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Displaying 71 - 80 of 251 in Policy Library
Displaying 71 - 80 of 1474 in Annals of Internal Medicine
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Effect of Four Hemoglobin Transfusion Threshold Strategies in Patients With Acute Myocardial Infarction and Anemia: A Target Trial Emulation Using MINT Trial Data: Annals of Internal Medicine: Vol 177, No 11
Background: The optimal hemoglobin threshold to guide red blood cell (RBC) transfusion for patients with acute myocardial infarction (MI) and anemia is uncertain. Objective: To estimate the efficacy of 4 individual hemoglobin thresholds (<10 g/dL [<100 g/L], <9 g/dL [<90 g/L], <8 g/dL [<80 g/L], and <7 g/dL [<70 g/L]) to guide transfusion in patients with acute MI and anemia. Design: Prespecified secondary analysis of the MINT (Myocardial Ischemia and Transfusion) trial using target trial emulation methods. (ClinicalTrials.gov: NCT02981407) Setting: 144 clinical sites in 6 countries. Participants: 3492 MINT trial participants with acute MI and a hemoglobin level below 10 g/dL. Intervention: Four transfusion strategies to maintain patients’ hemoglobin concentrations at or above thresholds of 10, 9, 8, or 7 g/dL. Protocol exceptions were permitted for specified adverse clinical events. Measurements: Data from the MINT trial were leveraged to emulate 4 transfusion strategies and estimate per protocol effects on the composite outcome of 30-day death or recurrent MI (death/MI) and 30-day death using inverse probability weighting. Results: The 30-day risk for death/MI was 14.8% (95% CI, 11.8% to 18.4%) for a <10-g/dL strategy, 15.1% (CI, 11.7% to 18.2%) for a <9-g/dL strategy, 15.9% (CI, 12.4% to 19.0%) for a <8-g/dL strategy, and 18.3% (CI, 14.6% to 22.0%) for a <7-g/dL strategy. Absolute risk differences and risk ratios relative to the <10-g/dL strategy for 30-day death/MI increased as thresholds decreased, although 95% CIs were wide. Findings were similar and imprecise for 30-day death. Limitation: Unmeasured confounding may have persisted despite adjustment. Conclusion: The 30-day risks for death/MI and death among patients with acute MI and anemia seem to increase progressively with lower hemoglobin concentration thresholds for transfusion. However, the imprecision around estimates from this target trial analysis precludes definitive conclusions about individual hemoglobin thresholds. Primary Funding Source: National Heart, Lung, and Blood Institute.
Critical Care: What You May Have Missed in 2023
Critical care medicine is a specialty that brings together a truly wide spectrum of patient populations, disease states, and treatment methods. This article highlights 10 important pieces of research from 2023 (and 1 from 2022) in critical care. The literature was screened for new evidence relevant to internal medicine physicians and hospitalists whose focus of practice is not critical care but who may be taking care of seriously ill patients. The articles highlight the diverse spectrum of pathology and interplay of various specialties that go into critical care. Topics include transfusion medicine, fluid resuscitation, safe intubation practices and respiratory failure, and the management of acute ischemic stroke. Several trials are groundbreaking, forcing clinicians to reconsider preexisting dogma and likely adopt new treatment strategies.
Oncology: What You May Have Missed in 2023
Advances in oncology treatment methods have improved outcomes and quality of life for patients with cancer. However, care of these patients can be complex, and the contribution of physicians from different specialties is crucial. This article highlights important publications from 2023 on topics across a wide spectrum relating to the management of oncology patients. The literature was screened for significant new evidence that is relevant to internal medicine specialists and subspecialists whose focus is not oncology. Two articles address the importance of social interventions targeting end-of-life care for low-income and minority patients and the well-being of caregivers. Two additional articles address screening considerations in patients at risk for colorectal and lung cancer. Two more articles address safe use of hormone-related therapies to treat symptoms of menopause and prevent disease recurrence or progression in patients diagnosed with noninvasive breast neoplasia. Finally, several articles were included on topics related to COVID-19 vaccination in patients with cancer, use of cannabinoids for cancer pain control, chronic autoimmune adverse effects related to use of immune checkpoint inhibitors, and the incidence of second primary neoplasms.
Factors Associated With Recurrent Pediatric Firearm Injury: A 10-Year Retrospective Cohort Analysis: Annals of Internal Medicine: Vol 177, No 10
Background: Firearm injuries are the leading cause of death among children aged 0 to 17 years in the United States. Objective: To examine the factors associated with recurrent firearm injury among children who presented with acute (index) nonfatal firearm injury in the St. Louis region. Design: Multicenter, observational, cohort study. Setting: 2 adult and 2 pediatric level I trauma hospitals in St. Louis, Missouri. Participants: Pediatric patients aged 0 to 17 years presenting with an index firearm injury between 2010 and 2019. Measurements: From the St. Louis Region-Wide Hospital-Based Violence Intervention Program Data Repository, we collected data on firearm-injured patient demographics, hospital and diagnostic information, health insurance status, and mortality. The Social Vulnerability Index was used to characterize the social vulnerability of the census tracts of patients’ residences. Analysis included descriptive statistics and time-to-event analyses estimating the cumulative incidence of experiencing a recurrent firearm injury. Results: During the 10-year study period, 1340 children presented with an index firearm injury. Most patients were Black (87%), non-Hispanic (99%), male (84%), and between the ages of 15 and 17 years (67%). The estimated risk for firearm reinjury was 6% at 1 year and 14% at 5 years after initial injury. Male children and those seen at an adult hospital were at increased risk for reinjury. Limitation: Our data set does not account for injuries occurring outside of the study period and for reinjuries presenting to nonstudy hospitals. Conclusion: Children who experience an initial firearm injury are at high risk for experiencing a recurrent firearm injury. Interventions are needed to reduce reinjury and address inequities in the demographic and clinical profiles within this cohort of children. Primary Funding Source: National Institutes of Health.
Glucagon-Like Peptide-1 Receptor Agonists and Risk for Suicidal Ideation and Behaviors in U.S. Older Adults With Type 2 Diabetes: A Target Trial Emulation Study: Annals of Internal Medicine: Vol 177, No 8
Background: A major concern has recently emerged about a potential link between glucagon-like peptide-1 receptor agonists (GLP-1 RAs) and increased risk for suicidal ideation and behaviors based on International Classification of Diseases codes. Objective: To investigate the association between GLP-1 RAs, compared with sodium–glucose cotransporter-2 inhibitors (SGLT2is) or dipeptidyl peptidase-4 inhibitors (DPP4is), and risk for suicidal ideation and behaviors in older adults with type 2 diabetes (T2D). Design: Two target trial emulation studies comparing propensity score (PS)–matched cohorts for GLP-1 RAs versus SGLT2is and GLP-1 RAs versus DPP4is. Setting: U.S. national Medicare administrative data from January 2017 to December 2020. Patients: Older adults (≥66 years) with T2D; no record of suicidal ideation or behaviors; and a first prescription for a GLP-1 RA, SGLT2i, or DPP4i. Measurements: The primary end point was a composite of suicidal ideation and behaviors. New GLP-1 RA users were matched 1:1 on PS to new users of an SGLT2i or DPP4i in each pairwise comparison. A Cox proportional hazards regression was used to estimate the hazard ratio (HR) and 95% CIs within matched groups. Results: This study included 21 807 pairs of patients treated with a GLP-1 RA versus an SGLT2i and 21 402 pairs of patients treated with a GLP-1 RA versus a DPP4i. The HR of suicidal ideation and behaviors associated with GLP-1 RAs relative to SGLT2is was 1.07 (95% CI, 0.80 to 1.45; rate difference, 0.16 [CI, −0.53 to 0.86] per 1000 person-years); the HR relative to DPP4is was 0.94 (CI, 0.71 to 1.24; rate difference, −0.18 [CI, −0.92 to 0.57] per 1000 person-years). Limitations: Low event rate; imprecise estimates; unmeasured confounders, such as body mass index; and potential misclassification of outcomes. Conclusion: Among Medicare beneficiaries with T2D, this study found no clear increased risk for suicidal ideation and behaviors with GLP-1 RAs, although estimates were imprecise and a modest adverse risk could not be ruled out. Primary Funding Source: American Foundation for Pharmaceutical Education, Pharmaceutical Research and Manufacturers of America Foundation, National Institute on Aging, and National Institute of Diabetes and Digestive and Kidney Diseases.
How Would You Manage HIV Pre-exposure Prophylaxis in This Patient With Medical Comorbidities?: Grand Rounds Discussion From Beth Israel Deaconess Medical Center: Annals of Internal Medicine: Vol 177, No 4
Despite advances in treatment, HIV infection remains an important cause of morbidity and mortality, with more than 30 000 new cases diagnosed in the United States each year. There are several interventions traditionally used to prevent HIV transmission, but these vary in effectiveness and there are challenges to their implementation. In 2014, the Centers for Disease Control and Prevention published initial guidance on the use of antiretroviral pre-exposure prophylaxis (PrEP) to prevent transmission of HIV infection in persons at risk based on multiple studies that showed it to be highly efficacious in various populations. It was updated in 2021 to reflect new drug options. The U.S. Preventive Services Task Force also recently updated its recommendations for PrEP, which strongly support its use in persons at risk. Despite its well-established effectiveness, the implementation of PrEP in clinical practice has been variable, especially among populations underserved by the medical system and marginalized by society. Fewer than one third of persons in the United States who are eligible for PrEP currently receive it. Here, 2 physicians experienced in HIV PrEP debate how best to identify patients who might benefit from PrEP, how to decide what regimen to use, and how to monitor therapy.
Extracorporeal Shock-Wave Lithotripsy and Endoscopy for the Treatment of Pain in Chronic Pancreatitis: A Sham-Controlled, Randomized Trial: Annals of Internal Medicine: Vol 177, No 6
Background: No randomized controlled trials have substantiated endoscopic decompression of the pancreatic duct in patients with painful chronic pancreatitis. Objective: To investigate the pain-relieving effect of pancreatic duct decompression in patients with chronic pancreatitis and intraductal stones. Design: 24-week, parallel-group, randomized controlled trial (ClinicalTrials.gov: NCT03966781) Setting: Asian Institute of Gastroenterology in India from February 2021 to July 2022. Participants: 106 patients with chronic pancreatitis. Intervention: Combined extracorporeal shock-wave lithotripsy (ESWL) and endoscopic retrograde pancreatography (ERP) compared with sham procedures. Measurements: The primary end point was pain relief on a 0- to 10-point visual analog scale (VAS) at 12 weeks. Secondary outcomes were assessed after 12 and 24 weeks and included 30% pain relief, opioid use, pain-free days, questionaries, and complications to interventions. Results: 52 patients in the ESWL/ERP group and 54 in the sham group were included. At 12 weeks, the ESWL/ERP group showed better pain relief compared with the sham group (mean difference in change, −0.7 [95% CI, −1.3 to 0] on the VAS; P = 0.039). The difference between groups was not sustained at the 24-week follow-up, and no differences were seen for 30% pain relief at 12- or 24-week follow-up. The number of pain-free days was increased (median difference, 16.2 days [CI, 3.9 to 28.5 days]), and the number of days using opioids was reduced (median difference, −5.4 days [CI, −9.9 to −0.9 days]) in the ESWL/ERP group compared with the sham group at 12-week follow-up. Safety outcomes were similar between groups. Limitation: Single-center study and limited duration of follow-up. Conclusion: In patients with chronic pancreatitis and intraductal stones, ESWL with ERP provided modest short-term pain relief. Primary Funding Source: Asian Institute of Gastroenterology and Aalborg University Hospital.
Displaying 71 - 75 of 75 in Annals of Internal Medicine: Clinical Cases
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.
Sarcomatoid Carcinoma of the Colon in a 46-Year-Old: A Rare Disease With Limited Literature | Annals of Internal Medicine: Clinical Cases
Sarcomatoid carcinoma (SCA) is an extremely aggressive, rare malignancy composed of mixed epithelial and mesenchymal components. Fewer than 10 cases of SCA of primary colonic origin have been reported in the literature. SCA has a poor prognosis. Currently, there is limited consensus regarding treatment recommendations. We review the current literature and present the case of a 46-year-old man with stage 3c sigmoid sarcomatoid carcinoma who presented with 3 months of abdominal distension, weight loss, and abdominal mass. The patient had a sigmoid colectomy with adjuvant chemotherapy and is currently alive at 8 months.
Spontaneous Ectopic Paraumbilical Variceal Bleeding in a Patient With Cirrhosis | Annals of Internal Medicine: Clinical Cases
Ectopic variceal hemorrhage is a rare sequela of portal hypertension, accounting for 5% of variceal bleeding events. Although mortality rates are high for this condition, there is no established management protocol. We present a patient case of spontaneous external hemorrhage from an ectopic paraumbilical varicosity in the setting of portal hypertension secondary to decompensated alcoholic cirrhosis that was treated effectively with transjugular intrahepatic portosystemic shunt placement.
Hyperplastic Polyps Discovered Because of Unprovoked Acute Upper Gastrointestinal Bleeding as an Unusual Presentation of Malignancy | Annals of Internal Medicine: Clinical Cases
Gastric hyperplastic polyps are small (<1 cm), asymptomatic, and found incidentally on esophagogastroduodenoscopy. Patients can present with dyspepsia, abdominal pain, anemia from chronic occult bleeding, and, rarely, acute upper gastrointestinal bleeding. Helicobacter pylori, autoimmune gastritis, and long-term use of proton-pump inhibitors can increase the risk for hyperplastic polyps. Dysplasia and carcinoma in the surrounding gastric mucosa with concomitant hyperplastic polyps can be seen but carcinoma and dysplasia within the hyperplastic polyp itself are extremely rare. We report on a 70-year-old White woman who presented with melena from what appeared to be hyperplastic polyps on esophagogastroduodenoscopy, but pathology reported frank intramucosal adenocarcinoma.