Search Results for: "depression"

Background: Time-restricted eating (TRE), limiting daily dietary intake to a consistent 8 to 10 hours without mandating calorie reduction, may provide cardiometabolic benefits. Objective: To determine the effects of TRE as a lifestyle intervention combined with current standard-of-care treatments on cardiometabolic health in adults with metabolic syndrome. Design: Randomized controlled trial. (ClinicalTrials.gov: NCT04057339) Setting: Clinical research institute. Participants: Adults with metabolic syndrome including elevated fasting glucose or hemoglobin A1c (HbA1c; pharmacotherapy allowed). Intervention: Participants were randomly assigned to standard-of-care (SOC) nutritional counseling alone (SOC group) or combined with a personalized 8- to 10-hour TRE intervention (≥4-hour reduction in eating window) (TRE group) for 3 months. Timing of dietary intake was tracked in real time using the myCircadianClock smartphone application. Measurements: Primary outcomes were HbA1c, fasting glucose, fasting insulin, homeostasis model assessment of insulin resistance, and glycemic assessments from continuous glucose monitors. Results: 108 participants from the TIMET study completed the intervention (89% of those randomly assigned; 56 women, mean baseline age, 59 years; body mass index of 31.22 kg/m2; eating window of 14.19 hours). Compared with SOC, TRE improved HbA1c by −0.10% (95% CI, −0.19% to −0.003%). Statistical outcomes were adjusted for age. There were no major adverse events. Limitation: Short duration, self-reported diet, potential for multiple elements affecting outcomes. Conclusion: Personalized 8- to 10-hour TRE is an effective practical lifestyle intervention that modestly improves glycemic regulation and may have broader benefits for cardiometabolic health in adults with metabolic syndrome on top of SOC pharmacotherapy and nutritional counseling. Primary Funding Source: National Institutes of Health.

Physician Humility: A Review and Call to Revive Virtue in Medicine

Physician virtues, including humility, are crucial for shaping a physician's identity and practice. The health care literature offers varied views on humility, and the rising call for discussing virtues as a framing for professional identity formation underscores the need for a clearer understanding of physician humility. This review aimed to develop a cohesive conceptualization of physician humility and to define how it functions in medical practice. To achieve this, a comprehensive search was done across PubMed, Ovid MEDLINE, Web of Science, Embase, ERIC, and PsycInfo, covering all records up to 30 October 2023. Articles were included if they discussed physician humility and excluded if they were unrelated to physician humility, focused on nonphysician health professionals, lacked conceptual depth, or focused solely on cultural humility. An applied thematic analysis was conducted. The results provide a synthesized conceptualization of physician humility across stances toward self, others, and the profession. The included articles identified the pivotal role of physician humility within the following 5 domains of medical practice: learning and professional growth, navigating error, uncertainty tolerance, trust and entrustment, and teamwork and communication. The authors highlight some of the intrapersonal, interpersonal, and sociocontextual challenges to cultivating and practicing physician humility. These findings highlight the importance of promoting humility in shaping physicians’ actions, thoughts, and relationships with patients, colleagues, and their profession. Integrating such virtues as humility into medical education is essential for upholding the ideals of the medical profession and cultivating moral agents who engage in self-reflection and embody the principles of exemplary physicians.

Development and Evaluation of a Framework for Identifying and Addressing Spin for Harms in Systematic Reviews of Interventions

“Spin” refers to misleading reporting, interpretation, and extrapolation of findings in primary and secondary research (such as in systematic reviews). The study of spin primarily focuses on beneficial outcomes. The objectives of this research were threefold: first, to develop a framework for identifying spin associated with harms in systematic reviews of interventions; second, to apply the framework to a set of reviews, thereby pinpointing instances where spin may be present; and finally, to revise the spin examples, offering guidance on how spin can be rectified. The authors developed their framework through an iterative process that engaged an international group of researchers specializing in spin and reporting bias. The framework comprises 12 specific types of spin for harms, grouped by 7 categories across the 3 domains (reporting, interpretation, and extrapolation). The authors subsequently gathered instances of spin from a random sample of 100 systematic reviews of interventions. Of the 58 reviews that assessed harm and the 42 that did not, they found that 28 (48%) and 6 (14%), respectively, had at least 1 of the 12 types of spin for harms. Inappropriate extrapolation of the results and conclusions for harms to populations, interventions, outcomes, or settings not assessed in a review was the most common category of spin in 17 of 100 reviews. The authors revised the examples to remove spin, taking into consideration the context (for example, medical discipline, source population), findings for harms, and methodological limitations of the original reviews. They provide guidance for authors, peer reviewers, and editors in recognizing and rectifying or (preferably) avoiding spin, ultimately enhancing the clarity and accuracy of harms reporting in systematic review publications.

Regulatory Framework for Cannabis: A Position Paper From the American College of Physicians

Cannabis, also known as marijuana, is the dried flowers, stems, seeds, and leaves of the Cannabis sativa plant. It contains more than 100 compounds, including tetrahydrocannabinol, which has psychoactive effects. Federal law prohibits the possession, distribution, and use of cannabis outside limited research activities, but most states have legalized cannabis for medical or recreational use. However, research into the potential therapeutic and adverse health effects of cannabis has been limited, in part because of the drug’s federal legal status. In this position paper, the American College of Physicians (ACP) calls for the decriminalization of possession of small amounts of cannabis for personal use and outlines a public health approach to controlling cannabis in jurisdictions where it is legal. ACP recommends the rigorous evaluation of the health effects and potential therapeutic uses of cannabis and cannabinoids as well as research into the effects of legalization on cannabis use. It also calls for evidence-based medical education related to cannabis and increased resources for treatment of cannabis use disorder.

Pulmonology: What You May Have Missed in 2023

The field of pulmonology saw significant advances in 2023. The publications highlighted in this article address advances and changes in practice related to asthma, chronic obstructive pulmonary disease (COPD), interstitial lung disease, pleural disorders, and sleep-disordered breathing. One article reviews data examining the efficacy of vaccination against respiratory syncytial virus, a respiratory viral illness that has had devastating effects globally. Four studies evaluate the role of various therapies in COPD, including dupilumab, ensifentrine, pulmonary rehabilitation programs, and lung volume reduction versus endobronchial valves. Another study explores the effect on vascular events of positive-pressure ventilation in patients with sleep-disordered breathing and recent stroke. The use of combination therapy with rituximab and mycophenolate mofetil on progression-free survival in patients with nonspecific interstitial pneumonia is the topic of another study. We also highlight an update of clinical recommendations for the evaluation of patients with pleural disorders and a systematic review analyzing the effectiveness of inhaled corticosteroids as a supplement to dual therapy for COPD.

Effect of Four Hemoglobin Transfusion Threshold Strategies in Patients With Acute Myocardial Infarction and Anemia: A Target Trial Emulation Using MINT Trial Data: Annals of Internal Medicine: Vol 177, No 11

Background: The optimal hemoglobin threshold to guide red blood cell (RBC) transfusion for patients with acute myocardial infarction (MI) and anemia is uncertain. Objective: To estimate the efficacy of 4 individual hemoglobin thresholds (<10 g/dL [<100 g/L], <9 g/dL [<90 g/L], <8 g/dL [<80 g/L], and <7 g/dL [<70 g/L]) to guide transfusion in patients with acute MI and anemia. Design: Prespecified secondary analysis of the MINT (Myocardial Ischemia and Transfusion) trial using target trial emulation methods. (ClinicalTrials.gov: NCT02981407) Setting: 144 clinical sites in 6 countries. Participants: 3492 MINT trial participants with acute MI and a hemoglobin level below 10 g/dL. Intervention: Four transfusion strategies to maintain patients’ hemoglobin concentrations at or above thresholds of 10, 9, 8, or 7 g/dL. Protocol exceptions were permitted for specified adverse clinical events. Measurements: Data from the MINT trial were leveraged to emulate 4 transfusion strategies and estimate per protocol effects on the composite outcome of 30-day death or recurrent MI (death/MI) and 30-day death using inverse probability weighting. Results: The 30-day risk for death/MI was 14.8% (95% CI, 11.8% to 18.4%) for a <10-g/dL strategy, 15.1% (CI, 11.7% to 18.2%) for a <9-g/dL strategy, 15.9% (CI, 12.4% to 19.0%) for a <8-g/dL strategy, and 18.3% (CI, 14.6% to 22.0%) for a <7-g/dL strategy. Absolute risk differences and risk ratios relative to the <10-g/dL strategy for 30-day death/MI increased as thresholds decreased, although 95% CIs were wide. Findings were similar and imprecise for 30-day death. Limitation: Unmeasured confounding may have persisted despite adjustment. Conclusion: The 30-day risks for death/MI and death among patients with acute MI and anemia seem to increase progressively with lower hemoglobin concentration thresholds for transfusion. However, the imprecision around estimates from this target trial analysis precludes definitive conclusions about individual hemoglobin thresholds. Primary Funding Source: National Heart, Lung, and Blood Institute.

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Displaying 61 - 70 of 86 in Annals of Internal Medicine: Clinical Cases

Multisystem Inflammatory Syndrome Leading to Myocardial Infarction After SARS-CoV-2 Vaccination | Annals of Internal Medicine: Clinical Cases

The most common adverse effects of SARS-CoV-2 vaccines are injection site reactions and systemic symptoms, such as fever and malaise, which are typically self-limiting. Multisystem inflammatory syndrome after SARS-CoV-2 vaccination (MIS-V) is rare. In this report, we describe a case of a 22-year-old man who developed MIS-V with myocardial infarction. Optical coherence tomography (OCT) showed blurring of intravascular structure, intimal thickening, and medial vessel destruction. High-dose glucocorticoid and antithrombotic therapy were effective as shown through improvement in OCT findings.

Reversible Improvement of Arterial Stenosis and Wall Thickness in Takayasu Arteritis Through Treatment With Tocilizumab | Annals of Internal Medicine: Clinical Cases

Early diagnosis and initiation of treatment in Takayasu arteritis (TA) is important to prevent irreversible arterial changes. A 39-year-old female was diagnosed with active TA. Subcutaneous administration of tocilizumab (162 mg/week) was initiated in combination with prednisolone (30 mg/d). After 21 months, the carotid arterial stenosis and wall thickness had normalized with only slight plaque on echocardiography. After 23 months, computed tomography showed normalization of the overall aortic stenosis and wall thickness. The prednisolone dosage could be reduced to 2 mg/d without relapse for >2 years. Early combination treatment of TA with tocilizumab prevented and normalized vascular stenosis and wall thickness.

Lymphomatoid Granulomatosis Presents With Nodal and Bone Marrow Invasion: A Case Report and Literature Review | Annals of Internal Medicine: Clinical Cases

Lymphomatoid granulomatosis (LYG) is a rare lymphoproliferative disease driven by Epstein-Barr virus (EBV) infection. It is characterized by pulmonary involvement; however, nodal and bone marrow invasion are very rare. Tissue biopsy is the cornerstone of diagnosis. To our knowledge, this is the first case of LYG presenting with nodal, spleen, and bone marrow invasion on initial work-up. Imaging suggested nodal and marrow site invasion along with classical lung lesions. Biopsy and immunoprofile confirmed EBV+ B-cell lymphoma, which is diagnostic of LYG grade 3. The patient responded to chemotherapy for this high-grade disease.

An Immunocompromised Adult With Oral Ulcers | Annals of Internal Medicine: Clinical Cases

Infection with Histoplasma capsulatum has a broad spectrum of clinical manifestations, ranging from asymptomatic, subclinical infection in the immunocompetent host to severe, disseminated disease in the immunocompromised host. We report a case of disseminated histoplasmosis with oral mucocutaneous manifestations in a patient with advanced HIV/AIDS and poor antiretroviral adherence. We also discuss key aspects in the diagnosis and management of disseminated histoplasmosis in patients with HIV/AIDS.

Pancreatic Acinar Cell Carcinoma in the Setting of a BRCA1 Germline Mutation | Annals of Internal Medicine: Clinical Cases

Pancreatic acinar cell carcinoma (PACC) is a rare neoplasm of the exocrine pancreas. PACC’s molecular and genetic features are poorly elucidated compared with pancreatic ductal cell carcinoma. Here, we present the patient case of a woman in her late 60s, with a BRCA1 germline mutation and a medical history of breast and lung adenocarcinomas diagnosed with PACC. A literature search identified only 2 reported cases of PACC associated with a BRCA1 germline mutation.

Methotrexate-Associated Lymphoproliferative Disorder With Gingival Swelling | Annals of Internal Medicine: Clinical Cases

A 63-year-old Japanese man being treated for pemphigus vulgaris with methotrexate (MTX) presented with a fever of unknown origin. His only symptom at onset was mild gingival swelling. Suspected to have gingivitis, he was followed for 1 month. After that, he presented with cervical lymphadenopathy, dysphagia, and bicytopenia, and a diagnosis of MTX-associated lymphoproliferative disorder (MTX-LPD) was finally made by gingival biopsy. He had spontaneous remission after the withdrawal of MTX. When MTX-treated patients complain of fever and oral lesions, even if the oral lesions present as mild gingival swellings, physicians should consider MTX-LPD and perform a diagnostic biopsy.

Rosai-Dorfman Disease Presenting as Massive Mediastinal Lymphadenopathy in an Elderly Man | Annals of Internal Medicine: Clinical Cases

We present a patient case of a 73-year-old man with new-onset substernal chest pain and B symptoms, found on computed tomography imaging to have massive mediastinal lymphadenopathy of more than 6 cm. Positron emission tomography imaging revealed fluorodeoxyglucose-avid nodes further extending to the axillary, abdominal, and inguinal regions. After a broad patient work-up for infectious, malignant, and rheumatic causes, he was ultimately diagnosed with Rosai-Dorfman disease, a rare histiocytic neoplasm, by excisional lymph node biopsy.

Prostate Adenocarcinoma With Atypical Immunohistochemistry Presenting With a Cheerio Sign | Annals of Internal Medicine: Clinical Cases

The most common cancer in men is prostate cancer. The Cheerio sign is the computed tomography finding of multiple pulmonary nodules with central lucency resembling the ring-shaped Cheerio breakfast cereal. Unlike bone metastasis, pulmonary involvement is less common. The Cheerio sign has malignant and benign etiologies. Thyroid transcription factor-1 (TTF-1) stain is commonly used in the diagnosis of primary lung cancer. TTF-1 positivity in cancers of prostate origin is rare, with only case reports and small case series available in the literature. Metastatic prostate cancer presenting with a Cheerio sign has not been reported in the literature.

A Rare Case of Paraneoplastic Dermatomyositis in a Patient With Metastatic Endometrial Cancer | Annals of Internal Medicine: Clinical Cases

Dermatomyositis (DM) is a rare autoimmune myopathy that presents with muscle weakness and characteristic skin manifestations. Certain malignancies are associated with DM, such as stomach, colorectal, ovarian, lung, pancreatic, and non-Hodgkin lymphoma. However, there are only rare reports of endometrial cancer with DM. In this report, we describe a case of anti–TIF-1-gamma and anti-Mi-2 antibody positive DM in a patient with stage IV endometrial cancer. This case illustrates the importance of considering DM as a paraneoplastic syndrome regardless of both stage and type of malignancy.

Metastatic Lobular Carcinoma of the Breast Masquerading as Gallstone Disease – A Case Report | Annals of Internal Medicine: Clinical Cases

The gallbladder is a rare site of breast cancer metastasis. We report the patient case of a 60-year-old woman with isolated metastasis to the gallbladder, which was surgically removed for symptomatic cholelithiasis, with a subsequent new diagnosis of infiltrating lobular carcinoma (ILC) of the breast. ILC tends to metastasize to unusual sites such as the gastrointestinal and genitourinary tracts, but these usually occur concurrently with other more common sites of distant metastasis such as the bone, lungs, and liver. Our case underscores the need for routine histologic examination of gallbladder after cholecystectomy.

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