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Placebo—The Unknown Variable in a Controlled Trial
Maryanne Demasi, PhD; Tom Jefferson, MD
doi : 10.1001/jamainternmed.2020.8670
JAMA Intern Med. 2021;181(5):577-578
The use of a placebo in controlled trials is essential for the reliable assessment of a therapeutic drug. Sometimes trialists use an active placebo that can mimic the possible harms of the experimental drug with no therapeutic effects on the condition being treated. For example, active placebos, such as atropine, may be used in trials of antidepressants, where the drugs under investigation can cause noticeable harms and the risk of bias owing to unblinding may be high.1
Declining Accuracy of the Traditional Diamond-Forrester Estimates of Pretest Probability of Coronary Artery DiseaseTime for New Methods
Raymond J. Gibbons, MSc, MD; Todd D. Miller, MD
doi : 10.1001/jamainternmed.2021.0171
JAMA Intern Med. 2021;181(5):579-580
The evaluation of patients with chest pain begins with clinical assessment, followed by (selective) noninvasive testing and invasive coronary angiography. Clinical assessment alone can provide an estimate of the likelihood of obstructive, anatomic coronary artery disease (CAD) before any testing is performed—this is an estimation of pretest probability (ePTP). Diamond and Forrester1 proposed such pretest estimates in 1979, in combination with Bayes’ theorem of conditional probability, and the results of noninvasive tests, to estimate the posttest likelihood of obstructive, anatomic CAD. This Viewpoint summarizes our assessment of the evidence for a temporal decline in the accuracy of Diamond-Forrester estimates, indicates which current method for ePTP is most reliable, and explains why ePTP remains clinically useful.
Outpatient Dietary Management of Electrolyte Disorders During COVID-19Food as Medicine
Yuenting Diana Kwong, MD, MAS; Kathleen D. Liu, MD, PhD; Lowell J. Lo, MD
doi : 10.1001/jamainternmed.2020.8897
JAMA Intern Med. 2021;181(5):581-582
what should I eat?” is one of most common questions patients ask in the clinical setting. Patients with diabetes are asked to adhere to a low-carbohydrate diet, while patients with hypertension should consume a low-salt diet. But truthfully, the process of calculating the milliequivalents (mEq) of each food element is tedious and often not feasible. In this essay we describe a 97-year-old patient who learned to titrate condensed chicken soup like a medicine during the coronavirus 2019 (COVID-19) pandemic.
Association of Medicaid Expansion With Quality in Safety-Net Hospitals
Paula Chatterjee, MD, MPH; Mingyu Qi, MSc; Rachel M. Werner, MD, PhD
doi : 10.1001/jamainternmed.2020.9142
JAMA Intern Med. 2021;181(5):590-597.
Importance Safety-net hospitals (SNHs) operate under limited financial resources and have had challenges providing high-quality care. Medicaid expansion under the Affordable Care Act led to improvements in hospital finances, but whether this was associated with better hospital quality, particularly among SNHs given their baseline financial constraints, remains unknown.
Severe Hypoglycemia Risk With Long-Acting Insulin Analogs vs Neutral Protamine Hagedorn Insulin
Marie C. Bradley, PhD, MPharm, MScPH; Yoganand Chillarige, MPA; Hana Lee, PhD; et al.
doi : 10.1001/jamainternmed.2020.9176
JAMA Intern Med. 2021;181(5):598-607.
Importance Previous studies have found that the risk of severe hypoglycemia does not differ between long-acting insulin analogs and neutral protamine Hagedorn (NPH) insulin in patients with type 2 diabetes. However, these studies did not focus on patients 65 years or older, who are at an increased risk for hypoglycemia, or did not include patients with concomitant prandial insulin use.
Effect of a Multifaceted Clinical Pharmacist Intervention on Medication Safety After Hospitalization in Persons Prescribed High-risk MedicationsA Randomized Clinical Trial
Jerry H. Gurwitz, MD; Alok Kapoor, MD, MSc; Lawrence Garber, MD; et al.
doi : 10.1001/jamainternmed.2020.9285
JAMA Intern Med. 2021;181(5):610-618
Importance The National Action Plan for Adverse Drug Event (ADE) Prevention identified 3 high-priority, high-risk drug classes as targets for reducing the risk of drug-related injuries: anticoagulants, diabetes agents, and opioids.
Effect of Osteopathic Manipulative Treatment vs Sham Treatment on Activity Limitations in Patients With Nonspecific Subacute and Chronic Low Back PainA Randomized Clinical Trial
Christelle Nguyen, MD, PhD; Isabelle Boutron, MD, PhD; Rafael Zegarra-Parodi; et al.
doi : 10.1001/jamainternmed.2021.0005
JAMA Intern Med. 2021;181(5):620-630
Importance Osteopathic manipulative treatment (OMT) is frequently offered to people with nonspecific low back pain (LBP) but never compared with sham OMT for reducing LBP-specific activity limitations.
Associations of Fish Consumption With Risk of Cardiovascular Disease and Mortality Among Individuals With or Without Vascular Disease From 58 Countries
Deepa Mohan, PhD; Andrew Mente, PhD; Mahshid Dehghan, PhD; et al.
doi : 10.1001/jamainternmed.2021.0036
JAMA Intern Med. 2021;181(5):631-649
Importance Cohort studies report inconsistent associations between fish consumption, a major source of long-chain ?-3 fatty acids, and risk of cardiovascular disease (CVD) and mortality. Whether the associations vary between those with and those without vascular disease is unknown.
Deficits in Advance Care Planning for Patients With Decompensated Cirrhosis at Liver Transplant Centers
Arpan Arun Patel, MD, PhD; Gery W. Ryan, PhD; Diana Tisnado, PhD; et al.
doi : 10.1001/jamainternmed.2021.0152
JAMA Intern Med. 2021;181(5):652-660
Importance The burden of end-of-life care for patients with cirrhosis is increasing in the US, and most of these patients, many of whom are not candidates for liver transplant, die in institutions receiving aggressive care. Advance care planning (ACP) has been associated with improved end-of-life outcomes for patients with other chronic illnesses, but it has not been well-characterized in patients with decompensated cirrhosis.
Unmet Need for Equipment to Help With Bathing and Toileting Among Older US Adults
Kenneth Lam, MD; Ying Shi, PhD; John Boscardin, PhD; et al.
doi : 10.1001/jamainternmed.2021.0204
JAMA Intern Med. 2021;181(5):662-670
Importance Home modification through seemingly mundane equipment, such as grab bars and shower seats, mitigates injury, dependence, and reduced quality of life in older adults coping with increasing disability. However, whether these interventions are underused in the US is unclear.
Association of SARS-CoV-2 Seropositive Antibody Test With Risk of Future Infection
Raymond A. Harvey, MPH; Jeremy A. Rassen, ScD; Carly A. Kabelac, BS; et al.
doi : 10.1001/jamainternmed.2021.0366
JAMA Intern Med. 2021;181(5):672-679
Importance Understanding the effect of serum antibodies to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on susceptibility to infection is important for identifying at-risk populations and could have implications for vaccine deployment.
JAMA Internal Medicine—The Year in Review, 2020
Rita F. Redberg, MD, MSc
doi : 10.1001/jamainternmed.2021.0351
JAMA Intern Med. 2021;181(5):583-584
we welcome the promise of 2021—to start to get control of the global pandemic via vaccinations against SARS-CoV-2 and effective public health measures and hopefully let the country get back to the hard work of promoting high-value health care that is affordable and available to all Americans. As a new US administration with significant health care expertise begins work, we are hopeful to see progress on complex issues, such as value-based payment, drug pricing, and transparency issues, to name a few.1We are interested to learn what the impact of sharply reduced elective health care visits and reduced cancer screenings will be as we track rates of breast cancer, lung cancer, heart disease, and many others in the coming decade. We are now in the 10th year of the JAMA Internal Medicine Less is More series and are pleased to see international attention to the harms of overdiagnosis and overtreatment and on programs to increase high-value care. Of course, our work is far from done, as health care costs continue to rise much faster than the gross domestic product and approach one-fifth of the US economy.
Screening for Asymptomatic Carotid Artery Stenosis in Adult PatientsUnclear Benefit but Downstream Risks
Salomeh Keyhani, MD, MPH; Eric M. Cheng, MD
doi : 10.1001/jamainternmed.2021.0029
JAMA Intern Med. 2021;181(5):585-587
Carotid artery stenosis is a risk factor for stroke, but a relatively small proportion of strokes (approximately 11%) can be attributed to atherosclerosis of the internal carotid arteries. There is no evidence that screening for carotid artery stenosis in the asymptomatic adult population (ie, no history or symptoms of stroke or transient ischemic attack) will reduce the risk of stroke, but there are downstream risks from identifying patients with carotid stenosis. Thus, in a recommendation statement1 and updated evidence report and systematic review,2 the US Preventive Services Task Force (USPSTF) has reaffirmed its 2014 recommendation3 against screening for asymptomatic carotid artery stenosis in the general adult population (D recommendation) based on an assessment of no benefit and possible harm.
Recommendations From Breast Cancer Centers for Frequent Screening Mammography in Younger Women May Do More Harm Than Good
Anand R. Habib, MD, MPhil; Deborah Grady, MD, MPH; Rita F. Redberg, MD, MS
doi : 10.1001/jamainternmed.2021.0161
JAMA Intern Med. 2021;181(5):588-589
Breast cancer continues to be the leading new cancer diagnosis and the second leading cause of death among women in the US.1 To reduce the incidence, morbidity, and mortality associated with breast cancer, accessible and affordable screening, diagnosis, treatment, and surveillance strategies that balance harms and benefits are needed.
The Cost and Safety of Insulin in Older Adults
Elbert S. Huang, MD, MPH; Kasia J. Lipska, MD, MHS
doi : 10.1001/jamainternmed.2020.9185
JAMA Intern Med. 2021;181(5):608-609
In the past 2 decades, managing type 2 diabetes has become more expensive, mostly because of higher spending on prescription medications, principally insulin.1 Approximately 20% to 30% of patients with type 2 diabetes require insulin to achieve a desired glycemic control target, and insulin has increased in price by more than 300% during the past decade.2 Because patients bear an increasing share of health care costs because of high out-of-pocket expenses in the form of deductibles, copayments, or coinsurance rates,3 it is not surprising that approximately one-quarter face a high out-of-pocket financial burden.4 In this context, using lower-cost insulin options, such as human insulin isophane suspension, compared with insulin analogs, may lessen the financial burden. However, use of insulin isophane suspension requires that practitioners and patients carefully consider its safety and efficacy.
Adverse Drug Events After Hospitalization—Are We Missing the Mark?
Tasce Bongiovanni, MD, MPP; Michael A. Steinman, MD
doi : 10.1001/jamainternmed.2020.9282
JAMA Intern Med. 2021;181(5):618-619
Care transitions, from an acute care hospitalization to home, are an especially dangerous time for older adults and can affect patient outcomes, cause harm, and, when done poorly, be extremely costly.1,2 Patients receive medications from new and different clinicians, which can lead to errors or discrepancies,3 including inappropriate discontinuation or unintentional inclusion of medications.4 Even if not prescribed erroneously, new medications have the potential to cause an adverse event. At least 20% of older adults will experience an adverse event in the weeks following hospitalization, with most being secondary to adverse drug-related events (ADEs). Of these, half are considered preventable or ameliorable.5
Fish, Cardiovascular Disease, and Mortality—What Is the Global Evidence?
Dariush Mozaffarian, MD, DrPH
doi : 10.1001/jamainternmed.2021.0045
JAMA Intern Med. 2021;181(5):649-651
Fish and shellfish (hereafter referred to as fish) are major sources of the dietary long-chain ?-3 fatty acids eicosapentaenoic acid (20:5n-3) and docosahexaenoic acid (22:6n-3) and also contain other nutrients, such as vitamin D, riboflavin, iodine, calcium, phosphorus, magnesium, potassium, zinc, and iron. The summed results of observational studies of fish intake, randomized clinical trials of fish oil supplements, and associated mechanistic and experimental studies suggest that regular fish consumption may decrease the incidence of myocardial infarction (MI) and coronary heart disease (CHD), with more uncertain effects on stroke, total cardiovascular disease (CVD), or other composite events, such as all-cause mortality.1-3 Yet, these summed findings obscure the inconsistent results of individual clinical trials, which have raised uncertainty and controversy about health benefits. Proposed explanatory factors for the heterogeneity have included dose, type of fish (oily vs white), methods for preparation of fish (baked or grilled vs fried), background fish consumption, underlying participant risk, outcome (eg, fatal CHD vs combined CVD events), and even presence of trace contaminants such as mercury or organic pollutants. In addition, associated behaviors of individuals who eat fish (eg, other dietary factors and socioeconomic status) could overestimate benefits in observational studies.
Advance Care Planning in Liver Transplant—Preparing for Both Life and Death
Nneka N. Ufere, MD; Jennifer C. Lai, MD, MBA
doi : 10.1001/jamainternmed.2021.0149
JAMA Intern Med. 2021;181(5):660-661
Patients with a diagnosis of decompensated cirrhosis experience high morbidity and have a median life expectancy of approximately 2 years in the absence of a liver transplant.1 Although thousands of patients receive a life-saving liver transplant every year, many thousands more die from complications of liver failure. Despite their poor prognosis, patients with decompensated cirrhosis are more likely to receive intensive and costly care during their last months of life compared with patients with other chronic life-limiting conditions.2 This finding suggests that patients with decompensated cirrhosis may have unique experiences within the health care system that make them particularly vulnerable to receiving high-intensity care at the end of life. Advance care planning (ACP), the process by which patients and their families prepare for decision-making for future medical care that is consistent with their goals, values, and preferences, has been associated with reduced emotional distress and health care use at the end of life for patients with serious illnesses.3 However, previous work has shown that hepatology clinicians rarely engage patients with decompensated cirrhosis in ACP.4,5
Addressing Unmet Adaptive Equipment Needs Through Primary Care
Brian E. McGarry, PT, PhD; Jason R. Falvey, PT, DPT, PhD
doi : 10.1001/jamainternmed.2021.0398
JAMA Intern Med. 2021;181(5):670-671
Older adults have a clear preference for aging in place, even as that becomes more difficult because of age-related health and mobility declines.1 Given the devastating effects of coronavirus disease 2019 (COVID-19) on the US nursing home population, the desire to avoid residential elder care settings is likely to grow. Yet, staying at home requires that individuals are as safe as possible from adverse events, such as falls, and capable of performing necessary activities so as to maintain a reasonable quality of life.
The Health Consequences of Restrictive Abortion Laws
Jamila Perritt, MD, MPH; Daniel Grossman, MD
doi : 10.1001/jamainternmed.2020.9279
JAMA Intern Med. 2021;181(5):713-714
In this issue of JAMA Internal Medicine, Gaj et al1 report that between 2017 and 2020, 35 states enacted 227 laws that restricted access to abortion care, and only 12 states and Washington, DC enacted 29 laws that expanded access. The findings are part of an accelerating trend since 2010 of states enacting laws that restrict access to abortion with deleterious consequences for people seeking care.
How to Advise Persons Who Are Antibody Positive for SARS-CoV-2 About Future Infection Risk
Mitchell H. Katz, MD
doi : 10.1001/jamainternmed.2021.0374
JAMA Intern Med. 2021;181(5):679
as a physician working in New York, New York, where coronavirus disease 2019 (COVID-19) hit hard in March and April of 2020, people often ask me how to interpret their severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) antibody results. Many people have positive test results for the antibody, some of them received a diagnosis of COVID-19, some of them had symptoms that were consistent with COVID-19 but were never tested because of a limited availability of testing, and some were never symptomatic but learned that they were positive for the antibody on a subsequent laboratory test. If they are positive, they want to know whether they are protected from a future infection with the virus.
Challenges in Testing for SARS-CoV-2 Among Patients Who Recovered From COVID-19
Mitchell H. Katz, MD
doi : 10.1001/jamainternmed.2020.7575
JAMA Intern Med. 2021;181(5):704-705
among patients who have recovered from COVID-19, repeated testing for SARS-CoV-2 may be done weeks or months after infection either as part of routine screening (eg, screening nursing home personnel on a weekly basis to prevent transmission of infections to patients) or because of the development of symptoms that are worrisome for reinfection. Unfortunately, the interpretation of positive test results in patients who have previously recovered from COVID-19 is fraught. The best widely available test, a real-time polymerase chain reaction (RT-PCR), is very sensitive for fragments of viral RNA and can be positive because of nonviable remnants of the virus. Currently, there is not a widely available test for determining whether the virus can reproduce and transmit infection.
Clinical Trials Without Clinical Sites
Steven R. Cummings, MD
doi : 10.1001/jamainternmed.2020.9223
JAMA Intern Med. 2021;181(5):680-684
Clinical trials conducted at clinical sites are limited to enrolling people who live nearby and are able to attend visits at clinics. Some types of clinical trials can be performed without clinical sites, which enables people to participate regardless of proximity to a clinical site or limitations that make visits difficult. Trials at clinical sites involve face-to-face relationships with in-person collection of informed consent, examinations, data, and specimens. In contrast, without clinical sites, informed consent and data are obtained online, limited examinations can be performed by telemedicine or visiting research nurses, biospecimens can be collected by visiting nurses or local laboratories, and treatments can be sent to homes or administered by nurses in participants’ homes. Trials without clinical sites require internet access and must adapt to the lack of face-to-face interactions with study staff, with communication conducted by email, telephone, or video. Many trials cannot be performed entirely without clinical sites because they require examinations, tests, or treatments that must be given at a clinical site. However, some of the methods required for trials without sites, such as online data collection, follow-up visits by telemedicine or research nurses, and delivery of treatments to home, could reduce the need for visits to clinical sites and reduce the burden of participating in a clinical trial. When feasible, conducting clinical trials without clinical sites has the potential to expand participation and the generalizability of their results.
Insulin Pump Treatment for the Hospitalized Patient
Samantha Coffer, MD; Lindsay Schlichting, BSN, RN, CDCES; John M. Cunningham, MD
doi : 10.1001/jamainternmed.2021.0106
JAMA Intern Med. 2021;181(5):685-686
A 52-year-old woman with prior kidney transplant and type 1 diabetes (T1D) presented to the hospital with pyelonephritis. To treat her diabetes, she used continuous subcutaneous insulin infusion, better known as insulin pump therapy. In the emergency department, the patient complained of nausea and vomiting. Her insulin pump was disconnected because of concerns over pump management and fear of hypoglycemia due to poor oral intake. After transitioning to multiple daily injections, she developed symptomatic hypoglycemia and hyperglycemia, with blood glucose levels ranging from 48 mg/dL (to convert to millimoles per liter multiply by 0.0555) through 324 mg/dL. The endocrinologist and the certified diabetes educator consulted to review the patient’s insulin pump settings and adjust insulin dosing. In light of the patient’s hemoglobin A1c level of 7.7% (to convert to the proportion of total hemoglobin, multiply by 0.01), which demonstrated near goal ambulatory glucose control, the patient resumed insulin pump therapy before discharge.
Avoiding a Crisis With High-Deductible Insurance PlansA Teachable Moment
Jenny A. Shih, MD; Katherine C. Wrenn, MD
doi : 10.1001/jamainternmed.2021.0109
JAMA Intern Med. 2021;181(5):687-688
A healthy 22-year-old man presented to a primary care clinic after 2 months of persistent nausea and vomiting. He had presented 2 months prior with back pain and intermittent vomiting without associated symptoms and underwent laboratory testing with results showing mild anemia. He returned for repeat testing, which demonstrated normal hemoglobin and hematocrit levels. Over the next 2 months, his symptoms progressed with ongoing nausea and vomiting, unintentional weight loss of 20 pounds, fatigue, and light-headedness. He denied fever, chills, or night sweats. Physical examination was notable for blood pressure of 100/50 mm Hg and heart rate of 103 beats per minute. His physician recommended further laboratory evaluation; however, he declined due to concerns about out-of-pocket costs with his high-deductible insurance plan because he felt he could not afford to pay for more testing following the testing he had paid for 2 months prior.
Missed Opportunity for Fall PreventionA Teachable Moment
Byron Crowe, MD; Elizabeth Eckstrom, MD, MPH; Juan N. Lessing, MD
doi : 10.1001/jamainternmed.2021.0221
JAMA Intern Med. 2021;181(5):689-690
A 76-year-old community-dwelling woman with a history of chronic obstructive pulmonary disease presented to the emergency department with hip pain after a fall. The results of imaging showed a displaced fracture of the left inferior pubic ramus. She was admitted for surgical treatment of the fracture.
Payment for Dialysis Services in the Individual Market
Erin Trish, PhD; Matthew Fiedler, PhD; Ning Ning, PhD; et al.
doi : 10.1001/jamainternmed.2020.7372
JAMA Intern Med. 2021;181(5):698-699
Although 80% of US patients who receive dialysis for end-stage kidney disease (ESKD) have Medicare as their primary payer, recent evidence suggests an increasing share with other coverage.1 Some policy makers allege that dialysis facilities encourage individual market enrollment by subsidizing individual market premiums through contributions to patient assistance foundations.2 This strategy could increase profits for facilities because commercial plans pay more for dialysis than Medicare,3 but could also increase individual market spending if patients receiving dialysis have above-average spending.
Unemployment Insurance, Health-Related Social Needs, Health Care Access, and Mental Health During the COVID-19 Pandemic
Seth A. Berkowitz, MD, MPH; Sanjay Basu, MD, PhD
doi : 10.1001/jamainternmed.2020.7048
JAMA Intern Med. 2021;181(5):699-702
More than 30 million jobs have been lost during the coronavirus disease 2019 (COVID-19) pandemic.1 Unemployment insurance (UI) was temporarily expanded by the Coronavirus Aid, Relief, and Economic Security (CARES) Act,2 but further reform is under debate. Key CARES Act provisions were adding $600 weekly federal payments to state payments (Federal Pandemic Unemployment Compensation), longer benefit duration (Pandemic Emergency Unemployment Compensation), and broadened eligibility for minimum-wage, self-employed, contract, and gig workers (Pandemic Unemployment Assistance).2
Assessment of SARS-CoV-2 RNA Test Results Among Patients Who Recovered From COVID-19 With Prior Negative Results
Flora Marzia Liotti, PhD; Giulia Menchinelli, PhD; Simona Marchetti, BSc; et al.
doi : 10.1001/jamainternmed.2020.7570
JAMA Intern Med. 2021;181(5):702-704
Some patients who have recovered from coronavirus disease 2019 (COVID-19) with documented negative real-time polymerase chain reaction (RT-PCR) results at the time of recovery have had subsequent positive RT-PCR test results for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)1,2 in the absence of any symptoms suggestive of new infection.3 It is unknown whether such patients are infectious and whether they should be quarantined. Real-time PCR is not a viral culture and does not allow determination of whether the virus is viable and transmissible. We investigated RT-PCR retested positive nasal/oropharyngeal swab (NOS) samples from recovered patients with COVID-19 with prior negative results for the presence of replicative SARS-CoV-2 RNA.4
Excess Mortality in California During the Coronavirus Disease 2019 Pandemic, March to August 2020
Yea-Hung Chen, PhD, MS; M. Maria Glymour, ScD, MS; Ralph Catalano, PhD, MRP; et al.
doi : 10.1001/jamainternmed.2020.7578
JAMA Intern Med. 2021;181(5):705-707
Few studies on excess deaths during the coronavirus disease 2019 (COVID-19) pandemic in the US have documented how excess mortality varies across population subgroups.1,2 Using time-series models, we estimated excess deaths in California between March and August 2020 by age, sex, race/ethnicity, and educational level. California has a population of 39.5 million, which is approximately 12% of the US population of 328.2 million.
Association of Medical Stimulants With Mortality in the US From 2010 to 2017
Joshua C. Black, PhD; Gabrielle E. Bau, MS; Janetta L. Iwanicki, MD; et al.
doi : 10.1001/jamainternmed.2020.7850
JAMA Intern Med. 2021;181(5):707-709
The role of nonopioids in the drug overdose epidemic in the US is frequently overshadowed. From 2015 to 2016, mortality rates involving cocaine and psychostimulants were smaller than opioids, but were rising faster than opioids.1 We examined individual substances listed on death certificates to better understand stimulant-associated mortality and assess rates over time.
Association of Smoking and Cumulative Pack-Year Exposure With COVID-19 Outcomes in the Cleveland Clinic COVID-19 Registry
Katherine E. Lowe, MSc; Joe Zein, MD, PhD; Umur Hatipo?lu, MD; et al.
doi : 10.1001/jamainternmed.2020.8360
JAMA Intern Med. 2021;181(5):709-711
There is limited and contradictory evidence on the association of smoking status with adverse outcomes of severe acute respiratory syndrome coronavirus 2 infection.1-3 Furthermore, current smoking status does not encompass the cumulative effect of smoking. To our knowledge, no studies have assessed the cumulative effect of smoking over time, as measured by pack-years, though a single study of coronavirus disease 2019 (COVID-19) in a small cohort of 102 patients with lung cancer found that the patients with severe outcomes had a higher average pack-year history (30 vs 20 years).4 We hypothesize that there is an adverse association of cumulative smoking exposure, as measured by pack-years, with outcomes of patients with COVID-19.
State Legislation Related to Abortion Services, January 2017 to November 2020
Eoin B. Gaj, BS; Jessica N. Sanders, PhD, MSPH; Phillip M. Singer, PhD
doi : 10.1001/jamainternmed.2020.8781
JAMA Intern Med. 2021;181(5):711-713
The 1973 US Supreme Court decision, Roe v Wade, simultaneously established the constitutional right to abortion and provided states with regulatory power over access to reproductive health services.1 Since Roe v Wade, the Supreme Court has heard 43 cases related to abortion, nearly all from states that have restricted access.2 To understand trends in abortion policies among states, we analyzed enacted legislation between January 2017 and November 2020.
Clinical Characteristics and Outcomes of Hospitalized Women Giving Birth With and Without COVID-19
Karola S. Jering, MD; Brian L. Claggett, PhD; Jonathan W. Cunningham, MD; et al.
doi : 10.1001/jamainternmed.2020.9241
JAMA Intern Med. 2021;181(5):714-717
Physiologic adaptations and changes in immune regulation may increase the risk of morbidity and mortality in pregnant women with respiratory infections.1,2 The effects of coronavirus disease 2019 (COVID-19) in pregnancy have not been fully delineated. We compared the clinical characteristics and outcomes of hospitalized women who gave birth with and without COVID-19.
Assessment of Screening Mammography Recommendations by Breast Cancer Centers in the US
Neal S. Patel, MEng; Mark Lee, BS, BA; Jennifer L. Marti, MD
doi : 10.1001/jamainternmed.2021.0157
JAMA Intern Med. 2021;181(5):717-719
Most countries recommend that women receive breast cancer screening every 2 years between ages 50 and 69 years.1 In 2009 and 2016, the US Preventive Services Task Force (USPSTF) updated its recommendations to advise that women receive screening mammography every 2 years between ages 50 and 74 years, with the decision to begin screening earlier (ie, ages 40-49 years) based on individual evaluation of risks and benefits.2 The updated USPSTF recommendations acknowledged the risk of overdiagnosis and the lack of reduction in all-cause mortality associated with screening that starts at any age.2 In 2015, the American Cancer Society recommended annual screening between ages 45 and 55 years, with screening every 1 to 2 years thereafter.3
Progressive PR Prolongation in an Asymptomatic Man
Thabo Mahendiran, MD; Claudia Herrera-Siklody, MD; Patrizio Pascale, MD
doi : 10.1001/jamainternmed.2020.9216
JAMA Intern Med. 2021;181(5):691-692
A man in his 70s attended his local medical center for an evaluation prior to travel. His medical history was remarkable only for recurrent deep vein thrombosis, for which he took rivaroxaban as the only medical treatment. He was completely asymptomatic. On clinical examination, he was found to be afebrile, with a respiratory rate of 16 breaths/min, oxygen saturation of 99% on room air, and a blood pressure of 145/75 mm Hg. His heart rate was 54 beats/min, prompting the recording of an electrocardiogram (ECG) (Figure). On retaking of the history, the patient was adamant that he had never experienced any dizziness, palpitations, or blackouts. Owing to the appearance of the ECG, the patient was referred for a cardiologic evaluation.
Sustained Postural Wide QRS Complex Tachycardia in an Intensive Care Unit Patient
Yinn Shaung Ooi, MD; Maria Eleni Drosou, MD; Gan-Xin Yan, MD, PhD
doi : 10.1001/jamainternmed.2021.0001
JAMA Intern Med. 2021;181(5):693-694
A patient in their 30s with obesity and a history of alcohol use was found to have recurrent arrhythmia on telemetry during an admission for acute pancreatitis. The patient had episodes of wide QRS complex tachycardia that were repetitive and frequent, sometimes sustained in duration, and interrupted only by brief intervals of normal sinus rhythm (Figure). These were associated with palpitations, particularly when the patient assumed a left lateral decubitus position, but not with chest pain, dyspnea, or presyncope or hemodynamic compromise. Two-dimensional echocardiography results showed normal left ventricular function without structural abnormalities. This occurred 3 weeks into the patient’s prolonged hospitalization that was complicated by delirium tremens, which led to intubation and ventilator-associated pneumonia that required multiple courses of antibiotic therapy. Two weeks before encountering the described arrhythmia, the patient had undergone insertion of a peripherally inserted central catheter (PICC) and tracheostomy. In response to the patient's wide QRS complex tachycardia, their electrolytes were replaced, and a 150-mg intravenous bolus of amiodarone was administered followed by an infusion at 1 mg per minute. However, this led to minimal to no effect on the arrhythmia burden.
ST Segment Elevation in a Patient With Myocardial MetastasesWhat Is Up With That?
Jonathan R. Salik, MD; Erika J. Parisi, MD; Rahul Sakhuja, MD, MPP
doi : 10.1001/jamainternmed.2021.0101
JAMA Intern Med. 2021;181(5):695-696
A man in his 70s with a history of multiple prior ST-segment elevation myocardial infarctions (STEMIs) and squamous cell carcinoma of the lung with metastatic disease to the brain and myocardium presented to the emergency department with progressive dyspnea on exertion. Ten months prior, the patient developed chest pain and was found to have an inferior STEMI from late in-stent thrombosis, for which he received 2 drug-eluting stents to the right coronary artery. A subsequent transthoracic echocardiogram demonstrated preserved left ventricular systolic function without regional wall motion abnormalities, a moderate pericardial effusion, and a new 2.8?×?2.6-cm mass in the left ventricular mid-apical anteroseptum consistent with a metastatic myocardial tumor (Figure, A).
Should I Get a Coronary CT Scan?
Michael A. Incze, MD, MSEd
doi : 10.1001/jamainternmed.2021.0168
JAMA Intern Med. 2021;181(5):732
Community Outbreak Investigation of SARS-CoV-2 Transmission Among Bus Riders in Eastern China—More Detailed Studies Are Needed
Paul Anantharajah Tambyah, MD; John Conly, MD; Andreas Voss, MD, PhD
doi : 10.1001/jamainternmed.2020.8567
JAMA Intern Med. 2021;181(5):719-720
To the Editor We read with interest the report by Shen et al1 and the ensuing media flurry that followed suggesting that the episode described provided evidence for “airborne spread” of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus. While we are aware that the virus may be “opportunistically” airborne during certain aerosol-generating procedures, we find it hard to believe that this was the case with this super-spreading event. There are several reasons for our skepticism:
Community Outbreak Investigation of SARS-CoV-2 Transmission Among Bus Riders in Eastern China—More Detailed Studies Are Needed—Reply
Ye Shen, PhD; Changwei Li, PhD; Feng Ling, MD
doi : 10.1001/jamainternmed.2020.8570
JAMA Intern Med. 2021;181(5):720-721
In Reply Tambyah et al raise several reasons why they do not believe that our case report of bus riders in eastern China1 supports an airborne transmission route of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).
Physicians’ Electrocardiogram Interpretations
Jean Jacques Noubiap, MD, MMed; Joseph Kamtchum-Tatuene, MD, MRes
doi : 10.1001/jamainternmed.2020.8598
JAMA Intern Med. 2021;181(5):721
To the Editor Cook and colleagues1 should be congratulated for compiling studies on the accuracy of medical students’ or physicians’ electrocardiogram (ECG) interpretations. However, in reading their report, we identified several methodological issues that undermine the validity of their analyses and the suggested implications.
Physicians’ Electrocardiogram Interpretations
Mengyang He, MD; Xiangling Deng, MD; Wenquan Niu, PhD
doi : 10.1001/jamainternmed.2020.8605
JAMA Intern Med. 2021;181(5):721-722
To the Editor We read with great interest the systematic review and meta-analysis by Cook et al,1 who found that the accuracy of physicians’ interpretations of electrocardiograms (ECGs), whether trained in interpretation or not, was inadequate, indicating the importance of enhancing ECG training for physicians. Electrocardiograms have been widely used from intensive care to regular physical examination, and have played an important role in the development of cardiovascular medicine.2 The conclusions of this meta-analysis1 are of great importance for medical construction. However, we raise 3 concerns regarding this systematic review and meta-analysis.
Physicians’ Electrocardiogram Interpretations—Reply
David A. Cook, MD, MHPE; Martin V. Pusic, MD, PhD
doi : 10.1001/jamainternmed.2020.8652
JAMA Intern Med. 2021;181(5):722-723
In Reply We appreciate the concerns raised in response to our Original Investigation1 and the suggestions for additional analyses we might have conducted in our meta-analysis of the accuracy of physicians’ electrocardiogram (ECG) interpretations. The comments of the authors of the Letters to the Editor highlight the trade-offs involved in summarizing a literature that is heterogeneous both in methodologic quality and in results.2-4 Indeed, we wrestled with whether or not to include such subgroup and sensitivity analyses as we planned our statistical approach. Ultimately, we deliberately decided to keep the analyses simple and parsimonious, to avoid conveying a false sense of precision in the quantitative results and to keep the message clear and focused.
Second-degree Atrioventricular Block
Laszlo Littmann, MD, PhD
doi : 10.1001/jamainternmed.2020.8601
JAMA Intern Med. 2021;181(5):723-724
To the Editor In a recent issue of JAMA Internal Medicine, Siegel et al1 presented an interesting case of an elderly person who experienced sudden cardiac death. Autopsy revealed that the cause of death was overdose with fentanyl and hydrocodone. Postmortem interrogation of an implanted loop recorder at the time of death demonstrated paroxysmal atrioventricular (AV) block resulting in asystole. Immediately preceding asystole, there were episodes of second-degree AV block that were characterized as Mobitz type II block. These episodes, however, were more typical for type I block. I believe it is important to correct this mistake because reclassification of the second-degree AV block clarifies the sequence of cardiac events surrounding the patient’s death.
Second-Degree Atrioventricular Block—Reply
Emily R. Siegel, BS; James W. Salazar, MD, MAS; Zian H. Tseng, MD, MAS
doi : 10.1001/jamainternmed.2020.8595
JAMA Intern Med. 2021;181(5):724
In Reply We thank Littmann for his comments on our Challenges in Clinical Electrocardiography.1 He asserts that the patient’s rhythm strip is consistent with Mobitz type I atrioventricular (AV) block and that this is important for understanding the cardiac events surrounding the patient’s death. We acknowledge that this is a challenging rhythm strip to perfectly discern owing to the low quality of the implantable loop recording and some ambiguous findings. On close analysis, Littmann has isolated an instance (strip II) in which it does appear that the PR interval prolongs and then shortens before and after a blocked P wave. Thus, we agree that this particular portion of the rhythm strip is most consistent with Mobitz I, which may be owing to the effect of fentanyl on the AV node via vagal tone. However, in another instance (strip I), the PR and RR intervals are constant and preserved through blocked P waves, which is consistent with infranodal block and Mobitz II. Given evidence of extant infranodal conduction disease by virtue of a wide QRS complex, the very long PR interval, both left and right bundle branch blocks on prior electrocardiograms, and the patient’s history of syncope, this patient has substrate for infranodal block as well. In other words, a patient can have features consistent with both Mobitz I (nodal) and Mobitz II (infranodal) second degree block, as the rhythm strip suggests in this case.
Timing of Dialysis Initiation and End-stage Kidney Disease Incidence
Qi Zhi Clayton Yang
doi : 10.1001/jamainternmed.2020.8809
JAMA Intern Med. 2021;181(5):724-725
To the Editor I would like to thank Hsu et al1 for their study investigating the trends between timing of dialysis initiation and end-stage kidney disease (ESKD) incidence among members of the Kaiser Permanente Northern California (KPNC) system. The study reported that timing of dialysis initiation based on estimated glomerular filtration rates (eGFR) had important effects on the size of the population with ESKD.
Timing of Dialysis Initiation and End-Stage Kidney Disease Incidence—Reply
Chi-yuan Hsu, MD, MSc; Alan S. Go, MD
doi : 10.1001/jamainternmed.2020.8806
JAMA Intern Med. 2021;181(5):725-726
In Reply We thank Yang for his interest in our article.1 We agree that our study population is not nationally representative. However, national dialysis registries such as the US Renal Data System lack information on the size or estimated glomerular filtration rate (eGFR) distribution of the underlying at-risk population from which patients with end-stage kidney disease (ESKD) arise. They are thus unable to address the question we aimed to answer.
Preventing Opioid-Induced Constipation
Chaker Ben Salem, MD; Asma Ben Abdelkrim, MD; Bouraoui Ouni, MD
doi : 10.1001/jamainternmed.2020.8894
JAMA Intern Med. 2021;181(5):726
To the Editor In their article, Saha et al1 do not include peripherally acting ?-opioid receptor antagonists (PAMORAs) as a possible option for prevention and treatment of opioid-induced constipation (OIC). A more biologically plausible approach to management of OIC is to use an effective PAMORA. In patients with cancer or noncancer-related pain who need opioid therapy for pain management, prescription of a prolonged-release opioid combined with PAMORA has been shown to be helpful in preventing OIC.2 Laxatives have a nonspecific action and do not target the underlying mechanisms of OIC, whereas PAMORAs constitute a novel class of drugs which reverse OIC. The main available PAMORAs are methylnaltrexone, naldemedine, and naloxegol for the treatment of OIC, and numerous clinical studies support their safety and efficacy.
Preventing Opioid-Induced Constipation—Reply
Srishti Saha, MD; Piyush Nathani, MD; Arjun Gupta, MD
doi : 10.1001/jamainternmed.2020.8886
JAMA Intern Med. 2021;181(5):726-727
In Reply We thank Ben Salem and colleagues for their interest in our article.1 In line with their letter, as well as with recommendations from guideline sources (including the American Gastroenterological Association, the European Society of Medical Oncology, and the Multinational Association of Supportive Care in Cancer), we agree that peripherally acting ?-opioid receptor antagonists (PAMORAs) play an important role in managing established opioid-induced constipation (OIC).2-4 However, we are unaware of data to support their routine use in OIC prevention. Traditional laxatives remain first-line pharmacologic agents to both prevent and treat OIC, with PAMORAs reserved to treat laxative-refractory OIC.2-4
Updated Information About Index Patient in Study of SARS-CoV-2 Transmission Among Bus Riders in Eastern China
doi : 10.1001/jamainternmed.2020.8608
JAMA Intern Med. 2021;181(5):727.
in the Original Contribution “Community Outbreak Investigation of SARS-CoV-2 Transmission Among Bus Riders in Eastern China,”1 published online first on September 1, 2020, in JAMA Internal Medicine, corrections were made to update information about the index patient from a subsequent field investigation and to add an omitted acknowledgment to thank the index patient and her family members for providing permission to publish this information. The authors provide explanation in a related Letter in Reply,2 and the article has been corrected.
Error in the Results Section
doi : 10.1001/jamainternmed.2020.9154
JAMA Intern Med. 2021;181(5):727
in the article titled “Association of Testosterone Levels With Anemia in Older Men: A Controlled Clinical Trial”1 published in the April 2017 issue of JAMA Internal Medicine, there was an error in the data presented in the Results section. Where it previously said “at month 12, 12 of 24 (58.3%) testosterone-treated men with unexplained anemia at baseline were no longer anemic, compared with 6 of 24 (22.2%) placebo-treated men,” the numerator was changed to 14 in the first case, and the denominator to 24 in the second case. This article was corrected online.
Error in Results Data
doi : 10.1001/jamainternmed.2021.0340
JAMA Intern Med. 2021;181(5):727.
in the Research Letter titled “Association of Smoking and Cumulative Pack-Year Exposure With COVID-19 Outcomes in the Cleveland Clinic COVID-19 Registry,”1 published online January 25, 2021, there was an error in data reported in the Results section. For heavy smokers who were 1.89 times more likely to die following a coronavirus disease 2019 diagnosis, the correct 95% CI is 1.29 to 2.76. The article has been corrected online.
Error in Figure
doi : 10.1001/jamainternmed.2021.1353
JAMA Intern Med. 2021;181(5):727
the Challenges in Clinical Electrocardiography titled, “Progressive PR Prolongation in an Asymptomatic Man,”1 published online March 1, 2021, included an error in the Figure in which the labels identifying the PR intervals were not visible. The article has been corrected online.
Error in Author Affiliation
doi : 10.1001/jamainternmed.2021.1536
JAMA Intern Med. 2021;181(5):727
in the Original Investigation titled “Associations of Fish Consumption With Risk of Cardiovascular Disease and Mortality Among Individuals With or Without Vascular Disease From 58 Countries,”1 published online March 8, 2021, in JAMA Internal Medicine, the author affiliation for Sadi Gulec was incorrect. The correct affiliation is Cardiology Department, Ankara University Medical School, Ankara, Turkey. This article has been corrected.
Error in Figure Value
doi : 10.1001/jamainternmed.2021.2050
JAMA Intern Med. 2021;181(5):727
in the Original Investigation entitled “Effect of a Multifaceted Clinical Pharmacist Intervention on Medication Safety After Hospitalization in Persons Prescribed High-risk Medications: A Randomized Clinical Trial,”1 the value listed in the “Randomized” oval of the Figure was “3606,” but should be “459.” This article was corrected online.
JAMA Internal Medicine Peer Reviewers in 2020
doi : 10.1001/jamainternmed.2021.0185
JAMA Intern Med. 2021;181(5):e210185.
