Health Care During Incarceration: A Policy Position Paper From the American College of Physicians

The American College of Physicians (ACP) has a long-standing commitment to improving the health of all Americans and opposes any form of discrimination in the delivery of health care services. ACP is committed to working toward fully understanding and supporting the unique needs of the incarcerated population and eliminating health disparities for these persons. In this position paper, ACP offers recommendations to policymakers and administrators to improve the health and well-being of persons incarcerated in adult correctional facilities.

Relationship Between Clinician Language and the Success of Behavioral Weight Loss Interventions: A Mixed-Methods Cohort Study: Annals of Internal Medicine: Vol 176, No 11

Background: International guidelines recommend that primary care clinicians recognize obesity and offer treatment opportunistically, but there is little evidence on how clinicians can discuss weight and offer treatment in ways that are well received and effective. Objective: To examine relationships between language used in the clinical visit and patient weight loss. Design: Mixed-methods cohort study. Setting: 38 primary care clinics in England participating in the Brief Intervention for Weight Loss trial. Participants: 246 patients with obesity seen by 87 general practitioners randomly sampled from the intervention group of the randomized clinical trial. Measurements: Conversation analysis of recorded discussions between 246 patients with obesity and 87 clinicians regarding referral to a 12-week behavioral weight management program offered as part of the randomized clinical trial. Clinicians’ interactional approaches were identified and their association with patient weight loss at 12 months (primary outcome) was examined. Secondary outcomes included patients’ agreement to attend weight management, attendance, loss of 5% body weight, actions taken to lose weight, and postvisit satisfaction. Results: Three interactional approaches were identified on the basis of clinicians’ linguistic and paralinguistic practices: creating a sense of referrals as “good news” related to the opportunity of the referral (n = 62); “bad news,” focusing on the harms of obesity (n = 82); or neutral (n = 102). Outcome data were missing from 57 participants, so weighted analyses were done to adjust for missingness. Relative to neutral news, good news was associated with increased agreement to attend the program (adjusted risk difference, 0.25 [95% CI, 0.15 to 0.35]), increased attendance (adjusted risk difference, 0.45 [CI, 0.34 to 0.56]), and weight change (adjusted difference, −3.60 [CI, −6.58 to −0.62]). There was no evidence of differences in mean weight change comparing bad and neutral news, and no evidence of differences in patient satisfaction across all 3 approaches. Limitations: Data were audio only, so body language and nonverbal cues could not be assessed. There is potential for selection bias and residual confounding. Conclusion: When raising the topic of excess weight in clinical visits, presenting weight loss treatment as a positive opportunity is associated with greater uptake of treatment and greater weight loss. Primary Funding Source: National Institute for Health and Care Research School for Primary Care Research and the Foundation for the Sociology of Health and Illness.

High- Versus Low-Dose Exercise Therapy for Knee Osteoarthritis: A Randomized Controlled Multicenter Trial: Annals of Internal Medicine: Vol 176, No 2

Background: The benefits of exercise in patients with knee osteoarthritis are well documented, but the optimal exercise dose remains unknown. Objective: To compare high-dose versus low-dose exercise therapy with regard to knee function, pain, and quality of life (QoL) in patients with long-term symptomatic knee osteoarthritis. Design: A Swedish and Norwegian multicenter randomized controlled superiority trial with multiple follow-ups up to 12 months after the intervention. (ClinicalTrials.gov: NCT02024126) Setting: Primary health care facilities. Patients: 189 patients with diagnosed knee osteoarthritis and a history of pain and decreased knee function were assigned to high-dose therapy (n = 98; 11 exercises; 70 to 90 minutes) or low-dose therapy (n = 91; 5 exercises; 20 to 30 minutes). Intervention: Patient-tailored exercise programs according to the principles of medical exercise therapy. Global (aerobic), semiglobal (multisegmental), and local (joint-specific) exercises were performed 3 times a week for 12 weeks under supervision of a physiotherapist. Measurements: The Knee Injury and Osteoarthritis Outcome Score (KOOS) was measured biweekly during the 3-month intervention period and at 6 and 12 months after the intervention. The primary end point was the mean difference in KOOS scores between groups at the end of the intervention (3 months). Secondary outcomes included pain intensity and QoL. The proportion of patients with minimal clinically important changes in primary and secondary outcomes was compared between groups. Results: Both groups improved over time, but there were no benefits of high-dose therapy in most comparisons. One exception was the KOOS score for function in sports and recreation, where high-dose therapy was superior at the end of treatment and at 6-month follow-up. A small benefit in QoL at 6 and 12 months was also observed. Limitation: There was no control group that did not exercise. Conclusion: The results do not support the superiority of high-dose exercise over low-dose exercise for most outcomes. However, small benefits with high-dose exercise were found for knee function in sports and recreation and for QoL. Primary Funding Source: Swedish Rheumatic Fund.

When States Step Up: California and the Case for State-Led Insulin Manufacturing

Health Care in Eastern Ukraine: An Overview

Left Atrial Appendage Occlusion Versus Anticoagulation in Atrial Fibrillation: Equipoise When Bleeding Risk Is High

Estimated Effect of Parathyroidectomy on Long-Term Kidney Function in Adults With Primary Hyperparathyroidism

Background: Multidisciplinary guidelines recommend parathyroidectomy to slow the progression of chronic kidney disease in patients with primary hyperparathyroidism (PHPT) and an estimated glomerular filtration rate (eGFR) less than 60 mL/min/1.73 m2. Limited data address the effect of parathyroidectomy on long-term kidney function. Objective: To compare the incidence of a sustained decline in eGFR of at least 50% among patients with PHPT treated with parathyroidectomy versus nonoperative management. Design: Target trial emulation was done using observational data from adults with PHPT, using an extended Cox model with time-varying inverse probability weighting. Setting: Veterans Health Administration. Patients: Patients with a new biochemical diagnosis of PHPT in 2000 to 2019. Measurements: Sustained decline of at least 50% from pretreatment eGFR. Results: Among 43 697 patients with PHPT (mean age, 66.8 years), 2928 (6.7%) had a decline of at least 50% in eGFR over a median follow-up of 4.9 years. The weighted cumulative incidence of eGFR decline was 5.1% at 5 years and 10.8% at 10 years in patients managed with parathyroidectomy, compared with 5.1% and 12.0%, respectively, in those managed nonoperatively. The adjusted hazard of eGFR decline did not differ between parathyroidectomy and nonoperative management (hazard ratio [HR], 0.98 [95% CI, 0.82 to 1.16]). Subgroup analyses found no heterogeneity of treatment effect based on pretreatment kidney function. Parathyroidectomy was associated with a reduced hazard of the primary outcome among patients younger than 60 years (HR, 0.75 [CI, 0.59 to 0.93]) that was not evident among those aged 60 years or older (HR, 1.08 [CI, 0.87 to 1.34]). Limitation: Analyses were done in a predominantly male cohort using observational data. Conclusion: Parathyroidectomy had no effect on long-term kidney function in older adults with PHPT. Potential benefits related to kidney function should not be the primary consideration for PHPT treatment decisions. Primary Funding Source: National Institute on Aging.

Effects of Dapagliflozin on Hospitalizations in Patients With Chronic Kidney Disease: A Post Hoc Analysis of DAPA-CKD: Annals of Internal Medicine: Vol 176, No 1

Background: Acute hospitalizations are common in patients with chronic kidney disease (CKD) and often lead to decreases in health-related quality of life and increased care costs. Objective: To determine the effects of dapagliflozin on first hospitalizations and all (first and subsequent) hospitalizations and to explore effects on cause-specific hospitalizations. Design: Post hoc analysis of a randomized, double-blind, placebo-controlled clinical trial. (ClinicalTrials.gov: NCT03036150) Setting: 386 ambulatory practice sites in 21 countries from 2 February 2017 through 12 June 2020. Participants: Adults with an estimated glomerular filtration rate of 25 to 75 mL/min/1.73 m2 and a urinary albumin–creatinine ratio of 200 to 5000 mg/g, with and without type 2 diabetes. Intervention: Dapagliflozin, 10 mg once daily, or matching placebo (1:1 ratio). Measurements: The effects of dapagliflozin on first hospitalizations for any cause, all hospitalizations, and cause-specific (first and recurrent) hospitalizations were determined. The reported system organ class was used to evaluate reasons for admission. Hospitalizations were analyzed using Cox proportional hazards regression models (first hospitalization), the Lin–Wei–Yang–Ying method (all hospitalizations or death), and negative binomial models (cause-specific hospitalizations). Results: The study included 4304 patients (mean age, 61.8 years; 33.1% women). During a median follow-up of 2.4 years, 2072 hospitalizations were reported among 1224 (28.4%) participants. Compared with placebo, dapagliflozin reduced risk for a first hospitalization (hazard ratio, 0.84 [95% CI, 0.75 to 0.94]) and all hospitalizations or death (rate ratio, 0.79 [CI, 0.70 to 0.89]). There was no evidence that the effects of dapagliflozin on first and all hospitalizations varied by baseline presence of type 2 diabetes (P for interaction = 0.60 for each). Compared with placebo, dapagliflozin reduced the rate of admissions due to cardiac disorders, renal and urinary disorders, metabolism and nutrition disorders, and neoplasms. Limitations: This was a post hoc analysis and should be viewed as hypothesis-generating. Hospitalizations and causes were reported by site investigators and were not centrally adjudicated. Conclusion: Dapagliflozin reduced the risk for hospitalization for any cause in patients with CKD with and without type 2 diabetes. Primary Funding Source: AstraZeneca.

Total Ankle Replacement Versus Arthrodesis for End-Stage Ankle Osteoarthritis: A Randomized Controlled Trial: Annals of Internal Medicine: Vol 175, No 12

Background: End-stage ankle osteoarthritis causes severe pain and disability. There are no randomized trials comparing the 2 main surgical treatments: total ankle replacement (TAR) and ankle fusion (AF). Objective: To determine which treatment is superior in terms of clinical scores and adverse events. Design: A multicenter, parallel-group, open-label randomized trial. (ISRCTN registry number: 60672307) Setting: 17 National Health Service trusts across the United Kingdom. Patients: Patients with end-stage ankle osteoarthritis, aged 50 to 85 years, and suitable for either procedure. Intervention: Patients were randomly assigned to TAR or AF surgical treatment. Measurements: The primary outcome was change in Manchester–Oxford Foot Questionnaire walking/standing (MOXFQ-W/S) domain scores between baseline and 52 weeks after surgery. No blinding was possible. Results: Between 6 March 2015 and 10 January 2019, a total of 303 patients were randomly assigned; mean age was 68 years, and 71% were men. Twenty-one patients withdrew before surgery, and 281 clinical scores were analyzed. At 52 weeks, the mean MOXFQ-W/S scores improved for both groups. The adjusted difference in the change in MOXFQ-W/S scores from baseline was −5.6 (95% CI, −12.5 to 1.4), showing that TAR improved more than AF, but the difference was not considered clinically or statistically significant. The number of adverse events was similar between groups (109 vs. 104), but there were more wound healing issues in the TAR group and more thromboembolic events and nonunion in the AF group. The symptomatic nonunion rate for AF was 7%. A post hoc analysis suggested superiority of fixed-bearing TAR over AF (−11.1 [CI, −19.3 to −2.9]). Limitation: Only 52-week data; pragmatic design creates heterogeneity of implants and surgical techniques. Conclusion: Both TAR and AF improve MOXFQ-W/S and had similar clinical scores and number of harms. Total ankle replacement had greater wound healing complications and nerve injuries, whereas AF had greater thromboembolism and nonunion, with a symptomatic nonunion rate of 7%. Primary Funding Source: National Institute for Health and Care Research Heath Technology Assessment Programme.

How Would You Screen This Patient for Colorectal Cancer?: Grand Rounds Discussion From Beth Israel Deaconess Medical Center: Annals of Internal Medicine: Vol 175, No 10

Colorectal cancer (CRC) is the third leading cause of cancer death for men and women in the United States, with an estimated 52 580 people expected to die in 2022. Most frequently, CRC is diagnosed among persons aged 65 to 74 years. However, among persons younger than 50 years, incidence rates have been increasing since the mid-1990s. In 2021, partially because of the rising incidence, the U.S. Preventive Services Task Force (USPSTF) recommended CRC screening for adults aged 45 to 49 years (Grade B recommendation). Options for CRC screening include stool-based and direct visualization tests. The USPSTF did not recommend a specific screening test; rather, its guidance was to select a test after a discussion with the patient. Here, a primary care physician and a gastroenterologist discuss the recommendation to begin CRC screening at age 45, review options for CRC screening, and discuss how to choose among the available options.