ACP Comments to CMS on 2019 Physician Fee Schedule and Quality Payment Program Final Rule

ACP Comment Letter to CMS Regarding CY 2018 Medicare Physician Fee Schedule Proposed Rule

ACP Response to Senate Finance Committee White Paper on Bolstering Chronic Care through Physician Payment

ACP Comments on Medicare Shared Savings Program Pathways to Success Proposed Rule

ACP Comments on 2025 Physician Fee Schedule, Medicare Shared Savings Program, and Quality Payment Program Proposed Rule

ACP Comment Letter Regarding the Physician Fee Schedule Proposed Rule for CY 2017

ACP Comments on 2020 Medicare Physician Fee Schedule, Quality Payment Program, and other Medicare Part B Updates Proposed Rule

Clinical Examples of the Centers for Medicare & Medicaid Services (CMS) Evaluation and Management (E/M) Services Documentation Guidelines (DGs) Project. Letter to Aspen Systems Corporation.

Documentation Guidelines for Evaluation and Management Services and Resource-Based Practice Expense Project, and Physician Supervision of Allied Health Professionals. Statement given before the Practicing Physicians Advisory Council.

Written Testimony to the House Small Business Committee on Medical Student Loan Debt

Risk and Risk Factors for Chronic Opioid Use Among Opioid-Naive Patients With Newly Diagnosed Musculoskeletal Pain in the Neck, Shoulder, Knee, or Low Back

We Should Measure What Matters in Bundled Payment Programs

Should We Screen This Patient for Carotid Artery Stenosis?: Grand Rounds Discussion From Beth Israel Deaconess Medical Center: Annals of Internal Medicine: Vol 167, No 7

In July 2014, the U.S. Preventive Services Task Force (USPSTF) published a clinical guideline on screening for asymptomatic carotid artery stenosis. The guideline recommended against screening in asymptomatic adults, based primarily on the results of 3 large randomized trials (grade D recommendation). The principal screening test was carotid ultrasonography, and the intervention in the 3 trials was carotid endarterectomy for patients with stenosis exceeding 50% to 60%. In a meta-analysis, carotid endarterectomy reduced rates of 1) perioperative stroke, death, or subsequent ipsilateral stroke and 2) perioperative stroke, death, or any subsequent stroke. The corresponding absolute risk differences were –2.0% (95% CI, –3.3% to –0.7%) and –3.5% (CI, –5.1% to –1.8%), respectively. However, perioperative stroke and death were substantially less common among the 3 randomized trials than in contemporaneous cohort studies (1.9% vs. 3.3%). In addition to stroke or death in patients receiving carotid endarterectomy, a harm of screening included the risk for angiography prompted by abnormal results on carotid ultrasonography. In this article, 2 discussants address the risks and benefits of screening for carotid artery disease as well as how to apply the guideline to an individual patient who is deciding whether to be screened.

Should This Patient Have Weight Loss Surgery?: Grand Rounds Discussion From Beth Israel Deaconess Medical Center: Annals of Internal Medicine: Vol 166, No 11

Obesity is an important public health priority in the United States. One third of U.S. adults are obese and therefore can expect higher rates of diabetes mellitus, other obesity-related comorbidities, and mortality. In 2013, the American Association of Clinical Endocrinologists, the Obesity Society, and the American Society for Metabolic and Bariatric Surgery issued a guideline that recommended weight loss (bariatric) surgery for all patients with a body mass index (BMI) of 40 kg/m2 or higher and for those with a BMI of 35 kg/m2 or greater in the presence of at least 1 obesity-related comorbidity. Among the 3 most commonly performed surgeries, the amount of excess weight reduction ranges from 49% for laparoscopic adjustable gastric banding to 76% for Roux-en-Y gastric bypass. In accredited centers, perioperative mortality averages 0.3%. In this Beyond the Guidelines, 2 experts in obesity management, a bariatric surgeon and a general internist, discuss the role of weight loss surgery versus dietary and lifestyle modification, both in general and for a specific patient who is eligible for surgery. Ethnic and age-related variability in the effects of obesity on mortality, as well as potential long-term benefits and risks of weight loss surgery for patient subgroups, are discussed.

Regarding Kindness

Update in General Internal Medicine: Evidence Published in 2016

Promoting Appropriate Use of Cardiac Imaging: No Longer an Academic Exercise

Advanced Practice Clinicians and Physicians in Primary Care: Still More Questions than Answers

Should We Screen for Type 2 Diabetes?: Grand Rounds Discussion From Beth Israel Deaconess Medical Center: Annals of Internal Medicine: Vol 165, No 7

The prevalence of diabetes in the United States is rising. Twelve percent of U.S. adults have diabetes and another 37% have impaired fasting glucose or impaired glucose tolerance. Diabetes is a major risk factor for such outcomes as cardiovascular disease, blindness, chronic kidney disease, and limb amputation. An important consideration is whether screening for abnormal glucose levels or diabetes reduces cardiovascular or all-cause morbidity and mortality. In October 2015, the U.S. Preventive Services Task Force published recommendations on screening for abnormal blood glucose and concluded that intensive lifestyle interventions have a moderate benefit in reducing progression to diabetes in patients who have abnormal blood glucose levels detected by screening. It found inadequate evidence that such screening reduces cardiovascular or all-cause mortality and no evidence of psychological or other harms from screening. The Task Force recommends glucose screening every 3 years for adults aged 40 to 70 years who are overweight or obese and do not have symptoms of diabetes. In this article, we present the case of a man who meets these criteria and explore his preferences and concerns regarding screening. Two experts then debate screening merits and benefits, the significance of abnormal blood glucose levels and diabetes as cardiovascular risk factors, and application of the guidelines to this particular patient.

Is Prostate-Specific Antigen Screening “Proven Ineffective Care”?

A Case of Multiple Skin Lesions After LipodissolveTM Injection | Annals of Internal Medicine: Clinical Cases

Mycobacterium abscessus (M. abscessus) is a rapidly growing nontuberculous mycobacterium commonly found in soil and water. It can cause localized infection when inoculated during surgical or cosmetic procedures. We describe a case of a patient who developed multiple skin nodules resulting from injection of LipodissolveTM for cosmetic purposes. We highlight the following points: M. abscessus can have inducible resistance to macrolides and may require novel agents for treatment; outbreaks can occur when injectables contaminated with M. abscessus are inoculated into the skin; and local health departments and the U.S. Food and Drug Administration should be contacted for outbreak investigation.

Scurvy's Systemic Clinical Picture: A Multiorgan Presentation of a Conspicuous Disease | Annals of Internal Medicine: Clinical Cases

A man whose diet was limited to consumption of chicken, fish, and bread was admitted for weight loss, dyspnea, and cutaneous lesions. Findings of the physical examination included lower-extremity purpura. Initial work-up demonstrated severe ferropenic anemia, hyperbilirubinemia, vertebral fracture, and dilation of the inferior vena cava and right cardiac chambers. Vitamin C deficiency was documented and, after adequate supplementation, the anemia, hyperbilirubinemia, and bleeding resolved. This case demonstrates the wide, unspecific, and reversible systemic manifestations associated with scurvy, its potential as a great mimicker, and the relevance of nutritional deficiencies even in an apparently nutrient-rich environment.

Case of Ibuprofen-Induced Liver Injury | Annals of Internal Medicine: Clinical Cases

Drug-induced liver injury (DILI) resulting from nonsteroidal anti-inflammatory drugs (NSAIDs) is a rare phenomenon; however, several cases have been reported in the literature and the LiverTox database. For ibuprofen in particular, only 22 cases have been reported, and the mechanism for liver injury is unclear. In this report, we discuss a case of ibuprofen-induced liver injury to highlight the evaluation of NSAID-induced DILI, as well as the likely mechanism of injury.

Atypical Epigastric Pain Reveals Obstructive Urosepsis in a Horseshoe Kidney | Annals of Internal Medicine: Clinical Cases

A 61-year-old woman presented with 2 days of nausea, vomiting and severe mid- to upper abdominal pain radiating to the right flank without any urinary symptoms. She was hypotensive, with leukocytosis and pyuria. Contrast-enhanced computed tomography demonstrated a horseshoe kidney and a 12- × 8- × 18-mm right ureteropelvic junction stone causing mild to moderate hydronephrosis. Blood and urine cultures were obtained before administration of antibiotics and remained negative. She received intravenous crystalloid therapy, ceftriaxone, and emergent percutaneous nephrostomy, with rapid hemodynamic recovery and normalization of leukocytosis by hospital day 1. This case highlights atypical presentations of obstructive urosepsis and the importance of early decompression.

Therapeutic Low-Density Lipoprotein Cholesterol-Lowering in a Patient With Familial Hyperlipidemia Refractory to PCSK9 Monoclonal Antibody (Evolocumab) | Annals of Internal Medicine: Clinical Cases

Patients with heterozygous familial hypercholesterolemia if untreated are at increased risk for atherosclerotic cardiovascular disease events by age 40 years. Inhibition of proprotein convertase subtilisin/kexin type 9 (PCSK9) is a demonstrated potent approach to low-density lipoprotein cholesterol (LDL-C)-lowering in this population. We describe a 67-year-old patient with heterozygous familial hypercholesterolemia who developed a paradoxical increase in LDL-C while on a PCSK9 monoclonal antibody but had a subsequent reduction in LDL-C when started on inclisiran, a PCSK9-directed oligonucleotide. The overall mechanism of monoclonal antibody refractoriness remains to be determined, but it indicates that PCSK9 as a target is still a viable option using a different mechanism.

Chronic Eosinophilic Pneumonia With Multiple Drug-Related Risk Factors: Diagnosis and Management | Annals of Internal Medicine: Clinical Cases

Chronic eosinophilic pneumonia is a rare illness characterized by pneumonic infiltrates with peripheral eosinophilia. The underlying cause is unknown, but it is associated with multiple medications. The present article reports a woman in her 60s with a history of chronic sinusitis and asthma who presented with subacute cough and hemoptysis and significant peripheral and bronchioalveolar eosinophilia. This patient also had anxiety and depression treated chronically with trazodone and venlafaxine, which are associated with eosinophilic pneumonia. Symptoms promptly resolved within 24 hours following steroid treatment. This article highlights the diagnostic challenge eosinophilic pneumonia presents.

Pulmonary Mucormycosis With Dissemination: A Case of Unrelenting Fever and Chest Pain | Annals of Internal Medicine: Clinical Cases

Pulmonary mucormycosis is a rare entity that requires a high index of clinical suspicion for diagnosis. Untreated mucormycosis results in dissemination with exceedingly high mortality rates. Here, we present the patient case of a previously healthy 21-year-old man who presented with fever, dyspnea, chest pain, and progressive pulmonary consolidation. This patient case highlights the expanded differential diagnosis of presumed bacterial pneumonia that fails to respond to initial management and details the clinical, radiographic, and pathologic findings consistent with diagnosing pulmonary mucormycosis.

Cardiac Tamponade Due to Entamoeba histolytica in a Patient in a Nonendemic Region | Annals of Internal Medicine: Clinical Cases

Entamoeba histolytica infection is classically associated with intestinal disease and liver abscesses in endemic regions. Pericardial involvement with cardiac tamponade is an exceptionally rare, life-threatening complication. We present a case of a 58-year-old man in the United States with no recent travel who developed pericardial tamponade due to diaphragmatic communication with an E histolytica liver abscess. His case underscores the need to consider parasitic infections in the differential diagnosis of purulent pericardial effusions, even in nonendemic areas, and demonstrates how serologic testing and multidisciplinary collaboration were critical for diagnosis and management of this unexpected condition.

Insights From a Case of MRSA Enterocolitis in the Setting of Rectal Cancer | Annals of Internal Medicine: Clinical Cases

Methicillin-resistant Staphylococcus aureus (MRSA) is a rare cause of infectious enterocolitis. We present a patient undergoing chemoradiation for rectal squamous cell carcinoma who presented with acute watery diarrhea, neutropenia, and radiographic findings consistent with colitis. Failure to improve with empirical antibiotics prompted readmission and repeat stool culture, which resulted with heavy growth MRSA responsive to oral vancomycin. Low clinical suspicion for MRSA as the causing agent led to a delay in appropriate antibiotics and prolonged hospitalization, which ultimately resulted in death. In patients who are immunocompromised with active malignancy and undifferentiated infectious enterocolitis, early MRSA screening and empirical coverage should be considered.

Apolipoprotein E Dyslipidemia and Nephrotic Syndrome: A Rare Connection | Annals of Internal Medicine: Clinical Cases

Severe hyperlipidemia warrants an extensive evaluation. We report a case of a 25-year-old man of Chinese descent seen in the cardiology-lipid clinic. He was found to have a serum low-density lipoprotein cholesterol of 12.12 mmol/L (468 mg/dL) and serum triglycerides of 2.29 mmol/L (203 mg/dL) during routine screening. Work-up revealed nephrotic-range proteinuria, and renal biopsy showed dilated glomerular capillary loops with lipid deposits, pathognomonic of lipoprotein glomerulopathy. Genetic studies showed apolipoprotein E3/E4 phenotype. He was treated with a high-intensity statin and fibrate therapy, which resulted in a marked improvement in dyslipidemia and proteinuria.

Academic detailing increased deprescribing of diabetes meds in older patients

MKSAP Quiz: Posthospital evaluation for severe COPD

Some THC products may improve chronic pain in the short term, review finds

Limited evidence supports continuing buprenorphine for acute pain in patients with OUD

Guideline updates recommendations on management of lower-limb PAD

Cannabis-based products associated with chronic pain improvement, review finds

New ACP clinical guidelines address diagnosis, management of adult patients with diverticulitis

MKSAP Quiz: Evaluation for stiffness and pain

Lack of coordination between health care systems associated with fatal opioid overdoses

Clinical practice guideline for acute gout recommends corticosteroids, NSAIDs, low-dose colchicine

New antibiotic, report on drug shortages | ACP Hospitalist

The risky rise of gabapentinoids | ACP Hospitalist

Nutrition, glycemic control, and more | ACP Hospitalist

New rules for predicting recovery after cardiac arrest | ACP Hospitalist

Home care vs. SNF, sepsis mortality | ACP Hospitalist

Hospitals reach for the stars | ACP Hospitalist

Tips to assess and treat acute-on-chronic pain | ACP Hospitalist

New biologics and treatment pearls for IBD | ACP Hospitalist

Causes of acute liver failure, from acetaminophen to Z | ACP Hospitalist

Top Hospitalists | ACP Hospitalist