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Displaying 211 - 220 of 432 in Annals of Internal Medicine
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Proprotein Convertase Subtilisin/Kexin Type 9 Monoclonal Antibodies for Acute Coronary Syndrome: A Narrative Review: Annals of Internal Medicine: Vol 164, No 9
Monoclonal antibodies that inhibit proprotein convertase subtilisin/kexin type 9 (PCSK9) are an emerging therapy for dyslipidemia. Acute coronary events induce a dynamic increase of PCSK9 levels that may play a role in plaque vulnerability of both culprit and nonculprit coronary vessels. Growing evidence highlights a potential key role of PCSK9 antibodies in managing acute coronary syndrome. This review describes the influence of PCSK9 antibodies on plaque composition and instability, as well as the pharmacokinetic profile and the potential anti-inflammatory and antithrombotic mechanisms associated with PCSK9 inhibition that may confer benefits during the early phase of acute coronary syndrome. The authors posit a rationale for the use of PCSK9 antibodies in patients with acute coronary syndrome and highlight the need for further investigation in this area.
Should We Screen for Coronary Heart Disease in Asymptomatic Persons?: Grand Rounds Discussion From Beth Israel Deaconess Medical Center: Annals of Internal Medicine: Vol 164, No 7
In March 2015, the American College of Physicians (ACP) released a clinical guideline on the value of screening for coronary heart disease (CHD) in asymptomatic persons. The guideline authors found that results of screening studies are unlikely to change patient management or the intensity of risk factor reduction strategies. Most events occur in patients who are at low to intermediate risk for CHD; and in low-risk asymptomatic patients, percutaneous coronary intervention in “screen-positive” patients does not improve outcomes and creates unnecessary risks. As a result, the ACP recommended against screening for asymptomatic patients who are at low risk for CHD. Instead, it recommended a focus on proven strategies, such as treatment of hypertension and hypercholesterolemia, to reduce risk in appropriately selected asymptomatic persons. Two discussants weigh the evidence for and against screening for CHD in asymptomatic patients with varying degrees of risk and provide recommendations for a specific patient who is uncertain whether to proceed to screening.
Estimating the Effect of Hospital Admission on Health Care Outcomes and Spending Among Persons With Dementia: A Quasi-experimental Study: Annals of Internal Medicine: Vol 0, No 0
Background: Because transitions in care settings can be confusing for persons with dementia (PWD), hospital admissions can negatively affect their physical and cognitive function. However, the effect of hospital admissions on patient outcomes and health care spending remains largely unknown. Objective: To estimate the effects of hospital admissions on health outcomes and health care spending among PWD. Design: Quasi-experimental instrumental variable method, using emergency physicians’ admission propensity as the instrument. Setting: United States. Patients: Medicare fee-for-service beneficiaries aged 66 years or older with dementia who visited an emergency department (ED) in 2017 to 2019. Measurements: Death, inpatient days (excluding the index hospital admission), and health care spending (excluding the index ED visit and hospital admission) within 30 and 90 days of ED visits. Results: Among 872 085 ED visits (62.9% women; mean age, 83.1 years) included in the analysis, 482 208 (55.3%) resulted in hospital admission. There was no evidence that hospital admission was associated with 30-day mortality rate (adjusted risk difference, −2.6 percentage points [pp] [95% CI, −5.2 to 0.1 pp]) or inpatient days (adjusted difference, 0.1 days [CI, −0.2 to 0.5 days]). Hospital admission was associated with higher 30-day health care spending (adjusted difference, $2547 [CI, $1390 to $3703]). Patterns were similar for 90-day outcomes. Limitation: Residual confounding. Conclusion: Among Medicare beneficiaries with dementia who visited an ED, there was no evidence that hospital admission was associated with mortality rates. Under conventional statistical criteria, an effect of hospital admissions between a 5.2-pp decrease and a 0.1-pp increase in 30-day mortality rates was highly compatible with the data. On the contrary, hospital admission was associated with higher health care spending. Primary Funding Source: None.
Risk for Scrotal Surgery After Laparoscopic Donor Nephrectomy: A Population-Based Cohort Study: Annals of Internal Medicine: Vol 179, No 1
Background: A potential long-term complication of living kidney donation in male donors is scrotal swelling on the same side as the nephrectomy, and some undergo surgery to relieve discomfort from the fluid collection. The long-term risk for this outcome attributable to donation is unknown. Objective: To evaluate long-term scrotal surgery rates after laparoscopic nephrectomy in male living kidney donors compared with nondonors. Design: Population-based cohort study (2002 to 2024). (ClinicalTrials.gov: NCT06716723) Setting: Linked administrative health care databases in Ontario, Canada. Participants: 898 male living kidney donors who had a laparoscopic nephrectomy were matched in a 1:10 ratio with 8980 male nondonors from the general population. The matching characteristics were age, date of cohort entry, rural residence, income, prior vasectomy, and prior inguinal hernia repair. Participants were followed for a median of 9 years, up to 22 years. Measurements: The primary outcome was hospitalization for surgery to address a unilateral scrotal fluid collection. Results: Donors and matched nondonors had a median age of 45 years. The rate of scrotal surgery was higher in donors than nondonors (70 of 898 donors [7.8%] vs. 19 of 8980 nondonors [0.2%]; 8.3 vs. 0.2 events per 1000 person-years; hazard ratio, 38.8 [95% CI, 22.1 to 67.9]; P < 0.001). The median time from donation to scrotal surgery was 5.2 years (IQR, 3.3 to 8.4 years); more than 90% of the surgeries were hydrocelectomies and were performed under general anesthesia. Over 20 years, the cumulative incidence was 13.8% in donors versus 0.7% in nondonors. Limitation: The precise causal mechanism remains unknown. Conclusion: Laparoscopic nephrectomy is associated with a higher risk for subsequent scrotal surgery in male living kidney donors. Primary Funding Source: Canadian Institutes of Health Research.
The Prevalence and Characteristics of Difficult Patient Encounters: A Systematic Review and Meta-analysis: Annals of Internal Medicine: Vol 179, No 3
Background: Patients are sometimes experienced as difficult by their providers. Purpose: To estimate the prevalence of difficult patient encounters among adults being seen in nonpsychiatric settings. Secondary goals were to assess patient and provider characteristics associated with difficulty as well as patient outcomes. Data Sources: MEDLINE, Web of Science, SciELO, ProQuest, Theses, Scopus, PsycInfo, Cochrane Central Register of Controlled Trials, Global Index Medicus, and EMBASE (inception through 7 July 2025). Study Selection: In duplicate and independently. Data Extraction: Prevalence, patient characteristics (sex, mental health diagnosis, somatization, personality disorders, and chronic pain), provider characteristics (type of provider, encounter setting, burnout, years of experience, and sex), and encounter outcomes (patient unmet expectations and satisfaction) were extracted in duplicate. Data Synthesis: The prevalence of difficult encounters among clinic patients was 0.17 (95% CI, 0.15 to 0.19). Patient characteristics that increased difficulty included personality disorders (relative risk [RR], 2.2 [CI, 1.5 to 3.1]), depression (RR, 1.9 [CI, 1.7 to 2.2]), anxiety (RR, 2.1 [CI, 1.7 to 2.6]), and chronic pain (RR, 1.9 [CI, 1.5 to 2.4]). Providers with less experience (weighted mean difference, −3.5 years [CI, −5.0 to −1.9 years]) rated more encounters as difficult. Patients perceived as difficult were more likely to have unmet visit expectations (RR, 1.9 [CI, 1.4 to 2.5]) and lower satisfaction (RR, 0.76 [CI, 0.65 to 0.88]). Limitation: Limited data and heterogeneity for many secondary analyses. Conclusion: Providers perceived 17% of clinic patients as difficult. Patients perceived as difficult were more likely to have depression, anxiety, a greater number of symptoms, personality disorders, or chronic pain. Less experienced providers were more likely to judge patients as difficult. Patients from difficult encounters had more unmet visit expectations and less satisfaction. Primary Funding Source: None. (PROSPERO: CRD42024583715)
Impacts of Communication Type and Quality on Patient Safety Incidents: A Systematic Review: Annals of Internal Medicine: Vol 178, No 5
Background: Poor communication in health care increases the risk for patient safety incidents. However, there is no up-to-date synthesis of these data. Purpose: To synthesize studies investigating how poor communication between health care practitioners and patients (and between different groups of practitioners) affects patient safety. Data Sources: Ovid MEDLINE, CINAHL, APA PsycInfo, CENTRAL, Scopus, and the ProQuest Dissertations & Theses Citation Index from 1 January 2013 to 7 February 2024. Study Selection: Studies published in any language that quantified the effects of poor communication on patient safety. Data Extraction: Two independent reviewers extracted data, assessed risk of bias, and appraised strength of evidence. Study heterogeneity precluded meta-analysis, so results were reported with narrative description, reporting medians and interquartile ranges (IQRs). Data Synthesis: Forty-six eligible studies (67 826 patients) were included. Risk of bias was low for 20, moderate for 16, and high for 10 studies. Four studies investigated whether poor communication was the only identified cause of a patient safety incident; here, poor communication caused 13.2% (IQR, 6.1% to 24.4%) of safety incidents. Forty-two studies investigated whether poor communication contributed to patient safety incidents alongside other causes; here, poor communication contributed to 24.0% (IQR, 12.0% to 46.8%) of safety incidents. Study heterogeneity was high in terms of setting, continent, health care staff, and safety incident type. The strength of the evidence was low or very low. Limitation: There was important study heterogeneity, generally low study quality, and poor reporting of essential data. Conclusion: Poor communication is a major cause of patient safety incidents. Research is needed to develop effective interventions and to learn more about how poor communication leads to patient safety incidents. Primary Funding Source: Stoneygate Trust. (PROSPERO: CRD42024507578)
Association of Semaglutide With Tobacco Use Disorder in Patients With Type 2 Diabetes: Target Trial Emulation Using Real-World Data: Annals of Internal Medicine: Vol 177, No 8
Background: Reports of reduced desire to smoke in patients treated with semaglutide, a glucagon-like peptide receptor agonist (GLP-1RA) medication for type 2 diabetes mellitus (T2DM) and obesity, have raised interest about its potential benefit for tobacco use disorders (TUDs). Objective: To examine the association of semaglutide with TUD-related health care measures in patients with comorbid T2DM and TUD. Design: Emulation target trial based on a nationwide population-based database of patient electronic health records. Setting: United States, 1 December 2017 to 31 March 2023. Participants: Seven target trials were emulated among eligible patients with comorbid T2DM and TUD by comparing the new use of semaglutide versus 7 other antidiabetes medications (insulins, metformin, dipeptidyl-peptidase-4 inhibitors, sodium-glucose cotransporter-2 inhibitors, sulfonylureas, thiazolidinediones, and other GLP-1RAs). Measurements: The TUD-related health care measures (medical encounter for diagnosis of TUD, smoking cessation medication prescriptions, and smoking cessation counseling) that occurred within a 12-month follow-up were examined using Cox proportional hazards and Kaplan–Meier survival analyses. Results: The study compared 222 942 new users of antidiabetes medications including 5967 of semaglutide. Semaglutide was associated with a significantly lower risk for medical encounters for TUD diagnosis compared with other antidiabetes medications, and was strongest compared with insulins (hazard ratio [HR], 0.68 [95% CI, 0.63 to 0.74]) and weakest but statistically significant compared with other GLP-1RAs (HR, 0.88 [CI, 0.81 to 0.96]). Semaglutide was associated with reduced smoking cessation medication prescriptions and counseling. Similar findings were observed in patients with and without a diagnosis of obesity. For most of the group comparisons, the differences occurred within 30 days of prescription initiation. Limitation: Documentation bias, residual confounding, missing data on current smoking behavior, body mass index, and medication adherence. Conclusion: Semaglutide was associated with lower risks for TUD-related health care measures in patients with comorbid T2DM and TUD compared with other antidiabetes medications including other GLP-1Ras, primarily within 30 days of prescription. These findings suggest the need for clinical trials to evaluate semaglutide’s potential for TUD treatment. Primary Funding Source: National Institutes of Health.
Long-Term Effects of Individualized Acupuncture for Chronic Neck Pain: A Randomized Controlled Trial: Annals of Internal Medicine: Vol 177, No 10
Background: Long-term effects of individualized acupuncture in persons with chronic neck pain (CNP) remain unknown. Objective: To evaluate the efficacy and safety of pressure pain, sensory-based individualized acupuncture for relieving CNP. Design: A 24-week multicenter randomized controlled clinical trial. (ChiCTR1800016371) Setting: Outpatient settings at 4 clinical centers in China from May 2018 to March 2020. Participants: 716 participants with CNP. Intervention: Participants were randomly assigned to a waiting list (WL) group or to 1 of 3 interventions, which consisted of 10 sessions over 4 weeks: higher sensitive acupoints (HSA), lower sensitive acupoints (LSA), and sham acupoints (SA) acupuncture groups. Measurements: The primary outcome was the change in the visual analogue scale (VAS) score for neck pain (range, 0 to 100) from baseline to 4 weeks, with a difference of 10 points considered the minimum clinically important threshold. The VAS was also assessed every 4 weeks through 24 weeks. Results: The modified intention-to-treat population included 683 participants. The mean baseline VAS was 50.36, 50.10, 49.24, and 49.16 for HSA, LSA, SA, and WL, respectively. Compared with a mean baseline to week 4 change of −12.16 in the HSA group, the mean changes were −10.19 in the LSA group (net difference [ND], −1.97 [95% CI, −5.03 to 1.09]), −6.11 in the SA group (ND, −6.05 [CI, −9.10 to −3.00]), and −2.24 in the WL group (ND, −9.93 [CI, −12.95 to −6.90]). The intervention effects persisted at 24-week follow-up. Limitation: Lack of complete blinding and limited generalizability. Conclusion: Individualized acupuncture interventions using high- or low-sensitivity acupuncture points were more effective in reducing CNP than SA and WL control groups sustained through 24 weeks, but the magnitude of relative improvement did not reach a minimal clinically important difference. Primary Funding Source: National Natural Science Foundation of China.
The Effect of Practitioner Empathy on Patient Satisfaction: A Systematic Review of Randomized Trials: Annals of Internal Medicine: Vol 177, No 2
Background: Practitioners who deliver enhanced empathy may improve patient satisfaction with care. Patient satisfaction is associated with positive patient outcomes ranging from medication adherence to survival. Purpose: To evaluate the effect of health care practitioner empathy on patient satisfaction, using a systematic review of randomized trials. Data Sources: Ovid MEDLINE, CINAHL, PsycInfo, Cochrane Central Register of Controlled Trials, and Scopus to 23 October 2023. Study Selection: Randomized trials published in any language that evaluated the effect of empathy on improving patient satisfaction as measured on a validated patient satisfaction scale. Data Extraction: Data extraction, risk-of-bias assessments, and strength-of-evidence assessments were done by 2 independent reviewers. Disagreements were resolved through consensus. Data Synthesis: Fourteen eligible randomized trials (80 practitioners; 1986 patients) were included in the analysis. Five studies had high risk of bias, and 9 had some concerns about bias. The trials were heterogeneous in terms of geographic locations (North America, Europe, Asia, and Africa), settings (hospital and primary care), practitioner types (family and hospital physicians, anesthesiologists, nurses, psychologists, and caregivers), and type of randomization (individual patient or clustered by practitioner). Although all trials suggested a positive change in patient satisfaction, inadequate reporting hindered the ability to draw definitive conclusions about the overall effect size. Limitations: Heterogeneity in the way that empathy was delivered and patient satisfaction was measured and incomplete reporting leading to concerns about the certainty of the underpinning evidence. Conclusion: Various empathy interventions have been studied to improve patient satisfaction. Development, testing, and reporting of high-quality studies within well-defined contexts is needed to optimize empathy interventions that increase patient satisfaction. Primary Funding Source: Stoneygate Trust. (PROSPERO: CRD42023412981)
Impact of Clinical Demands on the Educational Mission in Hospital Medicine at 17 Academic Medical Centers: A Qualitative Analysis: Annals of Internal Medicine: Vol 176, No 11
Background: Clinical growth is outpacing the growth of traditional educational opportunities at academic medical centers (AMCs). Objective: To understand the impact of clinical growth on the educational mission for academic hospitalists. Design: Qualitative study using semistructured interviews that were analyzed using a mixed inductive and deductive method at the semantic level. Setting: Large AMCs across the United States that experienced clinical growth in the past 5 years. Participants: Division heads, section heads, and other hospital medicine (HM) leaders who oversaw and guided academic and clinical efforts of HM programs. Measurements: Themes and subthemes. Results: From September 2021 to January 2022, HM leaders from 17 AMCs participated in the interviews, and 3 key themes emerged. First, AMCs’ disproportionate clinical growth highlighted the tension between clinical and educational missions. This included a mismatch in supply and demand for traditional teaching time, competing priorities, and clinical growth being seen as both an opportunity and a threat. Second, amid the shifting landscape of high clinical demands and evolving educational opportunities, hospitalists still strongly prefer traditional teaching. To address this mismatch, HM groups have had to alter recruitment strategies and create innovative solutions to help build academic careers. Third, participants noted a need to reimagine the role and identity of an academic hospitalist, emphasizing tailored career pathways and educational roles spanning well beyond traditional house staff teaching teams. Limitation: The study focused on large AMCs. Conclusion: Although HM groups have implemented many creative strategies to address clinical growth and keep education front and center, challenges remain, particularly heavy clinical workloads and a continued dilution of traditional teaching opportunities. Primary Funding Source: Society of Hospital Medicine Student Scholar Grant.