Building ResilienceThis link opens in a new windowIn this narrative medicine essay, an infectious diseases physician shares how her journey to and through a depressive episode led her to raise awareness of mental health challenges and to help create supportive working environments.Dec 23, 2024
Errors in Reported Laboratory ValuesThis link opens in a new windowIn the Original Investigation “Balloon Angioplasty vs Medical Management for Intracranial Artery Stenosis: The BASIS Randomized Clinical Trial,” published Online First September 5, 2024, and in the October 1, 2024, print/online issue of JAMA, there were errors in Tables S2, S3, and S12 in the Supplement. The author has explained these errors and corrections needed in a Letter to the Editor and has confirmed that there are no other errors in the article.Dec 23, 2024
Corrections for Conversion of Laboratory Values and Units of Activity LevelsThis link opens in a new windowTo the Editor On behalf of my coauthors, I write to address concerns raised by a reader regarding the data presented in the Supplement to our Original Investigation, “Balloon Angioplasty vs Medical Management for Intracranial Artery Stenosis: The BASIS Randomized Clinical Trial,” published online first on September 5, 2024, and in the October 1, 2024, print/online issue of JAMA. We value the feedback and have conducted a thorough review of the data, specifically supplemental Tables S2, S3, and S12.Dec 23, 2024
Endometriosis and Ovarian CancerThis link opens in a new windowTo the Editor As noted by Dr Barnard and colleagues, existing evidence confirms that endometriosis is associated with an elevated risk of ovarian cancer with differences by histotype. However, despite the varying presentations of endometriosis—most notably 3 macrosurgically visualized subphenotypes (endometriomas, superficial peritoneal, and/or deep lesions)—identifying women with endometriosis who are at high risk remains elusive. To address this question, the investigators leveraged data from the Utah Population Database and defined endometriosis subphenotypes by International Classification of Diseases (ICD) codes documented from 1992 to 2019 in more than 450 000 women. A consistent challenge in registry-based studies has been the selection of a comparison group. As demonstrated by Hermens et al in the Dutch nationwide registry, women diagnosed with ovarian cancer may be concurrently diagnosed with endometriosis, biasing estimated risk compared with members of the general population, who typically have not had pelvic surgery and whose endometriosis is more likely to remain undetected, leading to an observed 29 (95% CI, 20.7-40.9) times greater risk of endometrioid ovarian cancer (incident rate per 100 000 person-years, 29.7) when they included concurrent endometriosis diagnosis, but a much lower 2.6 (95% CI, 1.5-4.5)–fold greater risk when they excluded endometriosis diagnosed within 1 year of a diagnosis of ovarian cancer (incident rate per 100 000 person-years, 4.1). Unfortunately, Barnard and colleagues did not exclude concurrent diagnoses of ovarian cancer and endometriosis (17% of endometriosis and ovarian cancer diagnoses were within <1 year). Failure to exclude these concurrent diagnoses exacerbates the impact of detection bias that appears to be present in the article’s Figure 1. Sensitivity analyses excluding concurrent diagnoses would improve the validity of the results. In addition, the ICD code–based assignment of endometriosis subphenotypes is challenging given changes in documentation across the nearly 3-decade study period, known inconsistencies in ICD subcategory utilization in clinical practice, and erroneous subtype identification (eg, 617.0/N80.0 is not superficial endometriosis but most commonly denotes adenomyosis, while deep endometriosis cannot be inferred from ICD 9/10 codes, as it is not defined by location but rather lesion depth extending >5 mm under the peritoneal surface). Furthermore, since deep lesions were combined with endometriomas, the reader is unable to distinguish the true ovarian cancer risk for women with endometriomas vs deep lesions. Ultimately, the results may encourage clinicians to advise women with endometriomas or deep endometriosis toward prophylactic bilateral oophorectomy based on an overestimation of the true risk. Such an approach disregards the growing evidence of harm caused by inducing early menopause unnecessarily, including elevated risk of cardiovascular disease, bone fracture, and Alzheimer disease. As this is an essential question for women’s health, a reanalysis of the data are needed to guide women and clinicians in understanding a realistic estimation of their ovarian cancer risk and valid attribution to an accurately defined endometriosis subtype.Dec 23, 2024
Endometriosis and Ovarian CancerThis link opens in a new windowTo the Editor According to Dr Barnard and colleagues, after a mean follow-up of 12 years, women with endometriosis had an approximately 4-fold increased risk of ovarian cancer compared with women without endometriosis. The risk increased to almost 10-fold when the analysis was restricted to patients with deep infiltrating endometriosis and/or ovarian endometriomas. Consequently, the authors advocate for “improved ovarian cancer screening and prevention strategies among women with severe endometriosis.” However, Bretthauer and Kalager argue that “misconception and lack of knowledge among doctors and policy makers about absolute and relative risks obstruct shared decision making and hinder truly informed consent.”Dec 23, 2024
Endometriosis and Ovarian Cancer—ReplyThis link opens in a new windowIn Reply We agree with Dr Vercellini and colleagues, as stated in our original article, that the results of a single report should not change clinical care. We also agree that both clinical decisions and public health recommendations should consider absolute risks and therefore we reported risk differences in addition to hazard ratios. It is worth emphasizing that most women with endometriosis never develop ovarian cancer.Dec 23, 2024
DengueThis link opens in a new windowThis JAMA Insights explores several aspects of dengue virus infection, including epidemiology, diagnosis, and clinical management, following a global resurgence in both endemic and nonendemic regions.Dec 23, 2024
The Statistics of DiabetesThis link opens in a new windowDuring the long history of diabetes there has probably been no period during which it was subjected to the intensive study that has been accorded it since the discovery of insulin. Clinicians have long recognized the extent of the menace that diabetes represents. It is not merely the death of a small army of persons each year from diabetes that makes the situation formidable; the disorder incapacitates a further great army of otherwise normal persons. Consequently it becomes a public duty to awaken the nation and also the medical profession, if need of this becomes apparent, to the seriousness of a situation that has recently been emphasized vigorously anew by competent statisticians.Dec 23, 2024
Tirzepatide for Weight Reduction in Chinese Adults With ObesityThis link opens in a new windowTo the Editor A recent study reported that once-weekly treatment with tirzepatide can effectively lead to weight reduction. However, we have several concerns about this article. First, the effect of lifestyle in this study requires further exploration. Among patients receiving tirzepatide, there was a weight reduction of 11.3% to 15.1% compared with placebo. All patients underwent lifestyle intervention, and after 52 weeks of treatment, the placebo group had only a 2.3% reduction in body mass. Although the populations in the studies differed, the effect of lifestyle in the placebo group was significantly lower than in prior trials. Additionally, due to the Hawthorne effect, the tirzepatide group may have had improved uptake of the lifestyle intervention. Furthermore, data on the implementation of the lifestyle intervention in both the treatment and placebo groups were limited in this study. Second, a prior study reported a 20.9% weight reduction after 36 weeks of continuous tirzepatide use. However, patients who discontinued the drug experienced a 14% weight gain over the next 52 weeks despite undergoing lifestyle intervention. Does this imply that tirzepatide needs to be used long term to maintain weight control? If so, this raises concerns about the long-term safety of tirzepatide, including the risk of thyroid C-cell tumors mentioned in the black box warning. Third, during the tirzepatide dose escalation period, most participants reported at least 1 gastrointestinal adverse effect (eg, diarrhea, nausea, abdominal distension, vomiting, and gastroenteritis) and some patients discontinued the drug due to these gastrointestinal symptoms. Therefore, the suitability of tirzepatide for patients with preexisting gastrointestinal symptoms or conditions requires further investigation. Additionally, it is worth exploring whether certain medications that do not affect the efficacy of tirzepatide but can alleviate gastrointestinal symptoms could be used during the dose escalation period to improve patient comfort.Dec 23, 2024
Tirzepatide for Weight Reduction in Chinese Adults With Obesity—ReplyThis link opens in a new windowIn Reply We appreciate the letter from Ms Chen and colleagues about our article. First, differences in intensity of lifestyle interventions can affect weight reduction efficacy, with initial weight loss at 1 year ranging from −2% to −9%. Chen and colleagues ask about the efficacy of lifestyle interventions in our trial compared with results from the DIADEM-I and Look AHEAD trials, both of which included intensive lifestyle interventions. Our trial, similar to others investigating the efficacy and safety of antiobesity medications, implemented standard lifestyle interventions that closely reflected clinical practice. The weight reduction achieved in the placebo group was generally consistent with previous trials with similar objectives.Dec 23, 2024
The Ghazal and MelancholyThis link opens in a new windowThe ghazal is an ancient poetic form thought to have originated in 7th-century Arabic, and which later spread to medieval Persia via the work of the famed mystical poets Rumi and Hafez. In modern times, it is frequently performed in song in countries such as Iran and Pakistan, and has been brought into English by a number of contemporary poets, perhaps most notably by Agha Shahid Ali. The form typically consists of long-lined couplets with a repeated end word or phrase concluding each; the final couplet must reference (either explicitly or implicitly) the speaker’s name. In “Heart Failure: A Ghazal,” although written in quatrains (to fit into the JAMA poetry section), a classic theme of the ghazal, melancholy, is addressed. The repeated word “ponder” not only emphasizes the speaker’s meditative tone as he nears the end of his life, but also its sonic heaviness, punctuated by periods end-stopping each stanza, deepening the sense of search for meaning and closure. Yet the form’s inherent musicality, in its repetitions and in the sweep of its long sentences, also feels somehow sustaining, perhaps even neverendingly hopeful. The keen paradox between imminent mortality and the delights of intimate reflection is poignantly, even mystically, expressed, and certainly worth savoring, in the final lines: “…Thelonious Monk, some foolish old shoes,/a dog’s odd behavior, good books and fragments/of chat…//If you aren’t ended yet, there must be/a future doubtless with plenty to ponder.”Dec 23, 2024
Medical Education’s Learning OpportunityThis link opens in a new windowThis Viewpoint discusses the importance of teaching health policy to medical students so they can be informed on the everyday policy issues that patients may ask them about or for which their specialty societies may ask them to lobby.Dec 23, 2024
Gap Years—Unbridled Good or Unwarranted Cost?This link opens in a new windowThis Viewpoint discusses the increasing popularity of taking a gap year between college and medical school and raises questions about the perceived necessity of this trend, its financial and other costs, and the potential disadvantage it may pose to underrepresented minority applicants.Dec 23, 2024