The Mediterranean Diet for Irritable Bowel Syndrome: A Randomized Clinical Trial: Annals of Internal Medicine: Vol 178, No 12

Background: Patients with irritable bowel syndrome (IBS) frequently seek dietary advice, but few evidence-based options exist. Major societal guidelines recommend traditional dietary advice (TDA) as first-line therapy, with the cumbersome and resource-intensive low fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAP) diet reserved as second-line therapy. Recent pilot data suggest that the Mediterranean diet (MD), renowned for its general health benefits, improves IBS symptoms, but whether it can be considered another first-line dietary option is unknown. Objective: To determine if the MD is noninferior to TDA in managing IBS symptoms. Design: Randomized noninferiority clinical trial. (ClinicalTrials.gov: NCT05985018) Setting: Online virtual platform. Participants: 139 persons with IBS from across the United Kingdom. Intervention: 6 weeks of the MD (n = 68) or TDA (n = 71). Measurements: Primary end point was the proportion achieving clinical response, defined as 50-point or greater reduction in IBS Symptom Severity Scale (IBS-SSS). Secondary outcomes included changes in IBS-SSS scores, psychological health, somatic symptom reporting, quality of life, diet satisfaction, and Mediterranean Diet Adherence Screener (MEDAS). Results: Baseline characteristics (mean age, 40.4 years [range, 19 to 65 years]; 80% women) and IBS-SSS (mean, 309 [SD, 90]) were similar between groups. On modified intention-to-treat analysis, the primary end point was met by 62% (95% CI, 50% to 73%) following a MD versus 42% (CI, 31% to 55%) following TDA. The difference in clinical response favored the MD (difference, 20 percentage points [CI, 4 to 36 percentage points]; P = 0.017), demonstrating noninferiority and superiority. There was a greater reduction in the mean IBS-SSS after a MD than TDA (−101.2 vs. −64.5; Δ−36.7 [CI,−70.5 to −2.8]; P = 0.034). No statistically significant differences were seen between the groups with regard to changes in mood, somatic symptoms, quality of life, or diet satisfaction. The MEDAS significantly increased after a MD compared with TDA (P < 0.001). Limitation: No long-term data. Conclusion: The MD showed noninferiority and superiority to TDA in managing IBS symptoms. It represents a viable first-line dietary intervention for IBS. Primary Funding Source: None.

Care of the Patient With Asthma

Nearly 8% of the U.S. population is diagnosed with asthma, leading to more than 5 million office visits and 1 million emergency department visits annually. Both outpatient and inpatient internal medicine clinicians treat asthma frequently, but nuances in diagnosis and management have emerged. This article highlights many of these developments.

Temperature-Related Deaths in the United States, 1999 to 2024

Identifying Core Clinical Topics and Recommending Core Performance Measures for Internal Medicine Physicians: A Position Paper From the American College of Physicians

Internal medicine physicians are specialists who promote health, emphasize disease prevention, manage complex acute and chronic conditions in adults, and receive extensive training in the diagnosis and treatment of diseases affecting all systems of the human body. As a result, internal medicine performance measures (PMs) target several topics. Many PMs are not based on high-certainty evidence of at least moderate net benefit and are burdensome, with low or no value to patient care. The American College of Physicians (ACP) wants to provide a national focus to improve the quality of health care in the United States. The ACP is a leader in the evidence-based world, being the only physician organization designated as a GRADE (Grading of Recommendations Assessment, Development and Evaluation) Center, an Appraisal of Guidelines for Research and Evaluation (AGREE) Center, and a member of the Cochrane U.S. Network. Using a structured, stepwise, evidence-based approach, ACP identified the most important clinical topics evaluated and treated by internal medicine physicians. The ACP is also actively working toward recommending essential PMs for each core clinical topic that can be used to evaluate and improve patient care. This position paper describes ACP’s method and results of identifying core clinical topics. It also offers a blueprint for defining core PMs and illustrating the principals through application to 2 core clinical topics. The ACP plans to apply this method on PMs for other core clinical topics.

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.

Unifying Efforts to Empower Equitable Obesity Care: Synopsis of an American College of Physicians and Council of Subspecialty Societies Summit

Obesity is a leading cause of morbidity and mortality with health consequences that crosscut most medical specialties. Despite the emergence of effective and promising new therapies, many impediments to comprehensive obesity care remain. As part of their commitment to improving obesity care, the American College of Physicians (ACP) and its Council of Subspecialty Societies (CSS) held a summit on 24 October 2023 to identify barriers to and opportunities for collaborative action in the domains of physician education, health care policy and care delivery, and addressing weight bias. This report summarizes the summit proceedings and provides a postsummit synthesis from ACP and CSS. Key themes were centered on knowledge, advocacy, action, and compassion, including the need for culture change, paradigm shifts, and stakeholder engagement and collaboration; a focus on empowerment of both clinicians and patients; the importance of knowing patients as people to help address social determinants of health; the need to address learned helplessness; and the importance of embracing artificial intelligence and technology as disruptive innovations. Recommendations for next steps for collaborative action include leveraging and improving already available educational and clinical resources, developing obesity education and care standards that incorporate patients’ perspectives and address social determinants of health, developing community and public–private partnerships to improve access and public awareness, and coordinating messaging and policy advocacy efforts that align with mitigating the longstanding obesity epidemic.

Effectiveness and Safety of Statins in Type 2 Diabetes According to Baseline Cardiovascular Risk: A Target Trial Emulation Study: Annals of Internal Medicine: Vol 179, No 2

Background: Whether statins benefit patients with type 2 diabetes mellitus (T2DM) with low predicted 10-year cardiovascular risk is uncertain. Objective: To evaluate the effectiveness and safety of statin initiation for primary prevention among adults with T2DM stratified by predicted 10-year risk for cardiovascular disease (CVD). Design: Cohort study using target trial emulation. Setting: U.K. primary care using the IQVIA Medical Research Data database. Participants: Persons aged 25 to 84 years with a diagnosis of T2DM between 2005 and 2016 and no history of coronary artery disease, myocardial infarction, stroke, heart failure, myopathy, liver disease, rheumatic heart disease, schizophrenia, or cancer. Intervention: Statin initiation versus noninitiation, with estimation of the observational analogues of the intention-to-treat effect. Statin initiators were propensity score–matched to noninitiators in a 1:4 ratio within 4 QRISK3 strata of 10-year predicted cardiovascular risk: low (<10%), intermediate (10% to 19%), high (20% to 29%), and very high (≥30%). Measurements: Absolute risk differences (RDs) and risk ratios (RRs) at 10 years of follow-up for all-cause mortality and major CVD, as well as myopathy and liver dysfunction. Results: Statin initiation was associated with reductions in all-cause mortality and major CVD across QRISK3 strata. In the low-risk stratum, RDs and RRs were −0.53% (95% CI, −0.90% to −0.08%) and 0.80 (95% CI, 0.67 to 0.97), respectively, for all-cause mortality and −0.83% (95% CI, −1.28% to −0.34%) and 0.78 (95% CI, 0.66 to 0.91), respectively, for major CVD. A small increased risk for myopathy was observed in the moderate-risk stratum only, and there was no associated increased risk for liver dysfunction in any stratum. Limitations: Unmeasured confounding and underascertainment of some hospitalization outcomes. Conclusion: Statin use in T2DM for primary prevention was associated with reductions in all-cause mortality and major CVD across the full spectrum of predicted cardiovascular risk. Primary Funding Source: National Natural Science Foundation of China.

Association of Weekend Warrior and Other Physical Activity Patterns With Mortality Among Adults With Diabetes: A Cohort Study: Annals of Internal Medicine: Vol 178, No 9

Background: “Weekend warrior” and regularly active physical activity patterns have been associated with reduced mortality risk in the general population. The association in patients with diabetes is unknown. Objective: To examine the associations of different physical activity patterns, particularly weekend warrior and regularly active behavior, with all-cause, cardiovascular, and cancer mortality among adults with diabetes. Design: Prospective cohort study. Setting: National Health Interview Survey (1997 to 2018) linked to the National Death Index records through 31 December 2019. Participants: 51 650 U.S. adults with self-reported diabetes. Measurements: Participants categorized by 4 physical activity groups: inactive (reporting no moderate-to-vigorous physical activity [MVPA]), insufficiently active (MVPA <150 minutes per week), weekend warrior (MVPA ≥150 minutes per week in 1 to 2 sessions), and regularly active (MVPA ≥150 minutes per week in ≥3 sessions). Results: During a median follow-up of 9.5 years, 16 345 deaths (cardiovascular, 5620; cancer, 2883) were documented. Compared with inactive participants, multivariable-adjusted hazard ratios (HRs) for all-cause mortality were significantly lower across physical activity groups: insufficiently active persons (HR, 0.90 [95% CI, 0.85 to 0.95]), weekend warriors (HR, 0.79 [CI, 0.69 to 0.91]), and regularly active persons (HR, 0.83 [CI, 0.78 to 0.87]). These reductions were mostly due to benefits with cardiovascular mortality: insufficiently active persons (HR, 0.98 [CI, 0.89 to 1.07]), weekend warriors (HR, 0.67 [CI, 0.52 to 0.86]), and regularly active persons (HR, 0.81 [CI, 0.74 to 0.88]). There were fewer differences by cancer mortality: insufficiently active persons (HR, 0.88 [CI, 0.78 to 1.00]), weekend warriors (HR, 0.99 [CI, 0.76 to 1.30]), and regularly active persons (HR, 0.85 [CI, 0.75 to 0.96]). Limitation: Physical activity was self-reported and assessed at a single time point. Conclusion: Weekend warrior and regularly active physical activity patterns meeting current physical activity recommendations (MVPA ≥150 minutes per week) were associated with 21% and 17% lower risks for all-cause mortality and 33% and 19% lower hazards of cardiovascular mortality among adults with diabetes compared with those with diabetes who are physically inactive. Primary Funding Source: Capital’s Funds for Health Improvement and Research, and National Natural Science Foundation of China.

Effect of Systolic Blood Pressure Measurement Error on the Cost-Effectiveness of Intensive Blood Pressure Targets

Background: Analyses of clinical trials find that an intensive systolic blood pressure (SBP) target of less than 120 mm Hg is cost-effective compared with a target of less than 140 mm Hg for patients at high cardiovascular disease risk. However, guidelines from the American College of Cardiology and American Heart Association recommend a target of less than 130 mm Hg, citing blood pressure measurement error in routine practice. Objective: To evaluate the effect of measurement error on the cost-effectiveness of intensive SBP targets. Design: Microsimulation model varying SBP measurement error. Data Sources: SPRINT (Systolic Blood Pressure Intervention Trial) data and published literature. Target Population: Patients at high cardiovascular risk. Time Horizon: Lifetime. Perspective: Health care sector. Intervention: SBP targets of less than 120 mm Hg, less than 130 mm Hg, and less than 140 mm Hg. Outcome Measures: Incremental cost-effectiveness ratios (ICERs). Results of Base-Case Analysis: With research-grade SBP measurement (mean error, 0 mm Hg), the ICER for the target of less than 120 mm Hg versus less than 130 mm Hg was $24 400 per quality-adjusted life-year (QALY). With average measurement error (mean error, 7.3 mm Hg in the <120–mm Hg target), the ICER increased to $42 000 per QALY. Results of Sensitivity Analysis: The ICER for the target of less than 120 mm Hg was greater than $100 000 per QALY in scenarios with high error (mean error, ≥14.6 mm Hg in the <120–mm Hg target), when an inflection point for increasing risk for cardiovascular disease (CVD) was at or above 116 mm Hg, and in scenarios with a medication-taking disutility of at least 0.003 per antihypertensive medication. Limitation: Uncertainty in the relationship between low treated SBP (for example, <115 mm Hg) and cardiovascular risk. Conclusion: For SPRINT-eligible patients at high cardiovascular risk without diabetes or prior stroke, a target of less than 120 mm Hg seems cost-effective across most settings with SBP measurement error. In scenarios with high error and an increase in CVD risk at low SBPs, a target of less than 130 mm Hg may become cost-effective. Primary Funding Source: National Science Foundation and National Institute of Neurological Disorders and Stroke.

Epilepsy

Epilepsy is a common neurologic condition characterized by at least 1 unprovoked seizure and a high risk for recurrent seizures. Distinguishing epilepsy from conditions that can mimic seizures is important for accurate diagnosis and effective treatment. This article reviews the evaluation of patients suspected of having epilepsy and discusses behavioral strategies and pharmacologic and surgical therapies that can help reduce morbidity associated with recurrent seizures.