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)

Vaporized Nicotine Products for Smoking Cessation Among People Experiencing Social Disadvantage: A Randomized Clinical Trial: Annals of Internal Medicine: Vol 178, No 8

Background: Vaporized nicotine products (VNPs) are more effective than nicotine replacement therapy (NRT) for smoking cessation in general populations, but their effectiveness among low socioeconomic groups is largely unknown. Objective: To examine whether VNPs are more effective than NRT for smoking cessation among people experiencing social disadvantage. Design: Two-group, open-label, randomized trial with blinded outcome ascertainment. (Australian New Zealand Clinical Trials Registry ACTRN12621000076875) Setting: Australia, between March 2021 and December 2022. Participants: 1045 adults who smoked daily, were willing to quit smoking, and were receiving a government pension/allowance (proxy for social disadvantage). Intervention: Participants were randomly assigned (1:1) to either a free 8-week supply of NRT or VNPs, and all participants received text-message support. Measurements: The primary outcome was 6-month continuous smoking abstinence verified using a carbon monoxide breath test at 7-month follow-up. Analysis included randomly assigned participants in accordance with Russell Standard criteria and the intention-to-treat principle. Results: Among 1045 randomly assigned participants, 866 (82.9%) completed final follow-up. The verified 6-month continuous abstinence rate was 9.6% (50 of 523) in the NRT group and 28.4% (148 of 522) in the VNP group (posterior risk difference estimate, 18.7% [95% credible interval, 14.1% to 23.3%]; >99% posterior probability that VNP is superior). Self-reported adverse events occurred less frequently in the VNP group (355 events among 237 participants) compared with the NRT group (442 events among 278 participants; incident rate ratio, 0.75 [95% CI, 0.65 to 0.88]; P < 0.001). Limitations: Biochemical verification method tested short-term exposure to cigarette smoke. Conclusion: Findings indicate that VNPs were more effective than NRT for smoking cessation in this population. Given the challenges for cessation among these socially disadvantaged populations, VNPs present a promising treatment option for this priority group. Primary Funding Source: Australian National Health and Medical Research Council.

Associations Between Unconditional Cash Transfers and Postpartum Outcomes in the United States: A Systematic Review: Annals of Internal Medicine: Vol 178, No 7

Background: Unconditional cash transfers (UCTs) through social programs or direct cash transfers (DCTs) may address drivers of pregnancy-related morbidity and mortality. Purpose: To summarize evidence on UCTs and postpartum outcomes in the United States. Data Sources: PubMed, Embase, Web of Science, Social Science Research Network, and structured internet searches through 28 January 2025. Study Selection: Primary research reporting associations between UCTs and postpartum outcomes (0 to 2 years after delivery) in the United States. Data Extraction: Dual data extraction with predefined outcomes: infant or child care, reproductive health, substance use, other mental health outcomes, and other outcomes. Study quality was assessed using the Cochrane Risk of Bias 2 and ROBINS-I (Risk Of Bias In Non-randomised Studies – of Interventions) tools. Strength of evidence (SOE) was assessed using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. Data Synthesis: Eleven reports from 6 studies were identified. Four quasi-experimental (QE) studies examined 3 different social programs, 2 of which targeted populations with low incomes. Seven reports from 2 randomized controlled trials (RCTs) examined DCTs to postpartum persons with low incomes. The evidence on UCTs showed an increase in breastfeeding (high SOE [2 RCTs, 2 QE studies]), little or no difference in postpartum mood (high SOE [1 RCT, 2 QE studies]), and low SOE or insufficient evidence for all other associations. Limitations: Unpublished studies and those not published in English may have been missed. Nonrandomized studies were subject to reporting or recall bias, reducing SOE. Study heterogeneity prevented meta-analysis. Conclusion: Unconditional cash transfers increase breastfeeding in diverse settings and populations and result in little or no difference in postpartum mood specifically in persons with low incomes. No studies examined DCTs given during pregnancy. More evidence is needed on associations between UCTs and key clinical outcomes, such as postpartum maternal morbidity and mortality. Primary Funding Source: None. (Registered on Open Science Framework [https://osf.io/4c3nx]).

Glucagon-Like Peptide-1 Receptor Agonists and Risk for Gastroesophageal Reflux Disease in Patients With Type 2 Diabetes: A Population-Based Cohort Study: Annals of Internal Medicine: Vol 178, No 9

Background: Glucagon-like peptide-1 receptor agonists (GLP-1 RAs), medications used to treat type 2 diabetes and obesity, are associated with delayed gastric emptying, which is a risk factor for gastroesophageal reflux disease (GERD). However, evidence linking these drugs to GERD is limited. Objective: To estimate the effect of GLP-1 RAs compared with sodium–glucose cotransporter-2 (SGLT-2) inhibitors on the risk for GERD and its complications among patients with type 2 diabetes. Design: Active-comparator new-user cohort study emulating a target trial. Setting: U.K. Clinical Practice Research Datalink. Participants: Adults aged 18 years or older with type 2 diabetes initiating GLP-1 RAs or SGLT-2 inhibitors between 1 January 2013 and 31 December 2021, with follow-up until 31 March 2022. Measurements: The primary outcome was incident GERD, and the secondary outcome was its complications. Three-year risk differences (RDs) and risk ratios (RRs) were estimated and weighted using propensity score fine stratification. Results: The study included 24 708 new users of GLP-1 RAs and 89 096 new users of SGLT-2 inhibitors. Over a median follow-up of 3.0 years, the RRs were 1.27 (95% CI, 1.14 to 1.42) for GERD, with an RD of 0.7 per 100 patients, and 1.55 (95% CI, 1.12 to 2.29) for its complications, with an RD of 0.8 per 1000 patients, among GLP-1 RA users compared with SGLT-2 inhibitor users. Limitation: Residual confounding due to lack of information on dietary or lifestyle factors. Conclusion: The estimated effect of GLP-1 RAs compared with SGLT-2 inhibitors suggested a higher risk for GERD and its complications in patients with type 2 diabetes. Clinicians should be aware of this potential adverse effect to provide timely prevention and treatment strategies. Primary Funding Source: Canadian Institutes of Health Research.

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.

Comparison of Initial Artificial Intelligence (AI) and Final Physician Recommendations in AI-Assisted Virtual Urgent Care Visits

Background: Whether artificial intelligence (AI) assistance is associated with quality of care is uncertain. Objective: To compare initial AI recommendations with final recommendations of physicians who had access to the AI recommendations and may or may not have viewed them. Design: Retrospective cohort study. Setting: Cedars-Sinai Connect, an AI-assisted virtual urgent care clinic with intake questions via structured chat. When confidence is sufficient, AI presents diagnosis and management recommendations (prescriptions, laboratory tests, and referrals). Patients: 461 physician-managed visits with AI recommendations of sufficient confidence and complete medical records for adults with respiratory, urinary, vaginal, eye, or dental symptoms from 12 June to 14 July 2024. Measurements: Concordance of diagnosis and management recommendations of initial AI recommendations and final physician recommendations. Physician adjudicators scored all nonconcordant and a sample of concordant recommendations as optimal, reasonable, inadequate, or potentially harmful. Results: Initial AI and final physician recommendations were concordant for 262 visits (56.8%). Among the 461 weighted visits, AI recommendations were more frequently rated as optimal (77.1% [95% CI, 72.7% to 80.9%]) compared with treating physician decisions (67.1% [CI, 62.9% to 71.1%]). Quality scores were equal in 67.9% (CI, 64.8% to 70.9%) of cases, better for AI in 20.8% (CI, 17.8% to 24.0%), and better for treating physicians in 11.3% (CI, 9.0% to 14.2%), respectively. Limitations: Single-center retrospective study. Adjudicators were not blinded to the source of recommendations. It is unknown whether physicians viewed AI recommendations. Conclusion: When AI and physician recommendations differed, AI recommendations were more often rated better quality. Findings suggest that AI performed better in identifying critical red flags and supporting guideline-adherent care, whereas physicians were better at adapting recommendations to changing information during consultations. Thus, AI may have a role in assisting physician decision making in virtual urgent care. Primary Funding Source: K Health.

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

Burnout Prevalence Among U.S. Internal Medicine Physicians: A Cross-Sectional Study

Trends in Utilization of Glucose- and Weight-Lowering Medications After Tirzepatide Approval in the United States: A Population-Based Cohort Study: Annals of Internal Medicine: Vol 178, No 5

Background: Recent trends in use of tirzepatide, a dual glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic polypeptide receptor agonist (RA), versus other glucose-lowering medications (GLMs) and weight-lowering medications (WLMs) remain unexplored. Objective: To describe trends in insurance claims for GLMs and WLMs after tirzepatide approval. Design: Population-based cohort study. Setting: Claims data from a large U.S. commercial database (January 2021 to December 2023). Participants: Adults (aged ≥18 years) with type 2 diabetes (T2D) and without diabetes with dispensations for GLMs and WLMs. Any use was defined as medication dispensation regardless of prior use. Incident use was defined as dispensation without use in the preceding year. Measurements: Monthly trends in medication dispensations before and after tirzepatide market entry. Tirzepatide uptake was additionally compared with initial postapproval uptake of other GLMs and WLMs. Results: Tirzepatide dispensations increased markedly among adults with T2D prescribed GLMs, reaching 12.3% of all GLM dispensations by December 2023. Similar patterns were observed for sodium–glucose cotransporter-2 inhibitors (14.5% to 24.4%) and GLP-1 RAs (19.5% to 28.5%). Dispensations of other GLMs, including metformin, declined. Among adults without diabetes but prescribed WLMs, tirzepatide (0.0% to 40.6%) and semaglutide (2.4 mg) (0.0% to 32.2%) dispensations increased sharply, but semaglutide (2.0 mg) was the most frequently dispensed WLM, increasing from 37.8% to 45.7%. Dispensations of other WLMs declined. Similar trends were observed among incident users. Tirzepatide uptake was more rapid and sustained compared with initial postapproval periods for other medications. Limitation: Generalizability to U.S. adults without commercial health insurance is uncertain. Conclusion: These findings highlight the sharp uptake of tirzepatide after U.S. market entry and enhance understanding of the rapidly shifting landscape of prescribing patterns for GLMs and WLMs. Primary Funding Source: National Institute of Diabetes and Digestive and Kidney Diseases.

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