Koronavirus 2019

**Cutar Korona virus ce ta 2019 ** da turanci kuma **'coronavirus disease 2019**' a takaice  (**'COVID-19**') cuta ce mai **hadari sosai da take da lahani** ta kan sa matsanancin ciwo mai dauke dawayar cuta ta corona virus 2 (SARS-CoV-2).Cutar ta yaɗu a duniya tun daga shekarar 2019, wanda ta haifar da yaɗuwar cutar sankara a shekarar 2019, cutace Wanda ya halaka mutane da dama a fadin Duniya durkusar da masana`antu. 

## Yin suna.
Hukumar Kiwon Lafiya ta Duniya (WHO) ta sanar a ranar 11, ga watan Fabrairu shekarar 2020, cewa "COVID-19" zai kasance suna a hukumance da akayi wa cutar. Shugaban Hukumar Lafiya ta Duniya Tedros Adhanom Ghebreyesus ya ce "to" ya tsaya ne ga "Corona", "vi" ga "virus (kwayar cutar)"  "disease (cuta)", yayin da "19" ke nufin a shekarar 2019, da aka fara samun bullowar cutar a cikin ta, kamar yadda aka fara gano cutar a ranar 31, ga watan Disamba shekarar 2019. Tedros ya ce an zabi sunan ne don kauce wa nassoshi game da takamaiman wuri na kasar (watau Kasar Sin) da cutar ta faro daga gare ta, nau'in dabbobi, ko gungun mutane daidai da shawarwarin kasa da kasa don yin suna don nufin hana tarzoma.   

Cutar ta kasance mai suna COVID-19, yayin da WHO ta sake canza sunan cutar a matsayin SARS-COV-2 ta WHO amatsayin suna na ilimin lafiya.

## Alamu da bayyana.

Kwayar cutar tana yaduwa daga mutum daya zuwa wasu ta hanyar samun ruwa ko wani abu mai nau'in ruwa (hattat iska) ko jini, kwayar cutar, majina, yawu koma ta numfashi, yawanci ana samu ne yayin tari ko atishawa daga mai'dauke da ita. Lokaci daga samuwa zuwa farkon bayyanar cutar yakan kai gaba ɗaya tsakanin kwana goma sha hudu ne ko mako biyu zuwa 3, tare da matsakaiciyar nunawa a cikin kwana biyar ko dadaddiyar lokaci shine kwana arba'in.   Ainihin hanyar ganewar asali ita ce ta hanyar juyar da sarkoki na sarkokin  (rRT-PCR) daga samfurin n*asopharyngeal swab* ko samfurin sputum. Hakanan za'a iya amfani da assay na antibody, ta amfani da samfurin jini .  Hakanan ana iya gano kamuwa da cutar daga haduwa da alamun cutar da aka bayyana, abubuwan hadari, da kuma kirjin CT scan wanda ke nuna fasalin ciwon huhu, shima yanayi ne na gano mai cutar.   

Matakan da aka ba da shawarar hana yaduwar cutar sun hada da wanke hannu da sabulu akai-akai, daina shafar fuska, kiyayewa da yin nesa-nesa daga sauran mutane, da kuma taba fuskar mutum.  Yin amfani da takunkumi (masks) ga wadanda suke zargin suna da kwayar cutar, saboda kada su yada shi, da kuma masu kulawa dasu, amma a shawarar amfani da abin rufe fuska ga sauran jama'a.   Babu allurar rigakafi ko takamaiman maganin rigakafi don COVID-19, ayanzu; gudanarwa ya kunshi lura da alamun kuwa da cutar, kulawa ga masu taimakon Kansu (Dan kada suje su dauko su yaɗa, da matakan gwajin wanda basu dashi amma suke zargin sun kamu.  

Hukumar lafiya ta duniya wato World Health Organization (WHO) ta bayyana cewa, shekarar  duba da sha'tara zuwa dubu da ashirin (2019-20), coronavirus ta watsu a ko'ina dan haka ta zama pandemic (cutar dake ko'ina kuma kowa na kamawa), kuma a Harkokin Kiwon Lafiyar Jama'a gaggawa na kasa da kasa Damuwa (PHEIC).   An samu tabbacin watsa kwayar cutar a cikin kasashe da yawa a duk yankuna shida na Duniya da WHO take.

Wadanda ke kamuwa da kwayar cutar na iya zama asymptomatic ko habaka alamomin kamuwa da mura wadanda suka hada da zazzabi, tari, da gajeruwar numfashi.    Zawo gudawa da alamomi na sama kamar fitar da jini yayin tari, ko ciwon makogwaro ba su da yawa.  Alamun na iya ci gaba har zuwa ga ciwon huhu, gabar kwayoyin cuta da dama, da mutuwa a cikin mafi hadari.   

Lokacin fitar wadannan alamu ya fara ne daga kwanaki biyu zuwa kwanaki 14, tare da kiyasta tsintsiyar tsakanin kwanaki biyar zuwa kwanaki shida, a cewar Hukumar Lafiya ta Duniya (WHO).   Cutar ta Symptomatic tana daukar tsawon kwanaki zuwa makonni, kuma tsawon lokacin yana daidaita da sauran maganganun kiwon lafiya na ci gaba a cikin mutum.  

Wani binciken da aka yi a China ya gano cewa zane na CT ya nuna alamun gilashin kasa a cikin kashi 56%, amma 18% basu da binciken rediyo. 5% an shigar da su cikin rukunin kulawa mai zurfi, 2.3% na bukatar tallafin injiniyoyi na samun iska kuma 1.4% ya mutu.  Abubuwan hadin gilasai na kasa da na waje sune mafi yawan abubuwan binciken CT.  Solarfafawa, daidaitattun hanyoyin layi da alamar halo sune sauran binciken rediyo.  Da farko, raunuka suna iyakance ga huhu daya, amma yayin da cutar ke ci gaba, alamomi sun bayyana a cikin huhu biyu a cikin 88% na abin da ake kira "mara lafiya marasa lafiya" a cikin rukuni na binciken (rago don lokacin tsakanin bayyanar cututtuka da kirji CT ya 6-12 kwana).  An lura cewa yara suna da alamu marasa sauƙi fiye da manya.

## Sanadi.
Cutar tana haifar da kwayar cuta wadda ake saurin kamuwa da ita, cutar corona virus 2, (SARS-CoV-2), wacce a yanzu ita ake kira a matsayin corona virus na shekara ta 2019, (2019-nCoV).  An fara yada shi tsakanin mutane ne ta hanyar shakar numfashi ko majina daga hanci.  

Gabar huhu itace cutar COVID-19, tafi wa lahani ajikin mutum saboda virus na samun kaiwa enzyme ACE2 na jikin wanda ya kamu da cutar ne, wanda kuma suke nan da yawa a nnau'i irib II alveolar cells dake huhu. The virus uses a special surface *glycoprotein, called "spike"*, *to connect to ACE2 and intrude the hosting cell. The density of ACE2 in each tissue correlates with the severity of the disease in that tissue and some have suggested that decreasing ACE2 activity might be protective, though another  view is that increasing ACE2 using Angiotensin II receptor blocker drugs could be protective and that these hypotheses need to be tested by datamining of clinical patient records. As the alveolar disease progresses respiratory failure might develop and death might ensue. ACE2 might also be the path for the virus to assault the heart causing acute cardiac injury. People with existing cardiovascular conditions have worst prognosis.*

Kwayar cutar ana tunanin tana da asali ne ta dabbobi.  An ba da shi ta farko ga 'yan Adam a Wuhan, kasar Sin, a watan Nuwamba ko Disamba 2019, kuma asalin tushen kamuwa da cuta ya zama kwayar cutar-da-mutum zuwa farkon watan Janairu shekara ta 2020.

## Gwaji.

Hukumar lafiya ta Dumiya wato WHO ta buga da yawa gwaje-gwaje akan cutar. Na ainihi yadda ake gwajin cutar shine real-time reverse transcription polymerase chain reaction (rRT-PCR). *The test can be done on respiratory samples obtained by various methods, including nasopharyngeal swab or sputum sample. Results are generally available within a few hours to 2 days. Blood tests can be used, but these require two blood samples taken two weeks apart and the results have little immediate value. Chinese scientists were able to isolate a strain of the coronavirus and publish the genetic sequence so that laboratories across the world could independently develop polymerase chain reaction (PCR) tests to detect infection by the virus.*

Hakanan za'a iya yin gwajin COVID-19, tare da kayan gwajin rigakafin.  Magungunan rigakafi suna amfani da samfurin kwayar jini kuma yana iya samar da sakamako mai kyau ko da mutumin ya warke kuma cutar bata sake kasancewa ba.  Wata tawaga ce ta farko da kungiyar kwalliya ta nuna a Kwalejin Ilimin cuta ta Wuhan a ranar 17, ga Fabrairu shekarar  2020.   A ranar 25, ga Fabrairu, wata kungiya daga Duke – NUS Medical School a Singapore ta ba da sanarwar wani gwajin rigakafi don COVID-19 wanda zai iya ba da sakamako a cikin 'yan kwanaki.   

Jagororin bincike na asibitin Zhongnan na jami'ar Wuhan sun ba da shawarar hanyoyi don gano cututtukan cututtukan da suka danganta da sifofin asibiti da haɗarin cututtukan cututtukan. Wadannan sun hada da gano mutanen da ke da alamomi akalla biyu daga cikin alamu baya ga tarihin tafiya zuwa Wuhan ko tuntuɓar wasu mutanen da suka kamu da cutar: zazzabi, fasalolin kamuwa da cutar huhu, al'ada ko rage adadin ƙwayoyin farin jini, ko rage yawan ƙwayoyin cutar ta lymphocyte.  Nazarin da wata tawaga ta buga a Asibitin Tongji da ke Wuhan a ranar 26, ga Fabrairu 2020, ya nuna cewa kirjin CT scan na COVID-19 yana da hankali sosai (98%) fiye da karuwar polymerase (71%).  Sakamakon mara kyau na ƙila na iya faruwa saboda faɗuwar kit ɗin PCR, ko saboda ko dai batutuwa tare da samfurin ko batutuwan da suke yin gwajin. Sakamakon tabbatacce na ƙila ya zama da wuya.  
File:COVID19CT2.webp|Abubuwan bincike na yau da kullun na CT 
File:COVID19CT1.webp|CT hoto mai saurin ci gaban mataki 


Saboda allurar rigakafin SARS-CoV-2 ba a tsammanin ta kasance har zuwa 2021, a farkon,  wani sashi mai mahimmanci na kulawa da cutar ta COVID-19 na ƙoƙarin rage kololuwar ƙwayar cuta, wanda aka sani da karkatar da cutar .  Wannan yana taimakawa rage haɗarin ayyukan kiwon lafiya da ake fama da shi kuma yana ba da ƙarin lokaci don allurar rigakafi da magani.  

Matakan rigakafin don rage damar kamuwa da cuta a wurare tare da barkewar cutar sun yi kama da waɗanda aka buga don wasu coronaviruses: zauna gida, guji tafiya da ayyukan jama'a, wanke hannu da sabulu da ruwan zafi sau da yawa, gudanar da aikin tsabtace numfashi kuma ku guji taɓawa idanu, hanci, ko baki da hannayensu marasa wanke-wanke.   Dabarun nesanta kansu da jama'a suna nufin rage abokan hulɗa da masu cutar tare da manyan ƙungiyoyi ta hanyar rufe makarantu da wuraren aiki, da takaita tafiye-tafiye da soke taron jama'a. 

To prevent transmission of the virus, the US Centers for Disease Control and Prevention (CDC) recommends that infected individuals stay home except to get medical care, call ahead before visiting a healthcare provider, wear a face mask when exposed to an individual or location of a suspected infection, cover coughs and sneezes with a tissue, regularly wash hands with soap and water, and avoid sharing personal household items. The CDC also recommends that individuals wash hands often with soap and water for at least 20 seconds, especially after going to the toilet or when hands are visibly dirty, before eating and after blowing one's nose, coughing, or sneezing. It further recommended using an alcohol-based hand sanitiser with at least 60% alcohol, but only when soap and water are not readily available. The WHO advises individuals to avoid touching the eyes, nose, or mouth with unwashed hands. Spitting in public places also should be avoided.

## Rigakafi/Kulawa

Don hana yaduwar COVID-19:  

Tsaftace hannuwanku sau da yawa. Yi amfani da sabulu da ruwa, ko rubin da keɓaɓɓiyar hannu.

Kiyaye nesa daga duk wani mai amai da hancinsa.

Sanya abin rufe fuska lokacin jin jiki ba zai yiwu ba.

Karka taɓa idanun ka, hanci ko bakinka.

Rufe hanci da bakinka tare da gwiwarka hannunka mai lanƙwasa ko nama a yayin da kake tari ko hurawa.

Ka kasance a gida idan kana jin rashin lafiya.

Idan kana da zazzabi, tari da wahala numfashi, nemi likita.

Kira a gaba yana ba wa mai kula da lafiyarku kai tsaye kai tsaye zuwa ga ingantacciyar cibiyar lafiya. Wannan yana kiyaye ku, kuma yana hana yaduwar ƙwayoyin cuta da sauran kamuwa da cuta.

abin rufe fuska

abin rufe fuska na iya taimakawa wajen hana yaduwar kwayar cutar daga mutumin da ke sanya abin rufe fuska ga wasu. abin rufe fuska kadai ba su da kariya daga COVID-19, kuma ya kamata a haɗe shi da damuwa ta jiki da tsabtace hannu. Bi shawarar da karamar hukuma ta ba ku.

Babu magungunan rigakafi da aka keɓance su ga COVID-19 ayanzu. Ana kulawa da marasa lafiya ne tare da kulawar taimakawar ruwa da kuma iska (maganin oxygen). Ana gwajin magungunan rigakafin da ake bincike a jikin mutanen da ke da mummunar cuta.  Hukumar Lafiya ta Duniya ( WHO) da Hukumar Kula da Lafiya ta kasar China sun wallafa shawarwarin neman magani da za'a bi game da kulawa da mutanen da ke asibiti tare cutar ta COVID-19. Steroids kamar methylprednisolone bada shawarar yin anfani dasu sai dai idan cutar ta rikita ta hanyar matsananciyar damuwa na matsananciyar damuwa mai jinya.   CDC ta ba da shawarar cewa waɗanda suke zargin suna dauke da kwayar cutar su keɓance kansu, kuma mutane su riƙa wanke hannu akai-akai, da rufe hanci idan zasu yi atishawa ko hamma, su wanke hannu da sabulu idan sun fyace majina.  

Kula da mutanen da suka kamu da cutar ya haɗa da kiyaye kai da aiwatar da therapeutic manoeuvres, musamman sanda kuke aiwatar da abubuwa kamar intubation or hand ventilation waɗanda zasu iya haifar da aerosols.

Sai dai CDC ta bayar da abubuwan da za'ayi amfani dasu dan kare kai daga cutar kamar haka, da kuma yadda masu aikin kiwon lafiya zasu yi anfani dashi lokacin da Duke kula da mara lafiya (mai ɗauke da cutar ta Covid-19: na farko -1) A sanya babbar riga da zai rufe dukan jiki (wato *gown*), 2) A sanya abunda zai rufe hanci ba na tsumma ba, saidai abun da ke taimakawa wurin shaƙar iska maikyau (wato *mask or respirator*), 3) Gilas ko tabarau (wato *goggles or a face shield*), 4) safar hannu ba ta tsumma ba (wato *gloves*).

A watan Fabrairu na shekarar 2020, kasar Sin ta bullo da wani tsarin wayar hannu don shawo kan barkewar cutar.  Ana tambayar masu amfani don shigar da sunan su da lambar ID. The app damar iya gano 'kusa lamba' ta amfani da sa ido don haka wani hadarin kamuwa da cuta. Kowane mai amfani zai iya bincika matsayin sauran masu amfani uku. Idan aka gano yiwuwar haɗari, ƙa'idar ba wai kawai tana bada shawarar karancin kansa bane, yana kuma faɗakar da jami'an kiwon lafiyar na cikin gida.  

### Bincike.
WHO ta ba da shawarar masu sa kai su shiga cikin gwaji na inganci da amincin yiwuwar jiyya.  Akwai tabbatattun shaidu don sakewa tun daga Maris 2020.  Hakanan ana yin karatun Lopinavir/ritonavir a China.  An fara binciken *Chloroquine* a kasar Sin a watan Fabrairu na 2020, tare da sakamakon farko da ya yi daidai.  An ba da shawarar Nitazoxanide don cigaba cikin binciken vivo bayan nuna ƙarancin maida hankali sosai na SARS-CoV-2 .  

### Ilimin ɗabi'ar ɗan'Adam.
Mutane masu kamuwa da cutar na iya fuskantar damuwa daga keɓe, ƙuntatawa na tafiya, sakamakon  babu magani, ko tsoron kamuwa da cutar ma kanta.

## Hasashe.
Yawancin wadanda suka mutu sanadiyar cutar COVID-19 suna da rashin lafiya kafin nan, kamar su hawan-jini, ciwon-siga, da *cardiovascular disease.* A wani bincike a farkon bullar cutar, an gane cewa matsakaicin lokacin rayuwar mutum bayan kamuwarsa da mutuwarsa shine kwana goma sha hudu (14), ko daga 6, zuwa kwana 41. *In a study by the National Health Commission (NHC) of [[China]], men had a death rate of 2.8% while women had a death rate of 1.7%. In those under the age of 50, the risk of death is less than 0.5%, while in those over the age of 70, it is more than 8%. No deaths had occurred in patients under the age of 10 . Availability of medical resources and the socioeconomics of a region may also affect mortality.*

*Histopathological examinations of post-mortem lung samples showed diffuse alveolar damage with cellular fibromyxoid exudates in both lungs. Viral cytopathic changes were observed in the pneumocytes. The lung picture resembled acute respiratory distress syndrome (ARDS).*


File:Severity-of-coronavirus-cases-in-China-1.png|Verarfin cutar COVID19 da aka gano a China  
File:Illustration of SARS-COV-2 Case Fatality Rate 200228 01-1.png|alt = 3D Tsarin Kiwon Lafiya na har yanzu allon hoto wanda ke nuna ƙididdigar yawan mace-mace ta ƙarancin shekaru daga SARS-COV-2 a China. Bayanai daga 11 Fabrairu 2020.  
File:Comorbidity and severity in covid-19 data from China CDC Weekly 2020, 2(8), pp. 113-122 (cropped).png|Yawan mace-mace idan ya dogara da sauran matsalolin lafiya 


Gabaɗaya yawan mace-mace da cututtukan ƙwayoyin cuta saboda kamuwa da cuta ba su da tushe sosai; yayin da adadin mace-macen (CFR) ke canzawa lokaci-lokaci a cikin barkewar cutar ta yau, rabar da cututtukan da ke ci gaba da bayyanar cutar har yanzu ba a sani ba.   Ko yaya, bincike na farko ya haifar da adadin lambobin mace-mace tsakanin 2% zuwa 3%;  a cikin Janairu 2020, Hukumar ta WHO ta ba da shawarar cewa yawan masu shari'ar ya kusan 3%,  da 2% a cikin Fabrairu 2020, a Hubei.  Sauran lambobin CFR, waɗanda suka daidaita don bambance-bambance a lokacin tabbatarwa, mutuwa ko warke, sun kasance 7%  da 33% ga mutane a Wuhan 31, Janairu.  An unreviewed preprint binciken da na mallaka College London tsakanin 55, m lokuta lura da cewa farkon kimomi da mace-mace na iya zama da muni kamar yadda asymptomatic cututtuka da aka rasa suna. Sun kiyasta ma'anar kamuwa da cutar kamuwa da cuta (IFR, mace-maccen tsakanin kamuwa da cuta) ya kama daga 0.8% lokacin da suka hada da jigilar asymptomatic zuwa 18% yayin da suka hada da alamu kawai na cutar daga lardin Hubei.  Pauline Vetter, a cikin wata sanarwa a cikin BMJ ta lura cewa mace-mace a waje da lardin Hubei da alama ba su da ƙasa da cikin Hubei.  A fashewa a 2019-2020, ya sa a kalla 128,343, tabbatar da kamuwa da cutar da kuma 4,720,   mutuwar. 

Binciken sa ido na mutane tara, ba a sami kwayar cutar ta intrauterine a tsaye daga uwa zuwa jariri ba.  Hakanan, binciken kwatankwacin wucin gadi a Wuhan bai samo wata alama ta watsa kwayar cutar ta hanyar jima'i ba (daga mace zuwa abokiyar zama), amma marubutan sun lura cewa zazzabi yayin jima'i na iya faruwa ta wasu hanyoyin.  

## Bincike.
Saboda ganin mahimmancin rayuwar al'umma da kuma irin cigaba da yaɗuwa da cutar ke yi a Kullun a ko'ina na duniya, Ƙungiyoyi da dama na ilimin binciken lafiya sun shiga bincike tun lokacin da cutar ta bayyana, babu dare ba rana.    

### Kwayar rigakafi.
Babu wani magani da aka amince dashi na magance annobar a tacewar hukumar lafiya ta duniya (**WHO**) duk da haka amma akwai wasu magunguna da kasashen Koriya da Sin suka amince da su.
*Trials of many antivirals has been started in patients with COVID-19 including oseltamivir, lopinavir/ritonavir, ganciclovir, favipiravir, baloxavir marboxil, umifenovir, interferon alfa but currently there are no data to support their use. Korean Health Authorities recommend lopinavir/ritonavir or chloroquine and the Chinese 7th edition guidelines include interferon, lopinavir/ritonavir, ribavirin, chloroquine and/or umifenovir.*

An fara bincike a cikin hanyoyin da za a bi don gano cutar a cikin Janairu na shekara dubu biu da ashirin 2020, kuma magunguna da dama na rigakafi sun riga sun shiga gwaji na asibiti.   Kodayake sababbin magunguna gaba daya na iya ɗaukar har zuwa 2021, don haɓaka,  yawa daga cikin magungunan da ake gwadawa an riga an amince dasu don sauran alamun maganin rigakafi, ko kuma sun riga sun shiga cikin gwaji mai zurfi.  

Remdesivir da chloroquine yadda ya kamata suna hana coronavirus a cikin fitsari .  Ana sake gwada Remdesivir a Amurka da China.  

Sakamakon farko daga gwaji mai yawa, wanda aka sanar a cikin taron manema labarai da aka bayyana ta Gao, Tian da Yang, sun ba da shawarar cewa chloroquine yana da inganci kuma mai lafiya cikin kula da cututtukan COVID-19, "haɓaka binciken binciken huhun haɓaka, haɓaka juji da ƙwayar cuta, da gajeriyar cutar ”.  

Binciken da aka yi kwanan nan ya nuna cewa farkon farawar furotin na furotin ta hanyar ƙwaƙwalwar ƙwaƙwalwar ƙwaƙwalwar ƙwaƙwalwa mai mahimmanci 2 ( TMPRSS2 ) yana da mahimmanci don shigar da SARS-CoV-2, SARS-CoV da MERS-CoV ta hanyar hulɗa tare da mai karɓar ACE2 .   Wannan binciken ya nuna cewa TMPRSS2 inhibitor Camostat ya yarda da amfani da asibiti a Japan don hana ƙwayar cutar fibrosis a cikin hanta da cutar koda, cututtukan cututtukan cututtukan zuciya da cututtukan cututtukan cututtukan fata na iya zama ingantaccen zaɓi na zaɓi mara amfani.

## Duba kuma.
* Koronavirus a Najeriya
* Koronavirus a Nijar

## Manazarta.

## Hanyoyin haɗi na waje
*Cibiyoyin Kula da Cututtuka (CDC): Cutar Coronavirus 2019 (COVID-19)  
* Coronavirus Disease (COVID-19) 
* Cibiyoyin Kula da Cututtuka (CDC): Cutar Coronavirus 2019 (COVID-19) 
* Kungiyar Lafiya ta Duniya (WHO): Cutar Coronavirus (COVID-19) 
* Matakan Kawo COV19 na yawan jama'a, ta Cibiyar Kula da Cututtukan Cututtukan Amurka 
* Kiyaye yaduwar COVID-19 a cikin Jama'a, ta Cibiyar Kula da Cututtukan Cututtukan Amurka 
* Bayanai don Profwararruwar Kiwon Lafiya, ta Cibiyar Kula da Cututtuka ta Amurka 
* "SARS-CoV-2 (Severe acute respiratory syndrome coronavirus 2) Sequences" . Cibiyar Bayanai ta Kasa (NCBI) . 
* "Coronavirus: Latest news and resources" . BMJ . 
* "Novel Coronavirus Information Center" . Wani 
* "COVID-19 Resource Centre" . Lancet . 
* "SARS-CoV-2 and COVID-19" . Yanayi . 
* "Coronavirus (Covid-19)" . NEJM . 
* "Covid-19: Novel Coronavirus Content Free to Access" . Wiley . 
* "Coronavirus Disease 2019 (COVID-19)" . Cibiyar sadarwa ta JAMA .