Price Transparency in the Electronic Health Record —Reply
In Reply Regarding our Viewpoint on price transparency in EHRs, Dr Cho and colleagues suggest that clinicians are not adequately trained to discuss costs with patients. While we agree that clinicians are not traditionally trained to discuss costs with patients, these discussions are already occurring. Many patients face significant financial burdens affecting access; transparency merely provides information to help make decisions currently made in a vacuum. (Source: JAMA)
Source: JAMA - January 21, 2020 Category: General Medicine Source Type: research

US Organ Donation Policy
In Reply In our Viewpoint on the success of opt-in organ donation policy in the United States, we reviewed organ donation rates from opt-in and opt-out legal jurisdictions to provide a high-level comparison between these 2 authorization strategies. The rate was calculated as donors per 10  000 deaths, not donors per potential eligible donor as incorrectly stated by Dr Wall and colleagues. Donors per deaths is the best available data for an international comparison. (Source: JAMA)
Source: JAMA - January 21, 2020 Category: General Medicine Source Type: research

Effect of Sunscreen Application on Plasma Concentration of Sunscreen Active Ingredients
This randomized clinical trial assesses the systemic absorption and pharmacokinetics of the 6 active ingredients (avobenzone, oxybenzone, octocrylene, homosalate, octisalate, and octinoxate) in lotion, aerosol spray, nonaerosol spray, and pump spray sunscreen products under single- and maximal-use conditions. (Source: JAMA)
Source: JAMA - January 21, 2020 Category: General Medicine Source Type: research

Effect of Hydroxyethyl Starch vs Saline Volume Replacement on Complications After Major Abdominal Surgery
This randomized clinical trial assesses the effect of hydroxyethyl starch 130/0.4 (HES) vs normal saline for intravascular volume expansion in patients at risk of postoperative kidney injury on mortality and postoperative complications up to 14 days after major abdominal surgery. (Source: JAMA)
Source: JAMA - January 21, 2020 Category: General Medicine Source Type: research

Effect of Early Surgery vs Stepped Medical-Endoscopic-Surgical Management on Pain in Patients With Chronic Pancreatitis
This randomized clinical trial compares the effects of pancreatic drainage surgery within 6 weeks vs a stepped medical-endoscopy-surgical approach on pain score and relief over 18 months among patients with chronic pancreatitis. (Source: JAMA)
Source: JAMA - January 21, 2020 Category: General Medicine Source Type: research

Effect of Catheter Ablation With vs Without Renal Denervation on Atrial Fibrillation Recurrence
This randomized trial compares the effects of pulmonary vein isolation with vs without renal denervation on freedom from atrial fibrillation, atrial flutter, or atrial tachycardia at 1 year among patients with atrial fibrillation and hypertension. (Source: JAMA)
Source: JAMA - January 21, 2020 Category: General Medicine Source Type: research

Cryptosporidiosis
This JAMA Patient Page describes cryptosporidiosis, its symptoms, diagnosis, treatment, and prevention methods. (Source: JAMA)
Source: JAMA - January 21, 2020 Category: General Medicine Source Type: research

Silence
Cherry blossoms line the Saturday Market near Burnside. Back home, winter (Source: JAMA)
Source: JAMA - January 21, 2020 Category: General Medicine Source Type: research

This Quiet Lady: Learning to Be With Patients After a Parent ’s Death
In this narrative medicine essay, a surgical oncologist recalls helping her mother through her treatment and death from lung cancer and tells of the lesson she brought back to her own practice from the experience that the essence of clinical care is human connection: the ability to listen to others, witness their suffering, hear their joy, and be present in their company. (Source: JAMA)
Source: JAMA - January 21, 2020 Category: General Medicine Source Type: research

Jama
(Source: JAMA)
Source: JAMA - January 21, 2020 Category: General Medicine Source Type: research

Dengue Vaccine Protects Youth
Researchers have reported that a new vaccine against the dengue virus protected children and adolescents in a phase 3 trial conducted in Asia and Latin America. (Source: JAMA)
Source: JAMA - January 21, 2020 Category: General Medicine Source Type: research

Climate Change Puts Children at Risk
Urgent action is needed to meet the Paris Agreement climate goals to limit the potential health impacts on children worldwide, according to a statement from 120 international climate experts. (Source: JAMA)
Source: JAMA - January 21, 2020 Category: General Medicine Source Type: research

Cesarean Deliveries Not Linked to Obesity in Latest Study
A large Swedish study published in PLOS Medicine appears to debunk the idea that either elective or nonelective cesarean delivery increases the risk that a child will develop obesity. (Source: JAMA)
Source: JAMA - January 21, 2020 Category: General Medicine Source Type: research

Treatment Decisions for a Future Self —Ethical Obligations to Guide Truly Informed Choices
This Viewpoint discusses the reality that most decisions about treatment for incapacitated patients involve surrogate assessments of patients ’ past values at their baseline health, and it proposes that more ethical and informed decision-making would help surrogates consider the degree to which their loved one might be able to adapt to and value a future health state at what is a higher level of disability. (Source: JAMA)
Source: JAMA - January 14, 2020 Category: General Medicine Source Type: research

First US “Donation After Circulatory Death” Heart Transplant
An adult patient received a “donation after circulatory death” (DCD) heart transplant in the first such procedure to take place in the United States. Surgeons at Duke University Hospital in Durham, North Carolina, recently performed the operation as part of a clinical trial evaluating the Organ Care System (OCS) Heart, an investigational normothermic preservation system from Massachusetts-based TransMedics. An alternative to cold storage, the device keeps the donor heart pumping with warm oxygen- and nutrient-rich blood. (Source: JAMA)
Source: JAMA - January 14, 2020 Category: General Medicine Source Type: research

Can Apple Watches Detect Atrial Fibrillation?
Researchers tested a smartwatch-based irregular pulse notification algorithm for suspected atrial fibrillation among more than 400  000 US participants in a recent trial. The findings, published in the New England Journal of Medicine, came from the Apple Heart Study, a collaboration between technology giant Apple and Stanford Medicine. (Source: JAMA)
Source: JAMA - January 14, 2020 Category: General Medicine Source Type: research

Testing Hypothermic Preservation for Trauma Patients
Only 1 in 20 patients survive cardiac arrest from trauma-related blood loss. “Surgeons don’t have time to stop the bleeding before irreversible damage occurs to the brain and other vital organs,” trauma surgeon Samuel A. Tisherman, MD, of the University of Maryland School of Medicine in Baltimore, said in an email. (Source: JAMA)
Source: JAMA - January 14, 2020 Category: General Medicine Source Type: research

Opportunities and Challenges in Valuing and Evaluating Aging Physicians
In 2017, more than 15% of practicing physicians were older than 65 years. Without a national mandatory retirement age, many physicians plan to practice until they are in their 70s or 80s. Cognitive decline often accompanies aging, and the prevalence of dementia increases rapidly after age 70 years. Thus, it is not surprising that the issue of screening aging physicians for cognitive deficits has gained attention over the last decade. (Source: JAMA)
Source: JAMA - January 14, 2020 Category: General Medicine Source Type: research

Best Practices in Assessing Aging Physicians for Professional Competency
The unprecedented number and proportion of aging physicians in the workforce in both the United States and the world is a unique challenge of the current medical era. Fully 43% of all US physicians are aged 55 years or older, including 61% of psychiatrists, 52% of radiologists, 46% of general surgeons, and 44% of internists. Moreover, approximately 15% of practicing US physicians are older than 65 years, tripling from 23  000 in 1980 to 73 000 in 2012-2016. Every year, 20 000 more US physicians turn 65 years of age, and, even though half retire by age 65, many continue practicing for years and decades more. Indeed, U...
Source: JAMA - January 14, 2020 Category: General Medicine Source Type: research

Reform at the FDA —In Need of Reform
On December 23, 2016, the US Food and Drug Administration (FDA) announced the approval of nusinersen, the first drug for the devastating disease spinal muscular atrophy. The approval was based on an interim analysis of 82 patients in a single randomized trial; 40% of treated children improved, compared with none in the control group. The FDA had requested that the interim analysis be conducted. A press release emphasized the speed of agency action, with the review division director saying, “We worked hard to review this application quickly.” (Source: JAMA)
Source: JAMA - January 14, 2020 Category: General Medicine Source Type: research

How Effective and Safe Is Factor XI Inhibition in Preventing Venous Thrombosis?
The introduction of the direct oral anticoagulants for stroke prevention in atrial fibrillation and the management of thromboembolism has transformed the care of patients with these disorders. These drugs, which selectively and reversibly inhibit factor Xa or thrombin in the common pathway of the coagulation cascade, have a wide therapeutic window; this allows for simplified dosing regimens without laboratory monitoring of most adult patients as contrasted to vitamin K antagonists. This class of drug is also associated with a lower bleeding risk than vitamin K antagonists, which has been most clearly demonstrated by a 50% ...
Source: JAMA - January 14, 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 - January 14, 2020 Category: General Medicine Source Type: research

Early Returns From the Era of Precision Medicine
The era of precision medicine has arrived. A large share of new pharmaceuticals are tested and approved on the basis of biomarkers. Pharmacogenetics —the tailoring of drugs to patients based on 1 or more biomarkers—is used in conditions as diverse as HIV and thromboembolism. (Source: JAMA)
Source: JAMA - January 14, 2020 Category: General Medicine Source Type: research

The Patient Himself
Among the vices of advancing years are carping criticism, garrulity and needless admonition. To all of these I plead guilty and so can only beg your indulgence while I say a few things that I think should be said, knowing that I say them poorly and that I add nothing to our store of knowledge. (Source: JAMA)
Source: JAMA - January 14, 2020 Category: General Medicine Source Type: research

Incidence of Infectious Complications Following Cochlear Implantation in Children and Adults
This cohort study uses data from state health care databases to determine the incidence and timing of infectious complications following cochlear implant surgery among patients in 5 US states between 2006 and 2016. (Source: JAMA)
Source: JAMA - January 14, 2020 Category: General Medicine Source Type: research

CLABSI Differences Based on Criteria Used to Count Central Line Days
This study uses electronic health record (EHR) data to evaluate differences in central line –associated bloodstream infection (CLABSI) rates by how central line days are counted: once a day at a fixed time for all patients; a sampling-based approximation; or a validated electronic count. (Source: JAMA)
Source: JAMA - January 14, 2020 Category: General Medicine Source Type: research

Reporting of the Medical Licensing Examination
To the Editor Dr Swails and colleagues argued that the current 3-digit scoring system for the United States Medical Licensing Examination (USMLE) is a broken metric for evaluating residency applicants. They suggested that a pass-fail licensing examination with “individual mission–based holistic criteria” would be more appropriate. I disagree with their suggestion for several reasons. (Source: JAMA)
Source: JAMA - January 14, 2020 Category: General Medicine Source Type: research

Reporting of the Medical Licensing Examination
To the Editor The proposed change to a pass-fail score reporting for the USLME Step 1 Examination from the Federation of State Medical Boards and the National Board of Medical Examiners was based on the recommendations from the Invitational Conference on USMLE Scoring. I am concerned that the authors made several claims either without evidence (or have not cited that evidence) or in direct contradiction to established evidence to advance their view. The authors stated “…the narrow differences in examination scores used by some programs to exclude many applicants are arbitrary with neither clinical, nor statist...
Source: JAMA - January 14, 2020 Category: General Medicine Source Type: research

Reporting of the Medical Licensing Examination
To the Editor The Viewpoint by Dr Swails and colleagues concluded that “the current USMLE 3-digit scores may be distracting the medical education system from the goal of building an innovative, diverse, and resilient physician workforce.” Program directors of residency programs would likely disagree with these statements: “Changing the USMLE to a pass-fail format would require residency programs to find other, potentially more meaningful, ways of evaluating applicants”; “Medical knowledge may not be the most important skill required to meet the needs of patients and society”; and “...
Source: JAMA - January 14, 2020 Category: General Medicine Source Type: research

Recommendations Related to Genetic Testing for Breast Cancer
To the Editor The USPSTF found adequate evidence of moderate benefit for women whose family or personal history is associated with increased risk for BRCA1/BRCA2 mutations, whereas for women without such family history, it stated that the benefits are small to none. However, a BRCA1/BRCA2 mutation carrier without a positive family history still faces a substantial lifetime risk, with more than half the hazard of a BRCA1/BRCA2 mutation carrier with a positive family history. The proportion of these unsuspected mutation carriers is not negligibly small. In hospital-based settings at Hannover Medical School, current risk asse...
Source: JAMA - January 14, 2020 Category: General Medicine Source Type: research

Recommendations Related to Genetic Testing for Breast Cancer
To the Editor The recent Recommendation Statement by the US Preventive Services Task Force (USPSTF) on risk assessment, genetic counseling, and genetic testing for breast cancer susceptibility (BRCA) gene mutations seems to contain some internal inconsistencies. The Summary of Recommendations and Evidence section stated that women with either a personal or family history of BRCA-related cancers or an ancestry associated with BRCA mutations are recommended for risk assessment. However, in the USPSTF Assessment section, net benefit of the intervention was only ascribed to women with the relevant family or personal history, a...
Source: JAMA - January 14, 2020 Category: General Medicine Source Type: research

Reporting of the Medical Licensing Examination —Reply
In Reply Based on the letters from Mr Schneider, Drs Everett and Isea, and Dr Battisti, we find 2 key issues to discuss —transparency and competency. We absolutely agree that increased transparency and access to data, both from medical schools and through ERAS, would facilitate holistic review. Program directors have been lamenting the erosion of meaningful performance measures for years as medical schools increasi ngly moved to pass-fail grading. We wonder what role the narrow focus on academic metrics in residency selection may have played during this transition. Broadening the selection criteria beyond academic me...
Source: JAMA - January 14, 2020 Category: General Medicine Source Type: research

Recommendations Related to Genetic Testing for Breast Cancer —Reply
In Reply Dr Pinsky asks for more clarity on the USPSTF ’s recent recommendation. The USPSTF found that women with a personal or family history of breast or ovarian cancer, or an ancestry associated with BRCA1/2 mutations, are at increased risk for having a BRCA1/2 mutation. For these women, the benefits of risk assessment and potentially counseling an d testing outweigh the harms. Determining whether a woman may be a candidate for referral for counseling and possible genetic testing is a multistep process for primary care clinicians. The first step is to identify women with a personal or family history of breast or o...
Source: JAMA - January 14, 2020 Category: General Medicine Source Type: research

Effect of a Behavioral Intervention to Increase Vegetable Consumption on Prostate Cancer Progression
This randomized trial compares the effect of a counseling intervention to promote consumption of 7 or more daily vegetable servings vs an educational control on time to PSA- and biopsy-defined cancer progression in men with early-stage prostate cancer. (Source: JAMA)
Source: JAMA - January 14, 2020 Category: General Medicine Source Type: research

Comparison of Functional Patient-Reported Outcomes 5 Years After Treatments for Localized Prostate Cancer
This cohort study compares functional outcomes, including sexual and bowel function and urinary incontinence, associated with active surveillance, surgery, or radiation therapy 5 years after treatment. (Source: JAMA)
Source: JAMA - January 14, 2020 Category: General Medicine Source Type: research

Effect of Osocimab on Venous Thromboembolism Prevention Among Patients Undergoing Knee Arthroplasty
This phase 2 clinical noninferiority trial compared 4 doses of postoperative osocimab, a monoclonal antibody against factor XI, vs enoxaparin and apixiban on venous thromboembolism incidence among patients undergoing knee replacement. (Source: JAMA)
Source: JAMA - January 14, 2020 Category: General Medicine Source Type: research

Periorbital and Orbital Cellulitis
This JAMA Patient Page describes the causes, symptoms, diagnosis, and treatment of periorbital and orbital cellulitis. (Source: JAMA)
Source: JAMA - January 14, 2020 Category: General Medicine Source Type: research

Cognitive Testing of Older Clinicians Prior to Recredentialing
This JAMA Performance Improvement article reports the methods and outcomes of a cognitive screening program implemented at a US hospital to assess medical staff aged 70 years or older for clinical competency every 2 years as a requirement for reappointment. (Source: JAMA)
Source: JAMA - January 14, 2020 Category: General Medicine Source Type: research

One ’s Self I Sing Too
(Source: JAMA)
Source: JAMA - January 14, 2020 Category: General Medicine Source Type: research

Doctoring and Deportation —Immigration Advocacy as Primary Care
In this narrative medicine essay, a resident physician shares the story of a young Haitian woman with cancer whose survival was threatened with deportation for having missed her residency application deadline and of his role in advocating for her care with US citizenship and immigration services. (Source: JAMA)
Source: JAMA - January 14, 2020 Category: General Medicine Source Type: research

FDA Approval and Regulation of Pharmaceuticals, 1983-2018
This study uses publicly available and FDA data to describe changes in drug testing laws and standards, the use of new FDA approval programs and standards, changes in the role and authority of the FDA, and changes in the number of drugs the FDA has approved from 1983 to 2018. (Source: JAMA)
Source: JAMA - January 14, 2020 Category: General Medicine Source Type: research

Jama
(Source: JAMA)
Source: JAMA - January 14, 2020 Category: General Medicine Source Type: research

Pneumococcal Vaccine Recommendation
An updated recommendation from CDC ’s Advisory Committee on Immunization Practices (ACIP) suggests adults aged 65 years or older should receive only the 23-valent pneumococcal polysaccharide vaccine (PPSV23) with a few exceptions. (Source: JAMA)
Source: JAMA - January 14, 2020 Category: General Medicine Source Type: research

New Malaria Option
A newer antimalaria medication with a simplified dosing regimen may be useful in US patients as prophylaxis or as an antirelapse treatment, according to a review in the Morbidity and Mortality Weekly Report. (Source: JAMA)
Source: JAMA - January 14, 2020 Category: General Medicine Source Type: research

New Flu Antiviral Candidate May Thwart Drug Resistance
This Medical News article discusses an investigational influenza treatment that could overcome the growing problem of drug resistance. (Source: JAMA)
Source: JAMA - January 7, 2020 Category: General Medicine Source Type: research

Can an Evidence-Based Approach Improve the Patient-Physician Relationship?
The importance of the patient-physician relationship has been recognized for millennia. Concern that this special relationship is threatened has likely existed nearly as long, although more recently time constraints, insurer demands, novel technologies, and documentation burdens have intensified these worries. In their Special Communication in this issue of JAMA, Zulman et al report a novel study that proposes a limited number of evidence-based practices that may lead to more meaningful connections between patients and physicians. (Source: JAMA)
Source: JAMA - January 7, 2020 Category: General Medicine Source Type: research

Connecting With Patients —The Missing Links
These are trying times for the patient-physician relationship. Patients frequently report that their physician is not listening or, at least, that they do not feel heard. Some research suggests they are right —sometimes their physicians are not listening. Appointment times, although short, are longer than in the past and have increased from just over 15 minutes in 1995 to more than 20 minutes in 2015. However, too much of that time is directed not at the patient but at the patient’s virtual self, at what Verghese has called the “iPatient” via the now omnipresent electronic medical record (EMR). In t...
Source: JAMA - January 7, 2020 Category: General Medicine Source Type: research

Use of Powder in the Genital Area and Ovarian Cancer Risk
Women have used powders for genital hygiene for decades to absorb odor and moisture. While rates of powder use in the genital area have declined over the last 50 years, it remains a routine practice for some women. Commonly used products typically include talc, cornstarch, or some combination of both. Women may apply powders directly to the perineum or onto sanitary napkins, tampons, diaphragms, or underwear. Investigations of an association between the use of talc-containing powders for genital hygiene and epithelial ovarian cancer risks have provided inconsistent results to date and resulted in ongoing controversy. Since...
Source: JAMA - January 7, 2020 Category: General Medicine Source Type: research

New Option for Sickle Cell Disease
The FDA has boosted treatment options for sickle cell disease by approving voxeletor for adults and adolescents aged 12 years or older who have the illness. (Source: JAMA)
Source: JAMA - January 7, 2020 Category: General Medicine Source Type: research

Ear Tubes Can Be Inserted With Local Anesthesia
A recently approved device will enable young children who need tympanostomy tubes for otitis media to have them inserted with local anesthesia in a physician ’s office. Traditionally, children who needed the ear tubes underwent surgery requiring general anesthesia in a hospital or surgical center. (Source: JAMA)
Source: JAMA - January 7, 2020 Category: General Medicine Source Type: research