JAMA Current Issue

Highlights for February 20, 2018

Tue, 20 Feb 2018 00:00:00 GMT

Does Medicine Overemphasize IQ?

Emanuel EJ, Gudbranson E. — Tue, 20 Feb 2018 00:00:00 GMT

In this Viewpoint, Ezekiel Emanuel argues that emotional intelligence (EQ) is as important as IQ for the effective practice of medicine and calls for medical schools to evaluate the EQ of applicants and provide opportunities to enhance EQ among medical students.

Principles for a Framework for Alternative Payment Models

Nussbaum S, McClellan M, Metlay G. — Tue, 20 Feb 2018 00:00:00 GMT

This Viewpoint describes the Health Care Payment Learning and Action Network’s alternative payment model classification system and its framework principles.

Accountable Care at the Frontlines of a Health System

Ganguli I, Ferris TG. — Tue, 20 Feb 2018 00:00:00 GMT

This Viewpoint discusses tensions between the goals and realities of accountable care organizations and suggests ways for health system leaders to address these issues and improve health care quality and reduce costs.

Teaching Internal Medicine Residents About Palliative Care

Rosenberg LB. — Tue, 20 Feb 2018 00:00:00 GMT

In this essay, a palliative care physician reviews the case of a dying man who was admitted during her two-week tour as an attending physician for internal medicine as a good teaching case for residents to learn how to treat patients in the last moments of their lives.

Preventing Delirium in the ICU

Delaney A, Hammond N, Litton E. — Tue, 20 Feb 2018 00:00:00 GMT

Delirium is a complex problem, has a poorly understood pathophysiology, and usually manifests as a fluctuating disturbance of consciousness and cognition that develops over a short period and is associated with physical or mental illness. Delirium is not exclusively a complication of critical illness but develops in approximately one-third of patients treated in intensive care units (ICUs). The majority of these patients experience hypoactive delirium, a quietly confused state, rather than the more notable cases of agitated delirium, which present as overt hallucinations and hyperactivity.

Disentangling Health Care Billing

Lee VS, Blanchfield BB. — Tue, 20 Feb 2018 00:00:00 GMT

For many physicians, the term administration elicits a negative response. In fact, some administrative tasks and expenses, such as quality improvement personnel, cybersecurity, backup generators, and even parking, are necessary to enhance patient experience and care. Other expenses, most notably related to billing and insurance-related activities, seem less justifiable.

Time to Rethink the Approach to Treating Acute Respiratory Distress Syndrome

Gattinoni L, Marini JJ, Quintel M. — Tue, 20 Feb 2018 00:00:00 GMT

In this issue of JAMA, Fan et al review the treatment of acute respiratory distress syndrome (ARDS), focusing on recent randomized clinical trials (RCTs). Most of these RCTs failed to show that the interventions that were tested offered significant benefit. These predominantly negative results may prompt the question of whether other rational and more-effective ways are available to increase knowledge and improve treatment of a syndrome that is common, deadly, and arguably emblematic of modern intensive care. Although many of these trials were admirably executed, their failure to demonstrate benefit may often have been due to uncertainties regarding enrollment criteria and imprecise deployment of the interventions that were being tested.

Low-Fat vs Low-Carbohydrate Diet on Weight Loss in Overweight Adults

Gardner CD, Trepanowski JF, Del Gobbo LC, et al. — Tue, 20 Feb 2018 00:00:00 GMT

This randomized clinical trial compares the effects of a healthy low-fat vs a healthy low-carbohydrate diet on 12-month weight change among adults aged 18 to 50 years with a body mass index of 28 to 40 without diabetes, and investigates modification of the diet effect by genotype pattern or insulin secretion.

Effect of Haloperidol on Survival Among Critically Ill Adults at High Risk of Delirium

van den Boogaard M, Slooter AC, Brüggemann RM, et al. — Tue, 20 Feb 2018 00:00:00 GMT

This randomized clinical trial compares the effects of prophylactic haloperidol on 28-day survival in patients in the intensive care unit at high risk of developing delirium.

Costs Associated With Physician Billing and Insurance-Related Activities

Tseng P, Kaplan RS, Richman BD, et al. — Tue, 20 Feb 2018 00:00:00 GMT

This study estimates the administrative costs associated with physician billing activities in a large academic health care system with a certified electronic health record system.

Acute Respiratory Distress Syndrome

Fan E, Brodie D, Slutsky AS. — Tue, 20 Feb 2018 00:00:00 GMT

This review summarizes advances in the diagnosis and treatment of acute respiratory distress syndrome between 2012 and 2017.

Management of Acute Respiratory Distress Syndrome (ARDS) in Adults

Howell MD, Davis AM. — Tue, 20 Feb 2018 00:00:00 GMT

This JAMA Clinical Guidelines Synopsis summarizes the 2017 American Thoracic Society/European Society of Intensive Care Medicine/Society of Critical Care Medicine guideline on management of acute respiratory distress syndrome (ARDS) in adults.

Ulcerated Nodule of the Fingernail

Lipner SR. — Tue, 20 Feb 2018 00:00:00 GMT

A woman receiving immunosuppressant therapy after a prior kidney transplant presented with a tender ulcerated nodule on her fingernail with nail loss, purulent drainage, and histopathology showing a pyogenic granuloma–like response with atypical epithelioid and spindled cells adjacent to blood vessels. What would you do next?

Prevalence of Housing Problems Among Community Health Center Patients

Baggett TP, Berkowitz SA, Fung V, et al. — Tue, 20 Feb 2018 00:00:00 GMT

This study uses national survey data to assess the prevalence and health-related correlates of housing problems among community health center patients.

Organ Dysfunction After Individualized or Standard Blood Pressure Management

Karamchandani K, Carr ZJ, Bonavia A. — Tue, 20 Feb 2018 00:00:00 GMT

To the Editor In a randomized clinical trial, Dr Futier and colleagues assessed the effect of individualized vs standard blood pressure management strategies on postoperative organ dysfunction. We had concerns regarding the blood pressure goals that were established for the subgroup of patients that was assigned to the standard blood pressure group.

Organ Dysfunction After Individualized or Standard Blood Pressure Management

Mitchell K, Adams D, McHugh SM. — Tue, 20 Feb 2018 00:00:00 GMT

To the Editor Dr Futier and colleagues performed a study to evaluate the effects of targeting perioperative blood pressure based on patients’ individual preoperative blood pressures compared with standard practice. However, methodological issues raise questions about the results. The authors did not simply compare 2 groups with different perioperative blood pressure goals. Rather, they compared the outcomes of 2 completely different blood pressure management strategies.

Organ Dysfunction After Individualized or Standard Blood Pressure Management

Thiele RH. — Tue, 20 Feb 2018 00:00:00 GMT

To the Editor A randomized clinical trial comparing a standard blood pressure management regimen vs individualized therapy in patients undergoing major surgery suggested that individualized goals could reduce postoperative organ dysfunction. Unfortunately, the conclusions of the Intraoperative Norepinephrine to Control Arterial Pressure (INPRESS) study are not fully supported by the data.

Organ Dysfunction After Individualized or Standard Blood Pressure Management

Daoud M. — Tue, 20 Feb 2018 00:00:00 GMT

To the Editor Dr Futier and colleagues concluded that management targeting an individualized SBP minimized the risk of postoperative organ dysfunction compared with standard management. The authors used a composite primary outcome. Composite outcomes should include components that are of comparable severity and occur with similar frequency. It was not appropriate to combine the less severe and more common RIFLE (risk, injury, failure, loss of kidney function, and end-stage kidney disease) stage risk with the more severe and less common myocardial infarction, nor a Glasgow Coma Scale score of 14 or less with stroke. The incidence of acute kidney dysfunction was relatively large, so that it overwhelmed the other components of the composite primary outcome and effectively became the primary outcome.

Organ Dysfunction After Individualized or Standard Blood Pressure Management

Laffin LJ, Laffin MR. — Tue, 20 Feb 2018 00:00:00 GMT

To the Editor In a recent study, individualized perioperative blood pressure management compared with standard care in the setting of major surgery was found to reduce the risk of postoperative organ dysfunction. Although the study was hypothesis generating, the manner and rigor with which reference or normal resting blood pressure was obtained warrants further explanation.

Organ Dysfunction After Individualized or Standard Blood Pressure Management—Reply

Futier E, Pereira B, Jaber S. — Tue, 20 Feb 2018 00:00:00 GMT

In Reply Dr Karamchandani and colleagues suggest that exposing patients in the standard treatment group to a blood pressure threshold level lower than what is generally accepted may have predisposed patients to organ dysfunction. However, although there is accumulating evidence that intraoperative blood pressure is associated with outcomes, the goals for blood pressure are not well supported by robust evidence and there are few data to support any specific threshold.

Authorship Credit for Large Clinical Trials

Wilkinson ST, Sanacora G. — Tue, 20 Feb 2018 00:00:00 GMT

To the Editor Drs Mentzelopoulos and Zakynthinos outlined the goals for maintaining the academic integrity of research in a Viewpoint. However, the current structure of promotions in most academic settings discourages rather than promotes collaboration. This current structure is not good for clinical research, as it perpetuates, rather than helps to resolve, the continuing problem that the majority of clinical trials are relatively small, single-site studies that may be underpowered and of questionable significance and potential to advance medicine. In clinical research involving human participants, high statistical variability is frequently seen. Thus, high-quality, meaningful research usually means large sample sizes. Except in rare cases, this requires collaboration among large groups of researchers. Under the present criteria for academic promotion at many universities, whereby investigators are heavily rewarded for either first or last authorship and promoted based largely on individual rather than collaborative efforts, the motivation to participate in large collaborative efforts is markedly diminished.

Authorship Credit for Large Clinical Trials—Reply

Mentzelopoulos SD, Zakynthinos SG. — Tue, 20 Feb 2018 00:00:00 GMT

In Reply Drs Wilkinson and Sanacora propose broader distribution of authorship credit to augment involvement of academic researchers in randomized clinical trials (RCTs) and boost the multicenter evaluation of “preventive, diagnostic, and therapeutic interventions.” Despite current stringent authorship guidelines, data suggest that the number of mainly industry-sponsored, multinational RCTs is increasing, as are the proportions of large RCTs recruiting patients in 3 or more to more than 10 nations and more than 1 continent. These data suggest expansion of international collaborative networks associated with well-designed research projects to provide high-quality published evidence on potentially beneficial interventions.

Error in Figure

Tue, 20 Feb 2018 00:00:00 GMT

In the Original Investigation entitled “Association of Screening and Treatment With Breast Cancer Mortality by Molecular Subtype in US Women, 2000-2012” published in the January 9, 2018, issue of JAMA, an incorrect label was used in Figure 2A. In the key of Figure 2A, "SEER" should be "Observed US mortality." This article was corrected online.

Incorrect Data in Tables

Tue, 20 Feb 2018 00:00:00 GMT

In the Original Investigation entitled “Association of Blood Transfusion From Female Donors With and Without a History of Pregnancy With Mortality Among Male and Female Transfusion Recipients” published in the October 17, 2017, issue of JAMA, incorrect data were reported in tables. In Tables 2 and 3, the values reported in the “No. of Deaths Among Recipients/No. of Recipients” columns in the “Male Recipients” and “Female Recipients” sections should have been the numbers of ever-pregnant or never-pregnant female donors minus the numbers of male donors (reference category), rather than the total numbers of deaths and recipients. This article was corrected online.

Omitted Conflict of Interest Disclosures

Tue, 20 Feb 2018 00:00:00 GMT

In the Original Investigation entitled “Chemical Composition and Labeling of Substances Marketed as Selective Androgen Receptor Modulators and Sold via the Internet,” published in the November 28, 2017, issue of JAMA, there were omissions in the Conflict of Interest Disclosures section. The following disclosures should have been included: “Dr Bhasin reported receiving research grants from the National Institute of Diabetes and Digestive and Kidney Diseases, the National Institute of Child Health and Human Development, the National Institute on Aging, the National Institute of Nursing Research, Abbott, Ligand, Transition Therapeutics, Regeneron, Novartis, Althea, Biosensics, and Merck; receiving consulting fees from Sanofi and Regeneron; serving as the chair of the Endocrine Society’s expert panel that developed guideline for testosterone therapy of androgen deficiency in men; and serving on the American Board of Internal Medicine Endocrinology Board’s examination writing committee from 2006 to 2015 and as this committee’s chair from 2011 to 2015.” This article was corrected online.

ASO Therapy: Hope for Genetic Neurological Diseases

Muth CC. — Tue, 20 Feb 2018 00:00:00 GMT

This medical news interview discusses recent advances in antisense oligonucleotide therapies.

The Problem With Work Requirements for Medicaid

Carroll AE. — Tue, 20 Feb 2018 00:00:00 GMT

In November, the Trump administration announced that it would be more open to proposals from states that impose work requirements for Medicaid. In other words, it would allow states to apply restrictions on “able-bodied” adults who might apply for the program. This is an abrupt change from the Obama administration, which supported Medicaid eligibility by income levels, regardless of whether people had jobs or not.

Air Pollutants Undermine Infant Brain Development

Friedrich MJ. — Tue, 20 Feb 2018 00:00:00 GMT

Toxic air poses a threat to brain development in 17 million infants younger than 1 year who live in areas around the world where outdoor air pollution is at least 6 times higher than international limits, according to a report from the United Nations Children’s Fund (UNICEF). More than 12 million infants live in South Asia, and 4.3 million live in the East Asia and Pacific region. Many of these infants live in impoverished areas where they are subject to numerous environmental threats.

High Rates of Violent Death Among Rohingya

Friedrich MJ. — Tue, 20 Feb 2018 00:00:00 GMT

Violence was the direct cause of death for at least 6700 Rohingya civilians, including 730 children, living in the state of Rakhine, Myanmar, in the initial 31 days following the latest upsurge of unrest that began on August 25, 2017, according to surveys conducted by Médecins Sans Frontières (MSF).

Inflammatory Bowel Disease Goes Global

Friedrich MJ. — Tue, 20 Feb 2018 00:00:00 GMT

Since 1990, the rates of inflammatory bowel diseases (IBD) have been increasing in newly industrialized countries in Asia, Africa, South America, and the Middle East, according to a report from an international group of researchers.

Crackdown on Stem Cell Product

Voelker R. — Tue, 20 Feb 2018 00:00:00 GMT

A New Jersey–based company that processes and stores stem cell products derived from human adipose tissue has run aground of FDA regulations.

Shock Waves for Diabetic Foot Ulcers

Voelker R. — Tue, 20 Feb 2018 00:00:00 GMT

The FDA has approved the first shock wave device indicated for patients with diabetic foot ulcers.

Notable Year for Novel Drugs

Voelker R. — Tue, 20 Feb 2018 00:00:00 GMT

During 2017, the FDA’s Center for Drug Evaluation and Research (CDER) ushered 46 novel drugs through the approval process, the highest number per year over the last 10 years.

A Facial Plastic Surgeon’s Review of Wonder

Tollefson TT. — Tue, 20 Feb 2018 00:00:00 GMT

In this Arts and Medicine essay, a facial plastic and reconstructive surgeon who works with children with craniofacial differences reality checks R. J. Palacio’s story Wonder about a boy with Treacher Collins syndrome starting his first year of school among peers.

Not Wanting

Pucciani D. — Tue, 20 Feb 2018 00:00:00 GMT

No desire left. It has been buriedin the house on the hillamong the mounded cypresses shouldering the horizon. It wants to not want any more.

Medical Research and the Golden Rule

Tue, 20 Feb 2018 00:00:00 GMT

Recent phenomenal innovations and discoveries in medical science have prompted reexamination of ethical standards in experimentation. In the ensuing discussions and controversies, medical ethics has been defined in moral, legal, sociologic, theologic, and many other terms, and its limitations, flexibility, and function have been widely articulated and debated. But the essence of medical ethics, the golden rule, has been largely overlooked or undervalued: “Whatsoever ye would that men should do to you, do ye even so to them” (Matthew 7:12).

Acute Respiratory Distress Syndrome

Stevens JP, Law A, Giannakoulis J. — Tue, 20 Feb 2018 00:00:00 GMT

This JAMA Patient Page describes acute respiratory distress syndrome (ARDS) and its risk factors, treatment, and long-term effects.

JAMA

Tue, 20 Feb 2018 00:00:00 GMT