Data Errors
This article was corrected online. (Source: JAMA)
Source: JAMA - July 2, 2019 Category: General Medicine Source Type: research

Tanezumab for Painful Osteoarthritis
Osteoarthritis (OA) is a painful, disabling condition that arises from damage to cartilage, synovium, subchondral bone, and other joint structures. An estimated 300 million people worldwide have OA, including 30 million individuals in the United States, of whom more than 14 million have symptomatic, radiographically documented knee OA. Despite the enormous prevalence, cost, and disability associated with OA, no treatments are available to slow or reverse the inexorable destruction of joint structures that underlie the pain and disability of OA (although several agents are in various stages of evaluation, including strontiu...
Source: JAMA - July 2, 2019 Category: General Medicine Source Type: research

Outbreaks of Vaccine-Preventable Diseases
Outbreaks of vaccine-preventable diseases indicate failures in health care and public health systems. One type of failure occurs when a vaccine offers insufficient protection, for instance during an influenza season when the predominant circulating strain is unrelated to antigens included in the flu vaccine for that year. Another type of failure occurs when a safe and effective vaccine is available in wealthier nations, but is not accessible to eligible patients in less wealthy nations because it is prohibitively expensive. A third type of failure occurs when parents choose not to immunize their eligible children with reco...
Source: JAMA - July 2, 2019 Category: General Medicine Source Type: research

Can Alternative Payment Models Save Primary Care?
The concept of “primary care” became widely accepted in the 1960s as part of a broader acknowledgment that as medical care migrated from the once-dominant setting of the home to offices and hospitals, a surge of programs that promoted the value of general medical care was needed to help the generalist whose ro le was both economically and politically marginalized by specialties with higher compensation and stronger presence within academic departments. Medicare was introduced in 1965, the same year several reports were published by the Association of American Medical Colleges and the American Medical Asso ciati...
Source: JAMA - July 2, 2019 Category: General Medicine Source Type: research

Test Detects Prosthetic Joint Infection in Synovial Fluid
A recently cleared diagnostic test will help physicians determine whether patients with a prosthetic joint have an infection that requires revision surgery. (Source: JAMA)
Source: JAMA - July 2, 2019 Category: General Medicine Source Type: research

First PI3K Inhibitor for Breast Cancer
Alpelisib has received FDA approval for postmenopausal women, and men, with advanced or metastatic breast cancer whose tumors have a mutation in the PIK3CA gene. The drug is indicated for use in combination with the antiestrogen medication fulvestrant to treat hormone receptor (HR) –positive, human epidermal growth factor receptor 2 (ERBB2)–negative tumors after endocrine-based therapy. (Source: JAMA)
Source: JAMA - July 2, 2019 Category: General Medicine Source Type: research

Another Stem Cell Company Is Put On Notice
The FDA has notified another company —the 46th this year—that the unapproved stem cell products it sells for a number of illnesses likely are subject to regulation under the Federal Food, Drug, and Cosmetic Act and the Public Health Service Act. (Source: JAMA)
Source: JAMA - July 2, 2019 Category: General Medicine Source Type: research

Highlights for July 2, 2019
(Source: JAMA)
Source: JAMA - July 2, 2019 Category: General Medicine Source Type: research

Medicare For All or Medicare For More?
Many Democratic presidential candidates are voicing support for “Medicare for all,” a national health plan that would cover all US residents. At the same time, other candidates support proposals that sound like Medicare for all but are actually quite different and more incremental. And, just to make things even more confusing, a number of the candidates are on the record for supporting multiple proposals. (Source: JAMA)
Source: JAMA - July 2, 2019 Category: General Medicine Source Type: research

Physical Exercise and Physiologic Fitness
Enthusiasm for an end or object that is unquestionably good sometimes defeats its own purpose by encouraging extremes of performance which damage rather than improve. This has doubtless often been true of athletics. Pursued ostensibly to promote personal welfare, physical exercise is not infrequently carried to a point of overdoing which results in ultimate injury rather than benefit. (Source: JAMA)
Source: JAMA - July 2, 2019 Category: General Medicine Source Type: research

Survival of Patients With Liver Transplants Donated After Euthanasia vs Circulatory Death or Brain Death
This study compares graft and patient survival rates after transplantation of livers donated after euthanasia vs after circulatory death or brain death at a hospital in Belgium, where euthanasia is legalized. (Source: JAMA)
Source: JAMA - July 2, 2019 Category: General Medicine Source Type: research

Random-Effects Assumption in Meta-analyses
To the Editor Repeated clinical trials on a single medical intervention are never exact replications because patients differ and there are usually some variations in the intervention and outcome measurements. Such variations can lead to inconsistent results between studies on the same intervention. (Source: JAMA)
Source: JAMA - July 2, 2019 Category: General Medicine Source Type: research

Random-Effects Assumption in Meta-analyses
To the Editor In the context of meta-analysis of clinical trials, Drs Serghiou and Goodman outlined the differences between random-effects and fixed-effect models. They concluded that a random-effects approach is generally preferred, but others will conclude the opposite. Random-effects meta-analysis has several fundamental problems. (Source: JAMA)
Source: JAMA - July 2, 2019 Category: General Medicine Source Type: research

Glucose Control in the Perioperative Period
To the Editor Drs Simha and Shah provided a Clinical Update on perioperative glucose control in patients with diabetes undergoing elective surgery. They stated that “limited evidence suggests that good glucose control is likely to be beneficial in reducing postoperative mortality, length of hospital stay, and cardiovascular complications such as stroke.” In support, they cited a Cochrane Review. (Source: JAMA)
Source: JAMA - July 2, 2019 Category: General Medicine Source Type: research

Treat-to-Target Strategies in Rheumatoid Arthritis
To the Editor Treat-to-target strategies using disease activity scores are the cornerstone of rheumatoid arthritis (RA) treatment. Dr M øller-Bisgaard and colleagues compared a conventional treat-to-target strategy with a strategy that also incorporated absence of inflammation on magnetic resonance imaging (MRI). The MRI-guided treat-to-target strategy resulted in similar remission rates and percentages of patients without radiogra phic progression. However, in an exploratory analysis, 46% of the MRI-guided group had used biologics compared with 2% in the conventional strategy group. (Source: JAMA)
Source: JAMA - July 2, 2019 Category: General Medicine Source Type: research

Random-Effects Assumption in Meta-analyses —Reply
In Reply Our JAMA Guide to Statistics and Methods article was designed simply as a guide to understanding published meta-analyses using random-effects models, and both its purpose and word limits prevented a full discussion of all relevant dimensions. We tried to indicate that random-effects models should not be used to paper over highly heterogeneous effects, as reflected with the word caveats in the title and the statement in the text that “the estimated average effect can be nonsensical if the true individual study effects are too variable.” (Source: JAMA)
Source: JAMA - July 2, 2019 Category: General Medicine Source Type: research

Glucose Control in the Perioperative Period —Reply
In Reply In response to Dr Finucane ’s query about our presentation on the risks and benefits of intensive glucose control, we would like to point out that we do not advocate intensive glucose control in the perioperative period. We have, in fact, alluded to studies showing the potential harm of intensive glucose control in the intr aoperative period, and throughout the Clinical Update, we advocated for a target blood glucose of less than 180 mg/dL and avoidance of hypoglycemia. Our comment that “good” (not intensive) glucose control is likely to be beneficial was based on a meta-analysis by Sathya et al,...
Source: JAMA - July 2, 2019 Category: General Medicine Source Type: research

Treat-to-Target Strategies in Rheumatoid Arthritis —Reply
In Reply Dr van der Helm-van Mil and colleagues propose that the results of the IMAGINE-RA trial could have been more favorable to the MRI treat-to-target strategy if the MRI target had been chosen differently; eg, by incorporating tenosynovitis or synovitis or by choosing a different bone marrow edema cut-off level. We agree and acknowledged this in the article, stating “the 2-group study design did not allow investigators to test other potential MRI treatment targets.” (Source: JAMA)
Source: JAMA - July 2, 2019 Category: General Medicine Source Type: research

Brexanolone (Zulresso) for Postpartum Depression
This Medical Letter reviews use of brexanolone, an intravenous γ-aminobutyric acid type A receptor modulator, approved by the US Food and Drug Administration for treatment of postpartum depression. (Source: JAMA)
Source: JAMA - July 2, 2019 Category: General Medicine Source Type: research

Associations Between State Interventions and Vaccination Status Among Kindergartners in California
This observational study uses yearly cross-sectional school-entry data to calculate changes in rates of kindergartners attending California schools who were not up to date on required vaccinations before and after legislative and administrative initiatives in 2014-2017 intended to increase vaccine uptake. (Source: JAMA)
Source: JAMA - July 2, 2019 Category: General Medicine Source Type: research

Effect of Tanezumab on Joint Pain, Physical Function, and Patient Global Assessment of Osteoarthritis
This randomized clinical trial assesses 2 subcutaneous tanezumab dosing regimens vs placebo for osteoarthritis of the hip or knee. (Source: JAMA)
Source: JAMA - July 2, 2019 Category: General Medicine Source Type: research

Implementation of Population-Based Primary Care Payment and Health Care Quality Measures in Hawaii
This observational study uses Blue Cross Blue Shield claims and clinical registry data to evaluate whether payment reform that provided quality bonuses and a global budget shared savings incentive was associated with changes in health care quality measures, utilization, or spending in the first year of system implementation. (Source: JAMA)
Source: JAMA - July 2, 2019 Category: General Medicine Source Type: research

Home Intravenous Antibiotic Therapy
This JAMA Patient Page describes the utility of and procedures for administering intravenous antibiotics at home. (Source: JAMA)
Source: JAMA - July 2, 2019 Category: General Medicine Source Type: research

Pitting
(Source: JAMA)
Source: JAMA - July 2, 2019 Category: General Medicine Source Type: research

An Unexpected Asset
In this narrative medicine essay, a pediatrician diagnosed with breast cancer draws from her experiences as a medical trainee to help her endure the fear, anxiety, and uncertainty accompanying her disease while pregnant with her second child. (Source: JAMA)
Source: JAMA - July 2, 2019 Category: General Medicine Source Type: research

Jama
(Source: JAMA)
Source: JAMA - July 2, 2019 Category: General Medicine Source Type: research

Accuracy of Airflow Obstruction Thresholds for Predicting COPD-Related Hospitalization and Mortality
Diagnostic criteria for complex chronic diseases often include a threshold for a biomarker. In the case of chronic obstructive pulmonary disease (COPD) and hypertension, physiological biomarkers are applied. For COPD, the Global Initiative for Chronic Obstructive Lung Disease states that in a symptomatic individual with a relevant exposure (such as smoking), “the presence of a postbronchodilator FEV1:FVC of less than 0.70 confirms the presence of persistent airflow limitation and thus of COPD. ” A decreased ratio between forced expiratory volume in the first second and forced vital capacity (FEV1:FVC), is an ac...
Source: JAMA - June 25, 2019 Category: General Medicine Source Type: research

Dual Antiplatelet Therapy
Since evidence of increased risk of stent thrombosis with first-generation drug-eluting stents surfaced in 2005 and the US Food and Drug Administration advised interventional cardiologists to use dual antiplatelet therapy (DAPT) for 12 months following implantation of drug-eluting stents, the appropriate duration of DAPT has been widely studied and hotly debated. Dual antiplatelet therapy consists of concurrent administration of aspirin and a P2Y12 inhibitor. Determining the duration of DAPT requires a balance between 2 objectives: lowering the risk of ischemic events with more intense and longer antiplatelet therapy vs lo...
Source: JAMA - June 25, 2019 Category: General Medicine Source Type: research

Method Verifies Whether Pediatric Patients Fasted Before Blood Testing
Research by National Institutes of Health (NIH) scientists suggests that levels of free fatty acids (FFA) in their blood could help verify if children and teens fasted before undergoing testing for diabetes or other medical conditions. (Source: JAMA)
Source: JAMA - June 25, 2019 Category: General Medicine Source Type: research

HHS Issues Final ‘Conscience’ Rule
The US Department of Health and Human Services (HHS) Office for Civil Rights (OCR) recently issued thefinal “conscience” rule, which allows health care workers and entities to refuse to provide treatment, even in emergency situations. (Source: JAMA)
Source: JAMA - June 25, 2019 Category: General Medicine Source Type: research

Veterans Genomic Cohort Nearing 1 Million
TheMillion Veteran Program, a voluntary research initiative studying how genes affect veterans ’ health, recently enrolled its 750 000th participant. (Source: JAMA)
Source: JAMA - June 25, 2019 Category: General Medicine Source Type: research

Highlights for June 25, 2019
(Source: JAMA)
Source: JAMA - June 25, 2019 Category: General Medicine Source Type: research

Coordinating Community Planning for Transportation and Health
In ways often underappreciated, accessible transportation is fundamental to societal health. For example, although some patients have reliable access to private or public transportation for health-related visits, many others regularly encountermobility barriers that lead to missed appointments, slowed discharge processes, and other inefficiencies that disrupt or discourage care. In addressing these issues and more, coordinated community planning can integrate considerations for health, safety, mobility, and the environment to advance patient-centered care as well as population well-being. (Source: JAMA)
Source: JAMA - June 25, 2019 Category: General Medicine Source Type: research

Critique & amp; Cavil …
To those who are inclined to delve into the medical literature, I issue this invitation to join me in setting aside a day to honor that unsung, unacclaimed “heroperson,” the medical librarian. I have much empathy for medical librarians and, I believe, understanding of how readily they can become frustrated and wild-eyed as they respond to our requests to retrieve information about a specific topic, which they have a deuce of a time finding because the entity has been described under a variety of headings and, consequently, indexed in like fashion. Just the other day at the hospital, Dr. Ernie asked me for some ...
Source: JAMA - June 25, 2019 Category: General Medicine Source Type: research

Scope and Training of Clinicians Providing Unproven Stem Cell Interventions
This study describes the credentials and scope of training of physician and nonphysician practitioners working for US companies marketing unproven stem cell procedures. (Source: JAMA)
Source: JAMA - June 25, 2019 Category: General Medicine Source Type: research

Association of Opioid Quantity Prescribed and Preoperative Education With Postoperative Opioid Consumption
This cohort study investigates the association between reducing the number of opioid tablets prescribed after anterior cruciate ligament (ACL) reconstruction and postoperative opioid consumption and between preoperative opioid use education about nonopioid pain strategies and duration and quantity of opioid use. (Source: JAMA)
Source: JAMA - June 25, 2019 Category: General Medicine Source Type: research

Dietary Supplements for Brain Health
To the Editor In a recent Viewpoint, Dr Hellmuth and colleagues stated that “no known dietary supplement prevents cognitive decline or dementia.” We agree that there is no evidence that dietary supplements can prevent dementia, but that is partly because there have been few well-designed trials to test this idea. In trials of nutrients, a basic requirement is that to de tect any benefit, the participants should have suboptimal levels of the nutrient. This requirement is often not met, and there are reports of negative outcomes in trials (and meta-analyses) in which the participants were healthy and well nourish...
Source: JAMA - June 25, 2019 Category: General Medicine Source Type: research

Low Free Sugar Diet in Adolescents With Nonalcoholic Fatty Liver Disease
To the Editor A randomized clinical trial by Dr Schwimmer and colleagues investigated the effects of an 8-week low free sugar diet on nonalcoholic fatty liver disease progression in 40 adolescent boys. Participants in the intervention group were delivered foods with low levels of free sugar (
Source: JAMA - June 25, 2019 Category: General Medicine Source Type: research

Electroencephalography-Guided Anesthetic Administration and Postoperative Delirium
To the Editor Dr Wildes and colleagues analyzed whether intraoperative electroencephalography (EEG) guidance may reduce the rate of postoperative delirium. No reduction in the incidence of postoperative delirium was observed, which is in contradiction to a meta-analysis of randomized trials and guideline recommendations. (Source: JAMA)
Source: JAMA - June 25, 2019 Category: General Medicine Source Type: research

Electroencephalography-Guided Anesthetic Administration and Postoperative Delirium
To the Editor In a well-designed trial, EEG-guided anesthetic administration did not decrease the incidence of postoperative delirium. The authors concluded that their findings do not support the use of EEG-guided anesthesia for this indication. (Source: JAMA)
Source: JAMA - June 25, 2019 Category: General Medicine Source Type: research

Electroencephalography-Guided Anesthetic Administration and Postoperative Delirium
To the Editor The Electroencephalography Guidance of Anesthesia to Alleviate Geriatric Syndromes (ENGAGES) trial found no effect on postoperative delirium when intraoperative anesthesia depth was guided by EEG waveforms and derived parameters. However, there are various confounders and methodological issues that may have affected the authors ’ conclusions and study generalizability. (Source: JAMA)
Source: JAMA - June 25, 2019 Category: General Medicine Source Type: research

Dietary Supplements for Brain Health —Reply
In Reply Dr Smith and colleagues take issue with a statement in our Viewpoint, suggesting that in select patient groups, cognitive decline may be prevented or slowed with supplements. The authors cite data from the VITACOG trial, which found that participants with mild cognitive impairment and higher Hcy levels who received supplemental B vitamins showed slower brain atrophy in regions affected by Alzheimer disease compared with patients who received a placebo. Secondary analyses suggested links between neuroimaging findings and clinical and cognitive outcomes. While we encourage the rigorous approach of the VITACOG study,...
Source: JAMA - June 25, 2019 Category: General Medicine Source Type: research

Low Free Sugar Diet in Adolescents With Nonalcoholic Fatty Liver Disease —Reply
In Reply Messrs Tang and Gao raise 2 questions regarding our study of dietary sugar in pediatric nonalcoholic fatty liver disease. They suggest that the effect observed in our trial may have been solely a function of weight loss. The study was not designed to promote weight loss; participants ate without calorie or macronutrient restriction. In support of the argument for a weight loss effect, Tang and Gao reference practice guidelines that were written primarily for adults with nonalcoholic fatty liver disease and recommend weight loss of 5% to 10% of body weight. (Source: JAMA)
Source: JAMA - June 25, 2019 Category: General Medicine Source Type: research

Electroencephalography-Guided Anesthetic Administration and Postoperative Delirium —Reply
In Reply The generation of scientific knowledge is an iterative process. It is common for rigorous trials to modify or contradict previous evidence, especially when initial studies yield strongly positive results. The findings of the ENGAGES trial differ from the conclusion of a meta-analysis of trials that examined the effectiveness of intraoperative EEG guidance of anesthesia at preventing postoperative delirium. As such, the meta-analysis should be updated and the guidelines of the European Society of Anesthesiology and American Geriatric Society should be revised if necessary. (Source: JAMA)
Source: JAMA - June 25, 2019 Category: General Medicine Source Type: research

Another Amyloid-beta Blocker Fails to Halt Dementia
Verubecestat, an oral drug that blocks the production of amyloid- β, did not improve clinical ratings of dementia in patients with prodromal Alzheimer disease, according to atrial in theNew England Journal of Medicine. (Source: JAMA)
Source: JAMA - June 25, 2019 Category: General Medicine Source Type: research

Placental Growth Factor Testing for Faster Preeclampsia Diagnosis
Women with suspected preeclampsia were diagnosed sooner and had fewer serious adverse outcomes when clinicians had results of a test that detects circulating concentration of placental growth factor (PIGF), reported a real-worldtrial in theLancet. (Source: JAMA)
Source: JAMA - June 25, 2019 Category: General Medicine Source Type: research

Wearable Device Promotes Socialization in Kids With Autism
A wearable device driven by artificial intelligence significantly improved socialization in children with autism spectrum disorder (ASD) in combination with standard behavioral therapy, found atrial inJAMA Pediatrics. (Source: JAMA)
Source: JAMA - June 25, 2019 Category: General Medicine Source Type: research

Cariprazine Benefits Patients With Bipolar Depression
Cariprazine, a dopamine and serotonin receptor partial agonist, was effective in reducing depressive symptoms in adults with bipolar I depression, according to a phase 3trial in theAmerican Journal of Psychiatry. Few effective treatments are available for patients with bipolar depression, and those currently used can cause mania. (Source: JAMA)
Source: JAMA - June 25, 2019 Category: General Medicine Source Type: research

Supplements Improve Insulin Sensitivity
Overweight and obese adults had improved insulin sensitivity after taking dietary supplements of inulin-propionate ester (IPE) or a high-fermentable fiber, according to astudy inGut. (Source: JAMA)
Source: JAMA - June 25, 2019 Category: General Medicine Source Type: research

Discriminative Accuracy of FEV 1 :FVC Thresholds for COPD-Related Hospitalization and Mortality
This study used harmonized and pooled data from 4 US general population –based cohorts to determine the discriminative accuracy of various FEV1:FVC fixed thresholds for predicting COPD-related hospitalization and mortality. (Source: JAMA)
Source: JAMA - June 25, 2019 Category: General Medicine Source Type: research