Diet and Risk for Incident Diverticulitis in Women: A Prospective Cohort Study: Annals of Internal Medicine: Vol 178, No 6

Background: Patients with diverticulitis often attempt to control their diet with a particular focus on avoiding nuts and seeds. However, whether dietary patterns or dietary intake of nuts and seeds are associated with diverticulitis risk is poorly studied, particularly in women. Objective: To determine whether select diets affect incident diverticulitis risk in women. Design: Prospective cohort study. Setting: Cohort study in the United States and Puerto Rico. Participants: Women aged 35 to 74 years at enrollment who responded to food frequency and diverticulitis questionnaires and had no history of inflammatory bowel disease, cancer, or diverticulitis (n = 29 916). Intervention: Food frequency questionnaires were used to calculate dietary index scores and to assess intake of nuts, seeds, and corn. Measurements: Cox proportional hazards regression was used to estimate adjusted hazard ratios (aHRs) and 95% CIs for the associations between each dietary component or dietary index and diverticulitis risk. Results: 1531 cases of incident diverticulitis for 415 103 person-years of follow-up were identified. Intake of peanuts, nuts, and seeds (aHR,1.07 [95% CI, 0.91 to 1.25]) and fresh fruits with edible seeds (aHR,1.06 [CI, 0.90 to 1.24]) was not associated with incident diverticulitis. There was a reduced risk for incident diverticulitis in women in the highest quartile of healthy diets compared with the lowest quartile: the Dietary Approaches to Stop Hypertension diet (aHR, 0.77 [CI, 0.65 to 0.90]), the Healthy Eating Index (aHR, 0.78 [CI, 0.66 to 0.91]), the Alternative Healthy Eating Index (aHR, 0.81 [CI, 0.69 to 0.95]), and the Alternative Mediterranean diet (aHR, 0.91 [CI, 0.78 to 1.06]). Limitation: Confounding, selection bias, and measurement bias are possible. Conclusion: Healthy diets were associated with a reduced risk for incident diverticulitis in women. Consumption of nuts and seeds was not associated with diverticulitis risk. Primary Funding Source: National Institutes of Health.

Fecal Microbiota Transplantation Versus Vancomycin for Primary Clostridioides difficile Infection: A Randomized Controlled Trial: Annals of Internal Medicine: Vol 178, No 7

Background: Fecal microbiota transplantation (FMT) is recommended for recurrent Clostridioides difficile infection (CDI), but its role in primary CDI is unclear. Objective: To investigate the efficacy and safety of FMT in primary CDI. Design: Randomized, open-label, noninferiority, multicenter trial. (ClinicalTrials.gov: NCT03796650) Setting: Hospitals and primary care facilities in Norway. Patients: Adults with CDI (C difficile toxin in stool and ≥3 loose stools daily) and no previous CDI within 365 days before enrollment. Intervention: FMT without antibiotic pretreatment versus oral vancomycin, 125 mg 4 times daily for 10 days. Measurements: The primary end point was clinical cure (firm stools or <3 bowel movements daily) at day 14 and no disease recurrence within 60 days with the assigned treatment alone. Results: Of 104 randomly assigned patients, 100 received FMT or the first dose of vancomycin and were eligible for analysis. Clinical cure and no disease recurrence within 60 days without additional treatment was observed in 34 of 51 patients (66.7%) with FMT versus 30 of 49 (61.2%) with vancomycin (difference, 5.4 percentage points [95.2% CI, −13.5 to 24.4 percentage points]; P for noninferiority < 0.001, rejecting the hypothesis that response to FMT is 25 percentage points lower than response to vancomycin). Eleven patients in the FMT group and 4 in the vancomycin group had additional C difficile treatment. Clinical cure at day 14 and no recurrence with or without additional treatment was observed in 40 of 51 patients (78.4%) with FMT and 30 of 49 (61.2%) with vancomycin (difference, 17.2 percentage points [95.2% CI, −0.7 to 35.1 percentage points]). No significant differences in adverse events were observed between groups. Limitations: Open-label design and reliance on clinical end points. Conclusion: FMT may be considered as first-line therapy in primary CDI. Primary Funding Source: South-East Norway Health Trust.

Risk for Stroke After Newly Diagnosed Atrial Fibrillation During Hospitalization for Other Primary Diagnoses: A Retrospective Cohort Study: Annals of Internal Medicine: Vol 178, No 6

Background: Atrial fibrillation (AF) that is first diagnosed during hospitalization for other causes can subside with resolution of the inciting stressor. Objective: To describe the risk for stroke after newly diagnosed AF during hospitalization for other causes. Design: Population-based retrospective cohort study. Setting: Ontario, Canada. Participants: Patients aged 66 years or older discharged alive from the hospital between April 2013 and March 2023 with a first diagnosis of AF. Intervention: Newly diagnosed AF during hospitalization for other causes, categorized into cardiac medical, noncardiac medical, cardiac surgical, and noncardiac surgical. Measurements: The primary outcome was hospitalization for stroke. The cumulative incidence function was used to estimate crude incidence, censoring on anticoagulant dispensation. Inverse probability of censoring weights were used to account for informative censoring. Results: Atrial fibrillation was diagnosed in 20 639 patients (mean age, 77.1 years; 58.1% male) while hospitalized for other causes: 8340 (40.4%) for noncardiac medical, 7097 (34.4%) for cardiac surgical, 3553 (17.2%) for noncardiac surgical, and 1649 (8.0%) for cardiac medical diagnoses. At 1 year, anticoagulants were being dispensed to 26.4% of patients with CHA2DS2-VA scores of 1 to 4 and 35.2% of those with CHA2DS2-VA scores of 5 to 8. The 1-year risk for stroke without anticoagulation was 1.3% (95% CI, 0.7% to 2.3%) for cardiac medical, 1.2% (CI, 0.9% to 1.5%) for noncardiac medical, 1.1% (CI, 0.8% to 1.7%) for noncardiac surgical, and 1.0% (CI, 0.7% to 1.3%) for cardiac surgical patients. Patients with CHA2DS2-VA scores of 1 to 4 had a 1-year stroke risk of 0.7% (CI, 0.6% to 1.0%) without anticoagulation, compared with 1.8% (CI, 1.4% to 2.2%) at CHA2DS2-VA scores of 5 to 8. Limitation: Long-standing AF may have been misclassified as newly diagnosed, leading to overestimation of stroke risk. Conclusion: Among patients with newly diagnosed AF during hospitalization for other causes, a substantial proportion with low CHA2DS2-VA scores receive anticoagulation, with modest increases in this proportion at higher scores. The stroke risk in patients with CHA2DS2-VA scores greater than 4 approximated the 2% threshold commonly used to initiate anticoagulation in AF. Primary Funding Source: Canadian Cardiovascular Society.

Peer Review: Insights Gleaned From Observing the Editorial Process at Annals of Internal Medicine

The Past, Present, and Future of Restrictive Covenants in Medicine in the United States: A Narrative Review: Annals of Internal Medicine: Vol 178, No 1

Restrictive covenants (RCs) are clauses placed into employment agreements across various industries, and they are frequently used in health care—specifically within physician contracts. Given the most recent guidance and rule determined by the Federal Trade Commission in April 2024, the relevancy of RCs in health care has come under even more scrutiny in the latter half of 2024. This review will focus on the history of RC law and review the value of these clauses from the perspectives of the employer, practicing physician, and patient. We also provide the stakeholder responses to both the ban and the subsequent blockage of enforcement by a Texas federal court in August of 2024.

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.

Association Between False-Positive Results and Return to Screening Mammography in the Breast Cancer Surveillance Consortium Cohort

Background: False-positive results on screening mammography may affect women’s willingness to return for future screening. Objective: To evaluate the association between screening mammography results and the probability of subsequent screening. Design: Cohort study. Setting: 177 facilities participating in the Breast Cancer Surveillance Consortium (BCSC). Patients: 3 529 825 screening mammograms (3 184 482 true negatives and 345 343 false positives) performed from 2005 to 2017 among 1 053 672 women aged 40 to 73 years without a breast cancer diagnosis. Measurements: Mammography results (true-negative result or false-positive recall with a recommendation for immediate additional imaging only, short-interval follow-up, or biopsy) from 1 or 2 screening mammograms. Absolute differences in the probability of returning for screening within 9 to 30 months of false-positive versus true-negative screening results were estimated, adjusting for race, ethnicity, age, time since last mammogram, BCSC registry, and clustering within women and facilities. Results: Women were more likely to return after a true-negative result (76.9% [95% CI, 75.1% to 78.6%]) than after a false-positive recall for additional imaging only (adjusted absolute difference, −1.9 percentage points [CI, −3.1 to −0.7 percentage points]), short-interval follow-up (−15.9 percentage points [CI, −19.7 to −12.0 percentage points]), or biopsy (−10.0 percentage points [CI, −14.2 to −5.9 percentage points]). Asian and Hispanic/Latinx women had the largest decreases in the probability of returning after a false positive with a recommendation for short-interval follow-up (−20 to −25 percentage points) or biopsy (−13 to −14 percentage points) versus a true negative. Among women with 2 screening mammograms within 5 years, a false-positive result on the second was associated with a decreased probability of returning for a third regardless of the first screening result. Limitation: Women could receive care at non-BCSC facilities. Conclusion: Women were less likely to return to screening after false-positive mammography results, especially with recommendations for short-interval follow-up or biopsy, raising concerns about continued participation in routine screening among these women at increased breast cancer risk. Primary Funding Source: National Cancer Institute.

Beyond One-Size-Fits-All: Testing Insomnia Treatments in Special Populations

Maternal Health Equity and Respectful Maternity Care

How Would You Prevent Subsequent Strokes in This Patient? Grand Rounds Discussion From Beth Israel Deaconess Medical Center

Stroke is a major cause of morbidity, mortality, and disability. The American Heart Association/American Stroke Association recently published updated guidelines on secondary stroke prevention. In these rounds, 2 vascular neurologists use the case of Mr. S, a 75-year-old man with a history of 2 strokes, to discuss and debate questions in the guideline concerning intensity of atrial fibrillation monitoring in embolic stroke of undetermined source, diagnosis and management of moderate symptomatic carotid stenosis, and therapeutic strategies for recurrent embolic stroke of undetermined source in the setting of guideline-concordant therapy.