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Background: In embarking on randomized clinical trials (RCTs), researchers can hypothesize that a more intensive treatment is better than a less intensive treatment (positive hypothesis) or that a less intensive treatment is similar or noninferior to a more intensive treatment (negative hypothesis). Researchers may design noninferiority RCTs (NI-RCTs) to support negative hypotheses and standard RCTs (S-RCTs) to support negative or positive hypotheses. Regardless of hypotheses, S-RCTs and NI-RCTs should produce consistent results when assessing similar participants, interventions, control, and outcomes. Objective: To compare effect estimates in S-RCTs with positive hypotheses versus NI-RCTs and in S-RCTs with negative hypotheses versus NI-RCTs. Design: Meta-research. Setting: 98 meta-analyses. Participants: 468 RCTs, including 153 NI-RCTs and 315 S-RCTs (149 positive and 166 negative hypotheses). Intervention: S-RCTs as the exposure and NI-RCTs as the control. Measurements: The ratio of effect estimates between S-RCTs and NI-RCTs in each meta-analysis was combined across meta-analyses. Results: Standard RCTs with positive hypotheses produced effect estimates 1.47 (95% CI, 1.27 to 1.70) times larger than NI-RCTs; among RCTs rated as having low risk of bias for blinding, the ratio was 1.01 (CI, 0.70 to 1.45), whereas among those rated as having high or unclear risk of bias for blinding, the ratio was 1.81 (CI, 1.41 to 2.33). Standard RCTs with negative hypotheses did not produce statistically different effect estimates from NI-RCTs (ratio, 0.93 [CI, 0.84 to 1.03]). Limitation: Findings may be limited by residual differences between S-RCTs and NI-RCTs in the same meta-analysis. Conclusion: The researchers’ hypotheses may bias the results of published RCTs, especially those with high or unclear risk of bias for blinding. The effect of researchers’ hypotheses should be assessed in systematic reviews and clinical practice guidelines when RCTs addressing the same clinical question report conflicting hypotheses. Primary Funding Source: The Shenzhen Municipal Government, Guangdong Province, China, and the Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences.

A Pragmatic Approach to Streamlining Single-Use Plastics in Health Care

Lyme Disease

Lyme disease, caused by Borrelia burgdorferi, is the most common vector-borne disease in the United States, and the range of its tick vector continues to expand. Most Lyme disease cases are diagnosed with the onset of the erythema migrans rashes, which can be single or multiple and vary from a homogeneous erythema to bull’s-eye patterns. Serologic antibody testing is of low sensitivity at onset but becomes highly sensitive after a few weeks. Early dissemination may lead to neurologic and cardiac complications. Mono- or oligoarticular arthritis may develop in untreated patients. Antibiotic treatment is highly effective, but approximately 10% of treated patients experience persistent symptoms.

Effect of Acupuncture on Neurogenic Claudication Among Patients With Degenerative Lumbar Spinal Stenosis

Care of the Patient With Asthma

Nearly 8% of the U.S. population is diagnosed with asthma, leading to more than 5 million office visits and 1 million emergency department visits annually. Both outpatient and inpatient internal medicine clinicians treat asthma frequently, but nuances in diagnosis and management have emerged. This article highlights many of these developments.

The Role of Medical Experts in Transgender Legal Advocacy: A Historical Perspective on Kantaras v. Kantaras

This article examines the ethical challenges that medical experts have navigated when mobilizing biological and psychological evidence to advocate for transgender patients in legal proceedings across a quarter of a century. In 2002, clinicians from a private clinic in Galveston, Texas, testified on behalf of Michael Kantaras, a transgender male patient, during his divorce and custody trial. Presenting gender identity as an innate product of neuroendocrine development, medical experts in Kantaras v. Kantaras challenged portrayals of gender dysphoria as a psychological illness resulting from sociocultural factors. Although this biological argument was key to destigmatizing transgender identity and convincing the judge to rule in Michael's favor, transgender advocates have argued that such claims strengthen medical authority over transgender identities. The article draws parallels with L.W. v. Skrmetti, a 2023 case heard by the U.S. Supreme Court concerning bans on gender-affirming care for transgender minors, to analyze how physician experts have referenced neuroimaging and genetic-sequencing studies to support the biological foundations of transgender identity. Transgender advocates have similarly expressed concerns about the medicalization of their identities, criticizing these studies as limited with regard to capturing the diversity and complexity of transgender experiences. Through analysis of historical and contemporary court cases, this article identifies shifting evidence-based methods for studying sex, understanding gender identity, and evaluating gender-affirming care, as well as the rising prominence of patient-centered approaches that seek to move beyond medicalized conceptions of gender identity as key themes clinicians should consider in their advocacy for their transgender patients.

Trends in and Predictors of Physician Attrition From Clinical Practice Across Specialties: A Nationwide, Longitudinal Analysis: Annals of Internal Medicine: Vol 178, No 12

Background: The United States faces a predicted shortage of 36 500 physicians by 2036, with an increasing proportion of physicians leaving clinical practice or expressing an intent to do so. Evidence is limited about the extent to which stated intent to leave clinical practice translates to actual attrition from clinical practice and which factors are associated with this outcome. Objective: To characterize rates of physician attrition from clinical practice and to describe the factors associated with a differential likelihood of attrition. Design: Nationwide, longitudinal study. Setting: All clinical settings. Participants: Physicians who provided care to Medicare patients between 2013 and 2022. Measurements: Attrition from clinical practice. Results: The sample consisted of 712 395 physicians (70.8% male, 90.8% in urban settings). Unadjusted rates of clinical practice attrition increased significantly from 3.5% in 2013 to 4.9% in 2019 (rate difference, 1.4 percentage points [95% CI, 1.3 to 1.4 percentage points]). Rates of attrition increased across the study period for both male and female physicians, in both rural and urban settings, across specialties, across geographic regions, and in all groups of physicians aged 35 years or older. In adjusted models, female physicians and those practicing in rural areas were more likely to leave clinical practice. Caring for Medicare beneficiaries with a greater average risk score, a greater average age, and a greater percentage of dual-eligible beneficiaries was also associated with attrition. Limitation: Focus on services provided to Medicare fee-for-service beneficiaries. Conclusion: Rates of clinical practice attrition have increased since 2013. Specific physician and patient characteristics are associated with a greater risk for attrition. These findings have implications for workforce planning and the design of interventions to sustain the physician workforce. Primary Funding Source: The Physicians Foundation.

Epilepsy

Epilepsy is a common neurologic condition characterized by at least 1 unprovoked seizure and a high risk for recurrent seizures. Distinguishing epilepsy from conditions that can mimic seizures is important for accurate diagnosis and effective treatment. This article reviews the evaluation of patients suspected of having epilepsy and discusses behavioral strategies and pharmacologic and surgical therapies that can help reduce morbidity associated with recurrent seizures.

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