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Background: Pregnant women may be at increased risk for severe influenza-associated outcomes. Objective: To describe characteristics and outcomes of hospitalized pregnant women with influenza. Design: Repeated cross-sectional study. Setting: The population-based U.S. Influenza Hospitalization Surveillance Network during the 2010–2011 through 2018–2019 influenza seasons. Patients: Pregnant women (aged 15 to 44 years) hospitalized with laboratory-confirmed influenza identified through provider-initiated or facility-based testing practices. Measurements: Clinical characteristics, interventions, and in-hospital maternal and fetal outcomes were obtained through medical chart abstraction. Multivariable logistic regression was used to evaluate the association between influenza A subtype and severe maternal influenza-associated outcomes, including intensive care unit (ICU) admission, mechanical ventilation, extracorporeal membrane oxygenation, or in-hospital death. Results: Of 9652 women aged 15 to 44 years and hospitalized with influenza, 2690 (27.9%) were pregnant. Among the 2690 pregnant women, the median age was 28 years, 62% were in their third trimester, and 42% had at least 1 underlying condition. Overall, 32% were vaccinated against influenza and 88% received antiviral treatment. Five percent required ICU admission, 2% required mechanical ventilation, and 0.3% (n = 8) died. Pregnant women with influenza A H1N1 were more likely to have severe outcomes than those with influenza A H3N2 (adjusted risk ratio, 1.9 [95% CI, 1.3 to 2.8]). Most women (71%) were still pregnant at hospital discharge. Among 754 women who were no longer pregnant at discharge, 96% had a pregnancy resulting in live birth, and 3% experienced fetal loss. Limitation: Maternal and fetal outcomes that occurred after hospital discharge were not captured. Conclusion: Over 9 influenza seasons, one third of reproductive-aged women hospitalized with influenza were pregnant. Influenza A H1N1 was associated with more severe maternal outcomes. Pregnant women remain a high-priority target group for vaccination. Primary Funding Source: Centers for Disease Control and Prevention.

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.

Estimation of Breast Cancer Overdiagnosis in a U.S. Breast Screening Cohort

Background: Mammography screening can lead to overdiagnosis—that is, screen-detected breast cancer that would not have caused symptoms or signs in the remaining lifetime. There is no consensus about the frequency of breast cancer overdiagnosis. Objective: To estimate the rate of breast cancer overdiagnosis in contemporary mammography practice accounting for the detection of nonprogressive cancer. Design: Bayesian inference of the natural history of breast cancer using individual screening and diagnosis records, allowing for nonprogressive preclinical cancer. Combination of fitted natural history model with life-table data to predict the rate of overdiagnosis among screen-detected cancer under biennial screening. Setting: Breast Cancer Surveillance Consortium (BCSC) facilities. Participants: Women aged 50 to 74 years at first mammography screen between 2000 and 2018. Measurements: Screening mammograms and screen-detected or interval breast cancer. Results: The cohort included 35 986 women, 82 677 mammograms, and 718 breast cancer diagnoses. Among all preclinical cancer cases, 4.5% (95% uncertainty interval [UI], 0.1% to 14.8%) were estimated to be nonprogressive. In a program of biennial screening from age 50 to 74 years, 15.4% (UI, 9.4% to 26.5%) of screen-detected cancer cases were estimated to be overdiagnosed, with 6.1% (UI, 0.2% to 20.1%) due to detecting indolent preclinical cancer and 9.3% (UI, 5.5% to 13.5%) due to detecting progressive preclinical cancer in women who would have died of an unrelated cause before clinical diagnosis. Limitations: Exclusion of women with first mammography screen outside BCSC. Conclusion: On the basis of an authoritative U.S. population data set, the analysis projected that among biennially screened women aged 50 to 74 years, about 1 in 7 cases of screen-detected cancer is overdiagnosed. This information clarifies the risk for breast cancer overdiagnosis in contemporary screening practice and should facilitate shared and informed decision making about mammography screening. Primary Funding Source: National Cancer Institute.

Race/Ethnicity Trends Among U.S. Internal Medicine Residency Applicants and Matriculants: A Cross-Sectional Study

Selecting Treatments During an Infectious Disease Pandemic: Chasing the Evidence

Financial Profit: Not the Mission of Medicine

The Future of Medical Guidelines: Standardizing Clinical Care With the Humility of Uncertainty

Risk for Shoulder Conditions After Vaccination: A Population-Based Study Using Real-World Data

Background: Although shoulder conditions have been reported as an adverse event after intramuscular vaccination in the deltoid muscle, epidemiologic data on shoulder conditions after vaccination are limited. Objective: To estimate the risk for shoulder conditions after vaccination and assess possible risk factors. Design: Retrospective cohort study. Setting: Kaiser Permanente Southern California, a large integrated health care organization. Participants: Kaiser Permanente Southern California members aged 3 years or older who had an intramuscular vaccination administered in the deltoid muscle between 1 April 2016 and 31 December 2017. Measurements: A natural language processing (NLP) algorithm was used to identify potential shoulder conditions among vaccinated persons with shoulder disorder diagnosis codes. All NLP-identified cases were manually chart confirmed on the basis of our case definition. The characteristics of vaccinated persons with and without shoulder conditions were compared. Results: Among 3 758 764 administered vaccinations, 371 cases of shoulder condition were identified, with an estimated incidence of 0.99 (95% CI, 0.89 to 1.09) per 10 000 vaccinations. The incidence was 1.22 (CI, 1.10 to 1.35) for the adult (aged ≥18 years) and 0.05 (CI, 0.02 to 0.14) for the pediatric (aged 3 to 17 years) vaccinated populations. In the adult vaccinated population, advanced age, female sex, an increased number of outpatient visits in the 6 months before vaccination, lower Charlson Comorbidity Index, and pneumococcal conjugate vaccine were associated with a higher risk for shoulder conditions. Among influenza vaccines, quadrivalent vaccines were associated with an increased risk for shoulder conditions. Simultaneous administration of vaccines was associated with a higher risk for shoulder conditions among elderly persons. Limitation: Generalizability to other health care settings, use of administrative data, and residual confounding. Conclusion: These population-based data suggest a small absolute risk for shoulder conditions after vaccination. Given the high burden of shoulder conditions, clinicians should pay attention to any factors that may further increase risks. Primary Funding Source: Centers for Disease Control and Prevention.

Risk for Recurrent Venous Thromboembolism in Patients With Subsegmental Pulmonary Embolism Managed Without Anticoagulation: A Multicenter Prospective Cohort Study: Annals of Internal Medicine: Vol 175, No 1

Background: The incidence of pulmonary embolism has been increasing, but its case-fatality rate is decreasing, suggesting a lesser severity of illness. The clinical importance of patients with pulmonary embolism isolated to the subsegmental vessels is unknown. Objective: To determine the rate of recurrent venous thromboembolism in patients with subsegmental pulmonary embolism managed without anticoagulation. Design: Multicenter prospective cohort study. (ClinicalTrials.gov: NCT01455818) Setting: Eighteen sites between February 2011 and February 2021. Patients: Patients with isolated subsegmental pulmonary embolism. Intervention: At diagnosis, patients underwent bilateral lower-extremity venous ultrasonography, which was repeated 1 week later if results were negative. Patients without deep venous thrombosis did not receive anticoagulant therapy. Measurements: The primary outcome was recurrent venous thromboembolism during the 90-day follow-up period. Results: Recruitment was stopped prematurely because the predefined stopping rule was met after 292 of a projected 300 patients were enrolled. Of the 266 patients included in the primary analysis, the primary outcome occurred in 8 patients, for a cumulative incidence of 3.1% (95% CI, 1.6% to 6.1%) over the 90-day follow-up. The incidence of recurrent venous thromboembolism was 2.1% (CI, 0.8% to 5.5%) and 5.7% (CI, 2.2% to 14.4%) over the 90-day follow-up in patients with single and multiple isolated subsegmental pulmonary embolism, respectively. No patients had a fatal recurrent pulmonary embolism. Limitation: The study was restricted to patients with low-risk subsegmental pulmonary embolism. Conclusion: Overall, patients with subsegmental pulmonary embolism who did not have proximal deep venous thrombosis had a higher-than-expected rate of recurrent venous thromboembolism. Primary Funding Source: Heart and Stroke Foundation of Canada and French Ministry of Health Programme Hospitalier de Recherche Clinique.

Assessing COVID-19 Prevention Strategies to Permit the Safe Opening of Residential Colleges in Fall 2021

Background: Effective vaccines, improved testing technologies, and decreases in COVID-19 incidence prompt an examination of the choices available to residential college administrators seeking to safely resume in-person campus activities in fall 2021. Objective: To help college administrators design and evaluate customized COVID-19 safety plans. Design: Decision analysis using a compartmental epidemic model to optimize vaccination, testing, and other nonpharmaceutical interventions depending on decision makers' preferences, choices, and assumptions about epidemic severity and vaccine effectiveness against infection, transmission, and disease progression. Setting: U.S. residential colleges. Participants: Hypothetical cohort of 5000 persons (students, faculty, and staff) living and working in close proximity on campus. Measurements: Cumulative infections over a 120-day semester. Results: Under base-case assumptions, if 90% coverage can be attained with a vaccine that is 85% protective against infection and 25% protective against asymptomatic transmission, the model finds that campus activities can be resumed while holding cumulative cases below 5% of the population without the need for routine, asymptomatic testing. With 50% population coverage using such a vaccine, a similar cap on cumulative cases would require either daily asymptomatic testing of unvaccinated persons or a combination of less frequent testing and resumption of aggressive distancing and other nonpharmaceutical prevention policies. Colleges returning to pre–COVID-19 campus activities without either broad vaccination coverage or high-frequency testing put their campus population at risk for widespread viral transmission. Limitation: Uncertainty in data, particularly vaccine effectiveness (preventive and transmission); no distinguishing between students and employees; and assumes limited community intermixing. Conclusion: Vaccination coverage is the most powerful tool available to residential college administrators seeking to achieve a safe return to prepandemic operations this fall. Given the breadth of potential outcomes in the face of uncontrollable and uncertain factors, even colleges with high vaccination rates should be prepared to reinstitute or expand testing and distancing policies on short notice. Primary Funding Source: National Institute on Drug Abuse.

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