Treatment of Low Bone Density or Osteoporosis to Prevent Fractures in Men and Women

2025 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guideline for the Primary Care Management of Chronic Kidney Disease

Description: Management of chronic kidney disease (CKD) has been rapidly evolving, now involving many interventions that can be managed in the primary care setting. In April 2025, leadership within the U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense (DoD) approved a joint clinical practice guideline (CPG) for the primary care management of CKD. This synopsis reviews the 2025 recommendations related to diagnosis, assessment, and management of CKD. Methods: The VA/DoD Evidence-Based Practice Work Group assembled a team to update the 2019 VA/DoD CPG for the management of CKD. Guideline development conformed to the National Academy of Medicine’s tenets for trustworthy CPGs. The work group developed 12 key questions to guide a systematic evidence review and distilled 23 recommendations using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. The work group also created algorithms and appendices to help guide clinical decision making. Funding for the development of the guideline was provided by the VA. Recommendations: This synopsis reviews updated recommendations for the diagnosis, assessment, and monitoring of CKD; general management strategies including team management and education; shared decision making and indications for referral to nephrology for consideration of kidney replacement therapy or conservative management; management of hypertension; pharmacotherapy to reduce the risk for major adverse cardiovascular events, progression of kidney disease, and mortality; and prevention of contrast-associated acute kidney injury. New and updated recommendations about pharmacotherapy, such as angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers, sodium–glucose cotransporter 2 inhibitors, glucagon-like peptide 1 receptor agonists, nonsteroidal mineralocorticoid receptor antagonists, and statins, are highlighted in this synopsis.

A Synopsis of the 2025 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guideline for the Primary Care Management of Asthma

Description: The U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense (DOD) updated the 2019 joint clinical practice guideline (CPG) for the primary care management of asthma. This synopsis provides primary care providers with a summary of the updated 2025 recommendations regarding evaluation and management of veterans and military members with asthma. Methods: In 2024, the VA/DOD convened a guideline work group (WG), including clinical stakeholders, to update the joint VA/DOD guideline and conformed to the National Academy of Medicine's tenets for trustworthy CPGs. The WG drafted 12 key questions, reviewed systematically identified literature (20 July 2018 through 15 May 2024), evaluated the evidence, created algorithms, and advanced 21 evidence-based recommendations in accordance with the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. Recommendations: The WG strongly recommended inhaled corticosteroids (ICS) and streamlined management of asthma by suggesting a combination of ICS and rapid-onset long-acting β-agonist as both reliever and controller agents and step-up therapy by increasing ICS and/or adding long-acting anticholinergic agents. The WG also supported the management of symptomatic gastroesophageal reflux disease and obesity for better control of asthma. The WG suggested against the use of indoor air filtration devices. Finally, the WG outlined decision points for referral to a subspecialist.

Complications Associated With Transvenous Cardiac Implantable Electronic Devices: Recognition and Management: A Narrative Review: Annals of Internal Medicine: Vol 178, No 11

Cardiac implantable electronic devices (CIEDs) have increased the quality and duration of life for millions of patients. As their utilization continues to grow exponentially, clinicians need to diagnose and manage several device-associated complications that may arise during the CIED life cycle. This primer is tailored for the general internal medicine physician or hospitalist, who will inevitably take care of patients with CIEDs, to provide a contemporary update on the incidence and clinical manifestations of the 4 most common CIED complications, with the latest evidence to guide clinical management and expected outcomes. Specifically, this review focuses on: 1) generator/lead failure, which has decreased to less than 1% per year due to continuous advances in manufacturing and programming and is mostly managed conservatively with close monitoring; 2) CIED infections, which, while also rare at approximately 1% per year, carry a short-term mortality of 10% to 20%, thus requiring immediate diagnosis and often urgent treatment with lead extraction because antibiotic treatment is rarely effective; and 3) lead-related venous obstruction, which has highly variable incidence (5% to 30%) and manifestations, ranging from arm swelling to superior vena cava syndrome. Management options range from anticoagulation to balloon venoplasty, often with unsatisfying results. This review will also focus on 4) lead-related tricuspid regurgitation, which affects 20% to 30% of CIEDs and has become an area of intense interest with the development of percutaneous tricuspid treatments—where evidence is urgently needed to inform the need for lead extraction versus jailing during tricuspid interventions. The progressive adoption of leadless devices may significantly reduce many of these complications. Nonetheless, optimal management requires input from a multidisciplinary team of electrophysiologists and imaging, heart failure, and structural interventional specialists—who should be able to recognize and treat each complication promptly based on a rapidly evolving evidence base.

Diagnostic Follow-up of Positive Results on Low-Dose Computed Tomography Screening in the Medicare Population

Background: Diagnostic evaluation of positive screening results for lung cancer is critically important for optimal outcomes. Data on such follow-up are limited. Objective: To assess the use of diagnostic tests after positive results on lung cancer screening in clinical practice. Design: Retrospective cohort study. Setting: U.S. institutions performing diagnostic follow-up of lung cancer screening, 2015 to 2022. Participants: Persons with a first positive screening result at age 65 years or older who had Medicare fee-for-service coverage. Measurements: Rates of diagnostic test use (imaging or invasive procedures) within 1 year of an index positive screening result and rates of receiving guideline-concordant follow-up care and of receiving less or more intensive (than guideline-concordant) care. Multiple logistic regression was used to assess factors associated with less or more intensive care. Results: The cohort consisted of 64 555 persons. The rate of guideline-concordant care was 59.7% overall and increased with increasing Lung-RADS score: 49.2% for a score of 3, 68.6% for 4A, 74.1% for 4B, and 79.5% for 4X. Care was less intensive than recommended in 32.3% of participants, generally decreasing with Lung-RADS score: 39.3% for a score of 3, 24.7% for 4A, 25.9% for 4B, and 20.5% for 4X. Rates of more intensive care, applicable only for scores of 3 and 4A, were 11.5% and 6.7%, respectively. Among participants with Lung-RADS scores of 3 and 4A, non-Hispanic Black persons, those who currently smoked, and those undergoing baseline screening had significantly higher rates of less intensive care. Of all participants, 12.4% had a lung cancer diagnosis within 1 year. Invasive procedures were done in 16.2% of all participants and in 7.3% of those without eventual lung cancer. Limitations: The cohort was limited to those in fee-for-service Medicare plans. Information on institutional and patient socioeconomic factors was limited. Conclusion: About 60% of participants had guideline-concordant care, and about one third had less intensive care. Invasive procedure rates in those without cancer were low. Primary Funding Source: None.

Maternal Influenza-Like Illness and Neonatal Health During the 1918 Influenza Pandemic in a Swiss City

Exposure to the 1918 influenza pandemic may have been associated with preterm birth (<37 weeks). Other outcomes, such as infant size or weight, have rarely been explored. Using 2177 historical birth records from University Maternity Hospital of Lausanne, it was estimated whether in utero exposure to maternal influenza-like illness (ILI) during the 1918 pandemic was associated with pregnancy outcomes and whether associations varied depending on the trimester of ILI during pregnancy or on fetal sex. Generalized linear models and robust linear models were used to analyze the association between ILI and gestational age, stillbirth, and anthropometric measurements, adjusting on covariates. Analyses were stratified by fetal sex. A total of 282 (13%) women developed ILI during pregnancy. Exposure to ILI was associated with lower anthropometric measurements: low birthweight (LBW; <2500 g) (marginally adjusted percentage was 13.3% compared with 6.9% in the unexposed group; difference, 6.4 percentage points [95% CI, 5.5 to 7.2 percentage points]). There was strong evidence that third trimester exposure was associated with worse adverse pregnancy outcomes, including with LBW (difference, 12.8 percentage points [CI, 11.8 to 13.7 percentage points]) and preterm birth rates (difference, 9.4 percentage points [CI, 8.2 to 10.6 percentage points]). Maternal ILI may have triggered premature birth. The magnitude of the declines in anthropometric parameters was higher among male fetuses, and they had a higher stillbirth rate. For instance, males exposed during the third trimester had their birthweight lowered by 228.4 g (CI, −391.0 to −65.8 g) compared with 126.3 g among females [CI, −256.6 to 4.0 g]. Only 41% of infants exposed to first-trimester ILI were males, suggesting a selection against male fetuses through miscarriage. Our findings may not generalize to the entire population of Lausanne, as 34% of births were home births at the time.

Pharmacologic Treatment of Primary Osteoporosis or Low Bone Mass to Prevent Fractures in Adults: A Living Clinical Guideline From the American College of Physicians (Version 1: Update Alert 1: Surveillance Note 1)

Cannabis or Cannabinoids for the Management of Chronic Noncancer Pain: Best Practice Advice From the American College of Physicians

Description: The American College of Physicians’ Population Health and Medical Science Committee (PHMSC) developed this best practice advice to inform clinicians about what is currently known about the benefits and harms of cannabis or cannabinoids in the management of chronic noncancer pain and to provide advice for clinicians counseling patients seeking this therapy. Methods: The PHMSC considers areas where evidence is uncertain or emerging or practice does not follow the evidence to provide clinical advice based on a review and assessment of scientific work, including systematic reviews and individual studies. Sources of evidence included a living systematic review on cannabis and cannabinoid treatments for chronic noncancer pain and a series of living systematic reviews and primary studies. Best Practice Advice 1a: Clinicians should counsel patients about the benefits and harms of cannabis or cannabinoids when patients are considering whether to start or continue to use cannabis or cannabinoids to manage their chronic noncancer pain. Best Practice Advice 1b: Clinicians should counsel the following subgroups of patients that the harms of cannabis or cannabinoid use for chronic noncancer pain are likely to outweigh the benefits: young adult and adolescent patients, patients with current or past substance use disorder, patients with serious mental illness, and frail patients and those at risk for falling. Best Practice Advice 2: Clinicians should advise against starting or continuing to use cannabis or cannabinoids to manage chronic noncancer pain in patients who are pregnant or breastfeeding or actively trying to conceive. Best Practice Advice 3: Clinicians should advise patients against the use of inhaled cannabis to manage chronic noncancer pain.

Excess Mortality Rate in Black Children Since 1950 in the United States: A 70-Year Population-Based Study of Racial Inequalities

Background: Black Americans have lower wealth, income, and education and higher mortality rates than White Americans, especially during childhood. Objective: To document the extent and persistence of excess infant and childhood mortality in Black Americans between 1950 and 2019. Design: Population-based surveillance study. Setting: The United States of America. Patients: The entire population of the United States. Measurements: The investigators analyzed mortality data collected by the Centers for Disease Control and Prevention and the U.S. Census Bureau from 1950 to 2019 and calculated mortality rates, life expectancy, and years of potential life lost for White and Black Americans to estimate the absolute and relative sex- and age-specific excess mortality burden among Black Americans compared with White Americans. Results: The gaps in absolute life expectancy and age-standardized mortality between Black and White Americans decreased over the 70-year period beginning in 1950, but relative mortality in infants and children increased during this same period. The mortality rates in the 1950s for White and Black infants were 2703 and 5181 deaths per 100 000 persons, respectively, for an excess mortality ratio of 1.92 (95% CI, 1.91 to 1.93). In the 2010s, the mortality rates were 499 deaths per 100 000 persons in White infants and 1073 deaths per 100 000 persons in Black infants, for an excess mortality ratio of 2.15 (CI, 2.13 to 2.17). A total of 5.0 million excess deaths of Black Americans (including 522 617 infants) could have been avoided during these 7 decades if their mortality rates were equal to those of White Americans. Limitation: The effect of health inequities was measured without inquiring about the causes of these differences. Conclusion: Black infants, children, and adults have experienced persistent excess mortality in the United States since the 1950s relative to the White population. Primary Funding Source: None.

RAS blocker effects on first HF hospitalization or CV death does not differ in Black and non-Black patients with HFrEF

Source Citation Shen L, Lee MMY, Jhund PS, et al. Revisiting race and the benefit of RAS blockade in heart failure: a meta-analysis of randomized clinical trials. JAMA. 2024;331:2094-2104. 38809561