JAMA Intern Med Research Articles

Rescue of COVID-19 Patient Complicated by Spontaneous Pneumothorax and Acute Pulmonary Thromboembolism

Abstract Pulmonary thromboembolism is a common cardiovascular disease, with high morbidity and mortality rates in hospitalized patients. Because of clotting disorders and hypoxemia caused by COVID-19, critically ill patients are highly susceptible to thrombotic complications. A study published in the Journal of the American Medical Association in 2022 showed that the incidence of venous thromboembolism (VTE) in critically ill COVID-19 patients was approximately 10% to 35%, whereas the incidence of VTE in autopsy cases was as high as 60% (JAMA Intern Med 182:1063-1070). Clinicians need increased awareness of VTE in COVID-19 patients, to reduce the risk of deep vein thrombosis and pulmonary thromboembolism and to be alert to life-threatening complications.

Abstract PO3-27-08: Geographic Distribution and Accessibility of Clinical Trials for Advanced-Stage Breast Cancer in the United States: A Focus on Rural and Minority Health Disparities

Abstract Background: Our research examines the geographical distribution and accessibility of clinical trials for metastatic breast cancer patients in the U.S., spotlighting the challenges faced by rural communities and minority groups. Prior research indicated nearly half of these patients would have to commute over an hour to reach a trial site. [1] Our study provides a refreshed perspective on this issue, offering a more comprehensive analysis. Methods: Utilizing the ClinicalTrials.gov portal, we identified active interventional clinical trials for metastatic breast cancer patients as of November 25, 2022. We obtained distinct zip codes linked to these trials and, using 2020 census data, estimated the proportion of the U.S. populace residing within specific distances from these sites. Our analysis encompassed ethnicity, and other socio-economic parameters. Using GIS software, we also developed illustrative maps to visually represent the U.S. clinical trial accessibility landscape. Results: The majority of Americans diagnosed with metastatic breast cancer have clinical trials within their reach. A significant 81.8% of the U.S. populace resides within a 30-mile radius of a relevant clinical trial site. However, there is significant variation among ethnic groups, especially among American Indians, where 56.5% live within 30 miles of a clinical trial site. Conclusions: While a commendable 81.8% of the U.S. population resides within 30 miles of a metastatic breast cancer clinical trial site, our data underscores the uneven geographical spread of these trials. Our findings underscore the need for strategic initiatives to ensure clinical trials are within reach for every individual, irrespective of their location or background. Reference: 1. Galsky MD, Stensland KD, McBride RB, Latif A, Moshier E, Oh WK, Wisnivesky J. Geographic accessibility to clinical trials for advanced cancer in the United States. JAMA Intern Med. 2015 Feb;175(2):293-5. PMID: 25437434. Map of 30-, 60-, and 120-mile buffers from clinical trial sites open to patients with metastatic breast cancer. The U.S. Population living withing 30-, 60-, and 120-miles of an open clinical trial site for patients with metastatic breast cancer. Citation Format: Emily Westergard, Abigail Swenson, Zachary Schroeder, Wade Swenson. Geographic Distribution and Accessibility of Clinical Trials for Advanced-Stage Breast Cancer in the United States: A Focus on Rural and Minority Health Disparities [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO3-27-08.

CRC screening with sigmoidoscopy extends life by 110 d; other cancer screening tests do not extend life.

Bretthauer M, Wieszczy P, Løberg M, et al. Estimated lifetime gained with cancer screening tests: a meta-analysis of randomized clinical trials. JAMA Intern Med. 2023;183:1196-1203. 37639247.

In low-risk penicillin allergies, direct oral challenge was noninferior to skin testing followed by oral challenge.

Copaescu AM, Vogrin S, James F, et al. Efficacy of a clinical decision rule to enable direct oral challenge in patients with low-risk penicillin allergy: the PALACE randomized clinical trial. JAMA Intern Med. 2023;183:944-952. 37459086.

Part I: Interactive case: Menopause

Part I: Interactive case: Menopause

The NASEM Report: Are the Solutions Part of the Problem?

The NASEM Report: Are the Solutions Part of the Problem?

COVID-19 and smoking: Considerations after two years

COVID-19 and smoking: Considerations after two years

Journal Digest: IRT; Motivational Therapy; Mental Health Apps; and More

Journal Digest: IRT; Motivational Therapy; Mental Health Apps; and More

Byrne P, Demasi M, Jones M, Smith SM, O’Brien KK, DuBroff R. Evaluating the association between low-density lipoprotein cholesterol reduction and relative and absolute effects of statin treatment: a systematic review and meta-analysis. JAMA Intern Med 2022; 182: 474–481 (Meta-Analyse)

Meta-Analysen lassen annehmen, dass eine Senkung des LDL-Cholesterinwertes (LDL-C) um 1 mmol/l gegenüber Nicht-Behandelten das relative Risiko einer bedeutsamen Herz-Kreislaufkomplikation um rund 20 % reduziert. Wie stark wird aber das absolute Risiko der Mortalität und der kardiovaskulären Morbidität beeinflusst? Dieser Frage wurde in einer Meta-Analyse nachgegangen, die 21 grosse Studien umfasste, in denen während mindestens zwei Jahren eine Statintherapie mit Placebo oder gar keiner Behandlung verglichen wurde. In einem Teil der berücksichtigten Studien wurden Statine spezifisch als Primär- oder als Sekundärprävention verabreicht, andere Studien hatten eine gemischte Population. Die in den verschiedenen Studien mit der aktiven Therapie erreichte durchschnittliche LDL-C-Senkung lag zwischen 0,45 und 1,75 mmol/l. Die Meta-Analyse ergab eine absolute Reduktion der Gesamtmortalität um 0,8 % (95%-Vertrauensintervall CI 0,4–1,2 %), der Zahl der Myokardinfarkte um 1,3 % (CI 0,9–1,7 %) und der Schlaganfälle um 0,4% (CI 0,2–0,6 %), also mehrheitlich statistisch nicht-signifikante Resultate. Die Schlussfolgerung der Studie lautet, die absolute Risikoreduktion durch Statine sei bescheiden. Zudem würde die Qualität der Meta-Analyse durch eine markante Heterogenität der Studien beeinträchtigt.

Establishment of a dermatology clinic serving both patients living with HIV/AIDS and transgender individuals (PRIDE clinic) in an urban academic setting: Demographics, evolution, and lessons learned

To the Editor: Given structural barriers, marginalized populations, including LGBTQ+ individuals and people living with HIV, deserve improved care access. 1 Gonzales G. Przedworski J. Henning-Smith C. Comparison of health and health risk factors between lesbian, gay, and bisexual adults and heterosexual adults in the United States: results from the National Health Interview Survey. JAMA Intern Med. 2016; 176: 1344-1351https://doi.org/10.1001/jamainternmed.2016.3432 Crossref PubMed Scopus (224) Google Scholar , 2 Reisner S.L. Poteat T. Keatley J. et al. Global health burden and needs of transgender populations: a review. Lancet. 2016; 388: 412-436https://doi.org/10.1016/S0140-6736(16)00684-X Abstract Full Text Full Text PDF PubMed Scopus (558) Google Scholar , 3 Geter A. Herron A.R. Sutton M.Y. HIV-related stigma by healthcare providers in the United States: a systematic review. AIDS Patient Care STDS. 2018; 32: 418-424https://doi.org/10.1089/apc.2018.0114 Crossref PubMed Scopus (85) Google Scholar , 4 Yeung H. Luk K.M. Chen S.C. Ginsberg B.A. Katz K.A. Dermatologic care for lesbian, gay, bisexual, and transgender persons: epidemiology, screening, and disease prevention. J Am Acad Dermatol. 2019; 80: 591-602https://doi.org/10.1016/j.jaad.2018.02.045 Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar In 2014, we started monthly clinics within normal operations and clinic hours to serve patients living with HIV and associated dermatologic manifestations. These sessions were established as entry points to the system, to expedite access for new patients within 1 month of request, referred by partner clinic providers. Over time, a second population emerged from the same partner clinics: transgender and non-binary patients. The clinic slowly pivoted and rebranded to serve both communities: those living with HIV and transgender and non-binary patients. Importantly, these communities are distinct but show overlap in both population and resources used. 5 Becasen J.S. Denard C.L. Mullins et al. Estimating the prevalence of HIV and sexual behaviors among the US transgender population: a systematic review and meta-analysis, 2006–2017. Am J Public Health. 2019; 109: e1-e8https://doi.org/10.2105/ajph.2018.304727 Crossref PubMed Scopus (0) Google Scholar In 2020, the clinic was officially named PRoviding Integrated Dermatology for Everyone (PRIDE).

LONG-TERM ORAL SUPPRESSIVE ANTIBIOTIC THERAPY FOR PROSTHETIC VALVE ENDOCARDITIS WITH PERIVALVULAR EXTENSION

LONG-TERM ORAL SUPPRESSIVE ANTIBIOTIC THERAPY FOR PROSTHETIC VALVE ENDOCARDITIS WITH PERIVALVULAR EXTENSION

Racial bias in pulse oximetry: a significant problem in healthcare

British Journal of Healthcare AssistantsVol. 16, No. 9 Health MattersRacial bias in pulse oximetry: a significant problem in healthcareSarah Jane PalmerSarah Jane PalmerRegistered Nurse and Freelance WriterSearch for more papers by this authorSarah Jane PalmerPublished Online:13 Sep 2022https://doi.org/10.12968/bjha.2022.16.9.430AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Fawzy A, Wu TD, Wang K et al. Racial and ethnic discrepancy in pulse oximetry and delayed identification of treatment eligibility among patients With COVID-19. JAMA Intern Med. 2022;182(7):730–738. https://doi.org/10.1001/jamainternmed.2022.1906 https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2792653 Google ScholarSunday Times. Sajid Javid orders racial bias review after Covid deaths. 21 November 2021. https://www.thetimes.co.uk/article/sajid-javid-orders-racial-bias-review-after-COVID-deaths-wxtsbsxdc (accessed 25 August 2022) Google ScholarTobin MJ, Jubran A. Pulse oximetry, racial bias and statistical bias. Ann. Intensive Care. 2022;12, 2. https://doi.org/10.1186/s13613-021-00974-7 Crossref, Google ScholarValbuena VSM, Seelye S, Sjoding MW et al. Racial bias and reproducibility in pulse oximetry among medical and surgical inpatients in general care in the Veterans Health Administration 2013–2019: multicenter, retrospective cohort study. BMJ 2022; Jul 6;378:e069775 https://doi.org/10.1136/bmj-2021-069775 Google Scholar FiguresReferencesRelatedDetails 2 September 2022Volume 16Issue 9ISSN (print): 1753-1586ISSN (online): 2052-4420 Metrics History Published online 13 September 2022 Published in print 2 September 2022 Information© MA Healthcare LimitedPDF download

Abstract P200: Long-term Cardiovascular Risk In Hypertensive Emergencies Or Urgencies

Hypertensive emergencies (severely elevated blood pressure with evidence of acute, ongoing target-organ damage) are traditionally distinguished from “hypertensive urgencies” (if they really exist) by the need for prompt, but controlled, reduction in blood pressure in the former. The longer-term cardiovascular risk associated with these conditions has not been well characterized. A systematic review of the literature was therefore conducted, which identified 6 reports about subsequent death or cardiovascular hospitalization after successful treatment for either diagnosis ( J Hypertens . 2008; 26: 657; J Clin Hypertens . 2011; 13: 551; JAMA Intern Med . 2016; 176: 981; J Clin Hypertens . 2017; 19: 137; J Hypertens . 2021; 39: 2514; and Eur J Prev Cardiol . 2022; 29: 194). The pooled average annualized risk of death or cardiovascular hospitalization for patients with hypertensive emergencies was 26±8% (168 of 640, 4 reports); compared to 4±1% (76 of 2041, 5 reports) for hypertensive urgencies. Rates of the same outcome were 11±2% (8 of 70) among subjects randomized to placebo in the original Veterans Administration trial ( JAMA . 1967; 202: 1028), and 3±1% (182 of 6110 in two fairly recent trials in patients with less severe, but “high-risk” hypertension (LIFE: Lancet . 2002; 359: 995, VALUE: Lancet . 2004; 363: 2022). Despite moderate heterogeneity within the diagnostic groups, these data highlight the very high residual cardiovascular risk of people with successfully-treated hypertensive emergencies, compared to untreated Veterans with diastolic blood pressures between 115-129 mm Hg, both of which are much higher than people with hypertensive urgencies, or patients with hypertension and other cardiovascular risk factors.

Establishing the worth of deprescribing inappropriate medications: are we there yet?

Establishing the worth of deprescribing inappropriate medications: are we there yet?

Understanding the Prodromal Period of Necrotizing Soft Tissue Infections of the Genitalia (Fournier's Gangrene) and the Incidence, Duration, and Risk Factors Associated With Potential Missed Opportunities for an Earlier Diagnosis: A Population-based Longitudinal Study.

The purpose of this paper was to investigate patterns of health care utilization leading up to diagnosis of necrotizing soft tissue infections of the genitalia and to identify risk factors associated with potential diagnostic delay. IBM MarketScan Research Databases (2001-2020) were used to identify index cases of necrotizing soft tissue infections of the genitalia. We identified health care visits for symptomatically similar diagnoses (eg, penile swelling, cellulitis) that occurred prior to necrotizing soft tissue infections of the genitalia diagnosis. A change-point analysis identified the window before diagnosis where diagnostic opportunities first appeared. A simulation model estimated the likelihood symptomatically similar diagnosis visits represented a missed opportunity for earlier diagnosis. Patient and provider characteristics were evaluated for their associations with delay. We identified 8,098 patients with necrotizing soft tissue infections of the genitalia, in which 4,032 (50%) had a symptomatically similar diagnosis visit in the 21-day diagnostic window, most commonly for "non-infectious urologic abnormalities" (eg, genital swelling; 64%): 46% received antibiotics; 16% saw a urologist. Models estimated that 5,096 of the symptomatically similar diagnosis visits (63%) represented diagnostic delay (mean duration 6.2 days; mean missed opportunities 1.8). Risk factors for delay included urinary tract infection history (OR 2.1) and morbid obesity (OR 1.6). Visits to more than 1 health care provider/location in a 24-hour period significantly decreased delay risk. Nearly 50% of insured patients who undergo debridement for, or die from, necrotizing soft tissue infections of the genitalia will present to a medical provider with a symptomatically similar diagnosis suggestive of early disease development. Many of these visits likely represent diagnostic delay. Efforts to minimize logistic and cognitive biases in this rare condition may lead to improved outcomes if they lead to earlier interventions.

Sleep insecurity as a health disparity.

Sleep insecurity as a health disparity.

Redressing the gender imbalance across the publishing system

In The Lancet Infectious Diseases, Katharina Last and colleagues 1 Last K Hübsch L Cevik M et al. Association between women's authorship and women's editorship in infectious diseases journals: a cross-sectional study. Lancet Infect Dis. 2022; (published online July 12.)https://doi.org/10.1016/S1473-3099(22)00367-X Summary Full Text Full Text PDF PubMed Scopus (2) Google Scholar show that a higher proportion of women editors is associated with a higher proportion of women first and last authors in a sample of 11 027 articles from infectious diseases journals published in 2018 and 2019. The finding that women comprise about 49·3% of first authors and 34·9% of last authors is in keeping with previous reports. 2 Hart KL Perlis RH Trends in proportion of women as authors of medical journal articles, 2008–2018. JAMA Intern Med. 2019; 179: 1285-1287 Crossref PubMed Scopus (39) Google Scholar Indeed, for first authors, this result for infectious diseases journals is actually better than results for other medical specialties, such as cardiology or surgery. Association between women's authorship and women's editorship in infectious diseases journals: a cross-sectional studyThe proportion of women editors appears to influence the proportion of women last and first authors in the analysed infectious diseases journals. These findings might help to explain gender disparities observed in publishing in academic medicine and suggest a need for revised policies towards increasing women's representation among editors. Full-Text PDF

Fitted containment efficiency of face masks for reducing emission of aerosols in the indoor environment

Background: Face masks are a major tool for reducing the spread of COVID-19 has been the use of face masks because (1) they protect the wearer from aerosol laden virus in the environment and (2) they reduce aerosol emissions to the environment from infected individuals. Methods that quantify the fitted mask filtration efficiency for protection of the wearer are well established (eg, Sickbert-Bennett et al, JAMA Intern Med 2020;180:1607). In contrast, current methods for assessing face-mask containment efficiency are generally semiquantitative and rely on measurement of a very low concentration of aerosols emitted from a healthy or infected human, or the use of mannequins in which a high concentration of surrogate aerosols can be introduced inside the mask. Methods: Expanding on our standard methods used for fitted face-mask filtration efficiency, we designed a small-volume, low-ventilation chamber to accommodate a seated study participant. The study participant wore a ported face mask to allow introduction of a stream of 0.05 μm NaCl particles at a constant concentration (TSI 8026 particle generator) into the mask space. The ambient chamber concentration was continuously measured by a TSI 3775 condensation particle counter sampling 2 feet (~2 m) in front of the participant’s head over a series of three 3-minute periods: (1) resting, (2) reading out loud, and (3) repeated forceful coughing (2 × 10 coughs) (~450 L/min peak flows). Figure 1 shows a raw data sample for the coughing procedure. Containment efficiency (%) for each mask and procedure were determined as 100 × (1 – the average of all 1 − second ambient concentration values between 30 and 180 seconds divided by the same for the “no mask” condition). Results: Table 1 shows the average % containment efficiency for 2 study days with each mask or procedure in an adult male. The 2-ear-loop masks (KN95 and procedure) tested during coughing had the greatest reduction in % containment efficiency compared to that during resting breathing, likely owing to a decreased mask fit with transient pressure increase inside the mask associated with the coughs. The N95 was least affected by the introduction of reading and/or coughing, maintaining near 95% containment efficiency throughout. Conclusions: Our preliminary data on fitted containment efficiency of masks under different conditions suggest that the fitted containment efficiency closely mimics their performance for personal protection. This information that may aid in providing optimum source control in indoor environments.Funding: NoneDisclosures: None

Time trends in cancer and dementia related hospital admissions among Medicare fee-for-service population, 2013–2018

Cancer and dementia are two complicated morbidities that are commonly found in older adults and require substantial healthcare resources.[ [1] Caba Y. et al. The impact of dementia on cancer treatment decision-making, cancer treatment, and mortality: a mixed studies review. JNCI Cancer Spectr. 2021; 5: 1-18 Crossref Google Scholar , [2] McWilliams L. et al. A systematic review of the prevalence of comorbid cancer and dementia and its implications for cancer-related care. Aging Ment Health. 2017; : 1-18 Google Scholar ] Caring for patients with the co-presence of cancer and dementia, who suffer from impaired cognitive function with complex medical needs, is challenging for clinicians, caregivers, and healthcare systems. With the aging US population, the increasing number of older adults with these two comorbid conditions is likely to place a high demand on hospitals. Meanwhile, the shift of care delivery from inpatient to settings such as outpatient and homes, increasing reliance on family caregivers, and improved community care support may help reduce unnecessary hospitalizations.[ 3 2021 Alzheimer's disease facts and figures Alzheimers Dement. 2021; 17: 327-406 Crossref PubMed Scopus (739) Google Scholar , 4 Federman A.D. et al. Association of a bundled hospital-at-home and 30-day postacute transitional care program with clinical outcomes and patient experiences. JAMA Intern Med. 2018; 178: 1033-1040 Crossref PubMed Scopus (88) Google Scholar , 5 Handley N.R. Bekelman J.E. The oncology hospital at home. J Clin Oncol. 2019; 37: 448-452 Crossref PubMed Scopus (23) Google Scholar ] It is important to understand the pattern of hospitalization, which is one of the major drivers of healthcare costs and high financial and caregiving burden for patients and their families, among the growing population with cancer and dementia. While there has been extensive research on the incidence, prevalence, and healthcare utilization among older adults with either cancer or dementia, existing literature examining older adults with both conditions is scarce and limited in scope. [ [1] Caba Y. et al. The impact of dementia on cancer treatment decision-making, cancer treatment, and mortality: a mixed studies review. JNCI Cancer Spectr. 2021; 5: 1-18 Crossref Google Scholar , [2] McWilliams L. et al. A systematic review of the prevalence of comorbid cancer and dementia and its implications for cancer-related care. Aging Ment Health. 2017; : 1-18 Google Scholar , [6] Kedia S.K. et al. Health care utilization among elderly medicare beneficiaries with coexisting dementia and cancer. Gerontol Geriatr Med. 2017; 3 (p. 2333721416689042) Crossref PubMed Google Scholar , [7] Liu B. et al. Trends of hospitalizations among patients with both cancer and dementia diagnoses in New York 2007-2017. Healthc (Amst). 2021; 9100565 Google Scholar ] In particular, no national estimates exist regarding the hospitalization rates among older adults with comorbid cancer and dementia. To fill this gap, we examined the national and state-level trends in hospitalization rates among Medicare fee-for-service (FFS) beneficiaries with the co-presence of a major cancer (breast, prostate, lung, and colorectal) and dementia diagnoses. We hypothesized a growing trend of inpatient use among this population during the years 2013–2018. Due to the heterogeneity in cancer-specific prognosis and treatment, we also examined the trend of hospitalizations among this population by cancer types.

Recruiting "clean" chronic insomnia participants: the unicorn of sleep research.

Recruiting "clean" chronic insomnia participants: the unicorn of sleep research.