Search Results for: "depression"

Background: Time-restricted eating (TRE), limiting daily dietary intake to a consistent 8 to 10 hours without mandating calorie reduction, may provide cardiometabolic benefits. Objective: To determine the effects of TRE as a lifestyle intervention combined with current standard-of-care treatments on cardiometabolic health in adults with metabolic syndrome. Design: Randomized controlled trial. (ClinicalTrials.gov: NCT04057339) Setting: Clinical research institute. Participants: Adults with metabolic syndrome including elevated fasting glucose or hemoglobin A1c (HbA1c; pharmacotherapy allowed). Intervention: Participants were randomly assigned to standard-of-care (SOC) nutritional counseling alone (SOC group) or combined with a personalized 8- to 10-hour TRE intervention (≥4-hour reduction in eating window) (TRE group) for 3 months. Timing of dietary intake was tracked in real time using the myCircadianClock smartphone application. Measurements: Primary outcomes were HbA1c, fasting glucose, fasting insulin, homeostasis model assessment of insulin resistance, and glycemic assessments from continuous glucose monitors. Results: 108 participants from the TIMET study completed the intervention (89% of those randomly assigned; 56 women, mean baseline age, 59 years; body mass index of 31.22 kg/m2; eating window of 14.19 hours). Compared with SOC, TRE improved HbA1c by −0.10% (95% CI, −0.19% to −0.003%). Statistical outcomes were adjusted for age. There were no major adverse events. Limitation: Short duration, self-reported diet, potential for multiple elements affecting outcomes. Conclusion: Personalized 8- to 10-hour TRE is an effective practical lifestyle intervention that modestly improves glycemic regulation and may have broader benefits for cardiometabolic health in adults with metabolic syndrome on top of SOC pharmacotherapy and nutritional counseling. Primary Funding Source: National Institutes of Health.

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.

Development and Evaluation of a Framework for Identifying and Addressing Spin for Harms in Systematic Reviews of Interventions

“Spin” refers to misleading reporting, interpretation, and extrapolation of findings in primary and secondary research (such as in systematic reviews). The study of spin primarily focuses on beneficial outcomes. The objectives of this research were threefold: first, to develop a framework for identifying spin associated with harms in systematic reviews of interventions; second, to apply the framework to a set of reviews, thereby pinpointing instances where spin may be present; and finally, to revise the spin examples, offering guidance on how spin can be rectified. The authors developed their framework through an iterative process that engaged an international group of researchers specializing in spin and reporting bias. The framework comprises 12 specific types of spin for harms, grouped by 7 categories across the 3 domains (reporting, interpretation, and extrapolation). The authors subsequently gathered instances of spin from a random sample of 100 systematic reviews of interventions. Of the 58 reviews that assessed harm and the 42 that did not, they found that 28 (48%) and 6 (14%), respectively, had at least 1 of the 12 types of spin for harms. Inappropriate extrapolation of the results and conclusions for harms to populations, interventions, outcomes, or settings not assessed in a review was the most common category of spin in 17 of 100 reviews. The authors revised the examples to remove spin, taking into consideration the context (for example, medical discipline, source population), findings for harms, and methodological limitations of the original reviews. They provide guidance for authors, peer reviewers, and editors in recognizing and rectifying or (preferably) avoiding spin, ultimately enhancing the clarity and accuracy of harms reporting in systematic review publications.

Long COVID Definitions and Models of Care: A Scoping Review: Annals of Internal Medicine: Vol 177, No 7

Background: Definitions of long COVID are evolving, and optimal models of care are uncertain. Purpose: To perform a scoping review on definitions of long COVID and provide an overview of care models, including a proposed framework to describe and distinguish models. Data Sources: English-language articles from Ovid MEDLINE, PsycINFO, the Cochrane Library, SocINDEX, Scopus, Embase, and CINAHL published between January 2021 and November 2023; gray literature; and discussions with 18 key informants. Study Selection: Publications describing long COVID definitions or models of care, supplemented by models described by key informants. Data Extraction: Data were extracted by one reviewer and verified for accuracy by another reviewer. Data Synthesis: Of 1960 screened citations, 38 were included. Five clinical definitions of long COVID varied with regard to timing since symptom onset and the minimum duration required for diagnosis; 1 additional definition was symptom score–based. Forty-nine long COVID care models were informed by 5 key principles: a core “lead” team, multidisciplinary expertise, comprehensive access to diagnostic and therapeutic services, a patient-centered approach, and providing capacity to meet demand. Seven characteristics provided a framework for distinguishing models: home department or clinical setting, clinical lead, collocation of other specialties, primary care role, population managed, use of teleservices, and whether the model was practice- or systems-based. Using this framework, 10 representative practice-based and 3 systems-based models of care were identified. Limitations: Published literature often lacked key model details, data were insufficient to assess model outcomes, and there was overlap between and variability within models. Conclusion: Definitions of long COVID and care models are evolving. Research is needed to optimize models and evaluate outcomes of different models. Primary Funding Source: Agency for Healthcare Research and Quality. (Protocol posted at https://effectivehealthcare.ahrq.gov/products/long-covid-models-care/protocol.)

Regulatory Framework for Cannabis: A Position Paper From the American College of Physicians

Cannabis, also known as marijuana, is the dried flowers, stems, seeds, and leaves of the Cannabis sativa plant. It contains more than 100 compounds, including tetrahydrocannabinol, which has psychoactive effects. Federal law prohibits the possession, distribution, and use of cannabis outside limited research activities, but most states have legalized cannabis for medical or recreational use. However, research into the potential therapeutic and adverse health effects of cannabis has been limited, in part because of the drug’s federal legal status. In this position paper, the American College of Physicians (ACP) calls for the decriminalization of possession of small amounts of cannabis for personal use and outlines a public health approach to controlling cannabis in jurisdictions where it is legal. ACP recommends the rigorous evaluation of the health effects and potential therapeutic uses of cannabis and cannabinoids as well as research into the effects of legalization on cannabis use. It also calls for evidence-based medical education related to cannabis and increased resources for treatment of cannabis use disorder.

Pulmonology: What You May Have Missed in 2023

The field of pulmonology saw significant advances in 2023. The publications highlighted in this article address advances and changes in practice related to asthma, chronic obstructive pulmonary disease (COPD), interstitial lung disease, pleural disorders, and sleep-disordered breathing. One article reviews data examining the efficacy of vaccination against respiratory syncytial virus, a respiratory viral illness that has had devastating effects globally. Four studies evaluate the role of various therapies in COPD, including dupilumab, ensifentrine, pulmonary rehabilitation programs, and lung volume reduction versus endobronchial valves. Another study explores the effect on vascular events of positive-pressure ventilation in patients with sleep-disordered breathing and recent stroke. The use of combination therapy with rituximab and mycophenolate mofetil on progression-free survival in patients with nonspecific interstitial pneumonia is the topic of another study. We also highlight an update of clinical recommendations for the evaluation of patients with pleural disorders and a systematic review analyzing the effectiveness of inhaled corticosteroids as a supplement to dual therapy for COPD.

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Displaying 61 - 70 of 75 in Annals of Internal Medicine: Clinical Cases

Delayed Malaria Recrudescence and Relapse in the Setting of COVID-19 | Annals of Internal Medicine: Clinical Cases

It is unknown whether COVID-19 can trigger malaria recrudescence or relapse. Although Plasmodium falciparum recrudescence occurring years after infection is extremely rare, delayed Plasmodium vivax and Plasmodium ovale relapse from the latent hypnozoite stage is well described. We report a case of acute P falciparum and P ovale co-infection that occurred 2 weeks after COVID-19 in an otherwise immunocompetent patient living in a malaria nonendemic country and without exposure to malaria in the preceding 5 years. This case highlights a potential mechanism by which COVID-19–associated immune depletion and/or dysregulation may trigger a delayed presentation of malaria.

Cholecystalgia: An Atypical Presentation of Congestive Heart Failure in a New Diagnosis of Alcohol-Induced Cardiomyopathy | Annals of Internal Medicine: Clinical Cases

Right upper quadrant (RUQ) pain is a frequent presenting symptom in the emergency department, and gallstone-induced acute cholecystitis is one of the main causes; in addition, RUQ pain can be a consequence of several other conditions. Although rare, it may also indicate cholecystalgia from gallbladder edema, which is usually related to other conditions, such as congestive heart failure (CHF), alcoholic and nonalcoholic liver cirrhosis, acute viral or drug-induced hepatitis, renal failure, and hypoproteinemia. We present a case of cholecystalgia resulting from gallbladder edema in a patient with a newly diagnosed alcohol-induced cardiomyopathy without the common CHF signs and symptoms.

Therapeutic Management of Symptomatic Calcification in a Patient With Normophosphatemic Tumoral Calcinosis | Annals of Internal Medicine: Clinical Cases

Tumoral calcinosis is a rare autosomal recessive disorder marked by lobulated soft tissue calcifications not associated with physiologic osteogenesis but rather phosphate metabolism dysregulation. Management of this rare condition involves symptomatic medical management to slow progression of disability from growth of calcifications. Controversially, surgical management in acute presentations has been implemented with varying results. We report a case of a 31-year-old African American man with known history of tumoral calcinosis who presented complaining of acute pain/inflammation of his right ankle. Medical management alone was found to be inadequate, requiring calcification partial resection, of which this patient benefitted from without recurrence.

ACTH-Dependent Cushing Syndrome in Metastatic Acinic Cell Carcinoma: A Poor Prognostic Factor | Annals of Internal Medicine: Clinical Cases

Acinic cell carcinoma (ACC) with high-grade transformation is an aggressive subtype of salivary gland neoplasm. Only a few cases of adrenocorticotropic hormone (ACTH) production in metastatic ACC have been documented. We present a patient case of ACTH-dependent Cushing syndrome (CS) that developed 18 months after surgical resection of ACC. The original tissue sample was found to stain positive for ACTH, and the development of CS coincided with aggressive progression of ACC. Our case highlights the potential significance of ACTH staining in ACC and the development of CS as a signal of dedifferentiation, disease progression, and a poorer prognosis.

Chylothorax as the Initial Manifestation of Follicular Lymphoma | Annals of Internal Medicine: Clinical Cases

Chylothorax is the presence of chyle in the pleural space, which can occur with any disruption of the thoracic duct or its main tributaries. Here we describe the case of a 64-year-old nonsmoking woman who presented with shortness of breath and had findings of a massive right-sided chylous pleural effusion. She was subsequently diagnosed with high-grade follicular lymphoma and had chest tube placement and rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone therapy with complete response.

Lymphomatoid Granulomatosis Presents With Nodal and Bone Marrow Invasion: A Case Report and Literature Review | Annals of Internal Medicine: Clinical Cases

Lymphomatoid granulomatosis (LYG) is a rare lymphoproliferative disease driven by Epstein-Barr virus (EBV) infection. It is characterized by pulmonary involvement; however, nodal and bone marrow invasion are very rare. Tissue biopsy is the cornerstone of diagnosis. To our knowledge, this is the first case of LYG presenting with nodal, spleen, and bone marrow invasion on initial work-up. Imaging suggested nodal and marrow site invasion along with classical lung lesions. Biopsy and immunoprofile confirmed EBV+ B-cell lymphoma, which is diagnostic of LYG grade 3. The patient responded to chemotherapy for this high-grade disease.

Cutaneous Vasculopathy and Recalcitrant Lower-Extremity Ulcerations | Annals of Internal Medicine: Clinical Cases

Lower-extremity ulcerations are a frequent cause of hospitalization, and those that persist despite appropriate treatment warrant careful scrutiny. We present a case of chronic, progressive leg ulcerations in a young woman accompanied by oral and genital ulcers and retiform purpura. Repeat skin biopsy revealed an intravascular lymphoid infiltrate ultimately consistent with T-cell prolymphocytic leukemia, and she was treated successfully with alemtuzumab and allogeneic hematopoietic stem cell transplantation. Our case illustrates the importance of maintaining a broad differential for patients with ulcers recalcitrant to treatment or with acute on chronic worsening. Our report also highlights the successful response of this aggressive disease to hematopoietic stem cell transplantation.

A Case of Lamotrigine-Induced Inflammatory Myositis | Annals of Internal Medicine: Clinical Cases

We describe a 21-year-old woman with bipolar disorder who started taking lamotrigine 2 months ago who presented with fever and weakness. Physical examination revealed an erythematous rash over the right thenar eminence, as well as proximal muscle weakness in bilateral upper and lower extremities. Magnetic resonance imaging of the lower extremities showed patchy bilateral enhancing myositis. Right quadriceps muscle biopsy revealed inflammatory myopathy. Subsequent bone marrow biopsy demonstrated hemophagocytic lymphohistiocytosis. The patient started a prednisone taper for suspected inflammatory myositis and achieved full remission. This is one of the first descriptions of lamotrigine inducing an autoimmune response presenting as an inflammatory myositis.

Why So Salty? Transient Diabetes Insipidus After Discontinuation of Vasopressin | Annals of Internal Medicine: Clinical Cases

In recent years, vasopressin has been increasingly used as an early treatment of vasopressor-refractory septic shock. In this article, we describe 2 episodes of transient diabetes insipidus after vasopressin for the treatment of septic shock was discontinued, which adds to a modest number of case studies reporting the same phenomenon. With the anticipated continued use of vasopressin in intensive care units, it can be expected that this adverse effect will occur with some frequency. Awareness and early recognition of this phenomenon can lead to prompt diagnosis and treatment.

Successful Extracorporeal Membrane Oxygenation After a Challenging Cannulation in a Pregnant Patient With COVID-19 | Annals of Internal Medicine: Clinical Cases

Veno-venous extracorporeal membrane oxygenation (V-V ECMO) support for fulminant COVID-19 pneumonia in a person with a viable pregnancy is controversial because many experts recommend delivery of the fetus before maternal ECMO. We describe V-V ECMO use for COVID-19 in a pregnant person at 28 weeks gestation. An inability to pass a guidewire from the jugular vein to the inferior vena cava complicated bedside ECMO cannulation, mandating a jugular-femoral 2-cannula approach that involves risk near a gravid uterus. In this case, procedural flexibility and multispecialty collaboration led to good maternal and fetal outcomes after 6 days of ECMO support.

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