JAMA Network Articles of the Year 2020

For our fourth annual Articles of the Year, we ranked all Original Investigations, Special Communications, and Brief Reports according to online views in our journals between September 1, 2019, and September 30, 2020. Tacking on a 13th month allowed us to consider more of the important coronavirus disease 2019 (COVID-19) research we published this year. Each of the journal editors then offered perspectives via email on why this crop of articles captured readers’ attention.

It’s no surprise that case reports, clinical studies, and guidance on the novel coronavirus dominated the list in this unprecedented year, clinching 11 of our 13 journals’ top spots. As Howard Bauchner, MD, editor in chief of JAMA and the JAMA Network, and JAMA Executive Editor Phil B. Fontanarosa, MD, put it in a recent editorial, “Few people will forget the Great Pandemic of 2020, where and how they lived, how it substantially changed their lives, and for many, the profound human toll it has taken.”

Here we present the top-viewed articles from each of our journals in order of rank across the JAMA Network (Video).

Just before the World Health Organization (WHO) coined “COVID-19,” one of the first descriptions of the disease appeared in our flagship journal in early February. By late October, the report by researchers in Wuhan, China, had almost 1.5 million views and other authors had cited it more than 4000 times.

Subsequent publications confirmed many of the features of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection highlighted in the historic case study of 138 hospitalized patients, including clinical symptoms and risk factors for serious disease, Bauchner said. Patients who were older or who had comorbidities were more likely to be admitted to the intensive care unit (ICU), for example. The various therapies the manuscript mentions, including ineffective antibacterial therapies, reflected the best-guess treatments the first patients with COVID-19 received.

The article’s suggestion that rapid person-to-person transmission may have occurred foreshadowed the devastation that would follow. About a month after its publication online, the WHO officially declared the pandemic. At press time, more than 50 million cases have occurred and around 1.3 million people have died worldwide—at least (see below).

Some COVID-19 deaths were likely missed in the pandemic’s early days when testing was scarce. This article and another published in JAMA attempted to put a number on those lives lost using National Center for Health Statistics data.

“The article hit a nerve,” Robert Steinbrook, MD, JAMA Internal Medicine editor at large, wrote. “Physicians and the public alike clearly want to know how bad the COVID-19 pandemic is in the US and the article provided an answer.”

That answer: From March to May, the estimated number of excess deaths in the US due to any cause—122 300—was substantially higher than the 95 235 deaths officially attributed to COVID-19. Although some of the excess deaths this year could be directly due to infection, others could reflect indirect factors like health care avoidance during the outbreak.

The “excess death” approach compares mortality to previous years. In the past it’s been used to estimate a more accurate death count for new pathogens like pandemic influenza viruses and HIV in its first decade. The method hasn’t yet been applied to Asia, Africa, the Middle East, and South America during the pandemic, a gap the researchers said should be addressed to get a better understanding of the virus’s global toll.

Does COVID-19 damage the heart long-term? This study discovered abnormal cardiac magnetic resonance imaging (MRI) findings among 78 out of 100 patients 2 to 3 months after they tested positive for SARS-CoV-2. The results were alarming enough to “urgently require confirmation in a larger cohort,” the researchers wrote.

Most of the relatively young participants in Germany had asymptomatic, mild, or moderate infections, with only a third requiring hospitalization. Still, findings from MRI performed after the patients had cleared the virus were consistent with ongoing myocardial inflammation among 60 of them, regardless of how sick they had been or their preexisting conditions. Seventy-one participants also had detectable troponin levels, and for 5 of them the marker was significantly elevated.

The results added to emerging concerns about the virus’s lingering cardiac effects, which is now a major area of research. JAMA Cardiology Editor Robert O. Bonow, MD, cautioned that the jury is still out: “These data have created intense interest but need to be confirmed by other investigators, and longer-term studies are also needed to understand the importance of these findings,” he wrote.

This case series using data collected in January and February was among the first to report COVID-19’s neurological involvement. Of the study’s 214 patients hospitalized in Wuhan, 78 of them, or about 36%, had central or peripheral nervous system manifestations or skeletal muscular injuries. The most common nervous system symptoms were dizziness, headache, and taste or smell impairment, now well-known signs of COVID-19. While hospitalized, some of the patients—especially the sickest ones—experienced ischemic stroke, cerebral hemorrhage, impaired consciousness, or seizure.

The authors concluded that neurological symptoms are common in COVID-19 and should alert physicians to possible SARS-CoV-2 infection. At the time the article was published, COVID-19 was framed as an almost purely respiratory disease, according to JAMA Neurology Editor S. Andrew Josephson, MD. The study “started a worldwide conversation that even today continues,” he wrote. The surprising results led to “a series of investigations into understanding the basis of these neurological manifestations and their impact on diagnostic and therapeutic development.”

Leave it to COVID-19: This report from China, which suggested that wearing eyeglasses might protect against the novel coronavirus, is the highest viewed article in JAMA Ophthalmology’s history.

Only 16 of 276 patients—about 6%—in Hubei province hospitalized with COVID-19 in the study reported wearing eyeglasses for more than 8 hours a day. This was substantially less than the 32% of people in the same province with myopia, almost all of whom reported wearing glasses in a previous study.

The idea that glasses may be protective against SARS-CoV-2 infection has some biological plausibility, according to Neil Bressler, MD, the journal’s editor, but the association alone can’t prove cause and effect. “While it should not change practice, the study does provide an interesting hypothesis potentially worthy of additional research,” Bressler wrote.

Theoretically, eyeglasses might shield airborne viral particles or make a person less likely to touch their eyes while wearing them. There could be other explanations, though. People who wear glasses may be more likely to wash their hands or to be vigilant about social distancing, Bressler offered.

This clinical trial contributed to the understanding of chloroquine diphosphate and its derivative hydroxychloroquine as COVID-19 antivirals, a major debate in the pandemic’s early months. “Because [President] Trump endorsed the drug, there was a sudden spike in its use without any evidence that it works,” wrote Frederick P. Rivara, MD, MPH, editor of JAMA Network Open. This study, he noted, “provided critical information to the public and to physicians here and around the world,” adding a nail in the coffin to the drug’s use.

Preclinical studies suggested that a high chloroquine dose was needed for effectiveness against SARS-CoV-2. Based on those findings, researchers randomized hospitalized patients in Brazil to receive either a high-dose regimen for 10 days or a low-dose regimen for 5 days. All the patients were also taking azithromycin and most received oseltamivir.

An independent data and safety monitoring board recommended an unplanned interim analysis of the first 81 enrolled patients, which found higher mortality in the high-dose group—the opposite of the study’s hypothesis—as well as increased cardiac toxicity. Because the high-dose regimen’s risk of toxic effects outweighed its benefits, the trial was discontinued. “Pretty much after this, all randomized clinical trials of this were stopped,” Rivara wrote.

The early data from China and subsequently from Europe suggested that children with underlying comorbidities were at increased risk of serious COVID-19 illness. This study confirmed the same trend in the US population. Of 48 children admitted to 14 pediatric ICUs from mid-March to early April, 83% had significant preexisting conditions including immune suppression, obesity, and diabetes. More than a third of the children required invasive ventilation and 2 died. Still, these outcomes were better than for hospitalized adults, the authors noted.

At the time of its publication, this was the largest sample of inpatient pediatric patients with COVID-19 in the US. The findings have held up, said JAMA Pediatrics Editor Dimitri Christakis, MD, MPH. “We have a lot more COVID today and a lot more COVID in children today than we did back then,” he said in an interview. “Still, most children with COVID, even those that are in intensive care units, do fine—the mortality rate is very low—and children with underlying comorbidities are the ones that are at increased risk.”

This article in our heath policy channel provided constructive medical and legal guidance for physicians and other health professionals whose patients request a medical exemption from wearing a mask during the COVID-19 pandemic. As the authors note, some individuals with preexisting disabilities may not be able to wear a mask and thus should be advised to avoid close contact with other people in indoor spaces where they could be at greater risk of exposure to the novel coronavirus.

The article gained widespread attention because the use of masks during the pandemic has become highly politicized, noted John Z. Ayanian, MD, MPP, editor of JAMA Health Forum. “Some Americans view requirements to wear masks outside their homes as an infringement of their personal liberty, but the article cautions against granting medical exemptions from mask use because of these nonmedical concerns,” he wrote.

One of only 2 nonpandemic articles on this year’s list is a comprehensive analysis of the most common cancers in different regions of the world. JAMA Oncology publishes the Global Burden of Disease Study’s cancer findings every 2 years, “the definitive reference on the incidence and impact of cancer around the world,” wrote Mary L. Disis, MD, the journal’s editor. Countries use the data for planning public health campaigns.

The article examines how cancer types vary regionally, based on differing risk factor exposures, economics, lifestyles, and health care access. More infrequent malignancies in the US, like liver cancer or stomach cancer, are common in other countries, for example.

As in 2007, tracheal, bronchus, and lung cancer continued to cause the most years of life lost globally in 2017. One notable change: Due to an aging population and population growth, nonmelanoma skin cancers have increased 33%, from 5.8 million cases in 2007 to 7.7 million cases in 2017.

This Special Communication was one of the first publications to provide clear safety guidelines and protocols for patient care during the COVID-19 pandemic, according to Jay F. Piccirillo, MD, editor of JAMA Otolaryngology–Head & Neck Surgery. Unsurprisingly, physicians dealing with diseases of the ear, nose, and throat—and clinicians in general—wanted to know how to protect themselves from the new respiratory infection. Among other guidance, the publication offers recommendations for different levels of personal protective equipment (PPE) for patients and staff based on the perceived risk of the procedure and the patient’s COVID-19 status.

The article began a debate about early vs late timing of tracheostomy for ventilator-dependent patients with COVID-19. “As the pandemic has evolved and new knowledge gained about the timeline of infectivity and risk of transmission, effectiveness and availability of PPE, and the role of various therapeutics (eg, systemic corticosteroids), there has been a shift toward performing tracheostomies earlier in the course of illness for ventilator-dependent patients,” Piccirillo wrote.

In our only other nonpandemic article on this year’s list, high school students rated as calm and mature in a 1960 study were found to be less likely to develop dementia in old age. The findings agreed with those from midlife personality assessments, which have been criticized for being conducted when early stages of dementia may have already crept in. This study places those in context and provides more solid footing for the notion that personality characteristics earlier in life are associated with dementia later in life.

“A better understanding of aspects of brain function and personality which may be associated with dementia in late life can be useful in assessing risk and focusing prevention efforts on vulnerable individuals,” wrote JAMA Psychiatry Editor Dost Öngür, MD, PhD. “On a personal level, many of us wonder whether we will experience dementia in the future, and a paper that links assessments from adolescence with dementia captures the public’s attention.”

This year, dermatologists have been focused on the emergence of “COVID toes,” chilblains-like lesions on patients’ feet (and hands). The purplish red lesions, caused by inflamed small blood vessels, aren’t surprising among severely ill patients with COVID-19. But they’re more curious among otherwise healthy people who may not have a confirmed SARS-CoV-2 infection.

In this case series of 31 mostly young patients in Belgium presenting with chilblains in April, all tested negative for SARS-CoV-2 and antibodies and none had detectable virus on skin lesion biopsies. “Though there have been multiple strong studies showing an association of acral chilblains lesions in patients with COVID-19 infection, this is one of a number of studies that fail to demonstrate an association,” wrote Kanade Shinkai, MD, PhD, editor of JAMA Dermatology.

Chilblains-like lesions are rare, and the emergence of this skin finding on a large scale this spring is truly notable, she noted. Did this reflect a true rise in cases or increased awareness thanks to social media posts? And could lifestyle changes during the pandemic—like spending more time in sedentary positions or walking barefoot in cold homes—cause the lesions in some cases? Stay tuned: “There is significant ongoing attention to explain these skin findings and their relationship to COVID-19 infection,” Shinkai wrote.

This article informed readers of the significant increased risk of postoperative death and complications among 41 patients with COVID-19 who underwent emergency surgery in an Italian hospital early in the pandemic. Its popularity likely stemmed from being the first study to examine this important question using a tightly matched group of control patients, noted JAMA Surgery Editor Melina R. Kibbe, MD. The study spanned general, neurological, orthopedic, thoracic, and vascular surgery and included patients who underwent both general and regional anesthesia.

“The interesting yet concerning aspect of this study is that the 30-day postoperative mortality for patients with COVID-19 had an odds ratio of 9.5,” Kibbe wrote. “This was much higher than many had suspected, especially for a population in which 20% tested positive after surgery.” Patients with COVID-19 also had a 5-times higher risk of surgical complications. “These data suggest that, whenever possible, surgery should be postponed in patients with COVID-19,” the authors concluded, a policy that continues today.