JAMA

The study evaluated whether the YEARS diagnostic algorithm is as safe as and more efficient than computed tomographic pulmonary angiography (CTPA) for ruling out pulmonary embolism (PE) in patients with active cancer.

The FaceTime came through my phone, two rectangles of my siblings’ faces. John’s empty.

Patients with cancer are known to have increased rates of pulmonary embolism (PE) from their prothrombotic state, and computed tomographic (CT) pulmonary angiography has long served as the standard diagnostic test when PE is suspected. Professional guidelines and consensus documents have cautioned against applying clinical decision rules and D-dimer to exclude PE in patients with cancer, and the usual practice is to proceed directly to CT pulmonary angiography in this population. This practice carries several disadvantages. CT pulmonary angiography exposes patients to radiation, increases emergency department length of stay, requires exposure to iodinated contrast in patients who may have kidney impairment, and increases costs of care.

In this narrative medicine essay, a pediatric hospital medicine and pediatric infectious disease physician stilled by an Achilles tendon rupture compares his wish to expedite healing with pushing early-career physicians, a push that can delay recovery and careers, respectively.

In Reply I appreciate the response from Mr Engels and colleagues regarding the updated HRSA-supported Women’s Preventive Services guidelines and agree that the updated 2026 policy represents an important but incomplete advance in the completion of screening or diagnostic imaging after mammography. The updated HRSA recommendations for breast cancer screening for women at average risk now include the clinical recommendation to support additional testing to complete initial screening, if needed, which may be more common for women with dense breasts. A central distinction exists between completion imaging for incomplete or abnormal mammogram results and supplemental screening for women with dense breasts despite otherwise negative screening results. Further clarification is needed regarding whether supplemental imaging for dense breast masking is considered preventive screening rather than only diagnostic follow-up.

This study aimed to determine if sodium bicarbonate administered during in-hospital cardiac arrest increases the rate of sustained return of spontaneous circulation.

To the Editor In the VESALIUS-CV trial, Dr Marston and colleagues reported that evolocumab reduced first major adverse cardiovascular events (MACE) in patients with diabetes taking optimized lipid-lowering therapy and without known significant atherosclerosis over 5 years of follow-up. While the results are reassuring, additional context regarding absolute benefit and economic considerations may help inform clinical and policy interpretation.

Ischemic heart disease deaths have declined in the US since the 1990s, but they are increasingly attributable to modifiable risk factors such as body mass index (BMI) and hyperglycemia, a study published in JAMA Cardiology found.

This Medical News article is an interview with neurologist Gil Rabinovici, MD, about research presented at the recent Alzheimer’s Association International Conference in London.

The US Food and Drug Administration (FDA) approved a new subcutaneous starting dosage regimen for the amyloid β-directed antibody lecanemab-irmb, which would allow patients to begin the Alzheimer disease treatment at home.

The US Department of Health and Human Services (HHS) and the Centers for Medicare & Medicaid Services (CMS) announced a new initiative supporting more nutritious hospital meals.

The American College of Obstetricians & Gynecologists (ACOG) released updated clinical guidance on HIV screening and prevention.

Infections may increase the risk of psychiatric and neurological disorders, according to a study published in JAMA Psychiatry.

The US Food and Drug Administration (FDA) approved the first oral protein convertase subtilisin/kexin type 9 (PCSK9) inhibitor to reduce low-density lipoprotein (LDL) cholesterol. PCSK9 inhibitors have previously been available only as injectable therapies.

This JAMA Insights explores familial hypercholesterolemia (FH), including assessment and diagnosis, effective treatments, and management of both homozygous and heterozygous FH.

This cross-sectional study examines trends in cancer medicine approvals by the US Food and Drug Administration (FDA) for adult solid tumors between 2006 and 2025, including both original and supplemental indication approvals.

In this issue of JAMA, Granfeldt and colleagues share results of the Bicarbonate for In-Hospital Cardiac Arrest randomized clinical trial comparing routine administration of sodium bicarbonate with placebo during attempted resuscitation of 779 patients with in-hospital cardiac arrest. The physiological rationale for administering sodium bicarbonate is to temporarily reduce the profound metabolic acidosis that develops during cardiac arrest to reverse myocardial depression and improve catecholamine action. Sodium bicarbonate is hypertonic and may increase intravascular volume. The primary outcome of return of spontaneous circulation was not different after sodium bicarbonate (39%) relative to placebo (37%). The intervention also did not change secondary outcomes, including organ dysfunction in the first 72 hours, 30-day survival (12% vs 9%), functional scores, or quality-of-life scores. Among patients who survived, those in the sodium bicarbonate group had higher pH and blood bicarbonate values, demonstrating successful delivery of the intervention.

The Global Burden of Disease (GBD) 2023 study represents another step in the laudable, collective effort to better understand the causes of health, disease, and mortality around the world in a comprehensive and cohesive manner. The article in this issue of JAMA by the GBD 2023 LDL Cholesterol Collaborators reports trends in the global, regional, and national burden of cardiovascular disease (CVD) attributed to elevated low-density lipoprotein cholesterol (LDL-C) from 1990 to 2023. The study addresses an important and arguably underrecognized problem in many parts of the world. The methods are consistent with other GBD reports and represent the best current global estimates of elevated LDL-C. Other reports using pooled demographic health survey and related data have been published. This report extends the previous observations by linking findings to the global burden of CVD, namely ischemic heart disease and ischemic stroke, and by using the most contemporary data. Further refinement of these estimates is expected through future iterations of GBD and other large-scale pooling research.

Listen to the JAMA Editor’s Summary for an overview and discussion of the important articles appearing in JAMA.

This study from the Global Burden of Disease quantifies the global, regional, and national burden of cardiovascular disease (CVD) attributable to elevated low-density lipoprotein cholesterol (LDL-C) and assesses the contributions of population growth, aging, changes in LDL-C exposure, and risk-deleted rates to trends in this burden.

In Reply We appreciate the letters about our recent article. However, we disagree with Dr Huang’s characterization of the background lipid-lowering therapy in VESALIUS-CV. A total of 84% of patients were taking statin therapy, which is consistent with reported rates of statin intolerance of approximately 17% in observational cohort studies. Two-thirds of patients were receiving a high-intensity lipid-lowering regimen and 14% used ezetimibe. Furthermore, as already shown in VESALIUS-CV, there was no heterogeneity in the effect of evolocumab by background statin use or intensity of lipid-lowering regimen. Moreover, the data illustrate the clinical benefit of lowering low-density lipoprotein cholesterol levels down to close to 40 mg/dL in these patients. The specific combination of statin intensity, ezetimibe, and PCSK9 inhibition needed to achieve that level is immaterial because the clinical benefit per unit reduction in low-density lipoprotein cholesterol level has been shown to be the same for these 3 classes.

This study examines trends and correlates of current alcohol use, binge drinking, and heavy drinking among pregnant women in the US from 2011 to 2024.

To the Editor In response to the recent Viewpoint on breast density masking and precision screening, we want to highlight the Health Resources and Services Administration (HRSA)–supported Women’s Preventive Services guidelines, which include breast cancer screening for average-risk women. Under section 2713 of the Public Health Service Act, most private health insurance plans must cover HRSA’s recommended preventive services without patient cost sharing.

To the Editor Critically ill patients are at risk of distressing symptoms, including pain, agitation, and delirium, which can affect their outcomes. Physical restraints may prevent self-extubation and self-harm and protect frontline staff.

Government funding for biomedical research is the topic of this Healthy Dialogue conversation between JAMA Senior Editor Derek C. Angus, MD, MPH, and Jeremy Berg, PhD, former editor in chief of Science and former director of the National Institute of General Medical Sciences.

To the Editor Dr Sonneville and colleagues reported that in the R2D2-ICU randomized clinical trial, a restrictive vs liberal physical restraint strategy did not significantly change days alive without coma or delirium through day 14 among critically ill adults. This pragmatic study addressed an important and frequently debated ICU practice.

In “Both Sides of the Bed,” poetry allows clinicians to see their role not as merely technicians but fully embedded caregivers, akin to family members at the bedside. Perhaps most striking is the poem’s honesty about the grammar of medicine, how fluently medicalese conjugates suffering in the third person—until the disease arrives in someone beloved. The speaker, a junior clinician, knows the lexicon: “resection, margins, FOLFOX,/palliative intent.” Yet as a family member standing on the other side of that vocabulary, such terminology dissolves, and knowing the anatomy of the abdomen offers no immunity from grief. Thus the brother’s lyric accomplishes what the clinician’s consult note cannot, translating the numbing solitude of diagnosis into deeply shared experience. Those rectangles on a FaceTime screen, siblings kept at arm’s length by technology and jargon, are drawn onto the wards by poetry’s enlarging of the circle of care, inviting family and clinician alike to be not just observers of suffering, but full participants in it. (The clinical urgency is real. Colorectal cancer diagnoses have risen steeply among young adults. John is 33 years old.) Medicine never adequately prepares clinicians to feel such jarring statistics; poetry demands feeling them regardless. The poem’s final image of hospital beds “[c]lose enough now/to reach” names the essential gesture of healing: the closing of distance, however tentatively. When poetry invites us into the closeness of family and community, together we truly see both sides of the bed.

In Reply We thank Drs Tejpal and Sklar for their interest in the R2D2-ICU randomized clinical trial. The 2018 Society of Critical Care Medicine clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU conditionally recommend light rather than deep sedation in critically ill patients and favor propofol or dexmedetomidine over benzodiazepines for sedation in medical and surgical patients in the ICU not undergoing cardiac surgery. In the R2D2-ICU trial, propofol or dexmedetomidine was used as the first-line sedative strategy in 298 of 396 randomized patients (75.2%). We acknowledge that benzodiazepine exposure, particularly midazolam, has been associated with an increased risk of delirium in a dose-dependent fashion, especially with continuous infusion. In the R2D2-ICU trial, the proportion of patients receiving midazolam at randomization was well balanced between the 2 study groups, limiting the potential effect of midazolam exposure on study outcomes.

This randomized noninferiority clinical trial evaluates whether the YEARS diagnostic algorithm is as safe and efficient as computed tomographic pulmonary angiography for ruling out pulmonary embolism in patients with active cancer.

This Perspective discusses the “iPatient” and “iDoctor,” digital representations of the patient and physician, and the importance of the in-person visit and physical examination in health care settings increasingly using artificial intelligence.

This cross-sectional study uses a large dataset of pharmacy transactions to examine formulary-based rejections and subsequent dispensing of initial attempts to fill single-source branded drug prescriptions in the United States across all major types of insurance.

The combustion of millions of gallons of gasoline each year is providing facilities and comfort undreamed of a few decades ago. It has often been remarked that each form of progress is carried out to the detriment of some one. The cost of changes that benefit the many not infrequently involves the comfort of a few. Manifold advantages sometimes promote minor ills. This seems to apply to the gasoline engine, which has revolutionized motor traffic throughout the world. Only a few years ago, chronic intoxication with carbon monoxide was a medical rarity, usually chargeable to leaky gas pipes that allowed the escape of contaminating “water gas.” Today, carbon monoxide is recognized as a menace of automobile exhaust gases. The annual records of deaths through careless exposure in badly ventilated garages have begun to arouse attention; at any rate, the danger is understood even if it may too often still be disregarded. When, in 1923, Henderson and Haggard of Yale University included city streets in the list of possible harmful localities with respect to the presence of the deadly gas, there was some hesitation in believing that the “free air” outdoors could ever become really dangerous to health. Observations recently reported from Philadelphia actually support the existence of a definite street risk of repeated or chronic slight carbon monoxide anoxemia in congested mercantile districts of our large cities. At any rate, it is demonstrated that patrolmen who supervise heavy traffic movement may manifest symptoms of malaise at the end of a busy day’s work; and the offensive exhaust gas has been incriminated by demonstration of a saturation of the hemoglobin of the blood to a maximum value in some instances of 30 per cent. Relief is not difficult when once the cause of harm is known.

This JAMA Insights discusses the need to expand prison hospice and compassionate release and enrich clinician understanding of the needs of dying patients who are incarcerated to provide compassionate and appropriate end-of-life care.

The enormous development of automobile traffic along rural highways, which includes tourist cars and commercial trucks, has brought about a frightful increase in the number of accidents, which have now reached a much higher figure than those caused by the railways, even as the result of serious catastrophes. The number of fatal accidents occurring in France now exceeds three a day, while the number of more or less serious accidents, though not fatal, is twenty times as great. Every Monday morning, the newspapers devote half a column to a recital of the accidents occurring the day before; for Sunday, when the conditions are favorable for tourist traffic, produces regularly more fatal accidents than any other day in the week. Almost all these accidents occur in the rural sections, far from inhabited regions; for it is well known that many automobilists, when supervision by the authorities is removed, indulge in speeding, and then, too, in the rural sections, also the farmers with their horse-drawn vehicles pay little attention to traffic regulations. The result is that on the country highways the victims of accidents frequently suffer for want of medical care and treatment, especially if, as often happens, the automobile is demolished or put temporarily out of service by the accident. And even if the contrary is true, there are cases in which the injured person cannot be transported by ordinary means and must first be cared for by a physician, which may necessitate the application of a suitable appliance. In that event, the injured person may be compelled to rely on the kindness of other automobilists who happen along....

This randomized clinical trial examines whether administration of sodium bicarbonate during in-hospital cardiac arrest increases return of spontaneous circulation as well as survival and survival with a favorable neurologic outcome.

To the Editor To me, the principal unanswered question raised by the Effect of Evolocumab in Patients at High Cardiovascular Risk Without Prior Myocardial Infarction or Stroke (VESALIUS-CV) trial is whether that trial supports use of proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibition for primary prevention in high-risk patients or whether its findings are partly driven by incomplete optimization of conventional lipid-lowering therapy. In this study, 84% to 85% of participants received statins at baseline, yet only 63% to 65% were receiving high-intensity statin therapy, ezetimibe use was approximately 14%, and only 67% to 68% received a regimen expected to reduce low-density lipoprotein cholesterol levels by more than 50%. In that setting, the reported hazard reduction may reflect, at least in part, correction of incomplete background lipid-lowering therapy rather than the independent value of adding a PCSK9 inhibitor after standard treatment has been fully optimized. A stratified analysis by baseline treatment intensity, particularly among patients already receiving high-intensity statin therapy with or without ezetimibe, would therefore be highly informative. If a similar treatment effect is preserved in that subgroup, the case for an additive benefit would be strengthened. If it is attenuated, the findings would support a more restrained conclusion: that optimization of conventional therapy should precede medication intensification.

This JAMA Patient Page describes the signs and symptoms of tetanus, the risk factors, vaccinations for prevention, and how it is diagnosed and treated.