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Medical News & Perspectives
December 4, 2018

JAMA Network Articles of the Year 2018

JAMA. 2018;320(21):2188-2191. doi:10.1001/jama.2018.17934

For our second annual Articles of the Year, we did an accounting of all Original Investigations and Special Communications published in our journals between September 1, 2017, and August 31, 2018, and ranked them based on online views. We then interviewed the journal editors to find out why these articles proved so popular with physicians and, in many cases, the public.

This year, the topics range from trends in suicide attempts (yes, they’re on the rise) to a technique to restore a genuine smile in patients with facial paralysis. In between, there are reports on fish oil for heart health, US health care expenditures, a novel model of obesity, and more.

Here we present the top-viewed articles from each of the 13 journals in the JAMA family in order of rank across the network.

JAMA Psychiatry
Original Investigation
Published September 13, 2017

An article about suicide attempts tops our list this year, signaling awareness around the increasing public health challenge. The article attracted almost 500 000 views within a month of publication, with most of those views occurring in the first 2 days.

According to the analysis of data from 2 nationally representative face-to-face surveys of almost 70 000 adults, the percentage of individuals who recently attempted suicide increased from 0.62% in 2004 through 2005 to 0.79% in 2012 through 2013. The findings are in line with other surveys showing an increase in completed suicides over the past 2 decades.

The researchers noted that up to 10% of adults who make a serious suicide attempt complete the act within the following decade, making suicide attempts the biggest risk factor for completed suicides. Yet, “despite decades of research, we are still not very good at identifying individuals at risk for suicide or intervening to prevent suicide,” said JAMA Psychiatry Editor in Chief, Dost Öngür, MD, PhD.

Suicide is the most serious adverse health outcome associated with psychiatric disorders, Öngür said. In this study, younger adults with antisocial personality disorder, anxiety disorders, depressive disorders, and a history of violence disproportionately attempted suicide, as did those with less formal education.

Special Communication
Published February 15, 2018

Why does the United States spend so much more on health care than other wealthy nations? That’s the question the researchers behind the top-viewed article in our flagship journal set out to answer with this Special Communication. To do so, they compared US health care costs and potential drivers of spending to those from the 10 highest-income countries.

First, they confirmed that the United States spends more: 17.8% of its gross domestic product went to health care in 2016 while the runner-up, Switzerland, spent just 12.4%. Meanwhile, the United States had the lowest life expectancy and highest infant mortality on the list. Administrative costs, drug and device costs, and expensive procedures like magnetic resonance imaging and computed tomography contributed most to the sky-high cost of US health care.

“At a time when there are extensive discussions of the value of health care in the US, this is among the best contemporary analyses that focus on this issue,” said Howard Bauchner, MD, editor in chief of JAMA and the JAMA Network.

JAMA Cardiology
Original Investigation
Published January 31, 2018

The results of this meta-analysis of 10 large randomized clinical trials involving almost 78 000 people at high risk of coronary heart disease stood in contrast to the American Heart Association’s recommendation to consider fish oil supplementation for patients with a recent heart attack.

Fish oil supplements did not reduce the risk of coronary heart disease deaths, nonfatal heart attacks, fatal or nonfatal strokes, revascularization procedures, or all-cause mortality in the full study population, which included participants who had cardiovascular disease or were at high risk of developing it. The supplements also didn’t protect against major vascular events in any subgroup, including people with a history of heart disease, diabetes, high cholesterol, or statin use.

“It may be that Mother Nature packages all of this stuff better than we do when we put it in pills,” said Robert O. Bonow, MD, editor in chief of JAMA Cardiology.

But stay tuned... Clinical trials are currently looking at higher doses of prescription omega-3 fatty acids, which could turn up different results.

JAMA Oncology
Original Investigation
Published July 19, 2018

Many people with cancer use complementary medicine (CM) as part of their therapy, but whether this affects their use of conventional medicine or their survival has been an open question. In this retrospective observational study using data from the National Cancer Database, patients who used an “unproven” cancer treatment administered by nonmedical personnel along with at least 1 conventional treatment had a 2-fold greater risk of death than those who only used conventional treatments.

It wasn’t that the complementary treatments killed them. Rather, they were more likely to die because they were also far more likely to refuse surgery, radiotherapy, chemotherapy, and/or hormone therapy, the analysis suggested. The takeaway: complementary cancer treatments should be just that—a complement to conventional therapies, not an alternative.

The study had an Altmetric score of 3728, the highest of any of the top-viewed articles across the JAMA Network this year. According to JAMA Oncology Editor in Chief Mary L. Disis, MD, the data on cancer death outcomes drove much of the interest. However, critics said the study sample wasn’t truly reflective of CM use; although epidemiological data suggest that the majority of patients with cancer use complementary and alternative medicine, only 0.01% of patients in this study met the authors’ definition of using CM.

JAMA Internal Medicine
Special Communication
Published July 2, 2018

“Americans, as a group, are not getting thinner,” said Mitchell Katz, MD, deputy editor of JAMA Internal Medicine. That, in a nutshell, explains the popularity of this Special Communication, which proposed a novel mechanism of weight gain: the carbohydrate-insulin model of obesity.

According to the authors, the conventional model treats all calories as alike and focuses on “energy balance”: when we overeat and don’t compensate with physical activity, we gain weight. Their article turned that wisdom on its head. Overeating is a consequence of weight gain, “not the primary cause,” they posited. The explanation: A diet high in refined carbohydrates spikes insulin levels, promoting energy storage in fat cells. A lower concentration of fuel in the bloodstream triggers the starvation response, increasing hunger and slowing metabolism—and predisposing us to weight gain.

There are data to support both theories, according to Katz. In fact, an invited commentary published in the same issue argued against the newer model as the underlying explanation for obesity. “At this point, the evidence remains controversial,” Katz said.

JAMA Network Open
Original Investigation
Published June 22, 2018

This article in our newly launched open access journal sought to examine socioeconomic factors at the US county level that might explain the previously documented geographic overlap between support for the 2016 Republican presidential candidate and rates of chronic opioid use.

The article generated a lot of attention, “partly because it was misunderstood,” said Frederick P. Rivara, MD, editor in chief of JAMA Network Open. Many readers interpreted it as implying that chronic opioid use caused people to vote for now-President Donald Trump. Instead, the association between these factors in the study was mostly due to common underlying socioeconomic characteristics related to income, disability, insurance coverage, and unemployment.

“The article is one more piece of data indicating that some of the likely contributing factors” in the opioid crisis “relate to socioeconomic characteristics of the communities which have been most affected,” Rivara said. “Not surprisingly, these same characteristics may have also affected the 2016 presidential election vote.”

JAMA Pediatrics
Original Investigation
Published July 9, 2018

“One of the most common conundrums parents face is trying to facilitate a good night’s sleep for their baby and by extension for themselves,” said Dimitri Christakis, MD, editor in chief of JAMA Pediatrics. Introducing solids early to help infants sleep through the night has been widely recommended by some pediatricians and regarded as a myth by others, he said.

Among 1303 exclusively breastfed infants enrolled in this study, a secondary analysis of data from a larger randomized clinical trial, those introduced to solid foods at 3 months slept longer and woke less frequently than those who weren’t given solids. The difference in sleep duration was only around 17 minutes, but Christakis said the results still lend some credence to the long-held belief that introducing solids can help infants sleep longer at night. “For sleep-deprived parents, 17 minutes is real time,” he said. Very serious sleep problems, a major factor in maternal quality of life in the study, were also less frequent in the group introduced to solids.

According to Christakis, the study was unique: “It’s vanishingly rare that any parenting practice is subjected to this level of rigorous study. I suspect it has settled some arguments in clinics and at kitchen tables.”

JAMA Neurology
Original Investigation
Published August 13, 2018

Patients with a risk of stroke are commonly prescribed anticoagulants. When choosing an antithrombotic agent, physicians often recommend aspirin over more effective drugs because it’s believed to carry a lower risk of intracranial hemorrhage. But in at least 1 indication—non–valvular atrial fibrillation—there’s evidence that certain non–vitamin K antagonist oral anticoagulants (NOACs) don’t cause more adverse events than aspirin.

This systematic review and meta-analysis, which included data from 39 398 patients across 5 randomized clinical trials, assessed the risk of intracranial hemorrhage with 2 different NOACs vs aspirin across all indications. Apixaban and low-dose rivaroxaban (10 mg daily) had an intracranial hemorrhage risk similar to aspirin, whereas higher-dose rivaroxaban (15 to 20 mg daily) had a much greater risk than the over-the-counter drug.

“The lack of direct evidence comparing one non–vitamin K antagonist oral anticoagulant to another is a source of frustration on the front lines, and this article's meta-analysis approach helps resolve this lack of data specifically in regards to intracranial hemorrhage,” said JAMA Neurology Editor in Chief S. Andrew Josephson, MD.

JAMA Otolaryngology-Head & Neck Surgery
Original Investigation
Published September 7, 2017

In patients with the common condition laryngopharyngeal reflux, acid from the stomach irritates the throat, causing chronic sore throat, coughing, and trouble speaking. Patients are usually treated with proton pump inhibitors (PPIs), but many seek nonpharmaceutical alternatives like dietary approaches.

This study compared improvements based on changes in the Reflux Symptom Index (RSI) documented in medical records from 2 patient groups: one treated with PPIs and standard reflux precautions and the other with alkaline water, a plant-based Mediterranean-style diet, and standard precautions. A higher percentage of patients treated with the dietary approach achieved a clinically meaningful reduction in the RSI (62.6%) than did those who took PPIs (54.1%).

This potentially practice-changing study suggests that alkaline water and a plant-based, Mediterranean-style diet should be considered in the treatment of laryngopharyngeal reflux, according to Jay F. Piccirillo, MD, editor in chief of JAMA Otolaryngology–Head & Neck Surgery. “This approach may effectively improve symptoms and could avoid the costs and adverse effects of pharmacological intervention, as well as afford the additional health benefits associated with a healthy, plant-based diet,” he said.

JAMA Surgery
Original Investigation
Published September 20, 2017

In this study of records from more than 100 000 patients with gunshot or stab wounds in urban areas, those transported to a hospital by private vehicles were about 60% less likely to die than those transported by emergency medical services (EMS). The study suggests that even a short ambulance wait time may be lethal after a penetrating injury and that prehospital trauma care may have a limited role in these patients.

Public interest in what would otherwise be a discussion among trauma surgeons or EMS providers was likely fueled by the recent increase in mass shootings. “People, now more than ever, may be interested in knowing what to do if a shooting or other event occurs,” said Adil Haider, MD, deputy editor of JAMA Surgery.

In addition, some cities allow immediate transport of gunshot and stabbing victims by police while others require police to secure the scene before allowing EMS to transport the patient. This “tale of two cities” has been the subject of intense debate, according Haider, and the new study—although not directly related—added to that conversation.

“Even though the results are what they are, we must realize that EMS services do an incredible job,” Haider said. “Median transport time in urban locations is only 6 minutes.”

JAMA Ophthalmology
Original Investigation
Published October 5, 2017

Polypoidal choroidal vasculopathy (PCV) is a subtype of neovascular age-related macular degeneration (AMD) that’s endemic among people of Asian or African descent. There are 2 ways to treat PCV: with photodynamic therapy following intravenous infusion of the photosensitizing agent verteporfin (vPDT) or with injections of anti–vascular endothelial growth factor (anti-VEGF) agents in the fluid behind the lens of the eye.

This randomized clinical trial compared monotherapy with one of these anti-VEGF agents, ranibizumab, with combination ranibizumab plus vPDT in more than 300 Asian participants. On average, improvement in visual acuity was superior in the combination group compared with the monotherapy group, and there were also fewer injections over time in the combination group.

Age-related macular degeneration is a common cause of blindness, and any randomized clinical trial showing one treatment regimen superior to another has the potential to affect standard care, according to Neil Bressler, MD, editor in chief of JAMA Ophthalmology. But the jury is still out on whether the findings apply to other races with PCV or to other anti-VEGF agents.

JAMA Dermatology
Original Investigation
Published April 18, 2018

Almost half of US dermatologists employ an advanced practice professional (APP) such as a physician assistant as part of their practice. But the field is divided over the role of these nonphysician clinicians because of limited information about their performance.

In this medical record review of more than 33 000 skin cancer screening examinations, the number needed to biopsy to diagnose 1 case of skin cancer was significantly higher for physician assistants (3.9) than for dermatologists (3.3). To diagnose 1 case of melanoma, physician assistants needed to biopsy 39.4 pigmented lesions whereas dermatologists only needed to biopsy 25.4 pigmented lesions. Significantly fewer melanoma in situ were detected in patients screened by a physician assistant, suggesting that their diagnostic accuracy for this largely treatable early skin cancer was less than that of dermatologists.

“Finding ways to reduce wait times and improve access to dermatologic care is a priority for the specialty,” said JAMA Dermatology Editor in Chief Kanade Shinkai, MD, PhD. However, she added, “Papers such as this article are a call to action for the entire specialty to better understand the role of APPs, as well as to set standards for their scope of practice [and] performance.”

JAMA Facial Plastic Surgery
Original Investigation
Published March 22, 2018

After facial paralysis, the transfer of a functional muscle flap that mimics the movement of facial muscle groups can restore a patient’s smile. The gracilis thigh muscle is often used for this, but the current technique using 1 muscle strip, or “paddle,” typically produces a less-than-realistic “Mona Lisa smile” with limited lip elevation and no dental display or involvement of the outer eyes.

This study tested a refined version of the procedure using gracilis flaps with 2 paddles in 12 patients with complete paralysis on 1 side of the face. The new design improved the number of displayed teeth and smile width and symmetry on average from baseline. Four of the patients also had restored outer-eye wrinkling, a key component of a genuine or Duchenne smile.

“This beautifully illustrated paper helps us understand how this innovative surgical technique can bring about a more natural smile,” said John S. Rhee, MD, editor in chief of JAMA Facial Plastic Surgery. That’s important, he said, because “the power of the smile cannot be underestimated—influence, confidence, perceptions of wellness, personality, and mood.”

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