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Background: Hospitalization for alcohol use disorder (AUD) offers an opportunity to initiate evidence-based medications for alcohol use disorder (MAUDs). Objective: To describe patterns and factors associated with hospital initiation of MAUD. Design: Retrospective cohort study. Setting: Veterans Health Administration (VHA). Participants: Veterans hospitalized with a primary diagnosis of AUD in 2022 or 2023. Measurements: Patients had MAUD initiated as an inpatient or within 7 days of discharge. Logistic regression models estimated the predicted probabilities of MAUD initiation based on hospital fixed effects and demographic and clinical characteristics. Results: Among 29 041 hospitalizations for AUD of veterans without MAUD at baseline in 142 hospitals (median age, 55 years; 94% male), in 8932 hospitalizations (30.8%), MAUD was initiated as an inpatient or within 7 days; MAUDs were naltrexone (57.9%), acamprosate (16.5%), and injectable naltrexone (13.9%). Of MAUD initiations, 6221 (69.6%) were during an inpatient stay and the rest were within 7 days. Of the 6221 inpatient initiations, 97.7% had a prescription for MAUD within 30 days after discharge. In adjusted analyses, MAUD initiation was more likely for hospitalizations with a specialty addiction consultation and those receiving psychiatry versus medicine service. Initiation of MAUD was less likely for persons aged 65 years or older, men, American Indian or Alaska Native versus White veterans, frail veterans, veterans diagnosed with opioid use disorder, and those in the intensive care unit. The median hospital-level rate of MAUD initiation was 29.9% (IQR, 22.6% to 36.3%). Limitation: Generalizability to other health care systems. Conclusion: Within the VHA, 30% of hospitalizations for AUD resulted in MAUD initiation as an inpatient or within 7 days of discharge, with substantial variation across hospitals and patient demographic and clinical factors. These data indicate a need to identify and disseminate successful hospital-based strategies to increase prescribing of MAUD. Primary Funding Source: U.S. Department of Veterans Affairs and National Institute on Aging.

Talking With Patients About Health-Related Mis- and Disinformation

Much ado over acetaminophen

How Would You Manage This Patient With Idiopathic Acute Pancreatitis? Grand Rounds Discussion From Beth Israel Deaconess Medical Center

Acute pancreatitis is among the most frequent gastroenterologic reasons for hospitalization in the United States. This condition is associated with significant morbidity, including recurrent acute pancreatitis and chronic pancreatitis. Although most patient cases are due to biliary disease and ethanol, approximately 18% are idiopathic. Diagnostic and management options for idiopathic acute pancreatitis include genetic testing for a number of associated mutations and cholecystectomy to treat subclinical or undetected biliary disease. Endoscopic retrograde cholangiopancreatography, often with concomitant endoscopic sphincterotomy, is also sometimes considered in the management of idiopathic recurrent acute pancreatitis, although the role of this invasive procedure is generally limited. Here, 2 pancreatologists and coauthors of a recent American College of Gastroenterology guideline on the management of acute pancreatitis discuss issues related to genetic testing, cholecystectomy, and endoscopic retrograde cholangiopancreatography with endoscopic sphincterotomy for patients with acute idiopathic pancreatitis in general, and for a young woman recently diagnosed with this condition.

Neither Metformin nor Ursodeoxycholic Acid Effectively Treats Postacute Sequelae of COVID-19: A Randomized Clinical Trial: Annals of Internal Medicine: Vol 179, No 4

Background: There is no proven treatment to alleviate symptoms of postacute sequelae of SARS-CoV-2 infection (PASC), despite its substantial public health burden. Objective: To evaluate the efficacy of metformin and ursodeoxycholic acid (UDCA) in improving PASC symptoms in adults. Design: Double-blind, placebo-controlled, randomized clinical trial. (Clinical Research Information Service: KCT0009342) Setting: Two tertiary hospitals in South Korea, July 2024 to April 2025. Participants: Of 666 adults screened, 396 with a PASC index score of 12 or greater were randomly assigned. Intervention: Oral metformin (uptitrated to 1500 mg/d), UDCA (900 mg once daily), or double placebo for 14 days (1:1:1). Measurements: Proportion of participants achieving PASC recovery (index score <12) at 8 weeks. Results: Among 396 randomized participants (median age, 36 years [IQR, 28 to 49 years]; 72% women), 132 received metformin, 132 received UDCA, and 132 received placebo. The mean interval from SARS-CoV-2 infection was 9.8 months (SD, 7.5). The mean baseline PASC score was 19.3 (SD, 5.7). Recovery occurred in 63.6% (84 of 132) with metformin, 68.2% (90 of 132) with UDCA, and 68.2% (90 of 132) with placebo. Mean changes in PASC scores from baseline to week 8 were −10.05 (95% CI, −11.35 to −8.76) with metformin and −10.62 (CI, −11.79 to −9.45) with UDCA, compared with −10.43 (CI, −11.69 to −9.18) with placebo. Limitation: Findings may not be generalizable to patients with more severe or persistent long COVID. Conclusion: A 2-week course of metformin or UDCA did not significantly improve recovery from PASC. Primary Funding Source: National Institute of Infectious Diseases, National Institute of Health, South Korea

Core Performance Measures for Migraine Headache: A Review by the American College of Physicians

Migraine is a chronic condition that affects about 15% of the population in the United States and is characterized by recurrent, debilitating headache that lasts somewhere between 4 and 72 hours. Only 1 performance measure for migraine is currently in use in pay-for-performance programs. Although the American College of Physicians (ACP) broadly supports the role of performance measurement in performance improvement, this support is based on the principle that only measures that are evidence-based and meet high standards of methodological soundness are appropriate given their potential impact on patient care. ACP’s Performance Measurement Committee reviews performance measures using a rigorous process to recognize high-quality performance measures, address gaps and areas for improvement in performance measures, and help reduce reporting burden. This article presents a review of 1 performance measure that includes migraine and considers a potential core performance measure using ACP’s process to inform physicians, payers, and policymakers.

Iron Deficiency Anemia

Iron deficiency anemia (IDA) is caused by iron deficiency, a common yet underrecognized clinical entity. Populations at greatest risk include children, menstruating and pregnant persons, and people of low socioeconomic status. Timely diagnosis and management of iron deficiency are key to preventing IDA and require thorough assessment of the underlying cause and appropriate iron repletion through either oral or parenteral therapy. Blood transfusion does not provide adequate elemental iron but is sometimes indicated along with iron therapy in patients with cardiovascular compromise, active bleeding, or severe anemia where more rapid correction is warranted. Alternative causes of anemia can be differentiated by red blood cell morphology and reticulocyte count and should be considered if anemia persists despite adequate repletion of iron stores.

How Would You Manage This Diabetic Patient With a Foot Infection? Grand Rounds Discussion From Beth Israel Deaconess Medical Center

Foot infections are the most common cause of hospitalization in patients with diabetes. They may be superficial, involving only the skin, or deep, involving the soft tissues or bone. Superficial infections are generally caused by aerobic gram-positive cocci, whereas deep infections, including osteomyelitis, tend to be polymicrobial in origin. Clinical manifestations of skin and soft tissue infections include local evidence of inflammation, but peripheral neuropathy and peripheral artery disease may mask these findings. Management is determined by the extent of infection and often includes oral or parenteral antibiotic therapy in combination with surgical debridement. In 2023, the International Working Group on the Diabetic Foot and the Infectious Diseases Society of America updated their guideline on the diagnosis and management of diabetic foot infection. The guideline includes specific recommendations regarding the use of inflammatory markers, tissue and bone culture, and imaging studies in the diagnosis of diabetic foot infection, as well as the indications for surgical debridement and hospitalization. Here, 2 experts in this field, an infectious diseases physician and a podiatrist, debate how to manage the case of a diabetic patient with foot infection. They discuss diagnostic and treatment challenges in the care of this population.

Protecting the Integrity and Quality of the Medicare Advantage Program: A Position Paper From the American College of Physicians

Medicare Advantage (MA), the private plan option within Medicare, now enrolls more than half of all beneficiaries and is projected to keep expanding. The American College of Physicians (ACP) assesses the ethical and policy dimensions of this growth and its implications for the delivery of fair, high-quality, and fiscally responsible care to older adults and persons with disabilities. Payment and risk adjustment policies have created vulnerabilities to overpayment and favorable risk selection, whereas quality measurement remains fragmented and overly complex. Beneficiaries often face challenges in navigating plan choice, marketing practices, prior authorization, and access to clinicians and postacute services, with these barriers disproportionately affecting persons with low income, persons with several chronic conditions, or persons who live in rural communities. Limited transparency about ownership structures and relationships between insurers, “provider” networks, and investors complicates accountability and public oversight. ACP calls for reforms to ensure accurate payment, streamline and strengthen quality metrics, and protect enrollees from inappropriate utilization controls while supporting innovations that promote coordinated, patient-centered care. Collaborative engagement among policymakers, clinicians, health systems, insurers, and beneficiaries is essential to align MA with its original purpose and ensure that it complements traditional Medicare while providing accessible, affordable, and high-quality coverage for all who depend on it.

New GRADE Evidence-to-Decision Framework for Pairwise and Multiple Comparisons (GRADE Guidance 45)

Evidence-based decision making in health often requires comparison of multiple options for a given condition. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) evidence-to-decision (EtD) framework provides a structured approach for moving from evidence to decisions but was originally designed for pairwise comparisons. Hence, there is a need to accommodate decision making based on multiple comparisons, especially with the increasing use of systematic reviews and network meta-analyses in guideline development. Furthermore, since the original EtD framework was developed, further relevant GRADE guidance has been developed. The aim of this work was to develop a new EtD framework to accommodate multiple comparisons and reflect current GRADE guidance. The new EtD framework was revised and developed through iterative discussion, feedback, and refinement by the GRADE EtD Project Group and the GRADE Working Group. Experiences and examples from guideline developers, methodological experts, and other stakeholders informed improvements in its structure and usability for multiple comparisons and were subsequently approved by the GRADE Working Group. This article describes the new EtD framework, which now includes 2 corresponding parts for reviews of pairwise and multiple comparisons. The authors describe application to a review with multiple comparisons for the different parts of the EtD framework: the question definition, which now includes the presentation of values of health outcomes and decision thresholds; the assessment section, where the new “net effect” criterion has been included; and the conclusion section, which includes an adaptation for multiple comparisons. The article provides examples and suggestions for presentation of findings. The framework does have limitations, in that its usability has not been tested across a broad spectrum of guideline development contexts.

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