“A General Practitioner,” or All for Mercy’s Sake
As long ago as in the issue of this Journal for Oct. 13,1894, the promising merits of Ian Maclaren, the now popular story-teller, were recognized. We there spoke of Maclaren ’s “A General Practitioner,” as “a classic of its kind,” although it was far from being in classic dress at that time; it was then to be found only in a penny paper of London, called the British Weekly. Since that time, the features of the Highland country doctor, Dr. Weelum MacLure, have been made known all the world round in the “Bonnie Brier Bush” stories. And his physiognomy is everywhere recognized as that...
Source: JAMA - March 2, 2021 Category: General Medicine Source Type: research

Association Between COVID-19 Lockdown Measures and ED Visits for Violence-Related Injuries in Wales
This study investigates emergency department visits for violence-related injuries occurring at home and outside the home in Cardiff, Wales, before and after COVID-19 lockdown measures were instituted in March 2020. (Source: JAMA)
Source: JAMA - March 2, 2021 Category: General Medicine Source Type: research

The De-adoption of Low-Value Health Care
To the Editor In their Viewpoint, Dr Powers and colleagues analyzed 3 forces governing de-adoption of low-value care: evidence, eminence, and economics. A common denominator underlies them: the interest and convenience of the health care producers, providers, and purchasers. Fee-for-service creates strong incentives to continue delivering low-value but profitable care and technological abuse. More generally, it incentivizes provision of services with a profitable differential between the production costs and the fee applied by purchasers. The production cost is physician- or hospital team –specific, based also on spe...
Source: JAMA - March 2, 2021 Category: General Medicine Source Type: research

Antiretroviral Drug Recommendations for HIV Treatment and Prevention
To the Editor As HIV clinicians, we read with interest the new antiretroviral treatment guidelines published on behalf of the International Antiviral Society –USA. Nevertheless, we believe these guidelines failed to integrate emerging evidence and may have reflected implicit commercial bias. (Source: JAMA)
Source: JAMA - March 2, 2021 Category: General Medicine Source Type: research

Ticagrelor vs Clopidogrel for Patients With Acute Coronary Syndrome Undergoing Percutaneous Intervention
To the Editor A recent retrospective cohort analysis by Dr You and colleagues demonstrated that compared with clopidogrel, ticagrelor was not associated with better outcomes in patients from the US and South Korea with acute coronary syndrome (ACS) undergoing percutaneous intervention (PCI). However, there are several important discrepancies between this cohort analysis and the randomized Platelet Inhibition and Patient Outcomes (PLATO) trial. (Source: JAMA)
Source: JAMA - March 2, 2021 Category: General Medicine Source Type: research

The De-Adoption of Low-Value Health Care —Reply
In Reply We agree with Dr Donzelli that reforming health care payment is an essential step in reducing the delivery of low-value services. This is core to our argument around the economic forces that guide the de-adoption of low-value care. Within this realm of economic levers, Donzelli makes an important distinction between pay-for-performance and pay-for-health models, noting some inconsistent results from the former. Although there is evidence that targeted payment policies can reduce the provision of low-value care, we agree that more holistic value-based payment models are needed. Our understanding of how to best pay ...
Source: JAMA - March 2, 2021 Category: General Medicine Source Type: research

Antiretroviral Drug Recommendations for HIV Treatment and Prevention —Reply
In Reply Our recommendations for initial antiretroviral therapy are based on evidence from randomized clinical trials demonstrating superiority of InSTI-based therapy vs comparators that included boosted protease inhibitors or efavirenz. Additional benefits of dolutegravir-based and bictegravir-based therapies include a low risk of treatment-emergent resistance, lack of need for pretreatment genotype results, few significant drug interactions, and a highly favorable tolerability profile, along with a very low rate of discontinuation due to adverse effects. (Source: JAMA)
Source: JAMA - March 2, 2021 Category: General Medicine Source Type: research

Ticagrelor vs Clopidogrel for Patients With Acute Coronary Syndrome Undergoing Percutaneous Intervention —Reply
In Reply Dr Kim and colleagues state that the results of our study are not comparable with those of PLATO and suggest that our findings may differ because patients enrolled in PLATO had a higher proportion of prior myocardial infarction. First, as we mention in our article, PLATO failed to show benefit in North America and included few Asian patients. It did show that ticagrelor reduced ischemic events and increased the rate of nonprocedural bleeding. However, several studies have demonstrated that high-risk patients with ACS do not have a net benefit with ticagrelor. For example, the SWEDEHEART registry showed that ticagr...
Source: JAMA - March 2, 2021 Category: General Medicine Source Type: research

Consolidation With Blinatumomab vs Chemotherapy in First Relapse of B-Cell Acute Lymphoblastic Leukemia
This randomized trial compares the effects of postreinduction therapy consolidation using blinatumomab, an antibody construct that links CD3+ T cells to CD19+ leukemia cells, vs chemotherapy on disease-free survival among children, adolescents, and young adults with first relapse of B-cell acute lymphoblastic leukemia (ALL). (Source: JAMA)
Source: JAMA - March 2, 2021 Category: General Medicine Source Type: research

Effect of Blinatumomab vs Chemotherapy on Event-Free Survival in Children With High-Risk First Relapse of B-Cell ALL
This randomized trial compares the effects of blinatumomab, an antibody construct that links CD3+ T cells to CD19+ leukemia cells, vs consolidation chemotherapy as a third consolidation block before allogeneic hematopoietic stem cell transplant (HST) on event-free survival in children with high-risk first-relapse B-cell acute lymphoblastic leukemia (B-ALL). (Source: JAMA)
Source: JAMA - March 2, 2021 Category: General Medicine Source Type: research

Reason for Everything
I will work. I will work without a mask. I will mask the work of courage. I will say there is a reason, bury my aunt, and say it again. I will walk on any street without a graveyard without a mask. I will let our children play there. I will see them share the sand. I will let them touch each other. I will see them slip in soil. I will remember I played dead. I will forget two hundred thousand bodies. I will sift anything but ash. (Source: JAMA)
Source: JAMA - March 2, 2021 Category: General Medicine Source Type: research

It ’s Not Your Fault—Forgiveness in Illness and Death
In this narrative medicine essay an infectious diseases physician shares the sense of forgiveness she brings to anyone possibly involved in COVID-19 transmission, having learned as a child the healing power of family absolution after she witnessed the death of a cousin. (Source: JAMA)
Source: JAMA - March 2, 2021 Category: General Medicine Source Type: research

Diagnosis and Treatment of Irritable Bowel Syndrome
This narrative review summarizes the epidemiology, pathophysiology, diagnosis, management, and prognosis of irritable bowel syndrome. (Source: JAMA)
Source: JAMA - March 2, 2021 Category: General Medicine Source Type: research

Jama
(Source: JAMA)
Source: JAMA - March 2, 2021 Category: General Medicine Source Type: research

Addressing Excess Health Care Pricing With Backstop Price Caps
This Viewpoint reviews evidence that higher hospital prices reflect greater market power more than higher-quality services and proposes that backstop price caps can mitigate harms from the most excessive prices without constraining or distorting competitive health care markets. (Source: JAMA)
Source: JAMA - March 2, 2021 Category: General Medicine Source Type: research

Making Prescription Drugs More Affordable Under the Biden Administration
This Viewpoint discusses policies the Biden administration can enact to reduce costs, including benchmarking Medicare Part B drug payments to the lowest price paid in similar countries, preventing Part D plans from negotiating confidential rebates with manufacturers, and patent reform to promote generic drug use. (Source: JAMA)
Source: JAMA - March 2, 2021 Category: General Medicine Source Type: research

All-Cause Excess Mortality and COVID-19 –Related Mortality Among US Adults Aged 25-44 Years, March-July 2020
This study compares all-cause excess mortality and COVID-19 –related mortality during the early pandemic period (March-July 2020) with unintentional drug overdoses, the usual leading cause of death in young adults, during the same period in 2018 among adults aged 25 to 44 years. (Source: JAMA)
Source: JAMA - February 23, 2021 Category: General Medicine Source Type: research

Hydrocortisone, Vitamin C, and Thiamine for Treatment of Sepsis —Making Evidence Matter
The randomized trial, alone or as part of a meta-analysis, is the pinnacle of the evidence pyramid. Rigorously performed randomized trials offer key insights into the benefit of a treatment vs a control or of a new treatment compared with a standard treatment, although clinicians do not always adopt trial findings into practice. The resulting practice variability is inherent to the art of medicine but not always to the benefit of patients. (Source: JAMA)
Source: JAMA - February 23, 2021 Category: General Medicine Source Type: research

Baclofen to Prevent Agitation Caused by Alcohol Withdrawal in the ICU
Alcohol use and abuse is common in many societies and is associated with adverse effects on health. According to the US National Institute on Alcohol Abuse and Alcoholism, in 2019, an estimated 14.1 million adults aged 18 years and older had alcohol use disorder, defined as “chronic relapsing brain disease characterized by an impaired ability to stop or control alcohol use despite adverse social, occupational, or health consequences.” Among the numerous alcohol-related diseases and harms, including liver cirrhosis, obesity, some cancers, injury, and suicide, only s ome directly contribute to acute critical illn...
Source: JAMA - February 23, 2021 Category: General Medicine Source Type: research

Funding and DSMB Membership in the VICTAS Clinical Trial
Two unusual circumstances arose in the conduct, review, and publication of the VICTAS randomized clinical trial. First, the funder reportedly withdrew financial support for the study after enrollment of only 25% of the planned study sample, resulting in early termination of the study; and second, a member of the data and safety monitoring board (DSMB) is an author of the article. (Source: JAMA)
Source: JAMA - February 23, 2021 Category: General Medicine Source Type: research

Collecting Data About COVID-19 –Related Brain Symptoms
The National Institutes of Health (NIH) is planning to launch a new database and biobank to collect information from clinicians about neurological problems associated with coronavirus disease 2019 (COVID-19). (Source: JAMA)
Source: JAMA - February 23, 2021 Category: General Medicine Source Type: research

Detecting Heart Transplant Rejection Earlier, More Easily
A blood test performed better than a tissue biopsy —the standard diagnostic tool—in detecting acute heart transplant rejection, National Heart, Lung, and Blood Institute (NHLBI) researchers found in a recent study. (Source: JAMA)
Source: JAMA - February 23, 2021 Category: General Medicine Source Type: research

Locating COVID-19 Monoclonal Antibody Therapies
Physicians and patients in search of outpatient monoclonal antibody therapies for coronavirus disease 2019 (COVID-19) can turn to a recently launched federal government website and enter their zip code. (Source: JAMA)
Source: JAMA - February 23, 2021 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 - February 23, 2021 Category: General Medicine Source Type: research

From Economic Recovery to Health Resilience
For decades, scholars have debated not whether the economy and public health are interlinked, but how. Several recent studies indicate a strong and persistent correlation between lower incomes and excess mortality, though this link sometimes manifests over years or even generations. As it has with so much else, the coronavirus disease 2019 (COVID-19) pandemic has compressed time in a way that reveals the interconnection between the economy and public health. With the change in the federal administration, there is a renewed chance to challenge the false dichotomy of economic growth vs public health and adopt policies that a...
Source: JAMA - February 23, 2021 Category: General Medicine Source Type: research

The Worth of a Miracle
Many major open-heart operations are costly in terms of money, effort, and manpower. Would it not be wiser to divert this vast expenditure to wider uses? This question rarely bothers the people who are directly involved with the patient, but it causes much concern to those who evaluate priority. How can the equation of needs, logistics, and cost to society be sensibly resolved? (Source: JAMA)
Source: JAMA - February 23, 2021 Category: General Medicine Source Type: research

Risk of Spinal Hematoma After Lumbar Puncture
To the Editor The recently published article by Dr Bodilsen and colleagues reported the association between lumbar puncture and spinal hematoma in patients with coagulopathy. When interpreting their results, some issues should be considered. First, this study defined spinal hematoma based on diagnosis codes regarding spinal hematoma –related symptoms or treatments. The diagnosis of spinal hematoma should be based on neuroimaging data, including magnetic resonance imaging and computed tomographic scan results since diagnosis codes without regard to neuroimaging data may cause a misdiagnosis of spinal hematoma. Second,...
Source: JAMA - February 23, 2021 Category: General Medicine Source Type: research

Risk of Spinal Hematoma After Lumbar Puncture
To the Editor Dr Bodilsen and colleagues showed very low rates of spinal hematoma in patients both with and without coagulopathy in their large patient cohort. In a subgroup analysis of 1694 lumbar punctures among 1237 patients, the authors reported that the median needle size was 22 gauge (interquartile range, 22-22), and listed the number of procedures performed with traumatic vs atraumatic needles. Needle size and the use of atraumatic pencil-point needles have been previously shown to modulate the risk of other post –lumbar puncture complications; the use of smaller, atraumatic needles reduces the risk of complic...
Source: JAMA - February 23, 2021 Category: General Medicine Source Type: research

The Effect of Surgical Treatment on Obstructive Sleep Apnea
To the Editor The recent trial by Dr MacKay and colleagues, undertaken in a cohort of patients with sleep apnea, supported previous research that uvulopalatopharyngoplasty, with or without other surgical procedures, produces some benefits to patients. However, we have concerns not addressed by this trial regarding whether these benefits persist over time. In particular, we are interested to learn why the authors chose not to follow up their study cohort beyond 6 months. Furthermore, this study did not address the question of whether uvulopalatopharyngoplasty with tongue volume reduction has a greater benefit than uvulopala...
Source: JAMA - February 23, 2021 Category: General Medicine Source Type: research

Cervical Cancer Screening in Low- and Middle-Income Countries
To the Editor In their recent article, Ms Lemp and colleagues presented data about lifetime prevalence of cervical cancer screening in 55 low- and middle-income countries (LMICs). As leaders of Basic Health International, a nonprofit dedicated to the elimination of cervical cancer, we believe these data can help guide initiatives to implement cervical cancer prevention in locations where women are at highest risk. However, we are concerned that the methods used in this study did not capture a full picture of current cervical cancer screening programs in LMICs because the study used only data from surveys. Surveys from Cent...
Source: JAMA - February 23, 2021 Category: General Medicine Source Type: research

Risk of Spinal Hematoma After Lumbar Puncture —Reply
In Reply Dr Xu and colleagues raise several interesting questions about our study. First, they correctly point out that neuroimaging is the gold standard for the diagnosis of spinal hematoma and suggest that we may have missed some asymptomatic cases. However, neuroimaging data were unavailable for the registry-based part of the study, and we focused on clinically meaningful end points of neurological deficits requiring hospitalization. Reassuringly, in a medical record review of all lumbar punctures performed in patients with coagulopathy in the North Denmark Region during a 20-year period, we confirmed the very low absol...
Source: JAMA - February 23, 2021 Category: General Medicine Source Type: research

The Effect of Surgical Treatment on Obstructive Sleep Apnea —Reply
In Reply Drs Alderman and Agbetile raise several concerns about our SAMS trial findings, specifically that the 6-month surgical improvements may not persist over time, that long-term cardiovascular outcomes were not assessed, and that there should be a mortality benefit with OSA surgery. (Source: JAMA)
Source: JAMA - February 23, 2021 Category: General Medicine Source Type: research

Cervical Cancer Screening in Low- and Middle-Income Countries —Reply
In Reply We agree with Dr Cremer and colleagues that in countries with older surveys, our estimates do not reflect the impact of more recent programs that have conducted cervical cancer screening. Our study used the most recent nationally representative surveys for which we were able to access microdata. Given the relatively low frequency with which such surveys are carried out and the time required to do so, our estimates for each country are inevitably somewhat outdated. We have therefore highlighted in our article that readers should interpret our findings as pertaining to the year(s) of data collection of the survey in...
Source: JAMA - February 23, 2021 Category: General Medicine Source Type: research

Oral Rimegepant Safe, Effective for Migraine Prevention
Rimegepant is safe and effective for preventing migraines, a phase 2 and 3 trial published in The Lancet reported. The orally administered calcitonin gene –related peptide receptor antagonist is already approved for acute migraine treatment. No oral drugs are currently approved to both prevent and treat migraines. (Source: JAMA)
Source: JAMA - February 23, 2021 Category: General Medicine Source Type: research

Finerenone for Patients With CKD and Type 2 Diabetes
Finerenone reduced the risks of chronic kidney disease (CKD) progression and cardiovascular events among patients with CKD and type 2 diabetes in an international phase 3 trial. (Source: JAMA)
Source: JAMA - February 23, 2021 Category: General Medicine Source Type: research

Common Weight Loss Surgeries ’ Benefits Sustained at Year 7
Years after bariatric surgery, patients had sustained weight loss and similar quality of life improvements regardless of whether they had laparoscopic sleeve gastrectomy (LSG) —currently the favored procedure—or laparoscopic Roux-en-Y gastric bypass (LRYGB), according to results from a randomized equivalence trial. (Source: JAMA)
Source: JAMA - February 23, 2021 Category: General Medicine Source Type: research

Navigators Improve Autism Evaluations but Not Referrals to Care
Family navigators led to more toddlers being evaluated for autism spectrum disorder (ASD) in primary care clinics but not to more referrals for autism services, a trial published in Autism found. (Source: JAMA)
Source: JAMA - February 23, 2021 Category: General Medicine Source Type: research

Physician Videos Improve COVID-19 Knowledge Among Minorities
Informational videos starring physicians modestly improved coronavirus disease 2019 (COVID-19) knowledge among US Black and Latino adults regardless of the clinician ’s race, according to a trial published in the Annals of Internal Medicine. (Source: JAMA)
Source: JAMA - February 23, 2021 Category: General Medicine Source Type: research

Effect of Vitamin C, Thiamine, and Hydrocortisone on Ventilator- and Vasopressor-Free Days in Patients With Sepsis
This randomized trial compares the effect of vitamin C, thiamine, and hydrocortisone vs matching placebo on 30-day ventilator- and vasopressor-free days among patients with sepsis-induced respiratory and/or cardiovascular dysfunction. (Source: JAMA)
Source: JAMA - February 23, 2021 Category: General Medicine Source Type: research

Association of Rare CYP39A1 Variants With Exfoliation Syndrome Involving the Anterior Chamber of the Eye
This case-control study uses whole-exome sequencing to identify coding-sequence genetic variants associated with exfoliation syndrome, a form of glaucoma caused by abnormal fibrillar protein aggregates in the anterior eye. (Source: JAMA)
Source: JAMA - February 23, 2021 Category: General Medicine Source Type: research

Effect of Baclofen on Agitation Events in Patients With Unhealthy Alcohol Use Receiving Mechanical Ventilation
This randomized clinical trial compares the effects of high-dose baclofen vs placebo on agitation-related events among adults in the ICU with unhealthy alcohol use receiving mechanical ventilation. (Source: JAMA)
Source: JAMA - February 23, 2021 Category: General Medicine Source Type: research

Patient Information: Nystagmus
This JAMA Patient Page describes the types, causes, and treatment of nystagmus, a rhythmic involuntary movement of the eyes. (Source: JAMA)
Source: JAMA - February 23, 2021 Category: General Medicine Source Type: research

Knows
My brother who I told you died, his daughter's grown. She's thirty-five. She's grown but she's a child because she's got that syndrome, what's-it-called, it's like she's happy all the time. Not Asperger's. What is that called? It's like she can't be sad. It's strange. Autism. Down ’s. It's really strange. Down Syndrome. Right. So anyway, her father died, my brother who I told you died. That's his daughter, she's my niece, and we were worried how to tell her her dad had died because we didn't know how she'd react. And then my other niece, her sister, she's the younger one bu t in a way she's always been the older one,...
Source: JAMA - February 23, 2021 Category: General Medicine Source Type: research

Covid-19 Communication —The Need for Humanity, Empathy, and Grace
In this narrative medicine essay, a medical school professor expresses gratitude for the caring and empathy expressed by the team caring for her mother hospitalized with COVID-19 and emphasizes the importance of humanity and compassion over facts and statistics for families physically separated from their critically ill loved ones. (Source: JAMA)
Source: JAMA - February 23, 2021 Category: General Medicine Source Type: research

Diagnosis and Treatment of Multiple Sclerosis
This narrative review discusses the epidemiology and pathophysiology of multiple sclerosis and summarizes current evidence on its diagnosis and treatment using disease-modifying therapies and nonpharmacological interventions. (Source: JAMA)
Source: JAMA - February 23, 2021 Category: General Medicine Source Type: research

Jama
(Source: JAMA)
Source: JAMA - February 23, 2021 Category: General Medicine Source Type: research

Surprise Billing —A Flashpoint for Major Policy Issues in Health Care
This Viewpoint discusses the unexpected large billing that can occur when a patient receives care from an out-of-network physician or center (surprise billing) —its root causes and recent legislation that will provide some patients with protection, but not all. (Source: JAMA)
Source: JAMA - February 23, 2021 Category: General Medicine Source Type: research

From Digitization to Digital Transformation
This Viewpoint lays out policy priorities for advancing the digital transformation of US health information systems, including funding of infrastructure and enforcement of standards for EHR interoperability, data sharing, and usability. (Source: JAMA)
Source: JAMA - February 23, 2021 Category: General Medicine Source Type: research

COVID-19 Rates Increased Where In-Person College Classes Were Held
Coronavirus disease 2019 (COVID-19) incidence increased by 56% in counties where colleges held in-person classes after the start of last fall ’s school year, the CDC reported. (Source: JAMA)
Source: JAMA - February 23, 2021 Category: General Medicine Source Type: research

Drug-Resistant Yeast Infections Spread in COVID-19 Unit
Pandemic-related lapses in infection control practices may have caused an outbreak of multidrug-resistant Candida auris yeast infections in a Florida hospital ’s coronavirus disease 2019 (COVID-19) unit, investigators from the CDC and the Florida Department of Health reported. (Source: JAMA)
Source: JAMA - February 23, 2021 Category: General Medicine Source Type: research