Patient Navigation to Improve Colonoscopy Completion After an Abnormal Stool Test Result: A Randomized Controlled Trial: Annals of Internal Medicine: Vol 178, No 5

Background: Patient navigation is a recommended practice of the Guide to Community Preventive Services; little is known about whether it improves colonoscopy completion for adults who have received an abnormal stool test result. Objective: To determine whether patient navigation delivered to persons with an abnormal stool test result increased follow-up colonoscopy completion (primary) at 1 year. Design: Randomized controlled trial. (ClinicalTrials.gov: NCT03925883) Setting: A federally qualified health center (n = 32 clinics) in Washington state. Patients: Persons aged 50 to 75 years with an abnormal fecal test result in the prior month. Intervention: A 6-topic, telephone-based patient navigation program delivered by bilingual (English and Spanish) clinical staff. Measurements: Receipt of follow-up colonoscopy at 1 year (primary); time to colonoscopy receipt (secondary); and program effectiveness by patient characteristics, including patients’ probability of obtaining a colonoscopy without navigation, derived using health record data (secondary). Results: Of 985 participants enrolled (mean age, 61 years [SD, 6.8]; 170 [18%] had a Spanish-language preference listed in the medical record), 967 were included in the primary intention-to-treat analysis (479 in patient navigation, 488 in usual care). Receipt of follow-up colonoscopy was higher in the patient navigation group than in the usual care group (55.1% vs. 42.1%; risk difference, 13.0 percentage points [95% CI, 6.5 to 19.4 percentage points]). The intervention effect was not moderated by patients’ probability of obtaining a colonoscopy without navigation. Limitation: The study was primarily done during the height of the COVID-19 pandemic, which created additional barriers to colonoscopy at the health system and patient levels. Conclusion: These findings support the effectiveness of patient navigation for follow-up colonoscopy completion. Primary Funding Source: National Cancer Institute.

Annals On Call - Vascular Occlusive Crisis: Site of Care Matters

Excessive Alcohol Use and Alcohol Use Disorders: A Policy Brief of the American College of Physicians

Alcohol is used by more people in the United States than tobacco, electronic nicotine delivery systems, or illicit drugs. Several health conditions, including cancer, cardiovascular disease, and liver disease, are associated with excessive alcohol use and alcohol use disorder. Nearly 30 million people aged 12 years or older in the United States reported past-year alcohol use disorder in 2022, but—despite its prevalence—alcohol use disorder is undertreated. In this policy brief, the American College of Physicians outlines the health effects of excessive alcohol use and alcohol use disorder, calls for policy changes to increase the availability of treatment of alcohol use disorder and excessive alcohol use, and recommends alcohol-related public health interventions.

Gatekeepers of Extermination: SS Camp Physicians and Their Scope of Action

The role of camp physicians of the Waffen-SS (“Armed SS,” military branch of the Nazi Party’s Schutzstaffel) in the implementation of the Holocaust has been the subject of limited research, even though they occupied a key position in the extermination process. From 1943 and 1944 onward, SS camp physicians made the individual medical decisions on whether each prisoner was fit for work or was immediately subjected to extermination, not only at the Auschwitz labor and extermination camp but also in pure labor camps like Buchenwald and Dachau. This was due to a functional change in the concentration camp system during World War II, where the selection of prisoners, which had previously been carried out by nonmedical SS camp staff, became a main task of the medical camp staff. The initiative to transfer sole responsibility for the selections came from the physicians themselves and was influenced by structural racism, sociobiologically oriented medical expertise, and pure economic rationality. It can be seen as a further radicalization of the decision making practiced until then in the murder of the sick. However, there was a far-reaching scope of action within the hierarchical structures of the Waffen-SS medical service on both the macro and micro levels. But what can this teach us for medical practice today? The historical experience of the Holocaust and Nazi medicine can provide a moral compass for physicians to be sensitive to the potential for abuse of power and ethical dilemmas inherent in medicine. Thus, the lessons from the Holocaust could be a starting point for reflecting on the value of human life in the modern economized and highly hierarchical medical sector.

The Effect of Low-Dose Glucocorticoids Over Two Years on Weight and Blood Pressure in Rheumatoid Arthritis: Individual Patient Data From Five Randomized Trials

Background: Weight gain and hypertension are well known adverse effects of treatment with high-dose glucocorticoids. Objective: To evaluate the effects of 2 years of low-dose glucocorticoid treatment in rheumatoid arthritis (RA). Design: Pooled analysis of 5 randomized controlled trials with 2-year interventions allowing concomitant treatment with disease-modifying antirheumatic drugs. Setting: 12 countries in Europe. Patients: Early and established RA. Intervention: Glucocorticoids at 7.5 mg or less prednisone equivalent per day. Measurements: Coprimary end points were differences in change from baseline in body weight and mean arterial pressure after 2 years in intention-to-treat analyses. Difference in the change of number of antihypertensive drugs after 2 years was a secondary end point. Subgroup and sensitivity analyses were done to assess the robustness of primary findings. Results: A total of 1112 participants were included (mean age, 61.4 years [SD, 14.5]; 68% women). Both groups gained weight in 2 years, but glucocorticoids led, on average, to 1.1 kg (95% CI, 0.4 to 1.8 kg; P < 0.001) more weight gain than the control treatment. Mean arterial pressure increased by about 2 mm Hg in both groups, with a between-group difference of −0.4 mm Hg (CI, −3.0 to 2.2 mm Hg; P = 0.187). These results were consistent in sensitivity and subgroup analyses. Most patients did not change the number of antihypertensive drugs, and there was no evidence of differences between groups. Limitation: Body composition was not assessed, and generalizability to non-European regions may be limited. Conclusion: This study provides robust evidence that low-dose glucocorticoids, received over 2 years for the treatment of RA, increase weight by about 1 kg but do not increase blood pressure. Primary Funding Source: None.

The Fall of the Nation's First Gender-Affirming Surgery Clinic

Johns Hopkins Hospital established the first gender-affirming surgery (GAS) clinic in the United States in 1966. Operating for more than 13 years, the clinic was abruptly closed in 1979. According to the hospital, the decision was made in response to objective evidence claiming that GAS was ineffective. However, this evidence directly contradicted many contemporaneous studies and faced immediate criticism from the scientific community. Despite this resistance, it took the hospital nearly 40 years to resume performing GAS. Scientific evidence—imbued in scandal, bias, and moralism—was instrumentalized to serve broader institutional interests. The burgeoning field of plastic surgery tethered and then untethered GAS from its auspices in response to poor technical outcomes and transphobia. No longer serving surgeons' interests, the clinic was marginalized to “barely minimal facilities” in 1974, five years before GAS was formally banned. Over the next 5 years, the clinic co-inhabited space with the Department of Obstetrics and Gynecology. Simultaneously, the Department of Obstetrics and Gynecology navigated scandals related to reproductive technology (namely, the Dalkon Shield [A.H. Robins] controversy) until the clinic space was demolished in 1979. The study that informed the GAS ban was preferentially funded in keeping with the political economy of biomedical research. This article presents a spatial argument for how the closure of the nation's first GAS clinic was not based in empirical data alone but was manipulated to fuel political and institutional agendas.

A Framework for the Development of Living Practice Guidelines in Health Care

Background: Living practice guidelines are increasingly being used to ensure that recommendations are responsive to rapidly emerging evidence. Objective: To develop a framework that characterizes the processes of development of living practice guidelines in health care. Design: First, 3 background reviews were conducted: a scoping review of methods papers, a review of handbooks of guideline-producing organizations, and an analytic review of selected living practice guidelines. Second, the core team drafted the first version of the framework. Finally, the core team refined the framework through an online survey and online discussions with a multidisciplinary international group of stakeholders. Setting: International. Participants: Multidisciplinary group of 51 persons who have experience with guidelines. Measurements: Not applicable. Results: A major principle of the framework is that the unit of update in a living guideline is the individual recommendation. In addition to providing definitions, the framework addresses several processes. The planning process should address the organization's adoption of the living methodology as well as each specific guideline project. The production process consists of initiation, maintenance, and retirement phases. The reporting should cover the evidence surveillance time stamp, the outcome of reassessment of the body of evidence (when applicable), and the outcome of revisiting a recommendation (when applicable). The dissemination process may necessitate the use of different venues, including one for formal publication. Limitation: This study does not provide detailed or practical guidance for how the described concepts would be best implemented. Conclusion: The framework will help guideline developers in planning, producing, reporting, and disseminating living guideline projects. It will also help research methodologists study the processes of living guidelines. Primary Funding Source: None.

Accelerating COVID-19 Therapeutic Interventions and Vaccines (ACTIV): Designing Master Protocols for Evaluation of Candidate COVID-19 Therapeutics

Working in an unprecedented time frame, the Accelerating COVID-19 Therapeutic Interventions and Vaccines (ACTIV) public–private partnership developed and launched 9 master protocols between 14 April 2020 and 31 May 2021 to allow for the coordinated and efficient evaluation of multiple investigational therapeutic agents for COVID-19. The ACTIV master protocols were designed with a portfolio approach to serve the following patient populations with COVID-19: mild to moderately ill outpatients, moderately ill inpatients, and critically ill inpatients. To facilitate the execution of these studies and minimize start-up time, ACTIV selected several existing networks to launch the master protocols. The master protocols were also designed to test several agent classes prioritized by ACTIV that covered the spectrum of the disease pathophysiology. Each protocol, either adaptive or pragmatic, was designed to efficiently select those treatments that provide benefit to patients while rapidly eliminating those that were either ineffective or unsafe. The ACTIV Therapeutics-Clinical Working Group members describe the process by which these master protocols were designed, developed, and launched. Lessons learned that may be useful in meeting the challenges of a future pandemic are also described.

Medical Schools as Racialized Organizations: A Primer

The year 2020 saw the largest social movement in response to the police killings of Black people and anti-Black racism in U.S. history. As a result, medical schools and professional societies such as the American Medical Association and the Association of American Medical Colleges are reckoning with their role in perpetuating racial inequality and the impact of structural racism on medical training. Whether these efforts will translate into meaningful change has yet to be determined. Success depends on a deep understanding of the fundamental role racism plays in how medical schools function and an acknowledgment that current organizational structures and processes often serve to entrench, not dismantle, racial inequities. Drawing on racialized organizations theory from the field of sociology, this article gives an overview of scholarship on race and racism in medical training to demonstrate how seemingly race-neutral processes and structures within medical education, in conjunction with individuals’ biases and interpersonal discrimination, serve to reproduce and sustain racial inequality. From entrance into medical school through the residency application process, organizational factors such as reliance on standardized tests to predict future success, a hostile learning climate, and racially biased performance metrics ultimately stunt the careers of trainees of color, particularly those from backgrounds underrepresented in medicine (URM). These compounding disadvantages contribute to URM trainees’ lower matching odds, steering into less competitive and lucrative specialties, and burnout and attrition from academic careers. In their commitment against structural racism in medical training and academic medicine, medical schools and larger organizations like the Association of American Medical Colleges should prioritize interventions targeted at these structural barriers to achieve equity.

“We Do Not Want Him Because He Is a Jew”: The Montreal Interns' Strike of 1934

Speeches by modern-day White supremacists often include such statements as “Jews will not replace us.” In 1934, the French-speaking medical interns of Montreal's Roman Catholic hospitals went on strike because, they alleged, a Jew “replaced” a Roman Catholic French Canadian. Anti-Semitic social and economic boycotts and educational quotas were in existence in Canada from the 19th through the mid-20th century. There were particularly strong anti-immigrant and anti-Semitic feelings in the first half of the 20th century in Quebec, along with anti-Semitic pro-fascist political parties. In 1934, Montreal's Hôpital Notre-Dame (HND), a teaching hospital of the Université de Montréal (UM) medical school, was unable to hire a full complement of medical interns from among the newly graduated French-speaking Roman Catholic medical students. The hospital hired a French-speaking Jewish graduate of UM, Samuel Rabinovitch. The prospective interns at HND submitted a petition demanding that Rabinovitch be fired, stating, “We do not want him because he is a Jew.” On 14 and 15 June 1934, HND's interns went on strike to prevent Rabinovitch from taking up his duties. The strike spread to multiple hospitals in Montreal. A Jewish urology trainee at the Hôtel Dieu hospital, Abram Stilman, was also targeted. Rabinovitch resigned in order to bring the strike to an end. The strike buttressed the case in the first half of the 20th century for American and Canadian Jewish hospitals and medical schools to ensure the education of Jewish physicians, reminds us of the origins of the slogans of modern White supremacists, and reinforces the historical basis of efforts to promote diversity and inclusion in medical education.