Gout

This issue provides a clinical overview of gout, focusing on prevention and screening, diagnosis, and treatment. The content of In the Clinic is drawn from the clinical information and education resources of the American College of Physicians (ACP), including MKSAP (Medical Knowledge and Self-Assessment Program). Annals of Internal Medicine editors develop In the Clinic in collaboration with the ACP's Medical Education and Publishing divisions and with the assistance of additional science writers and physician writers.

Substance Use Disorders

This issue provides a clinical overview of substance use disorders, focusing on epidemiology, prevention, diagnosis, complications, and management. The content of In the Clinic is drawn from the clinical information and education resources of the American College of Physicians (ACP), including MKSAP (Medical Knowledge and Self-Assessment Program). Annals of Internal Medicine editors develop In the Clinic in collaboration with the ACP's Medical Education and Publishing divisions and with the assistance of additional science writers and physician writers.

Epilepsy

This issue provides a clinical overview of epilepsy, focusing on diagnosis, prevention, treatment, and further considerations. The content of In the Clinic is drawn from the clinical information and education resources of the American College of Physicians (ACP), including MKSAP (Medical Knowledge and Self-Assessment Program). Annals of Internal Medicine editors develop In the Clinic in collaboration with the ACP's Medical Education and Publishing divisions and with the assistance of additional science writers and physician writers.

Annals for Educators - 2 May 2017

Annals Video Summary - High-Concentration THC Cannabis Products and Mental Health Outcomes: A Systematic Review

How Would You Manage HIV Pre-exposure Prophylaxis in This Patient With Medical Comorbidities?: Grand Rounds Discussion From Beth Israel Deaconess Medical Center: Annals of Internal Medicine: Vol 177, No 4

Despite advances in treatment, HIV infection remains an important cause of morbidity and mortality, with more than 30 000 new cases diagnosed in the United States each year. There are several interventions traditionally used to prevent HIV transmission, but these vary in effectiveness and there are challenges to their implementation. In 2014, the Centers for Disease Control and Prevention published initial guidance on the use of antiretroviral pre-exposure prophylaxis (PrEP) to prevent transmission of HIV infection in persons at risk based on multiple studies that showed it to be highly efficacious in various populations. It was updated in 2021 to reflect new drug options. The U.S. Preventive Services Task Force also recently updated its recommendations for PrEP, which strongly support its use in persons at risk. Despite its well-established effectiveness, the implementation of PrEP in clinical practice has been variable, especially among populations underserved by the medical system and marginalized by society. Fewer than one third of persons in the United States who are eligible for PrEP currently receive it. Here, 2 physicians experienced in HIV PrEP debate how best to identify patients who might benefit from PrEP, how to decide what regimen to use, and how to monitor therapy.

The Effect of Influenza Vaccination for the Elderly on Hospitalization and Mortality: An Observational Study With a Regression Discontinuity Design: Annals of Internal Medicine: Vol 172, No 7

Background: Observational studies using traditional research designs suggest that influenza vaccination reduces hospitalizations and mortality among elderly persons. Accordingly, health authorities in some countries prioritize vaccination of this population. Nevertheless, questions remain about this policy's effectiveness given the potential for bias and confounding in observational data. Objective: To determine the effectiveness of the influenza vaccine in reducing hospitalizations and mortality among elderly persons by using an observational research design that reduces the possibility of bias and confounding. Design: A regression discontinuity design was applied to the sharp change in vaccination rate at age 65 years that resulted from an age-based vaccination policy in the United Kingdom. In this design, comparisons were limited to individuals who were near the age-65 threshold and were thus plausibly similar along most dimensions except vaccination rate. Setting: England and Wales. Participants: Adults aged 55 to 75 years residing in the study area during 2000 to 2014. Intervention: Seasonal influenza vaccine. Measurements: Hospitalization and mortality rates by month of age. Results: The data included 170 million episodes of care and 7.6 million deaths. Turning 65 was associated with a statistically and clinically significant increase in rate of seasonal influenza vaccination. However, no evidence indicated that vaccination reduced hospitalizations or mortality among elderly persons. The estimates were precise enough to rule out results from many previous studies. Limitation: The study relied on observational data, and its focus was limited to individuals near age 65 years. Conclusion: Current vaccination strategies prioritizing elderly persons may be less effective than believed at reducing serious morbidity and mortality in this population, which suggests that supplementary strategies may be necessary. Primary Funding Source: National Institute on Aging.

Firearm-Related Hospitalization and Death in Aotearoa New Zealand, 2000 to 2023: A Cohort Study: Annals of Internal Medicine: Vol 178, No 11

Background: There have been multiple changes to the Arms Act 1983 in Aotearoa New Zealand (NZ) which have subsequently been associated with reductions in firearm-related suicide. In response to the worst mass shooting in NZ’s history, stricter regulations on firearm ownership were introduced in 2020. Objective: To describe both individual- and population-level risks for firearm-related offenses, hospitalizations, and deaths in NZ and to summarize the annual costs (in U.S. dollars). Design: Retrospective cohort study. Setting: New Zealand. Participants: All NZ residents (individual-level data, 2000 to 2018; population-level data, 2000 to mid-2024). Measurements: Rates per million people for firearm-related hospitalizations and deaths secondary to assault, accidents, and suicide were examined. Years of life lost (YLLs) and age-adjusted rates were calculated as well as rate ratios (RRs) for hospitalization or death with 95% CIs. Results: Firearm-related hospitalizations and deaths due to self-harm or accidents decreased between 2000 and 2018, but rates due to assault increased 2.5-fold between 2014 and 2018. Hospitalizations due to accidents were higher for children aged 0 to 14 years than for persons aged 15 years or older (RR, 1.11 [95% CI, 0.97 to 1.27]). Māori (RR, 2.88 [CI, 2.30 to 3.61]) and Pacific Peoples (RR, 2.14 [CI, 1.57 to 2.92]) had higher rates of hospitalization due to assault than persons in the European/Other group. The average cost of firearm-related hospitalizations was $871 000 per year, and YLLs yielded a total mortality cost of $189 million per year. Limitation: The results include only firearm-related injuries and deaths resulting in hospitalization and do not include firearm-related injuries that did not result in hospitalization or other burdens of illness related to firearms. Conclusion: The high costs of firearm-related injuries underscore the importance of improving firearm-related harm reduction in NZ. This will depend on maintaining and strengthening current firearm access restrictions and could be enhanced through firearm education. Primary Funding Source: None.

SARS-CoV-2 Vaccine Antibody Response and Breakthrough Infection in Patients Receiving Dialysis

Background: Whether breakthrough SARS-CoV-2 infections after vaccination are related to the level of postvaccine circulating antibody is unclear. Objective: To determine longitudinal antibody-based response and risk for breakthrough infection after SARS-CoV-2 vaccination. Design: Prospective study. Setting: Nationwide sample from dialysis facilities. Patients: 4791 patients receiving dialysis. Measurements: Remainder plasma from a laboratory processing routine monthly tests was used to measure qualitative and semiquantitative antibodies to the receptor-binding domain (RBD) of SARS-CoV-2. To evaluate whether peak or prebreakthrough RBD values were associated with breakthrough infection, a nested case–control analysis matched each breakthrough case patient to 5 control patients by age, sex, and vaccination month and adjusted for diabetes status and region of residence. Results: Of the 4791 patients followed with monthly RBD assays, 2563 were vaccinated as of 14 September 2021. Among the vaccinated patients, the estimated proportion with an undetectable RBD response increased from 6.6% (95% CI, 5.5% to 7.8%) 14 to 30 days after vaccination to 20.2% (CI, 17.0% to 23.3%) 5 to 6 months after vaccination. Estimated median index values decreased from 91.9 (CI, 78.6 to 105.2) 14 to 30 days after vaccination to 8.4 (CI, 7.6 to 9.3) 5 to 6 months after vaccination. Breakthrough infections occurred in 56 patients, with samples collected a median of 21 days before breakthrough infection. Compared with prebreakthrough index RBD values of 23 or higher (equivalent to ≥506 binding antibody units per milliliter), prebreakthrough RBD values less than 10 and values from 10 to less than 23 were associated with higher odds for breakthrough infection (rate ratios, 11.6 [CI, 3.4 to 39.5] and 6.0 [CI, 1.5 to 23.6], respectively). Limitations: Single measure of vaccine response; ascertainment of COVID-19 diagnosis from electronic health records. Conclusion: The antibody response to SARS-CoV-2 vaccination wanes rapidly in persons receiving dialysis. In this population, the circulating antibody response is associated with risk for breakthrough infection. Primary Funding Source: Ascend Clinical Laboratory.

The Limitations of Poor Broadband Internet Access for Telemedicine Use in Rural America: An Observational Study