Creating a New National Workforce for Internal Medicine

The Cost of Lack of Health Insurance

The Advanced Medical Home: A Patient-Centered, Physician Guided Model of Healthcare

Senate: H.R. 3590, the Patient Protection and Affordable Care Act

Medicare Physician Fee Schedule for Calendar Year 2002. Letter to the Centers for Medicare & Medicaid Services (CMS).

2015 Medicare Physician Fee Schedule Final Rule Comment Letter

Group letter on Medicare Advantage network adequacy

Letter to Sen. Orrin Hatch Sharing ACP's Vision for Health Care Reform

ACP Letter Supporting the HEROES Act

Joint Letter Urging EPA to Continue to Count the Monetized Health Costs of Air Pollution

Improving Symptoms in Knee Osteoarthritis: Can We Get There From Here?

How Would You Manage Opioid Use in These Three Patients?: Grand Rounds Discussion From Beth Israel Deaconess Medical Center: Annals of Internal Medicine: Vol 166, No 7

The increase in overdose deaths from prescription opioids and heroin in the United States over the past 20 years is believed to have resulted from increases in prescription of opioids for management of acute and chronic pain. Managing chronic pain is challenging for primary care clinicians for many reasons, including the lack of evidence to guide practice. The Centers for Disease Control and Prevention published a comprehensive guideline in 2016 to help clinicians with opioid prescribing for chronic pain. In this Grand Rounds, the guideline is reviewed and an expert discusses its application to 3 patients prescribed opioids to treat chronic pain.

Update in General Internal Medicine: Evidence Published in 2016

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.

Has the Increase in Disability Insurance Participation Contributed to Increased Opioid-Related Mortality?

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

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.

Comparing Use of Low-Value Health Care Services Among U.S. Advanced Practice Clinicians and Physicians

Background: Many physicians believe that advanced practice clinicians (APCs [nurse practitioners and physician assistants]) provide care of relatively lower value. Objective: To compare use of low-value services among U.S. APCs and physicians. Design: Service use after primary care visits was evaluated for 3 conditions after adjustment for patient and provider characteristics and year. Patients with guideline-based red flags were excluded and analyses stratified by office- versus hospital-based visits, acute versus nonacute presentations, and whether clinicians self-identified as the patient's primary care provider (PCP). Setting: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS), 1997 to 2011. Patients: Patients presenting with upper respiratory infections (URIs), back pain, or headache. Measurements: Use of guideline-discordant antibiotics (for URIs), radiography (for URIs and back pain), computed tomography (CT) or magnetic resonance imaging (MRI) (for headache and back pain), and referrals to other physicians (for all 3 conditions). Results: 12 170 physician and 473 APC office-based visits and 13 359 physician and 2947 APC hospital-based visits were identified. Although office-based clinicians saw similar patients, hospital-based APCs saw younger patients (mean age, 42.6 vs. 45.0 years; P  < 0.001), and practiced in urban settings less frequently (49.7% vs. 81.7% of visits; P < 0.001) than hospital-based physicians. Unadjusted and adjusted results revealed that APCs ordered antibiotics, CT or MRI, radiography, and referrals as often as physicians in both settings. Stratification suggested that self-identified PCP APCs ordered more services than PCP physicians in the hospital-based setting. Limitation: NHAMCS reflects hospital-based APC care; NAMCS samples physician practices and likely underrepresents office-based APCs. Conclusion: APCs and physicians provided an equivalent amount of low-value health services, dispelling physicians' perceptions that APCs provide lower-value care than physicians for these common conditions. Primary Funding Source: U.S. Health Services and Research Administration, Ryoichi Sasakawa Fellowship Fund, and National Institutes of Health.

Correction: Previously Undisclosed Potential Conflict of Interest by an Author of American College of Physicians Clinical Guidelines

Rapid Diagnosis of Capnocytophaga Infection Made by Peripheral Blood Smear | Annals of Internal Medicine: Clinical Cases

Dog bites causing local infection are common but seldom lead to life-threatening complications. We present a case of a 52-year-old woman who presented with septic shock and multiorgan failure after sustaining a dog bite. At presentation, she was in multiorgan failure with a necrotic bite wound on her finger and a petechial rash on her face, arms, and legs. Abdominal imaging revealed asplenia. Her peripheral smear showed rod-like inclusions within neutrophils, consistent with intracellular bacilli. A diagnosis of Capnocytophaga infection was made. She was started on broad-spectrum antibiotics, including piperacillin–tazobactam, and made a full recovery.

Vitamin C Deficiency as a Mimicker of Vasculitis: A Case | Annals of Internal Medicine: Clinical Cases

Scurvy causes poor wound healing, hemarthrosis, petechiae, perifollicular hemorrhages, and nonspecific myalgia. Although studies report that scurvy can mimic vasculitis on physical examination, the disease lacks the laboratory evidence for vasculitis. We introduce a patient with scurvy whose clinical presentation and laboratory findings mimicked vasculitis, which led to a delayed diagnosis and high resource expenditure. This case highlights the importance of early dietary history in patients with concern for vasculitis. Early dietary history and involvement of the nutrition team can significantly decrease invasive and costly testing procedures and improve diagnosis and patient outcomes.

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.

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.

Iatrogenic Hyperkalemia Induced by Hypermagnesemia From Administration of Laxatives in a Patient With Gastroparesis | Annals of Internal Medicine: Clinical Cases

Magnesium-containing drugs such as magnesium citrate are popular over-the-counter laxatives used to treat constipation. Although generally well tolerated, excessive intake can result in potentially dangerous electrolyte abnormalities. Of these abnormalities, hyperkalemia is one that is heavily underreported. We report an elderly woman who presented for gastroparesis flare-up and constipation. She was given magnesium citrate and subsequently developed hypermagnesemia, which resulted in hyperkalemia. By presenting this case, we hope to increase awareness of this heavily underreported side effect of magnesium-based laxatives, especially in the setting of gastrointestinal disturbances that may affect the absorption of these electrolytes.

Osteomyelitis Pubis After Initiation of an SGLT2 Inhibitor | Annals of Internal Medicine: Clinical Cases

Osteomyelitis pubis is a rare infectious entity that is often misdiagnosed. Early clinical suspicion and appropriate diagnostic workup are required to prevent a delay in diagnosis and to differentiate the disease from alternative noninfectious diagnoses such as osteitis pubis. Herein, we report a case of osteomyelitis pubis with delayed diagnosis in a patient who recently initiated an SGLT2 inhibitor before the onset of symptoms. The effect of SGLT2 inhibitors on the risk of this disease is unknown but may warrant further investigation, as this case highlights.

Ophthalmoplegia and Tumor Lysis Syndrome: An Uncommon Presentation of Posttransplant Lymphoproliferative Disorder | Annals of Internal Medicine: Clinical Cases

A 55-year-old man presented with 1 month of fatigue, nausea, vomiting, and weight loss, and blurry vision in his left eye. He has a history of type 1 diabetes mellitus after allogenic kidney and pancreas transplantation 15 years prior. He was found to have tumor lysis syndrome (TLS), total left-sided ophthalmoplegia and ptosis, and left cavernous, abdomen, and pelvic masses. Biopsy revealed an Epstein-Barr virus–negative diffuse large B-cell lymphoma, a type of posttransplant lymphoproliferative disorder (PTLD). It is essential to consider PTLD in transplant patients who present with TLS and compressive neurologic deficits.

Recurrent Cryptogenic Stroke in a Young Woman: Congenital Thrombotic Thrombocytopenic Purpura Unmasked | Annals of Internal Medicine: Clinical Cases

Cryptogenic stroke of undetermined cause should warrant an exhaustive neurologic and cardiovascular workup. If no cause is identified, additional investigations should be individualized on the basis of clinical history and objective findings. Herein, we present the case of a young patient with a personal and family history of cryptogenic stroke who was investigated for thrombophilia. Transient thrombocytopenia and peripheral blood schistocytes led to an eventual diagnosis of congenital thrombotic thrombocytopenic purpura, which is characterized by vaso-occlusive end-organ complications. The diagnosis is confirmed by undetectable ADAMTS13 (a disintegrin and metalloproteinase with thrombospondin type 1 motifs, member 13) activity.

Lymphoid Interstitial Pneumonia Associated With Hashimoto Thyroid Disease | Annals of Internal Medicine: Clinical Cases

Lymphoid interstitial pneumonia (LIP) refers to the diffuse infiltration and accumulation of lymphocytes within the alveolar interstitium and may be associated with multiple autoimmune diseases, most notably Sjögren syndrome. Only rare cases of LIP have been reported in patients with Hashimoto thyroiditis. In these cases, the patients also had at least 1 additional autoimmune disease. We report a case of LIP in a 70-year-old woman whose only autoimmune disease was Hashimoto thyroiditis. This case supports the hypothesis that Hashimoto thyroiditis alone may instigate the development of LIP.

Beyond Uremia: Chronic Kidney Disease as a Cryptic Gateway for Opportunistic Neuroinvasion by John Cunningham Virus | Annals of Internal Medicine: Clinical Cases

Progressive multifocal leukoencephalopathy (PML), a devastating demyelinating central nervous system infection caused by John Cunningham virus (JCV) reactivation, typically occurs in profound immunosuppression. Chronic kidney disease (CKD) induces a state of “immunoparalysis” through uremic toxin-mediated T-cell dysfunction yet remains an underrecognized risk factor for PML. We present a 72-year-old man with end-stage renal disease who developed subacute expressive aphasia and confusion. Magnetic resonance imaging showed demyelinating white matter lesions, and cerebrospinal fluid confirmed JCV DNA, establishing PML. This case highlights CKD as a cryptic immunosuppressive state predisposing to PML and emphasizes the importance of considering PML in patients with CKD presenting with new, progressive neurologic deficits.

MKSAP quiz on head injuries | ACP Hospitalist

Acute exacerbation of COPD | ACP Hospitalist

Cases from The Ohio State University | ACP Hospitalist

Troponin, vitamin D, and more | ACP Hospitalist

Transitions of care, readmissions, and more | ACP Hospitalist

Readmissions metrics, procalcitonin testing in CAP, and more | ACP Hospitalist

Taking stock of the readmission penalties | ACP Hospitalist

Preop meds, resuscitation champions, and more | ACP Hospitalist

MKSAP quiz on discharge planning | ACP Hospitalist

Nutrition, contrast and AKI, and more | ACP Hospitalist