About The Study: The results of this study that included 573,000 persons suggest that hearing loss was associated with increased dementia risk, especially among people not using hearing aids, suggesting that hearing aids might prevent or delay the onset and progression of dementia. The risk estimates were lower than in previous studies, highlighting the need for more high-quality longitudinal studies.
Authors: Manuella Lech Cantuaria, Ph.D., of the University of Southern Denmark in Odense, is the corresponding author.
(doi:10.1001/jamaoto.2023.3509)
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About JAMA Network Open: JAMA Network Open is an online-only open access general medical journal from the JAMA Network. On weekdays, the journal publishes peer-reviewed clinical research and commentary in more than 40 medical and health subject areas. Every article is free online from the day of publication.
About The Study: The findings of this study of 2,709 patients hospitalized with sepsis from 2016 to 2019 at an urban tertiary care center suggest a language-based inequity in outcomes. Further studies are needed to understand drivers of this inequity, how it may manifest in other diverse health systems, and to inform equitable care models for patients with limited English proficiency.
Authors: Neha P. Limaye, M.D., M.P.H., of Mount Sinai Hospital in New York, is the corresponding author.
(doi:10.1001/jamanetworkopen.2023.50373)
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About The Study: This study that included 525 Black adolescents found an association between individual online racial discrimination and posttraumatic stress disorder symptoms and between posttraumatic stress disorder symptoms and suicidal ideation. These risk factors are important to consider in continuing studies of the cause of suicidal ideation for Black adolescents in the U.S.
Authors: Brendesha M. Tynes, Ph.D., of the University of Southern California, Los Angeles, is the corresponding author.
(10.1001/jamapsychiatry.2023.4961)
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For more information, contact JAMA Network Media Relations at 312-464-JAMA (5262) or emailmedia relations.
About JAMA Network Open: JAMA Network Open is an online-only open access general medical journal from the JAMA Network. On weekdays, the journal publishes peer-reviewed clinical research and commentary in more than 40 medical and health subject areas. Every article is free online from the day of publication.
About The Study: In this study of more than 1.3 million inpatient admissions for treatment of COVID-19 from March 2020 through March 2022, researchers estimated an average national medical resource use or hospital cost to deliver care per COVID-19 inpatient stay at $11,275. Hospital costs increased more than five times the rate of medical inflation over this period. This was explained partly by changes in the use of extracorporeal membrane oxygenation, which also increased over time. Nonetheless, costs to provide inpatient care increased even as care practices changed, vaccination rates increased, and the variants of concern evolved.
Authors: Kandice A. Kapinos, Ph.D., of the RAND Corporation in Arlington, Virginia, is the corresponding author.
(doi:10.1001/jamanetworkopen.2023.50145)
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About The Study: The findings of this systematic review and meta-analysis of 23 randomized clinical trials including 3,100 parents suggest that problem-solving skills training for parents of children with chronic health conditions may improve the psychosocial well-being of the parents, their children, and their families. Further high-quality randomized clinical trials with longer follow-up times and that explore physical and clinical outcomes are encouraged to generate adequate evidence.
Authors: Yuanhui Luo, Ph.D., of Central South University in Changsha, Hunan, China, is the corresponding author.
(doi:10.1001/jamapediatrics.2023.5753)
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About JAMA Network Open: JAMA Network Open is an online-only open access general medical journal from the JAMA Network. On weekdays, the journal publishes peer-reviewed clinical research and commentary in more than 40 medical and health subject areas. Every article is free online from the day of publication.
About The Study: This study of 67,000 freezing cycles among 47,000 patients reveals a distinct pattern in the utilization of cryopreserved oocytes among patients undergoing planned oocyte cryopreservation in the U.S. Despite the increase in number of patients pursuing oocyte cryopreservation, there is a notably low rate of return to utilize previously vitrified oocytes; notably, patients with poor ovarian response are more likely to return, although the time to return is similar to those with normal ovarian response.
Authors: Yuval Fouks, M.D., M.P.H., of Boston IVF-The Eugin Group in Waltham, Massachusetts, is the corresponding author.
(doi:10.1001/jamanetworkopen.2023.49722)
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About JAMA Network Open: JAMA Network Open is an online-only open access general medical journal from the JAMA Network. On weekdays, the journal publishes peer-reviewed clinical research and commentary in more than 40 medical and health subject areas. Every article is free online from the day of publication.
About The Study: The findings of this study including 345 participants suggest that post–COVID-19 brain health was impaired but, overall, no more than the brain health of patients from 3 non–COVID-19 cohorts of comparable disease severity. Long-term associations with brain health might not be specific to COVID-19 but associated with overall illness severity and hospitalization. This information is important for putting understandable concerns about brain health after COVID-19 into perspective.
Authors: Daniel Kondziella, M.D., M.Sc., Dr.Philos., and Michael Eriksen Benros, M.D., Ph.D., of Copenhagen University Hospital in Copenhagen, are the corresponding authors.
(doi:10.1001/jamanetworkopen.2023.49659)
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For more information, contact JAMA Network Media Relations at 312-464-JAMA (5262) or emailmedia relations.
About JAMA Network Open: JAMA Network Open is an online-only open access general medical journal from the JAMA Network. On weekdays, the journal publishes peer-reviewed clinical research and commentary in more than 40 medical and health subject areas. Every article is free online from the day of publication.
About The Study: In this study of 465,000 individuals, a higher self-reported frequency of adding salt to foods was associated with a higher risk of chronic kidney disease in the general population. These findings suggest that reducing the frequency of adding salt to foods at the table might be a valuable strategy to lower chronic kidney disease risk in the general population.
Authors: Lu Qi, M.D., Ph.D., of Tulane University in New Orleans, is the corresponding author.
(doi:10.1001/jamanetworkopen.2023.49930)
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About JAMA Network Open: JAMA Network Open is an online-only open access general medical journal from the JAMA Network. On weekdays, the journal publishes peer-reviewed clinical research and commentary in more than 40 medical and health subject areas. Every article is free online from the day of publication.
About The Study: In this study of children tested for SARS-CoV-2 infection in Canadian pediatric emergency departments, although children infected with SARS-CoV-2 reported increased chronic symptoms, few of these children developed post–COVID-19 condition, and overall quality of life did not differ from children with negative SARS-CoV-2 tests.
Authors: Stephen Freedman, M.D.C.M., M.Sc., of the University of Calgary in Calgary, Alberta, Canada, is the corresponding author.
(doi:10.1001/jamanetworkopen.2023.49613)
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About The Study: This nationwide case-time-control study revealed an increased risk of miscarriage associated with benzodiazepine use during pregnancy after accounting for measurable confounders, and results were unlikely to be due to unmeasured confounding. These findings underscore the necessity for health care professionals to meticulously balance the risk-benefit ratio when considering the use of benzodiazepines to treat psychiatric and sleep disorders during pregnancy.
Authors: Fei-Yuan Hsiao, Ph.D., of National Taiwan University in Taipei, Taiwan, is the corresponding author.
(10.1001/jamapsychiatry.2023.4912)
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About JAMA Network Open: JAMA Network Open is an online-only open access general medical journal from the JAMA Network. On weekdays, the journal publishes peer-reviewed clinical research and commentary in more than 40 medical and health subject areas. Every article is free online from the day of publication.
About The Study: In this study of individuals diagnosed with cancer in the National Cancer Database (NCDB), Hispanic and American Indian or Alaska Native individuals diagnosed with breast, colorectal, lung, and prostate cancer were undercaptured in the NCDB, but their representation improved over time. Increased study is needed to determine where these populations predominantly seek cancer care.
Authors: Juan Javier-DesLoges, M.D., M.S., of the University of California, San Diego, is the corresponding author.
(doi:10.1001/jamanetworkopen.2023.50237)
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About JAMA Network Open: JAMA Network Open is an online-only open access general medical journal from the JAMA Network. On weekdays, the journal publishes peer-reviewed clinical research and commentary in more than 40 medical and health subject areas. Every article is free online from the day of publication.
About The Study: In this study using data from three large prospective cohort studies among 123,000 individuals, low-carbohydrate diets that emphasized high-quality proteins, fats and carbohydrates from whole grains and other healthy plant-based foods were significantly associated with slower weight gain in the long term. In contrast, low-carbohydrate diets emphasizing animal-sourced proteins and fats or refined carbohydrates were associated with faster weight gain.
Authors: Qi Sun, M.D., Sc.D., of the Harvard T.H. Chan School of Public Health in Boston, is the corresponding author.
(doi:10.1001/jamanetworkopen.2023.49552)
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About JAMA Network Open: JAMA Network Open is an online-only open access general medical journal from the JAMA Network. On weekdays, the journal publishes peer-reviewed clinical research and commentary in more than 40 medical and health subject areas. Every article is free online from the day of publication.
About The Study: The results of this study suggest that artificial intelligence (AI) can be a useful and convenient tool for people who want to know the energy and macronutrient information of their foods. Although AI chatbots cannot replace nutritionists, they may provide real-time analysis of foods, and the capacity to harness AI technology in a supportive role may fundamentally transform the way nutritionists communicate with patients.
Authors: Jung-Su Chang, Ph.D., of Taipei Medical University in Taipei, Taiwan, is the corresponding author.
(doi:10.1001/jamanetworkopen.2023.50367)
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About JAMA Network Open: JAMA Network Open is an online-only open access general medical journal from the JAMA Network. On weekdays, the journal publishes peer-reviewed clinical research and commentary in more than 40 medical and health subject areas. Every article is free online from the day of publication.
About The Study: The findings of this prognostic study of cognitive outcomes at 2-year follow-up among 1,000 infants born very preterm suggest that predictive modeling in neonatal care could enable early and targeted intervention for very preterm infants most at risk for developing cognitive impairment.
Authors: Andrea K. Bowe, M.B., M.P.H., of University College Cork in Cork, Ireland, is the corresponding author.
(doi:10.1001/jamanetworkopen.2023.49111)
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About JAMA Network Open: JAMA Network Open is an online-only open access general medical journal from the JAMA Network. On weekdays, the journal publishes peer-reviewed clinical research and commentary in more than 40 medical and health subject areas. Every article is free online from the day of publication.
About The Study: Pet ownership was associated with slower rates of decline in verbal memory and verbal fluency among older adults living alone, but not among those living with others in this study of 7,900 participants age 50 and older. Pet ownership offset the associations between living alone and declining rates in verbal memory and verbal fluency. Further studies are needed to assess whether pet ownership slows the rate of cognitive decline in older adults living alone.
Authors: Ciyong Lu, Ph.D., of Sun Yat-sen University in Guangzhou, China, is the corresponding author.
(doi:10.1001/jamanetworkopen.2023.49241)
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About JAMA Network Open: JAMA Network Open is an online-only open access general medical journal from the JAMA Network. On weekdays, the journal publishes peer-reviewed clinical research and commentary in more than 40 medical and health subject areas. Every article is free online from the day of publication.
About The Study: In this study of 8,000 participants, negative wealth shock (a loss of 75% or more in total wealth over a 2-year period) was associated with accelerated cognitive decline and elevated risks of dementia among middle-aged and older U.S. adults, with modifications by age and ethnicity. These findings should be confirmed by further prospective and interventional studies.
Authors: Jing Guo, Ph.D., of the Zhejiang University School of Medicine in Hangzhou, China, is the corresponding author.
(doi:10.1001/jamanetworkopen.2023.49258)
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About JAMA Network Open: JAMA Network Open is an online-only open access general medical journal from the JAMA Network. On weekdays, the journal publishes peer-reviewed clinical research and commentary in more than 40 medical and health subject areas. Every article is free online from the day of publication.
About The Study: Among a national cohort of medical interns, over half experienced sexual harassment. Although harassment was prevalent across programs, institutional and specialty training variations in interns’ sexual harassment experiences exist, thereby providing additional evidence that residency programs and institutions play an important role in combating this widespread problem.
Authors: Elizabeth M. Viglianti, M.D., M.P.H., M.Sc., of the University of Michigan in Ann Arbor, is the corresponding author.
(doi:10.1001/jamanetworkopen.2023.49129)
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About The Study: Private equity acquisition of hospitals, on average, was associated with increased hospital-acquired adverse events despite a likely lower-risk pool of admitted Medicare beneficiaries, suggesting poorer quality of inpatient care. These findings heighten concerns about the implications of private equity on health care delivery.
Authors: Zirui Song, M.D., Ph.D., of Harvard Medical School in Boston, is the corresponding author.
(doi:10.1001/jama.2023.23147)
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About JAMA Network Open: JAMA Network Open is an online-only open access general medical journal from the JAMA Network. On weekdays, the journal publishes peer-reviewed clinical research and commentary in more than 40 medical and health subject areas. Every article is free online from the day of publication.
About The Study: The results of this study involving 70 youths with autism across four psychiatric inpatient hospitals suggest that wearable biosensing and machine learning may hold promise for identifying objective indicators of impending aggressive behaviors in youths with autism who are psychiatric inpatients. The findings may lay the groundwork for developing just-in-time adaptive intervention mobile health systems that may enable new opportunities for preemptive intervention.
Authors: Matthew S. Goodwin, Ph.D., of Northeastern University in Boston, is the corresponding author.
(doi:10.1001/jamanetworkopen.2023.48898)
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About JAMA Network Open: JAMA Network Open is an online-only open access general medical journal from the JAMA Network. On weekdays, the journal publishes peer-reviewed clinical research and commentary in more than 40 medical and health subject areas. Every article is free online from the day of publication.
About The Study: This systematic review of 120 studies with 14,000 participants found that Asian, Black, Hispanic, and Indigenous (e.g., Alaska Native, American Indian, and Native Hawaiian) participants were underrepresented in neonatal clinical trials, while white participants were overrepresented. There was wide variation in the terms used to report race and ethnicity data, and geographic representation was unevenly distributed, with some central and western U.S. regions underrepresented.
Authors: Elliott M. Weiss, M.D., M.S.M.E., of the University of Washington School of Medicine in Seattle, is the corresponding author.
(doi:10.1001/jamanetworkopen.2023.48882)
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About The Study: Compared with prior decades, the number of new dermatologic drug approvals by the Food and Drug Administration (FDA) increased between 2012 and 2022. Nearly half of these drugs were considered first in class or first in indication, and several were deemed clinically useful or to have high added therapeutic benefit by health technology assessment organizations in Germany, Canada, or France.
Authors: Ravi Gupta, M.D., M.S.H.P., of the Johns Hopkins University School of Medicine in Baltimore, is the corresponding author.
(doi:10.1001/jamadermatol.2023.5036)
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About JAMA Network Open: JAMA Network Open is an online-only open access general medical journal from the JAMA Network. On weekdays, the journal publishes peer-reviewed clinical research and commentary in more than 40 medical and health subject areas. Every article is free online from the day of publication.
About The Study: This pilot pragmatic clinical trial included 243 homebound older adults with self- or proxy-reported dementia found a lower although nonsignificant likelihood of nursing home placement among those receiving daily-delivered meals compared with those receiving drop-shipped frozen meals. While this study was not powered to detect meaningful, statistically significant differences in nursing home placement, its feasibility and initial results warrant exploration in an adequately powered trial.
Authors: Kali S. Thomas, Ph.D., of the Brown University School of Public Health in Providence, Rhode Island, is the corresponding author.
(doi:10.1001/jamanetworkopen.2023.47195)
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About The Study: The findings of this systematic review and meta-analysis of 15 randomized clinical trials with an effective population size of 2,786 patients suggest that daily tooth brushing may be associated with significantly lower rates of hospital-acquired pneumonia, particularly in patients receiving mechanical ventilation, lower rates of intensive care unit (ICU) mortality, shorter duration of mechanical ventilation, and shorter ICU length of stay. Policies and programs encouraging more widespread and consistent toothbrushing are warranted.
Authors: Michael Klompas, M.D., M.P.H., of Harvard Medical School and Harvard Pilgrim Health Care Institute in Boston, is the corresponding author.
(doi:10.1001/jamainternmed.2023.6638)
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About The Study: The results of this study raise concerns that benefit programs may add relative advantages for white children compared with Black and Hispanic children and contribute to racial and ethnic disparities in child protective services investigations. States’ eligibility criteria and distribution practices should be examined to promote equitable effects on adverse child outcomes.
Authors: Henry T. Puls, M.D., of Children’s Mercy Kansas City, is the corresponding author.
(doi:10.1001/jamapediatrics.2023.5521)
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About The Study: Although standard artificial intelligence (AI) models improve diagnostic accuracy, systematically biased AI models reduced diagnostic accuracy, and commonly used image-based AI model explanations did not mitigate this harmful effect in this multicenter randomized clinical vignette survey study involving hospitalist physicians, nurse practitioners, and physician assistants from 13 states.
Authors: Michael W. Sjoding, M.D., of the University of Michigan Medical School, and Jenna Wiens, Ph.D., of the University of Michigan, Ann Arbor, are the corresponding authors.
(doi:10.1001/jama.2023.22295)
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About JAMA Health Forum: JAMA Health Forum is an international, peer-reviewed, online, open access journal that addresses health policy and strategies affecting medicine, health and health care. The journal publishes original research, evidence-based reports and opinion about national and global health policy; innovative approaches to health care delivery; and health care economics, access, quality, safety, equity and reform. Its distribution will be solely digital and all content will be freely available for anyone to read.
About JAMA Network Open: JAMA Network Open is an online-only open access general medical journal from the JAMA Network. On weekdays, the journal publishes peer-reviewed clinical research and commentary in more than 40 medical and health subject areas. Every article is free online from the day of publication.
About The Study: The results of this study of data on 57,000 adults who received living donor kidney transplants indicate that additional work is necessary to identify transplant program and center-level strategies to improve racial equity in access to living donor kidney transplant.
Authors: Lisa M. McElroy, M.D., M.S., of the Duke University School of Medicine in Durham, North Carolina, is the corresponding author.
(doi:10.1001/jamanetworkopen.2023.47826)
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About JAMA Network Open: JAMA Network Open is an online-only open access general medical journal from the JAMA Network. On weekdays, the journal publishes peer-reviewed clinical research and commentary in more than 40 medical and health subject areas. Every article is free online from the day of publication.
About The Study: This study found that patients screened in the emergency department (ED) were more likely to screen positive for Social Determinants of Health (SDOH) needs, which is not surprising given utilization patterns. Patients with SDOH needs have limited health care access and are more likely to use the ED than primary care. Although primary care–based screening found lower SDOH needs relative to the ED, primary care may be better optimized to follow and ultimately address SDOH needs.
Authors: Stacie Vilendrer, M.D., M.B.A., M.S.H.P., of the Stanford University School of Medicine, in Palo Alto, California is the corresponding author.
(doi: 10.1001/jamanetworkopen.2023.48646)
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About JAMA Network Open: JAMA Network Open is an online-only open access general medical journal from the JAMA Network. On weekdays, the journal publishes peer-reviewed clinical research and commentary in more than 40 medical and health subject areas. Every article is free online from the day of publication.
About The Study: In this study of 13,000 patients, few patients undergoing surgical procedures completed preoperative life-sustaining treatment documentation, with disparities in documentation rates based on race, ethnicity, rurality of patient residence, history of mental health disability, and access to high-volume facilities within a Veterans Affairs cohort.
Authors: Adela Wu, M.D., of the U.S. Department of Veterans Affairs, in Palo Alto, California is the corresponding author.
(doi: 10.1001/jamanetworkopen.2023.48235)
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About JAMA Network Open: JAMA Network Open is an online-only open access general medical journal from the JAMA Network. On weekdays, the journal publishes peer-reviewed clinical research and commentary in more than 40 medical and health subject areas. Every article is free online from the day of publication.
About The Study: Fewer calories were purchased in restaurants with calorie labels compared with those with no labels, suggesting that consumers are sensitive to calorie information on menu boards, according to the results of this study of 2,329 Mexican-inspired fast food restaurants in six U.S. locations. Associations differed by location.
Authors: Brian Elbel, Ph.D., M.P.H., of the New York University School of Medicine in New York, is the corresponding author.
(doi:10.1001/jamanetworkopen.2023.46851)
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About JAMA Network Open: JAMA Network Open is an online-only open access general medical journal from the JAMA Network. On weekdays, the journal publishes peer-reviewed clinical research and commentary in more than 40 medical and health subject areas. Every article is free online from the day of publication.
About The Study: The findings of this diagnostic study of 1,890 eyes of 958 participants support the potential of artificial intelligence as an objective tool in screening for autism spectrum disorder (ASD) and possibly for symptom severity using retinal photographs. Retinal photograph use may speed the ASD screening process, which may help improve accessibility to specialized child psychiatry assessments currently strained by limited resources.
Authors: Yu Rang Park, Ph.D., and Keun-Ah Cheon, M.D., Ph.D., of the Yonsei University College of Medicine in Seoul, Republic of Korea, are the corresponding authors.
(doi:10.1001/jamanetworkopen.2023.47692)
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About JAMA Network Open: JAMA Network Open is an online-only open access general medical journal from the JAMA Network. On weekdays, the journal publishes peer-reviewed clinical research and commentary in more than 40 medical and health subject areas. Every article is free online from the day of publication.
About The Study: In this study of 18,000 academic physicians, approximately one-third reported moderate or greater intention to leave within two years. Burnout, lack of professional fulfillment, and other well-being factors were associated with intention to leave, suggesting the need for a comprehensive approach to reduce physician turnover.
Authors: Mickey T. Trockel, M.D., Ph.D., of the Stanford University School of Medicine in Stanford, California, is the corresponding author.
(doi:10.1001/jamanetworkopen.2023.47894)
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About JAMA Network Open: JAMA Network Open is an online-only open access general medical journal from the JAMA Network. On weekdays, the journal publishes peer-reviewed clinical research and commentary in more than 40 medical and health subject areas. Every article is free online from the day of publication.
About The Study: In this study of 6,247 patients with heart failure with reduced ejection fraction, patients living in neighborhoods with lower neighborhood-level socioeconomic status had significantly higher odds of nonadherence to guideline-directed medical therapy. These findings highlight the importance of considering neighborhood-level disparities when developing approaches to improve medication adherence.
Authors: Amrita Mukhopadhyay, M.D., of the NYU Grossman School of Medicine in New York, is the corresponding author.
(doi:10.1001/jamanetworkopen.2023.47519)
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For more information, contact JAMA Network Media Relations at 312-464-JAMA (5262) or emailmedia relations.
About JAMA Network Open: JAMA Network Open is an online-only open access general medical journal from the JAMA Network. On weekdays, the journal publishes peer-reviewed clinical research and commentary in more than 40 medical and health subject areas. Every article is free online from the day of publication.
About The Study: The natural history of sleep disturbances was associated with both resolved and incident emotional and behavioral difficulties in this study of 17,000 preschool-aged children. Routine screening and precise intervention for sleep disturbances may benefit the psychosocial well-being of this population.
Authors: Fan Jiang, M.D., Ph.D., and Guanghai Wang, Ph.D., of Shanghai Jiao Tong University in Shanghai, are the corresponding authors.
(doi:10.1001/jamanetworkopen.2023.47623)
Editor’s Note: Please see the article for additional information, including other authors, author contributions and affiliations, conflict of interest and financial disclosures, and funding and support.
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For more information, contact JAMA Network Media Relations at 312-464-JAMA (5262) or emailmedia relations.
About The Study: In this study including 4,819 women with benign breast disease (BBD) in the percutaneous biopsy era, overall risk of breast cancer was increased versus the general population (ductal carcinoma in situ and invasive cancer combined), similar to that in historical BBD cohorts. Development and validation of pathologic classifications including both BBD severity and multiplicity may enable improved breast cancer risk stratification.
Authors: Amy C. Degnim, M.D., of the Mayo Clinic in Rochester, Minnesota, is the corresponding author.
(doi:10.1001/jamasurg.2023.6382)
Editor’s Note: Please see the article for additional information, including other authors, author contributions and affiliations, conflict of interest and financial disclosures, and funding and support.
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For more information, contact JAMA Network Media Relations at 312-464-JAMA (5262) or emailmedia relations.
About JAMA Network Open: JAMA Network Open is an online-only open access general medical journal from the JAMA Network. On weekdays, the journal publishes peer-reviewed clinical research and commentary in more than 40 medical and health subject areas. Every article is free online from the day of publication.
About The Study: The findings from this study using 2016-2021 data on 10,000 adolescents in the U.S. suggest that pregnant adolescents increasingly used e-cigarettes, with the highest use among white adolescents. Results from this analysis found that, unlike cigarette use, e-cigarette use during late pregnancy was not statistically significantly associated with an increased risk of small-for-gestational-age birth among adolescents. Due to the uncertainty of this nonsignificant association, future research could benefit from a larger sample size.
Authors: Xiaozhong Wen, M.D., Ph.D., of the State University of New York at Buffalo, is the corresponding author.
(doi:10.1001/jamanetworkopen.2023.47407)
Editor’s Note: Please see the article for additional information, including other authors, author contributions and affiliations, conflict of interest and financial disclosures, and funding and support.
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For more information, contact JAMA Network Media Relations at 312-464-JAMA (5262) or emailmedia relations.
