ACP Response to the U.S. Senate Committee on Health, Education, Labor and Pensions White Paper “Preparing for the Next Pandemic”

Solutions to the Challenges Facing Primary Care Medicine: Comprehensive Strategies from ACP

Rural Primary Care

Patient Access to Internist-Subspecialists in Gatekeeper Health Plans

Nurse Practitioners in Primary Care

Immigration Position Statement

Five Prescriptions for Ensuring the Future of Primary Care

Ethical Considerations for Use of Patient Incentives to Promote Personal Responsibility for Health: West Virginia Medicaid & Beyond

Eating Disorders: Anorexia Nervosa and Bulimia

Domestic Violence

On the Labels We Carry

How Would You Treat This Patient Hospitalized With Community-Acquired Pneumonia?: Grand Rounds Discussion From Beth Israel Deaconess Medical Center: Annals of Internal Medicine: Vol 174, No 12

Community-acquired pneumonia is a major cause of morbidity and mortality in the United States, leading to 1.5 million hospitalizations and at least 200 000 deaths annually. The 2019 American Thoracic Society/Infectious Diseases Society of America clinical practice guideline on diagnosis and treatment of adults with community-acquired pneumonia provides an evidence-based overview of this common illness. Here, 2 experts, a general internist who served as the co–primary author of the guidelines and a pulmonary and critical care physician, debate the management of a patient hospitalized with community-acquired pneumonia. They discuss disease severity stratification methods, whether to use adjunctive corticosteroids, and when to prescribe empirical treatment for multidrug-resistant organisms such as methicillin-resistant Staphylococcus aureus and Pseudomonas aeruginosa.

Burst Case Scenario: Why Shorter May Not Be Any Better When It Comes to Corticosteroids

Rethinking Opioid Dose Tapering, Prescription Opioid Dependence, and Indications for Buprenorphine

What Physicians and Health Organizations Should Know About Mandated Imaging Appropriate Use Criteria

The Appropriate Use Criteria Program, enacted by the Centers for Medicare & Medicaid Services in response to the Protecting Access to Medicare Act of 2014 (PAMA), aims to reduce inappropriate and unnecessary imaging by mandating use of clinical decision support (CDS) by all providers who order advanced imaging examinations (magnetic resonance imaging; computed tomography; and nuclear medicine studies, including positron emission tomography). Beginning 1 January 2020, documentation of an interaction with a certified CDS system using approved appropriate use criteria will be required on all Medicare claims for advanced imaging in all emergency department patients and outpatients as a prerequisite for payment. The Appropriate Use Criteria Program will initially cover 8 priority clinical areas, including several (such as headache and low back pain) commonly encountered by internal medicine providers. All providers and organizations that order and provide advanced imaging must understand program requirements and their options for compliance strategies. Substantial resources and planning will be needed to comply with PAMA regulations and avoid unintended negative consequences on workflow and payments. However, robust evidence supporting the desired outcome of reducing inappropriate use of advanced imaging is lacking.

How Would You Manage This Patient With Gout?: Grand Rounds Discussion From Beth Israel Deaconess Medical Center: Annals of Internal Medicine: Vol 169, No 11

Gout is the most common form of inflammatory arthritis. In 2012, the American College of Rheumatology (ACR) issued a guideline, which was followed in 2017 by one from the American College of Physicians (ACP). The guidelines agree on treating acute gout with a corticosteroid, nonsteroidal anti-inflammatory drug, or colchicine and on not initiating long-term urate-lowering therapy (ULT) for most patients after a first gout attack and in those whose attacks are infrequent (<2 per year). However, they differ on treatment of both recurrent gout and problematic gout. The ACR advocates a “treat-to-target” approach, and the ACP did not find enough evidence to support this approach and offered an alternative strategy that bases intensity of ULT on the goal of avoiding recurrent gout attacks (“treat-to-avoid-symptoms”) with no monitoring of urate levels. They also disagree on the role of a gout-specific diet. Here, a general internist and a rheumatologist discuss these guidelines; they debate how they would manage an acute attack of gout, if and when to initiate ULT, and the goals for ULT. Lastly, they offer specific advice for a patient who is uncertain about whether to begin this therapy.

Combined Gabapentinoid and Opioid Use: The Consequences of Shifting Prescribing Trends

Cannabis for Pain and Posttraumatic Stress Disorder: More Consensus Than Controversy or Vice Versa?

Note to an Oncology Fellow

Should This Patient Have Weight Loss Surgery?: Grand Rounds Discussion From Beth Israel Deaconess Medical Center: Annals of Internal Medicine: Vol 166, No 11

Obesity is an important public health priority in the United States. One third of U.S. adults are obese and therefore can expect higher rates of diabetes mellitus, other obesity-related comorbidities, and mortality. In 2013, the American Association of Clinical Endocrinologists, the Obesity Society, and the American Society for Metabolic and Bariatric Surgery issued a guideline that recommended weight loss (bariatric) surgery for all patients with a body mass index (BMI) of 40 kg/m2 or higher and for those with a BMI of 35 kg/m2 or greater in the presence of at least 1 obesity-related comorbidity. Among the 3 most commonly performed surgeries, the amount of excess weight reduction ranges from 49% for laparoscopic adjustable gastric banding to 76% for Roux-en-Y gastric bypass. In accredited centers, perioperative mortality averages 0.3%. In this Beyond the Guidelines, 2 experts in obesity management, a bariatric surgeon and a general internist, discuss the role of weight loss surgery versus dietary and lifestyle modification, both in general and for a specific patient who is eligible for surgery. Ethnic and age-related variability in the effects of obesity on mortality, as well as potential long-term benefits and risks of weight loss surgery for patient subgroups, are discussed.

Uphill and Downhill Esophageal Varices Secondary to Pulmonary Hypertension | Annals of Internal Medicine: Clinical Cases

Downhill esophageal varices (EVs) are rare endoscopic findings and coincide with superior vena cava (SVC) obstruction. Historically, downhill EVs have been associated with malignancy, thrombosis, or iatrogenic SVC obstruction. Few cases of “benign obstruction”, as in pulmonary hypertension (PH) with tricuspid regurgitation (TR), have been reported. Downhill EV can result in life-threatening bleeds; however, there are no current guidelines regarding treatment or surveillance endoscopy. We report a case of both uphill and downhill EV due to benign obstruction from PH and TR, leading to the diagnosis of decompensated cirrhosis.

Skeletal Fluorosis: “Huffing” of Inhalant Computer Cleaning Fluid | Annals of Internal Medicine: Clinical Cases

Skeletal fluorosis is a disorder characterized by the deposition of fluoride within the bones. It is a rare presentation in the United States since the administration of sodium fluoride for the treatment of osteoporosis was discontinued several years ago. We report an adult woman manifesting skeletal fluorosis involving both axial and appendicular bones secondary to “huffing” (inhalation) of various commercial electronic cleaning products containing 1,1 difluoroethane. It is important to be alert to the presence of this disorder in patients abusing inhalants to prevent bone deformities, fragility fractures, and consequential morbidities.

Eosinophilic Fasciitis: Clinical Signs Leading to Diagnosis | Annals of Internal Medicine: Clinical Cases

Eosinophilic fasciitis is a rare disease characterized by peripheral eosinophilia and inflammatory infiltrate on muscular fascia and subcutaneous tissue. Patients present with edema and stiffening of limbs, progressing rapidly to fibrosis. The Groove sign is a classical physical examination finding. A skin–fascia–muscle biopsy is the gold standard for diagnosis, but nuclear magnetic resonance imaging is also useful. Glucocorticoids in high doses are the initial treatment of choice. We report the patient case of a 22-year-old man with expressive eosinophilia and whose clinical findings (Groove sign and others) led to the diagnosis.

Immune Checkpoint Inhibitor Use in Microscopic Colitis | Annals of Internal Medicine: Clinical Cases

Immune checkpoint inhibitors (ICIs) are a novel class of anticancer therapies that can result in autoimmune pathology known as immune-related adverse events (irAEs). Because of the risk for irAEs, patients with preexisting autoimmune diseases have been excluded from safety trials for ICIs. Although the pathophysiology of microscopic colitis is not fully understood, it is considered part of the spectrum of immune-mediated gastrointestinal diseases. Little is known about the effects of ICIs on patients with microscopic colitis. This case series describes 4 patients with microscopic colitis requiring ICIs for cancer therapy and gastrointestinal-related outcomes after ICI therapy.

A Sole Left Coronary Artery | Annals of Internal Medicine: Clinical Cases

Coronary artery anomalies are defined as coronary patterns that do not fit the usual origins and branching patterns from the ascending aorta. One such CAA includes a single coronary artery: a rare (often incidental) finding of only 1 coronary artery supplying the entire heart. This anomaly poses risks to the patient, with complications such as myocardial infarction and sudden cardiac death. Our patient case was a woman with high-risk coronary artery disease (CAD) who was incidentally found to have a single coronary artery. This is an important anatomical anomaly that can alter signs, symptoms, and subsequent treatment of patients with CAD.

Uncommon Presentation of Autoimmune Pancreatitis With Refractory Ulcerative Colitis | Annals of Internal Medicine: Clinical Cases

Patients diagnosed with autoimmune pancreatitis (AIP) are at significantly higher risk for ulcerative colitis (UC), and the concurrent diagnoses continue to be a challenge to recognize. A previously healthy symptomatic 23-year-old man was diagnosed with type II AIP with UC and, despite aggressive treatment with steroids and infliximab, ultimately had a total colectomy. This patient case illustrates the association between AIP and UC and proposes that a concomitant diagnosis suggests a worse prognosis. Determining the relationship between these 2 pathologies and early diagnosis will allow physicians to escalate therapy more quickly and improve outcomes in patients.

From Risk to Reality: How Pregnancy in Cystic Fibrosis Has Transformed | Annals of Internal Medicine: Clinical Cases

Left Wrist Osteomyelitis Secondary to Mycoplasma orale: A Case Report | Annals of Internal Medicine: Clinical Cases

Mycoplasma orale is a fastidious oropharyngeal commensal that rarely causes invasive disease. We report a 73-year-old immunocompromised man with destructive, culture-negative wrist osteomyelitis/septic arthritis refractory to multiple antibiotic regimens. Broad-range bacterial polymerase chain reaction at 2 independent reference laboratories concordantly identified M orale. He had staged surgical debridements and received a short course of high-dose daptomycin selected on the basis of in vitro susceptibility data, with resolution and no recurrence. This case underscores early molecular diagnostics and suggests daptomycin, alongside aggressive source control, as a salvage option when conventional Mycoplasma-active regimens fail.

Digoxin-Like Toxicity After Tejocote Root and Yellow Oleander Ingestion: The Hidden Dangers of Herbal Supplements | Annals of Internal Medicine: Clinical Cases

Tejocote root (Crataegus mexicana) is a common herbal supplement used for weight loss and to induce bowel movements. In recent years, there has been an increase in the number of cases of digoxin-like toxicity associated with consumption of tejocote root, and substitution of tejocote root with yellow oleander. We present a case of excess tejocote ingestion to induce a bowel movement that resulted in subsequent gastrointestinal upset and cardiac arrhythmia. This report highlights the potential risks associated with the consumption of tejocote root, particularly due to suspected inclusion of yellow oleander after a Food and Drug Administration–issued warning of several supplements.

A Case of Dacrystic Seizure in a 72-Year-Old Man | Annals of Internal Medicine: Clinical Cases

Dacrystic seizures are rare, stereotyped episodes of ictal crying. We describe a 72-year-old man with recurrent crying spells, initially attributed to orthostatic hypotension with psychogenic episodes. Electroencephalography monitoring captured interictal left frontal spikes and diffuse background slowing. Magnetic resonance imaging demonstrated a prominent left mesial temporal lesion, though no episodes were identified in the 24-hour monitoring period. The patient was treated with levetiracetam and reported significantly fewer events at home. Clinical response confirms the diagnosis. This case highlights the diagnostic challenge of emotional seizure semiologies and the critical role of multidisciplinary evaluation, particularly for hospitalists encountering atypical neurologic presentations.

COVID-19 in community hospitals | ACP Hospitalist

Cases from Oregon Health & Science University | ACP Hospitalist

PE in pregnancy, normal troponins | ACP Hospitalist

Cases from Oregon Health & Science University | ACP Hospitalist

New cardiac warning for fluoroquinolones | ACP Hospitalist

Antibiotics and AKI, stroke rehab, and more | ACP Hospitalist

Frail elderly, Enterobacteriaceae infections, and more | ACP Hospitalist

Speed of sepsis care, early feeding for mild pancreatitis, and more | ACP Hospitalist

Upper gastrointestinal bleed | ACP Hospitalist

Young hospitalists choosing locum tenens | ACP Hospitalist