: JAMA - August 13, 2019 Category: General Medicine Source Type: research

Gluten and Celiac Disease Risk
Celiac disease provides a unique model for autoimmune research because the following key elements are known: the specific genes involved in its pathogenesis and the environmental trigger. Substantial genetic research has uncovered the strong influence of the HLA antigen and its mechanistic role in presenting deamidated gluten to effector immune cells involved in the pathogenesis of celiac disease. Researchers also have identified more than 57 alleles in addition to HLA genes that confer risk. Although this information is crucial to understanding celiac disease, it cannot explain the substantial increase in the prevalence o...
Source: JAMA - August 13, 2019 Category: General Medicine Source Type: research

Blood Pressure and Dementia
Alzheimer disease and related dementias affect nearly 10% of US adults older than 65 years. With an aging population, the prevalence of dementia is likely to increase, adding to the enormous burden on affected patients, their caregivers, and the health care system. Besides Alzheimer pathology (eg, amyloid and tau protein deposition) in the brain, there is increasing evidence of the contributions of vascular pathology (eg, stroke, subclinical infarct, and ischemic white matter changes) on dementia occurrence. Furthermore, these 2 common pathologies can coexist in individual patients, with evidence that cerebrovascular insul...
Source: JAMA - August 13, 2019 Category: General Medicine Source Type: research

Highlights for August 13, 2019
(Source: JAMA)
Source: JAMA - August 13, 2019 Category: General Medicine Source Type: research

Bringing It Home: The Shift in Where Health Care Is Delivered
Many health care organizations give little more than lip service to becoming “patient-centered.” Perhaps it’s because our legal and regulatory environments preclude true system transformation that focuses on what patients need and want. But laws and regulations are changing, albeit slowly, and we are shifting to value-based payment methodologies that reward improved ou tcomes and lowered costs. (Source: JAMA)
Source: JAMA - August 13, 2019 Category: General Medicine Source Type: research

Gomers
The Dean was a gentle, bearded man, a pipe-smoking neurologist. He loved to sail in the San Juan islands. He was a far-seeing person and was not given to anger. The failures, large and small, of his medical students were duly noted, but the Dean always saw past these failures to the future successes of his embryo physicians. The only times I ever saw the Dean angry was when he heard someone using the term “gomer.” (Source: JAMA)
Source: JAMA - August 13, 2019 Category: General Medicine Source Type: research

Pulmonary Embolism Hospitalization, Readmission, and Mortality Rates in Older Adults
This study uses Medicare billing codes to characterize trends in readmission and mortality rates for Medicare fee-for-service beneficiaries with pulmonary embolism (PE) between 1999 and 2015 to assess changes accompanying recent diagnostic and therapeutic changes in management of the disease. (Source: JAMA)
Source: JAMA - August 13, 2019 Category: General Medicine Source Type: research

Perceived Bullying Among Internal Medicine Residents
This study uses IM-ITE survey data to characterize the proportion of internal medicine residents in 2016 who self-reported having been bullied during their residency training. (Source: JAMA)
Source: JAMA - August 13, 2019 Category: General Medicine Source Type: research

Sex Differences in Grant Funding
To the Editor Dr Oliveira and colleagues compared National Institutes of Health (NIH) grant amounts to first-time male and female principal investigators (PIs). The authors suggested that their data indicate that there are “[f]unding disparities favoring men” among certain grant types. However, their data may be misleading because the authors presented only the numerator data, ie, the size of the grant award. Missing is the denominator, ie, the dollar amount the investigators actually requested—the “unknown de nominator problem.” Perhaps women actually requested smaller awards. Therefore, comp...
Source: JAMA - August 13, 2019 Category: General Medicine Source Type: research

Sex Differences in Grant Funding
To the Editor A recent study described sex differences in the amount of NIH funds awarded to comparable first-time male and female PIs. Concerns have been raised previously about sex differences in grant attainment, compensation, and well-being of physician-scientists funded by the NIH. Numerous mechanisms underlying these differences have been described, including unconscious biases and sex differences in negotiation behaviors. (Source: JAMA)
Source: JAMA - August 13, 2019 Category: General Medicine Source Type: research

Time Horizons in Cost Analyses
To the Editor Drs Basu and Maciejewski discussed time horizons in economic models, which should be long enough to capture all potential differences in outcomes associated with the treatments compared. For therapies extending survival over the entire life span, a lifetime horizon is recommended. However, survival trajectories among patient subgroups may vary and can influence survival in a nonlinear fashion. In these situations, using average survival gains to estimate a time horizon can be misleading and may result in the use of a time horizon that is shorter than the expected survival in certain subgroups. We illustrate t...
Source: JAMA - August 13, 2019 Category: General Medicine Source Type: research

Strategies to Adjust Positive End-Expiratory Pressure in Patients With ARDS
To the Editor No benefit in death or days free from mechanical ventilation were reported with PES-guided PEEP titration vs an empirical high PEEP-Fio2 strategy in patients with moderate to severe ARDS. What was the racial/ethnic composition of the patients included in the 2 groups of the study, as significant racial/ethnic and sex differences in ARDS mortality exist in the United States? Also, significantly more men were in the PES-guided PEEP group than in the empirical high PEEP-Fio2 group (P  = .01). (Source: JAMA)
Source: JAMA - August 13, 2019 Category: General Medicine Source Type: research

Strategies to Adjust Positive End-Expiratory Pressure in Patients With ARDS
To the Editor Dr Beitler and colleagues for the EPVent-2 Study Group conducted a randomized clinical trial of titrating positive end-expiratory pressure (PEEP) according to end-expiratory pleural pressure estimated from esophageal pressure (PES) in patients with acute respiratory distress syndrome (ARDS). The PES approach studied was compelling as a means of individualizing PEEP according to chest wall mechanics. While the results are disappointing, we argue that they are not altogether surprising. (Source: JAMA)
Source: JAMA - August 13, 2019 Category: General Medicine Source Type: research

Strategies to Adjust Positive End-Expiratory Pressure in Patients With ARDS
To the Editor In the EPVent-2 study of patients with ARDS, PEEP in the PES-guided group was titrated based on the assumption that end-expiratory PES is directly representative of pleural pressure and that positive end-expiratory PES with concomitant negative PL indicates that the chest wall causes collapse of alveoli at end expiration. To prevent this assumed collapse, PEEP was increased until PL was zero or above according to an empirical PL  − Fio2 table. The level of end-expiratory PES is thus a measure of the assumed negative effect of the chest wall on the lung. During the first week, there was an ...
Source: JAMA - August 13, 2019 Category: General Medicine Source Type: research

Sex Differences in Grant Funding —Reply
In Reply Using public data, we found that first-time female PIs received significantly smaller median NIH grant awards than their male counterparts. The median difference was $39  106, with a range by grant type and institution. There were no statistically significant differences in research breadth, productivity, or the number of citations between men and women prior to the grant. (Source: JAMA)
Source: JAMA - August 13, 2019 Category: General Medicine Source Type: research

Time Horizons in Cost Analyses —Reply
In Reply Dr Majer and colleagues point out the need to encompass heterogeneity of time horizons. We did not cover the topic of heterogeneity in our article, nor did we intend to say that all cohorts, for instance those with different starting ages, should have the same time horizon in a cost-effectiveness analysis. We had specifically pointed out that the appropriate time horizon should extend to cover all relevant benefits and harms of the interventions being evaluated. (Source: JAMA)
Source: JAMA - August 13, 2019 Category: General Medicine Source Type: research

Strategies to Adjust Positive End-Expiratory Pressure in Patients With ARDS —Reply
In Reply Using esophageal manometry to estimate pleural pressure helps delineate contribution of lung vs chest wall mechanics to clinically observed airway pressures. Transpulmonary pressure provides a truer estimate of distension of aerated lung parenchyma (ie, stress of the ventilated lung regions) than airway pressures alone. In preclinical ARDS models, injury ascribed to atelectrauma can occur from high shear forces generated during repetitive tidal reopening of fluid-filled or collapsed small airways. Drs Sklar and Goligher argue that chest wall mechanics are of negligible relevance to lung recruitability and individu...
Source: JAMA - August 13, 2019 Category: General Medicine Source Type: research

Long-term Exposure to Ambient Air Pollution and Change in Emphysema and Lung Function
This cohort study examines the association between long-term exposure to ambient ozone, black carbon, and other air pollutants and progression of CT-defined percent emphysema and decline in lung function in adults in 6 US metropolitan regions. (Source: JAMA)
Source: JAMA - August 13, 2019 Category: General Medicine Source Type: research

Gluten Intake in First 5 Years and Incidence of Celiac Disease and Autoimmunity in At-Risk Children
This cohort study investigates the association between gluten intake in the first 5 years of life and celiac disease autoimmunity and biopsy-confirmed celiac disease in genetically at-risk children over a median 9-year follow-up. (Source: JAMA)
Source: JAMA - August 13, 2019 Category: General Medicine Source Type: research

Association Between Intensive vs Standard Blood Pressure Control and Cerebral White Matter Lesions
This substudy of the SPRINT randomized clinical trial evaluates the association between intensive (systolic blood pressure
Source: JAMA - August 13, 2019 Category: General Medicine Source Type: research

Association of Midlife to Late-Life Blood Pressure Patterns With Incident Dementia
Over 24 years plus follow-up, this community-based cohort study monitored individuals categorized by midlife and late-life blood pressure levels to evaluate association between blood pressure levels and incident dementia. (Source: JAMA)
Source: JAMA - August 13, 2019 Category: General Medicine Source Type: research

Small Kidney Tumors
This JAMA Patient Page describes small kidney tumor diagnoses and treatment options. (Source: JAMA)
Source: JAMA - August 13, 2019 Category: General Medicine Source Type: research

Neither Pause nor Gaze at What Is Passing
For weeks, she said little, hummed moans in sweet chords, pale florets blooming on cheeks, chest, breasts. (Source: JAMA)
Source: JAMA - August 13, 2019 Category: General Medicine Source Type: research

Supporting the Delicate Infant-Mother Bond
In this narrative medicine essay, a pediatrician realizes after her infant daughter undergoes treatment for elevated bilirubin that until then her advice to new parents may have interfered with the infant-mother bond yet forgives herself the distress she may have caused. (Source: JAMA)
Source: JAMA - August 13, 2019 Category: General Medicine Source Type: research

Extracorporeal Life Support for Adults With Respiratory Failure and Related Indications
This narrative review summarizes the mechanisms and set-up of extracorporeal life support (ECLS) including extracorporeal membrane oxygenation (ECMO) and extracorporeal carbon dioxide removal (ECCO2R), its indications, complications, goals of treatment, and the need to build on evidence base for the intervention so it is used nationally and in a standardized fashion. (Source: JAMA)
Source: JAMA - August 13, 2019 Category: General Medicine Source Type: research

Jama
(Source: JAMA)
Source: JAMA - August 13, 2019 Category: General Medicine Source Type: research

Tuberculin Antigen Shortage
The CDC recently warned clinicians of a potential 3- to 10- month shortage of Aplisol (tuberculin PPD), 1 of 2 tuberculin antigens approved by the US Food and Drug Administration for tuberculosis skin tests. (Source: JAMA)
Source: JAMA - August 13, 2019 Category: General Medicine Source Type: research