Joint Letter to Congress Supporting Funding for the National Institutes of Health (NIH) for FY2022

Joint Letter Requesting National Interest Exceptions and Expedited Processing for Physicians

Joint Coalition letter to Secretary Noem Requesting an National Interest Exemption for IMGs Requiring H1-B Visas

BBA'97: A Look at the Current Impact on Providers and Patients. Testimony Given of Behalf of the American College of Gastroenterology and the American College of Physicians-American Society of Internal Medicine to the Subcommittee on Health and Environment Committee on Commerce, United States House of Representatives.

Utilization Management. Statement of the American College of Physicians given before the Committee on Utilization Management by Third Parties, Institute of Medicine, June 6, 1988

Physician Practice Expenses: What Does the Independent Research Show?

Joint Letter to Congressional Leadership on Extension of Telehealth Flexibilities

ACP Comment Letter on CMS Draft Quality Measures Development Plan

Medical Professional Liability

Gastroenterology/Hepatology: What You May Have Missed in 2023

This article summarizes clinically important gastroenterology developments from 2023 for internal medicine specialists. In colorectal cancer screening, a new RNA fecal screening test is on the horizon, as well as a new analysis on the benefits of using artificial intelligence in screening colonoscopy to detect more polyps. There is new evidence for management of gastrointestinal bleeding, a new drug for treatment of recurrent small-intestinal angiodysplasia, and a new endoscopic treatment method in patients with gastrointestinal tumor bleeding. The authors feature a randomized trial about amitriptyline as treatment for patients with irritable bowel syndrome by primary care providers and bring you news about new biologic agents for inflammatory bowel disease and eosinophilic esophagitis. Finally, they review 2 important articles on new terminology and management of metabolic dysfunction–associated fatty liver disease.

Extracorporeal Shock-Wave Lithotripsy and Endoscopy for the Treatment of Pain in Chronic Pancreatitis

Update in Gastroenterology and Hepatology: Evidence Published in 2015

Voice Dictation

Revised REACH-B Model for Hepatocellular Carcinoma Risk Prediction in Patients With Chronic Hepatitis B

Dollars and Sense: The Cost of Cancer Screening in the United States

Physician Humility: A Review and Call to Revive Virtue in Medicine

Physician virtues, including humility, are crucial for shaping a physician's identity and practice. The health care literature offers varied views on humility, and the rising call for discussing virtues as a framing for professional identity formation underscores the need for a clearer understanding of physician humility. This review aimed to develop a cohesive conceptualization of physician humility and to define how it functions in medical practice. To achieve this, a comprehensive search was done across PubMed, Ovid MEDLINE, Web of Science, Embase, ERIC, and PsycInfo, covering all records up to 30 October 2023. Articles were included if they discussed physician humility and excluded if they were unrelated to physician humility, focused on nonphysician health professionals, lacked conceptual depth, or focused solely on cultural humility. An applied thematic analysis was conducted. The results provide a synthesized conceptualization of physician humility across stances toward self, others, and the profession. The included articles identified the pivotal role of physician humility within the following 5 domains of medical practice: learning and professional growth, navigating error, uncertainty tolerance, trust and entrustment, and teamwork and communication. The authors highlight some of the intrapersonal, interpersonal, and sociocontextual challenges to cultivating and practicing physician humility. These findings highlight the importance of promoting humility in shaping physicians’ actions, thoughts, and relationships with patients, colleagues, and their profession. Integrating such virtues as humility into medical education is essential for upholding the ideals of the medical profession and cultivating moral agents who engage in self-reflection and embody the principles of exemplary physicians.

Colorectal Cancer Screening Completion and Yield in Patients Aged 45 to 50 Years: An Observational Study: Annals of Internal Medicine: Vol 177, No 12

Background: Guidelines now recommend initiating colorectal cancer (CRC) screening at age 45 years rather than 50 years, but little is known about screening completion and yield among people aged 45 to 49 years. Objective: To evaluate fecal immunochemical test (FIT) completion and yield in patients aged 45 to 49 versus 50 years. Design: Retrospective cohort study. Setting: Kaiser Permanente Northern California, Washington, and Colorado. Patients: Those distributed a FIT kit during January to September 2022. Measurements: FIT completion within 3 months, FIT positivity, receipt of colonoscopy within 3 months after a positive FIT result, and colonoscopy yield. Results: A total of 267 732 FIT kits were distributed: 213 928 (79.9%) to patients aged 45 to 49 years, and 53 804 (20.1%) to those aged 50 years. Overall, FIT completion was slightly higher in patients aged 45 to 49 years (38.9% vs. 37.5%; adjusted risk ratio [aRR], 1.05 [95% CI, 1.04 to 1.06]), although at Colorado, those aged 45 to 49 years were substantially less likely to complete a FIT (30.7% vs. 40.2%; aRR, 0.77 [CI, 0.73 to 0.80]). Overall, FIT positivity was lower in patients aged 45 to 49 years (3.6% vs. 4.0%; aRR, 0.91 [CI, 0.84 to 0.98]), and receipt of colonoscopy after a positive FIT result was similar between groups (64.9% vs. 67.4%; aRR, 1.00 [CI, 0.94 to 1.05]). Adenoma detection was lower in the younger group (58.8% vs. 67.7%; aRR, 0.88 [CI, 0.83 to 0.95]). Yields were similar for adenoma with advanced histology (13.2% vs. 15.9%; aRR, 0.86 [CI, 0.69 to 1.07]), polyp with high-grade dysplasia (3.4% vs. 5.1%; aRR, 0.68 [CI, 0.44 to 1.04]), sessile serrated lesion (10.3% vs. 11.7%; aRR, 0.92 [CI, 0.71 to 1.21]), and CRC (2.8% vs. 2.7%; aRR, 1.10 [CI, 0.62 to 1.96]). Limitation: The small number of neoplasia events contributed to wide CIs. Conclusion: Similar FIT completion and yield rates in people aged 45 to 50 years support initiation of CRC screening at age 45 years. Primary Funding Source: Kaiser Permanente Sidney R. Garfield Memorial Fund.

Oncology: What You May Have Missed in 2023

Advances in oncology treatment methods have improved outcomes and quality of life for patients with cancer. However, care of these patients can be complex, and the contribution of physicians from different specialties is crucial. This article highlights important publications from 2023 on topics across a wide spectrum relating to the management of oncology patients. The literature was screened for significant new evidence that is relevant to internal medicine specialists and subspecialists whose focus is not oncology. Two articles address the importance of social interventions targeting end-of-life care for low-income and minority patients and the well-being of caregivers. Two additional articles address screening considerations in patients at risk for colorectal and lung cancer. Two more articles address safe use of hormone-related therapies to treat symptoms of menopause and prevent disease recurrence or progression in patients diagnosed with noninvasive breast neoplasia. Finally, several articles were included on topics related to COVID-19 vaccination in patients with cancer, use of cannabinoids for cancer pain control, chronic autoimmune adverse effects related to use of immune checkpoint inhibitors, and the incidence of second primary neoplasms.

Viral Load–Based Prediction of Hepatocellular Carcinoma Risk in Noncirrhotic Patients With Chronic Hepatitis B: A Multinational Study for the Development and External Validation of a New Prognostic Model: Annals of Internal Medicine: Vol 177, No 10

Background: A nonlinear association between serum hepatitis B virus (HBV) DNA levels and hepatocellular carcinoma (HCC) risk has been suggested in patients with chronic hepatitis B (CHB). Objective: To develop and externally validate a prognostic model for HCC risk in noncirrhotic adult patients with CHB and no notable alanine aminotransferase (ALT) elevation. Design: Multinational cohort study. Setting: A community-based cohort in Taiwan (REVEAL-HBV [Risk Evaluation of Viral Load Elevation and Associated Liver Disease/Cancer-Hepatitis B Virus]; REACH-B [Risk Estimation for HCC in CHB] model cohort) and 8 hospital-based cohorts from Korea and Hong Kong (GAG-HCC [Guide with Age, Gender, HBV DNA-HCC] and CU-HCC [Chinese University-HCC] cohorts). Participants: Model development: 6949 patients with CHB from a Korean hospital-based cohort. External validation: 7429 patients with CHB combined from the Taiwanese cohort and 7 cohorts from Korea and Hong Kong. Measurements: Incidence of HCC. Results: Over median follow-up periods of 10.0 and 12.2 years, the derivation and validation cohorts identified 435 and 467 incident HCC cases, respectively. Baseline HBV DNA level was one of the strongest predictors of HCC development, demonstrating a nonlinear parabolic association in both cohorts, with moderate viral loads (around 6 log10 IU/mL) showing the highest HCC risk. Additional predictors included in the new model (Revised REACH-B) were age, sex, platelet count, ALT levels, and positive hepatitis B e antigen result. The model exhibited satisfactory discrimination and calibration, with c-statistics of 0.844 and 0.813 in the derivation and validation cohorts with multiple imputation, respectively. The model yielded a greater positive net benefit compared with other strategies in the 0% to 18% threshold. Limitation: Validation in cohorts of other races and receiving antiviral treatment was lacking. Conclusion: Our new prognostic model, based on the nonlinear association between HBV viral loads and HCC risk, provides a valuable tool for predicting and stratifying HCC risk in noncirrhotic patients with CHB who are not currently indicated for antiviral treatment. Primary Funding Source: Korean government.

Unexpected Therapeutic Effect of GLP-1 Receptor Agonists in Patients With Refractory IBS-D: A Case Series | Annals of Internal Medicine: Clinical Cases

Irritable bowel syndrome with diarrhea (IBS-D) is a common functional gastrointestinal disorder. It is primarily caused by increased intestinal transit. GLP-1 receptor agonists (GLP-1 RAs) are widely used for obesity and diabetes management. They have been shown to decrease intestinal motility as a side effect. We present a 67-year-old woman and a 23-year-old woman, both with long-standing, debilitating IBS-D. Both achieved a 22.7-kg weight loss with GLP-1 RA use. They also reported resolution of diarrhea and improved quality of life. This case series suggests potential therapeutic benefits of GLP-1 RA use in hypermotility associated with IBS-D.

Cardiac Tamponade Due to Entamoeba histolytica in a Patient in a Nonendemic Region | Annals of Internal Medicine: Clinical Cases

Entamoeba histolytica infection is classically associated with intestinal disease and liver abscesses in endemic regions. Pericardial involvement with cardiac tamponade is an exceptionally rare, life-threatening complication. We present a case of a 58-year-old man in the United States with no recent travel who developed pericardial tamponade due to diaphragmatic communication with an E histolytica liver abscess. His case underscores the need to consider parasitic infections in the differential diagnosis of purulent pericardial effusions, even in nonendemic areas, and demonstrates how serologic testing and multidisciplinary collaboration were critical for diagnosis and management of this unexpected condition.

Autopsy Case of Colonic Plasmablastic Lymphoma Exhibiting Unique Endoscopic Phenotypic Changes During Ulcerative Colitis Therapy | Annals of Internal Medicine: Clinical Cases

Plasmablastic lymphoma (PBL), a rare and aggressive CD20-negative B-cell lymphoma, has been increasingly recognized in individuals who are HIV-negative and who are also immunosuppressed. To our knowledge, we report the first autopsy case of a 74-year-old woman with ulcerative colitis (UC) who developed colonic PBL under immunosuppressive therapy. Serial colonoscopies demonstrated a morphologic transformation from serpiginous ulcers to elevated lesions. The patient ultimately died because of carcinomatous lymphangitis. Autopsy showed widespread metastases and numerous flat elevated lesions with lobulations throughout the colon. This case demonstrates a unique endoscopic phenotypic transition in colonic PBL, suggesting the importance of careful monitoring for timely diagnosis in immunosuppressed UC patients.

Concurrent Phenylalanine Hydroxylase–Related Disorder and Celiac: A Rare Co-occurrence With Implications for Clinical Management | Annals of Internal Medicine: Clinical Cases

Comorbid nutritional disorders can present with clinical management challenges. Phenylalanine hydroxylase (PAH) deficiency and celiac disease are both associated with dietary protein intolerance, yet they are different disorders. Phenylalanine hydroxylase deficiency is a rare genetic disorder that results in elevated levels of phenylalanine (Phe) in the blood. It causes multisystemic abnormalities, including neurologic findings, seizures, episodic tremor, ataxia, and cognitive and sensory disturbances. In contrast, celiac disease is a common nutritional disorder that arises from immune-mediated enteropathy against dietary gluten. Herein, we describe the clinical findings in an adult with PAH deficiency and celiac disease to showcase some opportunities for improved personalized nutritional management.

Digoxin-Like Toxicity After Tejocote Root and Yellow Oleander Ingestion: The Hidden Dangers of Herbal Supplements | Annals of Internal Medicine: Clinical Cases

Tejocote root (Crataegus mexicana) is a common herbal supplement used for weight loss and to induce bowel movements. In recent years, there has been an increase in the number of cases of digoxin-like toxicity associated with consumption of tejocote root, and substitution of tejocote root with yellow oleander. We present a case of excess tejocote ingestion to induce a bowel movement that resulted in subsequent gastrointestinal upset and cardiac arrhythmia. This report highlights the potential risks associated with the consumption of tejocote root, particularly due to suspected inclusion of yellow oleander after a Food and Drug Administration–issued warning of several supplements.

Tremors and Memory Loss From Hypomagnesemia and Hypocalcemia Secondary to Long-Term Proton Pump Inhibitor Use | Annals of Internal Medicine: Clinical Cases

Proton pump inhibitors (PPIs) are commonly prescribed for short-term use but are often taken chronically, including through over-the-counter (OTC) access. Long-term use has been linked to hypomagnesemia and hypocalcemia, which may cause serious complications. A 47-year-old man on PPIs for 5 years presented with cramps, spasms, tremors, disorientation, and amnesia. Tests showed low magnesium and calcium, with other causes excluded. Proton pump inhibitor treatment was discontinued and supplementation initiated, leading to marked recovery. Chronic PPI use should be considered in unexplained electrolyte abnormalities, even in patients not at high risk, highlighting the need for cautious prescribing, periodic monitoring, and reassessment of OTC availability.

Hyperbaric Oxygen for Refractory Colonic Ulcerations in a Patient With Immunotherapy-Induced Colitis: A Case Report | Annals of Internal Medicine: Clinical Cases

Colitis is a common complication of immune checkpoint inhibitors (ICIs), often responsive to steroids or biologics. However, persistent symptoms may occur in patients with complicating factors such as altered gastrointestinal anatomy. In this context, hyperbaric oxygen therapy (HBOT) may be a novel treatment. We present a woman with lung cancer who developed refractory ICI colitis. She had a history of partial colectomy. Despite corticosteroids, vedolizumab ×3 doses, and fecal microbiota transplantation, she experienced persistent bleeding and ulcerations in the distal rectum with suspected ischemia. The patient had HBOT, resulting in complete resolution of clinical symptoms within 2 weeks.

A Case Report of Syphilitic Hepatitis | Annals of Internal Medicine: Clinical Cases

A 49-year-old woman presented to the emergency department with acute right upper quadrant pain. Laboratory results were consistent with cholestatic liver injury. Potential common causes—such as obstructive, viral, and autoimmune conditions—were excluded. She began developing systemic symptoms, including rash, vision changes, and headaches. The patient was subsequently found to have secondary syphilis with neurosyphilis and syphilitic hepatitis. Although syphilitic hepatitis is a rare presentation of the disease, syphilis should be considered as a possible cause of transaminitis with a cholestatic pattern of liver injury.

Fever of Unknown Origin Due to Legionella dumoffii Bioprosthetic Aortic Valve Endocarditis | Annals of Internal Medicine: Clinical Cases

Legionella dumoffii is a rare human pathogen but has been known to cause infective endocarditis. The diagnosis is challenging as this bacterium is difficult to grow in standard culture media. We present a case of a patient with fever of unknown origin (FUO) who was diagnosed with L dumoffii bioprosthetic aortic valve endocarditis using metagenomic next-generation sequencing. After identification of this pathogen and targeted antibiotic treatment, the patient experienced complete resolution of symptoms. Legionella dumoffii infective endocarditis should be considered in patients with FUO and prosthetic heart valves.

Isolated Subcutaneous Sarcoidosis (Darier–Roussy Disease) Without Systemic Involvement: Diagnostic Challenge and Remission Following Intralesional Therapy | Annals of Internal Medicine: Clinical Cases

Subcutaneous sarcoidosis (Darier–Roussy disease) is a rare variant of cutaneous sarcoidosis characterized by painless subcutaneous nodules. We present the case of a 55-year-old woman with a firm, nontender mass overlying her right triceps region, initially misdiagnosed as cellulitis. Biopsy revealed a noncaseating granuloma consistent with subcutaneous sarcoidosis. Extensive systemic work-up was unremarkable, confirming isolated disease. The lesion resolved within 6 months following 2 intralesional corticosteroid injections administered 2 months apart, with no recurrence over 4 years. This case highlights the diagnostic challenges of subcutaneous sarcoidosis and the importance of histopathologic confirmation and multidisciplinary evaluation, even in the absence of systemic symptoms.

Therapeutic hypothermia, HAI network, and more | ACP Hospitalist

Manage meds to treat GI bleeding before, after endoscopy | ACP Hospitalist

Checklists, deferred care, and more | ACP Hospitalist

Resident supervision, nerve agents, and clinical conferences | ACP Hospitalist

Inflammatory bowel disease and other tricky conditions | ACP Hospitalist

Pinpointing severe pancreatitis | ACP Hospitalist

Spotlight on NAFLD outcomes

Introducing ACP Gastroenterology Monthly

Annals On Call: Metabolic dysfunction-associated steatotic liver disease

A next-generation mt-sDNA test had 94% sensitivity for colorectal cancer and 91% specificity for advanced neoplasia

Spotlight on acute kidney injury in cirrhosis

Recommendations updated on surveillance after colonoscopy and polypectomy

Update looks at gastroenterology/hepatology research from 2024

In the Clinic, 2023 summary highlight gastroenterology topics

Annals On Call: Mediterranean diet in the management of irritable bowel syndrome

Improving palliative care in cirrhosis