How Would You Manage This Patient With Decreased Bone Density? Grand Rounds Discussion From Beth Israel Deaconess Medical Center

Osteoporosis is a skeletal condition characterized by low bone mass and fragility resulting in an increased risk for fracture. It affects all bones, but fractures most often occur in the hip and spine. Osteoporosis is common in postmenopausal women, with estrogen deficiency thought to be a major contributing factor. Screening for osteoporosis with bone densitometry is recommended in all women 65 years of age or older and in postmenopausal women younger than 65 who are at increased risk. In 2023, the American College of Physicians published updated guidance on the pharmacologic treatment of osteoporosis. Among the recommendations was for clinicians to take an individualized approach regarding whether to start treatment with a bisphosphonate in women older than 65 years with osteopenia (a lesser degree of bone loss) to reduce the risk for fractures. Here, 2 bone endocrinologists debate how to manage a patient with both osteopenia and osteoporosis on bone densitometry. They discuss how to interpret and address these findings.

Long-Term Mpox Sequelae 11 to 18 Months After Acute Illness: A Cohort Study in Two U.S. Cities: Annals of Internal Medicine: Vol 179, No 3

Background: Little was known about persistent sequelae of mpox before the 2022 multinational clade II mpox virus outbreak. Objective: To characterize post-mpox sequelae 11 to 18 months after acute mpox diagnosis and compare outbreak-associated psychosocial and behavioral impact between at-risk persons who had or did not have mpox. Design: Cohort study. Setting: New York City, New York, and Houston, Texas. Participants: Adults attending HIV, pre-exposure prophylaxis, or sexually transmitted infection clinics diagnosed with mpox during May 2022 to January 2023 (post-mpox) or at risk for but never diagnosed with mpox (no-mpox). Measurements: All participants completed psychosocial and behavioral self-assessments. A clinician also assessed post-mpox participants by clinical history and physical examination; persisting mpox physical sequelae were classified by tissue affected and effect on appearance or function. Associations between post-mpox physical sequelae and medical history, acute mpox severity, and sociodemographic characteristics were assessed using marginally adjusted probabilities (presented as risk ratios with 95% CIs). Results: A total of 154 post-mpox and 201 no-mpox participants were enrolled. The proportion of participants reporting increased psychobehavioral symptoms was generally similar between groups. Fifty-eight percent (89 of 154) of post-mpox participants had at least 1 persistent sequela; 56% (86 of 154) were appearance related, of which 51% (44 of 86) occurred at 2 or fewer sites. Thirteen percent (20 of 154) of post-mpox participants had functional sequelae, of whom 50% (10 of 20) and 35% (7 of 20) had ongoing anorectal and urinary dysfunction, respectively. Limitations: Participants may not be representative of mpox-affected and susceptible populations. Findings may over- or underestimate frequency or severity of severe mpox sequelae. Conclusion: Post-mpox sequelae frequently persisted 11 to 18 months after acute mpox, with limited body distribution or physical morbidity but with continued social and sexual effects. Primary Funding Source: Centers for Disease Control and Prevention.

High-Concentration Delta-9-Tetrahydrocannabinol Cannabis Products and Mental Health Outcomes: A Systematic Review: Annals of Internal Medicine: Vol 178, No 10

Background: Rapid changes in the legalized cannabis market have led to the predominance of high-concentration delta-9-tetrahydrocannabinol (THC) cannabis products. Purpose: To systematically review associations of high-concentration THC cannabis products with mental health outcomes. Data Sources: Ovid MEDLINE through May 2025; EMBASE, Allied and Complementary Medicine Database, Cochrane Library, Database of Abstracts of Reviews of Effects, CINAHL, and Toxicology Literature Online through August 2024. Study Selection: Two reviewers independently selected studies with high-concentration THC defined as greater than 5 mg or greater than 10% THC per serving or labeled as “high-potency concentrate,” “shatter,” or “dab.” Data Extraction: Outcomes included anxiety, depression, psychosis or schizophrenia, and cannabis use disorder (CUD). Results were categorized by association direction and by study characteristics. Therapeutic studies were defined by use of cannabis to treat medical conditions or symptoms. Data Synthesis: Ninety-nine studies (221 097 participants) were included: randomized trials (42%), observational studies (47%), and other interventional study designs (11%); more than 95% had moderate or high risk of bias. In studies not testing for therapeutic effects, high-concentration THC products showed consistent unfavorable associations with psychosis or schizophrenia (70%) and CUD (75%). No therapeutic studies reported favorable results for psychosis or schizophrenia. For anxiety and depression, 53% and 41% of nontherapeutic studies, respectively, reported unfavorable associations, especially among healthy populations. Among therapeutic studies, nearly half found benefits for anxiety (47%) and depression (48%), although some also found unfavorable associations (24% and 30%, respectively). Limitation: Moderate and high risk of bias of individual studies and limited evaluation of contemporary products. Conclusion: High-concentration THC products are associated with unfavorable mental health outcomes, particularly for psychosis or schizophrenia and CUD. There was some low-quality evidence, inconsistent by population, for therapeutic benefits for anxiety and depression. Primary Funding Source: Colorado General Assembly, House Bill 21-1317.

Benefits and Harms of Pharmacologic Treatments in Adults With Overweight or Obesity: A Living Systematic Review and Network Meta-analysis for the American College of Physicians

Background: Overweight and obesity are closely linked to diseases such as type 2 diabetes, coronary heart disease, and stroke and have been shown to increase mortality risk. Purpose: To conduct a living systematic review of pharmacologic treatments for weight management in overweight or obesity in adults. Data Sources: MEDLINE and Cochrane Central Register of Controlled Trials until October 2025. Study Selection: Randomized controlled trials that compared pharmacologic treatments for weight management (dulaglutide, exenatide, liraglutide, lixisenatide, naltrexone–bupropion, orforglipron, phentermine, phentermine–topiramate, retatrutide, semaglutide, semaglutide–cagrilintide, tirzepatide, or any combination with or without lifestyle intervention [LI]) for overweight or obesity (body mass index ≥25 kg/m2) in adults for outcomes such as mortality, weight loss, and quality of life. Data Extraction: One reviewer extracted data and assessed risk of bias and certainty of the evidence; a second reviewer verified these data. Data Synthesis: The review included 69 studies with a total of 112 511 participants. Thirty-seven studies were at low risk of bias. In meta-analyses, nearly all studied interventions were more effective than placebo and/or LI in reducing weight, but more discontinuations due to adverse events were observed. Semaglutide probably reduced mortality and major adverse cardiovascular events (MACE), and both semaglutide and tirzepatide led to the greatest weight loss compared with placebo and/or LI in pairwise and network meta-analyses. Evidence for outcomes such as mortality, MACE, and serious adverse events was limited. Limitation: Direct head-to-head comparisons of different treatments were limited. Conclusion: Nearly all studied interventions were more effective than placebo and/or LI in reducing weight. Semaglutide and tirzepatide showed the most favorable results across outcomes. Primary Funding Source: American College of Physicians. (PROSPERO: CRD42023491646)

Annals for Hospitalists - December 2024

Hemochromatosis

Hemochromatosis is an inheritable condition that mainly affects White populations of European descent. Most patients remain asymptomatic, but others develop advanced organ damage that reduces quality of life and long-term survival. Arthropathy, diabetes mellitus, cirrhosis, hypogonadotropic hypogonadism, and cardiomyopathy are key clinical manifestations. Primary care and hospital medicine physicians play an essential role in early identification of this disease, which can be accomplished via standard hematologic testing. Early diagnosis and therapeutic phlebotomy improve clinical outcomes.

Optimizing Ethical Care, Quality, and Safety in Long-Term Services and Supports: A Position Paper From the American College of Physicians

Long-term services and supports (LTSS) in the United States have faced substantial and enduring challenges. They encompass services for persons who can no longer independently care for themselves because of cognitive decline, functional limitations, chronic illness, or the sequelae of such conditions. These services are delivered in institutional and noninstitutional settings, such as nursing homes, assisted living facilities, and home- and community-based programs. This position paper by the American College of Physicians examines the ethical implications of current LTSS business models and practices and their effect on vulnerable persons receiving care in these settings. These models and practices include approaches to staffing, resource allocation, health equity, and attention to patient preferences and patient-centered care, as well as business strategies that focus on profit rather than patient care and ownership structures that can lack transparency and hinder accountability. Addressing these challenges necessitates a collaborative approach among policymakers, health care systems, researchers, physicians and other health care professionals, LTSS facility and agency owners, patients, and caregivers. By embracing shared goals through a collaborative approach, an LTSS system can be cultivated that optimizes ethical care, quality, and safety, ensuring respect for all individuals across their lifespan.

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.

The Rise of Psilocybin Use in the United States: A Multisource Observational Study