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Clinical Trials Overlook Diseases of Low-Income Countries

JAMA - Mar, 16/02/2021 - 02:00
Conditions like respiratory infections, tuberculosis, and enteric infections that disproportionately affect low-income countries are consistently understudied in clinical trials, according to a recent study.

High-Income Countries Have Secured the Bulk of COVID-19 Vaccines

JAMA - Mar, 16/02/2021 - 02:00
High-income countries have reserved more than half of the world’s coronavirus disease 2019 (COVID-19) vaccine doses despite representing just 14% of the world’s population, according to an analysis of publicly available data on premarket purchase agreements.

A Blueprint for Comprehensive Medicaid Reform

JAMA - Mar, 16/02/2021 - 02:00
This Viewpoint proposes broad principles to guide Medicaid reform as a means to advance health equity, including stabilization of its funding and coverage; coordination of its infrastructure; alignment of health care and social spending at the point of care; and a value-based approach to benefits.

Declining Life Expectancy in the United States—The Need for Social Policy as Health Policy

JAMA - Mar, 16/02/2021 - 02:00
This Viewpoint reviews the social and economic drivers of declines in longevity in the US, especially among lower socioeconomic status groups, and proposes policy options for the Biden-Harris administration to mitigate the trend, including an increase in the federally mandated minimum wage.

JAMA

JAMA - Mar, 16/02/2021 - 02:00

Diagnosis and Treatment of Metastatic Colorectal Cancer

JAMA - Mar, 16/02/2021 - 02:00
This narrative review summarizes treatment options for patients with unresectable metastatic colorectal cancer, focusing on the importance of genomic profiling to identify KRAS/NRAS/BRAF variants to guide immunotherapy.

Enjoy the Vase—Everything Changes

JAMA - Mar, 16/02/2021 - 02:00
In this narrative medicine essay, a psychiatrist finally at peace after his wife's death to cancer learns that his prostate-specific antigen levels have begun to rise, reminding him to embrace uncertainty, a loss of control, and change.

Hospital Vigil

JAMA - Mar, 16/02/2021 - 02:00
While doctors operate, striving to save your life, I walk a windowless corridor—no clocks, surely past midnight—find the neurosurgery waiting room, open the door and stop, ambushed by aromas of Sunday dinner. A family eats, rosary beads slid wordlessly, chairs and loveseats pulled around a table spread with fried chicken in a bucket, quarts of slaw, baked beans, mashed potatoes. Plastic cutlery and napkins sealed in packets like surgical instruments. A stranger offers me a paper plate, blank as a communion wafer, inviting me to sit down with them, break bread, pray this picnic won’t become a wake.

Patient Information: Lateral Internal Sphincterotomy

JAMA - Mar, 16/02/2021 - 02:00
This JAMA Patient Page explains lateral internal sphincterotomy, a surgical procedure used for treatment of anal fissures unresponsive to supportive or medical therapy.

Effect of High-Intensity Strength Training on Pain From Knee Osteoarthritis

JAMA - Mar, 16/02/2021 - 02:00
This randomized trial compares the effects of high- vs low-intensity strength training vs control on 18-mo knee pain and knee joint compressive force among adults with knee pain and radiographic evidence of osteoarthritis.

Associations of Maternal Cardiovascular Health in Pregnancy With Offspring Cardiovascular Health in Early Adolescence

JAMA - Mar, 16/02/2021 - 02:00
This international cohort study examines associations between the cardiovascular (CV) health of pregnant women (defined by 5 CV risk factors) and CV health of their offspring at ages 10 to 14 years.

Geographic Differences in Uncontrolled Chronic Medical Conditions—Reply

JAMA - Mar, 16/02/2021 - 02:00
In Reply Dr Tompkins and colleagues suggest additional analyses to clarify the relationship between moving and chronic medical conditions in reference to our recent publication. We would first emphasize that our study does not argue that there is a relationship between moving itself and the prevalence of uncontrolled chronic conditions. Rather, our study sought to estimate the association between changes in individuals’ likelihood of an uncontrolled chronic condition after moving and the difference in the prevalence of the uncontrolled chronic condition between movers’ destination vs origin zip code. Conceptually, we compared changes in chronic condition control among people from the same zip code who subsequently moved to separate zip codes with different rates of chronic condition control, after adjusting for secular trends in outcomes among nonmovers from their zip code (eFigure 2 in the Supplement). The primary analysis accounted for baseline differences in chronic condition control associated with moving itself by including patient-specific fixed effects. The primary analysis also accounted for changes in chronic condition control over time associated with the time since each person moved by including quarter-years since moving as fixed effects.

The Advantages of Medicare Advantage—Reply

JAMA - Mar, 16/02/2021 - 02:00
In Reply Even though I agree with Dr Metz that a key criterion of health care reform is to provide “better care to more people for less money,” this should not be the only factor considered when choosing a reform strategy. In the US, many people value choice and the avoidance of disruption of familiar forms of health care coverage.

Wound Dressings for Obese Women After Cesarean Delivery—Reply

JAMA - Mar, 16/02/2021 - 02:00
In Reply Drs Vo and Richards express concerns about the difference in duration of the prophylactic negative pressure wound therapy device vs standard wound dressing in our recent study involving obese women after cesarean delivery. As a pragmatic trial, our study compared effects of typical use of prophylactic negative pressure wound therapy and standard wound dressing. The average duration of use of prophylactic negative pressure wound therapy was 4 days, which is within the 2 to 7 days recommended by the manufacturer. Similarly, consistent with practice in most clinical settings in the US, the duration of standard wound dressing was 24 to 48 hours, and new dressings were not placed after the initial dressing was removed, unless there was a complication such as wound dehiscence. Therefore, the differences in duration of prophylactic negative pressure wound therapy and standard wound dressing in the trial were by design and do not represent confounding.

Database Updates and Resulting Changes in Data in Study of Vaginal Mesh Hysteropexy vs Vaginal Hysterectomy

JAMA - Mar, 16/02/2021 - 02:00
To the Editor My coauthors and I report some database updates and resulting changes in our Original Investigation titled “Effect of Vaginal Mesh Hysteropexy vs Vaginal Hysterectomy With Uterosacral Ligament Suspension on Treatment Failure in Women With Uterovaginal Prolapse: A Randomized Clinical Trial,” published in the September 17, 2019, issue of JAMA. During the final database cleaning for the final 5-year study database lock, a biannual study-wide audit review of the Pelvic Organ Prolapse Quantification (POPQ) examination data identified some updates that influenced the value of the primary outcome (treatment failure). There were 3 failure events for which a POPQ data correction either increased the time to initial failure (1 patient randomized to undergo hysteropexy) or changed the value of the event from a failure to a nonfailure (1 patient randomized to undergo hysteropexy and 1 randomized to undergo hysterectomy). In addition, there were a few minor database updates that did not affect the primary outcome but altered some of the at-visit failure and failure-type rates. The adjusted hazard ratio of failure for hysteropexy vs hysterectomy changed from 0.62 to 0.61.

Geographic Differences in Uncontrolled Chronic Medical Conditions

JAMA - Mar, 16/02/2021 - 02:00
To the Editor Using Veterans Health Administration records, Dr Baum and colleagues estimated the differences in the prevalence of uncontrolled chronic conditions across the population of veterans who moved and the likelihood of uncontrolled chronic conditions after moving. They also provided an E-value estimating the strength of association that an unknown confounder must explain the observed association. However, this article did not provide a measure of the original strength of the association. It would have been illustrative if the authors had provided an original odds ratio or relative risk of disease for comparison purposes.

The Advantages of Medicare Advantage

JAMA - Mar, 16/02/2021 - 02:00
To the Editor In a recent JAMA Forum, Dr Butler considered the political appeal of Medicare Advantage expansion, including growing enrollment, promotion of managed care, and lower federal spending. However, this appeal misses the purpose of health care reform, succinctly summarized by William Kissick, MD, as the simultaneous achievement of increased access, decreased costs, and improved outcomes. A simpler description is better care to more people for less money.

Wound Dressings for Obese Women After Cesarean Delivery

JAMA - Mar, 16/02/2021 - 02:00
To the Editor In their recent article, Dr Tuuli and colleagues found no difference in the rates of superficial or deep surgical site infection between obese women randomized to prophylactic negative pressure wound therapy vs standard wound dressing after cesarean delivery. We have some concerns, however, about how the standard wound dressings were managed in this study. Negative pressure dressings are designed to be kept intact for a relatively long period on closed incisions, while typical surgical dressings are changed more frequently. In this study, the dressings in the control group were removed after 24 hours. However, the authors did not provide any data about whether these wounds were redressed, frequency of dressing changes, or whether there was any change in the type of dressing after the initial postoperative dressing was removed. Variations in these factors are potential confounders that make it difficult to draw conclusions about the comparative efficacy of negative pressure wound therapy in obese women after cesarean delivery.

Current Comment

JAMA - Mar, 16/02/2021 - 02:00

Diagnosis and Treatment of Anal Fissures in 2021

JAMA - Mar, 16/02/2021 - 02:00
This JAMA Insights Clinical Update reviews the diagnosis and management of anal fissures, including use of supportive, topical, injection, and surgical treatment options.
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