ACP Letter to UnitedHealthCare on Efforts to Address the COVID-19 Pandemic

ACP Letter to NASEM Regarding Committee on Primary Care

ACP Letter to House Sponsors of the Patient Protection and Affordable Care Enhancement Act (H.R. 1425)

ACP Letter to Congress in Support of the George Floyd Policing Act of 2021

ACP letter of support for H.R. 8765 the Prioritizing Primary Care Act

ACP Letter on the House Energy and Commerce Health Subcommittee"s Hearing on Medicare Proposals

ACP Letter of Support for the Nomination of Dr. Robert Califf for Food and Drug Administration Commissioner

ACP Letter of Opposition to H.R. 7520, the Efficiency Adjustment Delay Act

ACP Letter Expressing Concern About the I CAN Act, H.R. 8812

ACP Feedback Letter to the Medicare GME Working Group Regarding Draft GME Legislation

State Intimate Partner Violence–Related Firearm Laws and Intimate Partner Homicide Rates in the United States, 1991 to 2015

Background: To prevent intimate partner homicide (IPH), some states have adopted laws restricting firearm possession by intimate partner violence (IPV) offenders. “Possession” laws prohibit the possession of firearms by these offenders. “Relinquishment” laws prohibit firearm possession and also explicitly require offenders to surrender their firearms. Few studies have assessed the effect of these policies. Objective: To study the association between state IPV-related firearm laws and IPH rates over a 25-year period (1991 to 2015). Design: Panel study. Setting: United States, 1991 to 2015. Participants: Homicides committed by intimate partners, as identified in the Federal Bureau of Investigation's Uniform Crime Reports, Supplementary Homicide Reports. Measurements: IPV-related firearm laws (predictor) and annual, state-specific, total, and firearm-related IPH rates (outcome). Results: State laws that prohibit persons subject to IPV-related restraining orders from possessing firearms and also require them to relinquish firearms in their possession were associated with 9.7% lower total IPH rates (95% CI, 3.4% to 15.5% reduction) and 14.0% lower firearm-related IPH rates (CI, 5.1% to 22.0% reduction) than in states without these laws. Laws that did not explicitly require relinquishment of firearms were associated with a non–statistically significant 6.6% reduction in IPH rates. Limitations: The model did not control for variation in implementation of the laws. Causal interpretation is limited by the observational and ecological nature of the analysis. Conclusion: Our findings suggest that state laws restricting firearm possession by persons deemed to be at risk for perpetrating intimate partner abuse may save lives. Laws requiring at-risk persons to surrender firearms already in their possession were associated with lower IPH rates. Primary Funding Source: Robert Wood Johnson Foundation.

Lectures on Inhumanity: Teaching Medical Ethics in German Medical Schools Under Nazism

Nazi medicine and its atrocities have been explored in depth over the past few decades, but scholars have started to examine medical ethics under Nazism only in recent years. Given the medical crimes and immoral conduct of physicians during the Third Reich, it is often assumed that Nazi medical authorities spurned ethics. However, in 1939, Germany introduced mandatory lectures on ethics as part of the medical curriculum. Course catalogs and archival sources show that lectures on ethics were an integral part of the medical curriculum in Germany between 1939 and 1945. Nazi officials established lecturer positions for the new subject area, named Medical Law and Professional Studies, at every medical school. The appointed lecturers were mostly early members of the Nazi Party and imparted Nazi political and moral values in their teaching. These values included the unequal worth of human beings, the moral imperative of preserving a pure Aryan people, the authoritarian role of the physician, the individual's obligation to stay healthy, and the priority of public health over individual-patient care. This article shows that there existed not only a Nazi version of medical ethics but also a systematic teaching of such ethics to students in Nazi Germany. The findings illustrate that, from a historical point of view, the notion of “eternal values” that are inherent to the medical profession is questionable. Rather, the prevailing medical ethos can be strongly determined by politics and the zeitgeist and therefore has to be repeatedly negotiated.

Guidelines to Limit Added Sugar Intake: Junk Science or Junk Food?

Bone Health and Bone-Targeted Therapies for Nonmetastatic Prostate Cancer: A Systematic Review and Meta-analysis: Annals of Internal Medicine: Vol 167, No 5

Background: Bone health is a significant concern in men with prostate cancer. Purpose: To evaluate the effectiveness of drug, supplement, and lifestyle interventions aimed at preventing fracture, improving bone mineral density (BMD), or preventing or delaying osteoporosis in men with nonmetastatic prostate cancer. Data Sources: Ovid MEDLINE (1946 to 19 January 2017), EMBASE (1980 to 18 January 2017), and the Cochrane Database of Systematic Reviews (19 January 2017). Study Selection: Randomized trials and systematic reviews of trials that were published in English; involved men with nonmetastatic prostate cancer; and compared bone-targeted therapies with placebo, usual care, or other active treatments. Data Extraction: Two reviewers independently extracted study characteristics and assessed study risk of bias for each outcome. Data Synthesis: Two systematic reviews and 28 reports of 27 trials met inclusion criteria. All trials focused on men with nonmetastatic prostate cancer who were initiating or continuing androgen deprivation therapy (ADT). Bisphosphonates were effective in increasing BMD, but no trial was sufficiently powered to detect reduction in fractures. Denosumab improved BMD and reduced the incidence of new radiographic vertebral fractures in 1 high-quality trial. No trials compared calcium or vitamin D versus placebo. Three lifestyle intervention trials did not show a statistically significant difference in change in BMD between exercise and usual care. Limitations: Most trials were of moderate quality. Only 2 randomized controlled trials were designed to examine fracture outcomes. Potential harms of treatments were not evaluated. Conclusion: Both bisphosphonates and denosumab improve BMD in men with nonmetastatic prostate cancer who are receiving ADT. Denosumab also reduces risk for radiographic vertebral fractures, based on 1 trial. More trials studying fracture outcomes are needed in this population. Primary Funding Source: Program in Evidence-Based Care.

Dear Plagiarist: A Letter to a Peer Reviewer Who Stole and Published Our Manuscript as His Own

Scientific Misconduct Hurts

Accuracy of Cardiovascular Risk Prediction Varies by Neighborhood Socioeconomic Position: A Retrospective Cohort Study: Annals of Internal Medicine: Vol 167, No 7

Background: Inequality in health outcomes in relation to Americans' socioeconomic position is rising. Objective: First, to evaluate the spatial relationship between neighborhood disadvantage and major atherosclerotic cardiovascular disease (ASCVD)–related events; second, to evaluate the relative extent to which neighborhood disadvantage and physiologic risk account for neighborhood-level variation in ASCVD event rates. Design: Observational cohort analysis of geocoded longitudinal electronic health records. Setting: A single academic health center and surrounding neighborhoods in northeastern Ohio. Patients: 109 793 patients from the Cleveland Clinic Health System (CCHS) who had an outpatient lipid panel drawn between 2007 and 2010. The date of the first qualifying lipid panel served as the study baseline. Measurements: Time from baseline to the first occurrence of a major ASCVD event (myocardial infarction, stroke, or cardiovascular death) within 5 years, modeled as a function of a locally derived neighborhood disadvantage index (NDI) and the predicted 5-year ASCVD event rate from the Pooled Cohort Equations Risk Model (PCERM) of the American College of Cardiology and American Heart Association. Outcome data were censored if no CCHS encounters occurred for 2 consecutive years or when state death data were no longer available (that is, from 2014 onward). Results: The PCERM systematically underpredicted ASCVD event risk among patients from disadvantaged communities. Model discrimination was poorer among these patients (concordance index [C], 0.70 [95% CI, 0.67 to 0.74]) than those from the most affluent communities (C, 0.80 [CI, 0.78 to 0.81]). The NDI alone accounted for 32.0% of census tract–level variation in ASCVD event rates, compared with 10.0% accounted for by the PCERM. Limitations: Patients from affluent communities were overrepresented. Outcomes of patients who received treatment for cardiovascular disease at Cleveland Clinic were assumed to be independent of whether the patients came from a disadvantaged or an affluent neighborhood. Conclusion: Neighborhood disadvantage may be a powerful regulator of ASCVD event risk. In addition to supplemental risk models and clinical screening criteria, population-based solutions are needed to ameliorate the deleterious effects of neighborhood disadvantage on health outcomes. Primary Funding Source: The Clinical and Translational Science Collaborative of Cleveland and National Institutes of Health.

Will Physicians Vote?

The Long and Winding Road to Clinical Guidelines on the Diagnosis and Management of Gout

Cytokine Inhibition in Patients With Chronic Fatigue Syndrome: A Randomized Trial: Annals of Internal Medicine: Vol 166, No 8

Background: Interleukin-1 (IL-1), an important proinflammatory cytokine, is suspected to play a role in chronic fatigue syndrome (CFS). Objective: To evaluate the effect of subcutaneous anakinra versus placebo on fatigue severity in female patients with CFS. Design: Randomized, placebo-controlled trial from July 2014 to May 2016. Patients, providers, and researchers were blinded to treatment assignment. (ClinicalTrials.gov: NCT02108210) Setting: University hospital in the Netherlands. Patients: 50 women aged 18 to 59 years with CFS and severe fatigue leading to functional impairment. Intervention: Participants were randomly assigned to daily subcutaneous anakinra, 100 mg (n = 25), or placebo (n = 25) for 4 weeks and were followed for an additional 20 weeks after treatment (n = 50). Measurements: The primary outcome was fatigue severity, measured by the Checklist Individual Strength subscale (CIS-fatigue) at 4 weeks. Secondary outcomes were level of impairment, physical and social functioning, psychological distress, and pain severity at 4 and 24 weeks. Results: At 4 weeks, 8% (2 of 25) of anakinra recipients and 20% (5 of 25) of placebo recipients reached a fatigue level within the range reported by healthy persons. There were no clinically important or statistically significant differences between groups in CIS-fatigue score at 4 weeks (mean difference, 1.5 points [95% CI, −4.1 to 7.2 points]) or the end of follow-up. No statistically significant between-group differences were seen for any secondary outcome at 4 weeks or the end of follow-up. One patient in the anakinra group discontinued treatment because of an adverse event. Patients in the anakinra group had more injection site reactions (68% [17 of 25] vs. 4% [1 of 25]). Limitation: Small sample size and wide variability in symptom duration; inclusion was not limited to patients with postinfectious symptoms. Conclusion: Peripheral IL-1 inhibition using anakinra for 4 weeks does not result in a clinically significant reduction in fatigue severity in women with CFS and severe fatigue. Primary Funding Source: Interleukin Foundation and an independent donor who wishes to remain anonymous.