About Foot Wear
“How beautiful are thy feet, with shoes, O! Prince’s daughter,” says the Song of Solomon, and it must be confessed as a fact true of our time that modern feet must be hidden by shoes to give an approach in appearance to a perfect classic standard. Toes twisted out of shape, thick projections a t points of contact, clubbed nails, corns in various uncanny situations, and bunions on the joints, make the actual foot so far from being a thing of beauty that it is only to be viewed in private and then by the chiropodist. (Source: JAMA)
Source: JAMA - July 16, 2019 Category: General Medicine Source Type: research

Price Increases of Protected Class Drugs in Medicare Part D Relative to Inflation, 2012-2017
This study characterizes price increases exceeding inflation between 2012 and 2017 for protected-class drugs (antineoplastics, antiretrovirals, antidepressants, antipsychotics, anticonvulsants, and immunosuppressants for transplant patients) that would lead to their exclusion from Medicare Part D coverage based on excessive cost under a 2018 CMS rule intended to facilitate more effective price negotiations. (Source: JAMA)
Source: JAMA - July 16, 2019 Category: General Medicine Source Type: research

Association Between Hurricane Declarations and Survival of Patients With Lung Cancer Undergoing Radiation
This study uses National Cancer Database data to estimate associations between hurricane disaster declarations, which could disrupt electrical power, and survival of patients undergoing radiotherapy for nonoperative locally advanced non –small cell lung cancer between 2004 and 2014. (Source: JAMA)
Source: JAMA - July 16, 2019 Category: General Medicine Source Type: research

Intravenous Acetaminophen for Postoperative Delirium
To the Editor The DEXACET trial found a decreased incidence of postoperative delirium in older patients after cardiac surgery who received intravenous (IV) acetaminophen vs placebo combined with propofol or dexmedetomidine. Dr Subramaniam and colleagues suggested that the difference in the primary outcome, incidence of delirium, may have been driven in part by reduction in opioid consumption in the acetaminophen group compared with the placebo group. The reduction in opioid requirements must therefore be carefully examined. (Source: JAMA)
Source: JAMA - July 16, 2019 Category: General Medicine Source Type: research

Cannabis as a Substitute for Opioids
To the Editor In their critique of the availability of medical marijuana for patients suffering from chronic pain or struggling with opioid use disorder, Drs Humphreys and Saitz omitted important facts about the New York State Medical Marijuana Program, the limited availability of medication for addiction treatment (also known as medication-assisted treatment), and why clinical research on marijuana is so sparse. (Source: JAMA)
Source: JAMA - July 16, 2019 Category: General Medicine Source Type: research

Outcomes Associated With Overlapping Surgery
To the Editor In their study of overlapping surgery, Dr Sun and colleagues concluded that “among adults undergoing common operations, overlapping surgery was not significantly associated with differences in in-hospital mortality or postoperative complication rates but was significantly associated with increased surgery length.” However, their reported intraoperative times are consist ently longer than empirical data, and the conclusions they draw do not seem warranted by their data. (Source: JAMA)
Source: JAMA - July 16, 2019 Category: General Medicine Source Type: research

Outcomes Associated With Overlapping Surgery
To the Editor Dr Sun and colleagues performed a large database analysis of 66  430 overlapping surgical procedures. However, the challenges of large database studies include insufficiently granular data that may affect interpretation of the results. (Source: JAMA)
Source: JAMA - July 16, 2019 Category: General Medicine Source Type: research

Intravenous Acetaminophen for Postoperative Delirium —Reply
In Reply We agree with Dr Wanek that the fentanyl conversion factor for morphine equivalents was incorrect. A conversion factor of 2.4 was used per current recommendations for conversion of fentanyl transdermal patch dosage in micrograms per hour to morphine equivalents in milligrams per day. Cardiac surgical patients in this trial received IV fentanyl; therefore, the correct conversion factor for fentanyl in an opioid-naive patient is 100 (ie, 100 µg of fentanyl = 10 mg of morphine). We recalculated additional postoperative analgesic requirements as the sum of (fentanyl dose × 100) + (hydromorpho...
Source: JAMA - July 16, 2019 Category: General Medicine Source Type: research

Cannabis as a Substitute for Opioids —Reply
In Reply Dr Gonzalez and colleagues provide detail regarding the New York State Medical Marijuana Program, noting that dispensaries overseen by pharmacists sell regulated products and that certifying practitioners must consult a prescription monitoring program. Some regulation of putatively medical cannabis is clearly better than none, but the New York standards are well below those set for the practice of medicine generally, in which preferred prescribed medications have clinical trial –derived evidence of efficacy and safety in specific doses for specific conditions. (Source: JAMA)
Source: JAMA - July 16, 2019 Category: General Medicine Source Type: research

Outcomes Associated With Overlapping Surgery —Reply
In Reply Drs Urwin and Emanuel raise 2 concerns with our study on overlapping surgery. First, they note that the reported surgical times may not be representative, as the mean surgical times in the study are longer than times from other sources. These differences may stem from the fact that the institutions in our study were largely tertiary academic referral centers, where cases may take longer because of increased complexity and the presence of trainees. In this sense, our study may not be representative, as it did not include many relevant settings (ie, practice in community hospitals), but the magnitude of difference b...
Source: JAMA - July 16, 2019 Category: General Medicine Source Type: research

Endovascular Reperfusion Therapy and Acute Ischemic Stroke Outcomes
This cohort study uses data from the Get With the Guidelines-Stroke registry to report associations between time to treatment and functional outcomes among patients in clinical practice with acute ischemic stroke treated with endovascular recanalization. (Source: JAMA)
Source: JAMA - July 16, 2019 Category: General Medicine Source Type: research

Effect of Flexible Family Visitation on Delirium Among Patients in the Intensive Care Unit
This cluster-crossover randomized clinical trial compares the effects of a flexible visitation policy (up to 12 hours per day) vs a standard visitation policy (up to 4.5 hours per day) on delirium incidence among ICU patients. (Source: JAMA)
Source: JAMA - July 16, 2019 Category: General Medicine Source Type: research

Association Between State-Mandated Protocolized Sepsis Care and In-hospital Adult Sepsis Mortality
This cohort study uses hospital discharge data to compare 30-day in-hospital mortality of patients with sepsis in New York State before vs after implementation of regulations mandating rapid administration of antibiotics and fluid resuscitation and compares those data with mortality in 4 comparison states (Florida, Maryland, Massachusetts, and New Jersey) without such a mandate. (Source: JAMA)
Source: JAMA - July 16, 2019 Category: General Medicine Source Type: research

Effect of an ICU Diary on PTSD Symptoms Among Patients Receiving Mechanical Ventilation
This randomized clinical trial compared the effects of a diary filled out by clinicians and family members during an intensive care unit (ICU) stay to ground their memory of events after discharge vs usual care on symptoms of posttraumatic stress disorder, anxiety, and depression in patients and family members after discharge. (Source: JAMA)
Source: JAMA - July 16, 2019 Category: General Medicine Source Type: research

Steroid Side Effects
This JAMA Patient Page describes use of steroid medications and the side effects that can result. (Source: JAMA)
Source: JAMA - July 16, 2019 Category: General Medicine Source Type: research

Jacqui ’s Comet
The steadfast stars I expected to navigate this new course all scroll their screens instead, (Source: JAMA)
Source: JAMA - July 16, 2019 Category: General Medicine Source Type: research

What ’s in a Name or Title?
In this narrative medicine essay, an associate director of an internal medicine residency program describes when a student addressed her in an email by her first name but at the same time the student addressed a male colleague as “Doctor” and explains how she decided to handle the discrepancy. (Source: JAMA)
Source: JAMA - July 16, 2019 Category: General Medicine Source Type: research

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(Source: JAMA)
Source: JAMA - July 16, 2019 Category: General Medicine Source Type: research

Containing Nipah Virus Infection
Isolating adults with respiratory symptoms resulting from Nipah virus infection may help stem the spread of the virus, a New England Journal of Medicinestudy suggests. (Source: JAMA)
Source: JAMA - July 16, 2019 Category: General Medicine Source Type: research

Growing Global Alcohol Use
Increasing alcohol use worldwide threatens to derail the World Health Organization ’s (WHO’s) goal of cutting alcohol use by 10% by 2025, according to a study in The Lancet. (Source: JAMA)
Source: JAMA - July 16, 2019 Category: General Medicine Source Type: research

Reducing Cervical Cancer Deaths
A combination of increased cervical cancer screening, better coverage with the human papillomavirus (HPV) vaccine, and better access to radiotherapy will be needed to cut global cervical cancer incidence and deaths, according to a pair of studies in The Lancet Oncology. (Source: JAMA)
Source: JAMA - July 16, 2019 Category: General Medicine Source Type: research

Biomarker Test for Myalgic Encephalomyelitis/Chronic Fatigue Syndrome
Myalgic encephalomyelitis/chronic fatigue syndrome affects at least 2 million people in the United States. Despite its prevalence, there ’s no laboratory test for the disease, and its diagnosis is based on symptoms like exhaustion, unrefreshing sleep, and light sensitivity. For patients with this debilitating condition, getting a diagnosis is often a long and expensive process. Now, a long-awaited biomarker-based test for the myste rious disease could be on the horizon. (Source: JAMA)
Source: JAMA - July 9, 2019 Category: General Medicine Source Type: research

Patient Receives First Genetically Engineered Phage Treatment
A pediatric patient with cystic fibrosis and a double-lung transplant received a genetically engineered 3-phage cocktail to treat a life-threatening antibiotic-resistant Mycobacterium abscessus infection for which all standard therapeutic options had been exhausted. Over 7 months of twice-daily intravenous infusions, as well as daily topical phage therapy, the 15-year-old patient ’s surgical wound and skin lesions healed gradually and her lung and liver function improved. No adverse reactions to the treatment were reported. (Source: JAMA)
Source: JAMA - July 9, 2019 Category: General Medicine Source Type: research

Smartphone-Based Detection of Middle Ear Fluid
Researchers are developing a way for both physicians and parents to detect and monitor middle ear fluid in children with nothing more than a smartphone and a piece of paper. In a proof-of-concept study published in Science Translational Medicine, clinicians used the new smartphone-based system to detect middle ear fluid in 98 pediatric ears with 85% sensitivity and 82% specificity, accuracy comparable with pneumatic otoscopy and tympanometry, the recommended techniques. Parents using the system classified 25 out of 26 ears as accurately as clinicians using the system. (Source: JAMA)
Source: JAMA - July 9, 2019 Category: General Medicine Source Type: research

Misalignment in Table and Typographical Errors in Text and Figure
This article was corrected online. (Source: JAMA)
Source: JAMA - July 9, 2019 Category: General Medicine Source Type: research

Omitted Conflict of Interest Disclosures
This article was corrected online. (Source: JAMA)
Source: JAMA - July 9, 2019 Category: General Medicine Source Type: research

Peroral Endoscopic Myotomy (POEM) vs Pneumatic Dilation
Achalasia is a rare esophageal motor disorder, with a prevalence of approximately 10 cases per 100  000 adults, and is characterized by progressive degeneration of ganglion cells in the myenteric plexus of the esophagus that leads to insufficient swallow-induced relaxation of the lower esophageal sphincter (LES) and absence of peristalsis along the esophageal body. Consequently, the passage of food from the esophagus to the stomach is impaired and results in symptoms of solid and liquid food dysphagia, regurgitation, chest pain, pulmonary complications, and weight loss. (Source: JAMA)
Source: JAMA - July 9, 2019 Category: General Medicine Source Type: research

Highlights for July 9, 2019
(Source: JAMA)
Source: JAMA - July 9, 2019 Category: General Medicine Source Type: research

Heritable Genome Editing: Is a Moratorium Needed?
(Source: JAMA)
Source: JAMA - July 9, 2019 Category: General Medicine Source Type: research

Risk, Benefit, and Fairness in a Big Data World
There is much hope and even more hype that research using big data derived from a large volume of electronic health records, in combination with claims and a variety of health-related sources, can improve the access to, quality of, and cost of health care. The ability of computers to learn from large databases to the point that they can outperform clinicians could result in lower health care costs and improve access and quality. But patients could foil these efforts by refusing to share their data for research if they perceive more harms than benefits. (Source: JAMA)
Source: JAMA - July 9, 2019 Category: General Medicine Source Type: research

Current Comment
(Source: JAMA)
Source: JAMA - July 9, 2019 Category: General Medicine Source Type: research

Association Between FDA Buprenorphine Labeling Change to Improve Access and Medicare Part D Prior Authorization Requirement
This study describes changes in the proportion of Medicare Part D plans requiring prior authorization for buprenorphine products before and after a 2017 FDA rquirement that the drug ’s label emphasize the importance of drug treatment of opioid use disorder. (Source: JAMA)
Source: JAMA - July 9, 2019 Category: General Medicine Source Type: research

Analysis of Long-term Benefits of Intensive Blood Pressure Control
To the Editor The SPRINT MIND Investigators assessed whether intensive blood pressure control would reduce risk of probable dementia compared with standard blood pressure control. There were 149 probable dementia events among 4678 participants in the intensive treatment group and 176 events among 4683 participants in the standard treatment group. The hazard ratio was 0.83 (95% CI, 0.67-1.04; P  = .10). Based primarily on the hazard ratio analysis, the authors concluded that intensive blood pressure control did not significantly reduce risk of probable dementia. However, valid hazard ratio analysis requires th...
Source: JAMA - July 9, 2019 Category: General Medicine Source Type: research

Limiting Opioid Prescribing
To the Editor The Viewpoint by Dr Chua and colleagues discussed opioid prescribing limits for treatment of acute pain. I agree that uniform limits based on 5- or 7-day supplies are problematic. For a 5-day supply, up to 60 pills can be prescribed. However, a previous study reported that opioid consumption during the first 2 weeks after an emergency department visit for acute pain was a median of seven 5-mg morphine pills (or equivalent). To adequately supply 80% of patients, the study estimated that 30 pills would be sufficient for patients with fractures, 15 for those with renal colic, and 20 for those with other conditio...
Source: JAMA - July 9, 2019 Category: General Medicine Source Type: research

Resuscitation Strategies Using Peripheral Perfusion vs Serum Lactate Levels
To the Editor Dr Hern ández and colleagues conducted a randomized clinical trial (RCT) comparing sepsis resuscitation strategies targeting capillary refill time (CRT) vs lactate clearance. Studies that gauge peripheral perfusion using easy, reproducible, and resource-independent bedside methods are needed. However, we h ave some concerns about the study. (Source: JAMA)
Source: JAMA - July 9, 2019 Category: General Medicine Source Type: research

Resuscitation Strategies Using Peripheral Perfusion vs Serum Lactate Levels
In this study, the difference between 28-day mortality in the CRT group (34.9%) and the lactate group (43.4%) was −8.5%, with a 95% CI ranging from −18.2% to 1.2%. Because the lower bound of the CI includes the 15% difference for a clinically meaningful effect used for sample size calculation, the trial should be interpreted as inconclusive regarding the superiority of CRT-guided resuscitation but as ruling out superiority of lactate-guided resuscitation. (Source: JAMA)
Source: JAMA - July 9, 2019 Category: General Medicine Source Type: research

Analysis of Long-term Benefits of Intensive Blood Pressure Control —Reply
In Reply Mr McCaw and colleagues point out the potential utility of alternative approaches to analysis of survival data when the intervention effect may vary over time, as appears to be the case for the outcome of probable dementia in SPRINT. The proportional hazards model is known to be robust to certain departures from the assumption of constant proportionality, and when our analysis was prespecified in 2010, we did not expect to observe an increasing separation of the incidence curves late in the follow-up period. We were careful to note the increasing difference in our report of results from our prespecified analysis. (Source: JAMA)
Source: JAMA - July 9, 2019 Category: General Medicine Source Type: research

Limiting Opioid Prescribing —Reply
In Reply We agree with Dr Daoust that individualized opioid prescribing and co-analgesic prescribing should be considered. We also agree that preventing excessive opioid prescribing for acute pain is important to reduce misuse of unused opioids. In our Viewpoint, we questioned whether policy limits are the optimal mechanism to achieve this goal. On the one hand, even the most stringent 3-day limits still allow for prescribing that is higher than the amount consumed by the average patient with acute pain. For example, as we noted in our Viewpoint, median opioid consumption in a study of Michigan patients undergoing 1 of 12 ...
Source: JAMA - July 9, 2019 Category: General Medicine Source Type: research

Resuscitation Strategies Using Peripheral Perfusion vs Serum Lactate Levels —Reply
In Reply We agree with Drs Patel and Bergl that many studies of septic shock have overestimated control group mortality and effect size. However, in the ANDROMEDA-SHOCK trial, the delta for mortality in the control group was only 1.6% (expected 45% minus actual 43.4%). This is lower than reported in other studies. The problem with our study was overestimation of the effect size: 15% anticipated vs 8% actual. We based our effect size on studies that have reported on early resuscitation and high mortality in patients with persistently abnormal peripheral perfusion after initial resuscitation, given the limitations of lactate...
Source: JAMA - July 9, 2019 Category: General Medicine Source Type: research

Peroral Endoscopic Myotomy vs Pneumatic Dilation for Treatment-Naive Patients With Achalasia
This randomized clinical trial compares the effects on symptoms and recurrence of peroral endoscopic myotomy (POEM) vs pneumatic dilation for the initial treatment of idiopathic achalasia. (Source: JAMA)
Source: JAMA - July 9, 2019 Category: General Medicine Source Type: research

Effect of Recombinant Zoster Vaccine on Herpes Zoster After Autologous Stem Cell Transplantation
This randomized trial compares the effects of 2 doses of nonlive adjuvanted recombinant zoster vaccine vs placebo on incidence of herpes zoster in adults who had undergone autologous hematopoietic stem cell transplantation. (Source: JAMA)
Source: JAMA - July 9, 2019 Category: General Medicine Source Type: research

Subclinical Hypothyroidism
This JAMA Patient Page describes subclinical hypothyroidism and its causes, symptoms, and treatment. (Source: JAMA)
Source: JAMA - July 9, 2019 Category: General Medicine Source Type: research

Triptych
At seven weeks you are little more than a heartbeat four weeks four chambers is the mnemonic I ’ve stored away along with an image of a tube twisting upon itself like a pair of jeans in the wash when you leave us in the middle of the day forgive me— it feels like losing something I didn’t know I had. That night, we wrap ourselves tightly in sarcasm ibuprofen& booze knowing that of course you ’ll be back. (Source: JAMA)
Source: JAMA - July 9, 2019 Category: General Medicine Source Type: research

The Sound of Silence —When There Are No Words
In this narrative medicine essay, a surgeon and palliative care physician describes the isolating silence that she felt her after the slaying of her father in Egypt when she was 18 years old and how that lingering silence has come to guide her when sitting with patients, when there are no words. (Source: JAMA)
Source: JAMA - July 9, 2019 Category: General Medicine Source Type: research

Subclinical Hypothyroidism —A Review
This narrative review summarizes causes of subclinical hyperthyroidism, reviews controversies related to its clinical significance as a risk factor for heart failure, ischemic heart disease, and dementia, and discusses management considerations, including indications for observation vs thyroid hormone supplementation. (Source: JAMA)
Source: JAMA - July 9, 2019 Category: General Medicine Source Type: research

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(Source: JAMA)
Source: JAMA - July 9, 2019 Category: General Medicine Source Type: research

Diabetes Incidence Decreases
The number of people newly diagnosed with diabetes decreased substantially between 2009 and 2017, while the number of people living with the disease in the United States has leveled off, according to a study by CDC scientists published in British Medical Journals Open Diabetes Care and Research. (Source: JAMA)
Source: JAMA - July 9, 2019 Category: General Medicine Source Type: research

Medical Tourism –Linked Infections
Twelve US patients have been diagnosed with Verona integron-encoded metallo- β-lactamase–producing carbapenem-resistant Pseudomonas aeruginosa (VIM-CRPA), after undergoing invasive medical procedures in Mexico, according to a CDC report. (Source: JAMA)
Source: JAMA - July 9, 2019 Category: General Medicine Source Type: research

Three Identical Strangers and The Twinning Reaction
This Arts and Medicine feature reviews Three Identical Strangers and The Twinning Reaction, 2 documentaries telling the story of identical twins and triplets adopted as infants into separate families who were unknowing participants in a 2-decade nature vs nurture study of child development, beginning in 1960. (Source: JAMA)
Source: JAMA - July 2, 2019 Category: General Medicine Source Type: research

For Alzheimer Pathology, Light and Sound Stimulation May Hold Promise
A combination of visual and auditory stimulation reduced brain amyloid- β peptide (Aβ) and improved memory in mouse models of Alzheimer disease (AD), according to recent preclinical research. (Source: JAMA)
Source: JAMA - July 2, 2019 Category: General Medicine Source Type: research