Patients Before Paperwork

Advocacy in Action Remove Stigma From Licensure, Credentialing Applications By Gianna Melillo for I.M. Matters To help remove one barrier to access, physician advocates across the country are working to revise intrusive mental health questions on medical licensing and credentialing applications, one state at a time. View here!

Noteworthy Resources for Well-being

ACP: Design Your Own Well-being Program Explore these tools to create a well-being program tailored to any organization's needs and budget. View here!

In the News

White House Summit on Arts and Culture Earlier this year, the White House held the first ever summit on arts and culture in Washington, DC. "Music," said U.S. Surgeon General Dr. Vivek Murthy, "can, in a matter of seconds, make me feel better ... I've prescribed a lot of medicines as a doctor over the years. There are few I've seen that have that kind of extraordinary, instantaneous effect." Read here!

How We Show Up

By Hugo Davila Grijalva, MD, FACP

From the Trenches

Learn the importance of: "Conquering Imposter Syndrome" Read about how Dr. Kerry Palomara, ACP Well-being expert, uses physician peer coaching to alleviate imposter syndrome. Read here! "How We Show Up" By current Michigan Chapter WBC and Mindfulness-Based Stress Reduction teacher Dr. Hugo Davila.

July 19, 2024

Professional Fulfillment Zone

Cultivating Excellence: The Power of Coaching in Medical Education—New Webinar Is Available Now! Coaching is more than a buzzword! It is a vital skill for medical educators and leaders striving to create meaningful impact in today's fast-paced academic and clinical settings.

Patients Before Paperwork

Advocacy in Action Get Involved: Participate in Essential Advocacy Now Join more than 15,000 colleagues in the Advocates for Internal Medicine Network (AIMn) in advocating for the interests of internal medicine in Washington, DC, and across the country. The AIMn program is for ACP members interested in participating in federal advocacy. It is designed to help members engage with their federal lawmakers on policy issues important to ACP and internal medicine. Follow @AdvocatesIM

Noteworthy Resources for Well-being

ACP: Design Your Own Well-being Program Explore these tools to create a well-being program tailored to any organization's needs and budget. View here!

In the News

Quality Agenda for Internal Medicine From the American College of Physicians Annals of Internal Medicine: May 2025 by Darilyn V. Moyer, Cynthia D. Smith, Shari M. Erickson, Davoren Chick, and Amir Qaseem

Screening for Breast Cancer: Recommendations From the U.S. Preventive Services Task Force

Acupuncture for Treatment of Menopausal Hot Flashes

Heart Problems in Adults Who Survived Cancer as Children

Warning Symptoms May Prevent Some Cases of Sudden Cardiac Arrest

The Effect of Heat Exposure on Myocardial Blood Flow and Cardiovascular Function

Background: Heat extremes are associated with greater risk for cardiovascular death. The pathophysiologic mechanisms mediating this association are unknown. Objective: To quantify the myocardial blood flow (MBF) requirements of heat exposure. Design: Experimental study. (ClinicalTrials.gov: NCT04549974) Setting: Laboratory-based. Participants: 61 participants, comprising 20 healthy young adults (mean age, 28 years), 21 healthy older adults (mean age, 67 years), and 20 older adults with coronary artery disease (CAD) (mean age, 70 years). Intervention: Participants were heated until their core temperature increased 1.5 °C; MBF was measured before heat exposure and at every increase of 0.5 °C in core temperature. Measurements: The primary outcome was MBF measured by positron emission tomography–computed tomography. Secondary outcomes included heart rate, blood pressure, and body weight change. Results: At a core temperature increase of 1.5 °C, MBF increased in healthy young adults (change, 0.8 mL/min/g [95% CI, 0.5 to 1.0 mL/min/g]), healthy older adults (change, 0.7 mL/min/g [CI, 0.5 to 0.9 mL/min/g]), and older adults with CAD (change, 0.6 mL/min/g [CI, 0.3 to 0.8 mL/min/g]). This represented a 2.08-fold (CI, 1.75- to 2.41-fold), 1.79-fold (CI, 1.59- to 1.98-fold), and 1.64-fold (CI, 1.41- to 1.87-fold) change, respectively, from preexposure values. Imaging evidence of asymptomatic heat-induced myocardial ischemia was seen in 7 adults with CAD (35%) in post hoc analyses. Limitations: In this laboratory-based study, heating was limited to about 100 minutes and participants were restricted in movement and fluid intake. Participants refrained from strenuous exercise and smoking; stopped alcohol and caffeine intake; and withheld β-blockers, calcium-channel blockers, and nitroglycerin before heating. Conclusion: Heat exposure that increases core temperature by 1.5 °C nearly doubles MBF. Changes in MBF did not differ by age or presence of CAD, but some older adults with CAD may experience asymptomatic myocardial ischemia. Primary Funding Source: Canadian Institutes of Health Research.

Reducing Low-Value Health Care

Death Need Be in All Caps: The Risk of “Risk Calculation” When Black Folk Are Dying

Moving Beyond Aggregation: Seeking Effective Tools to Advance Health Equity

Estimating the Effects of Health Policy Initiatives: Where We Are and Where We Need to Go

Relaxing Transfusion Thresholds for Patients With Myocardial Infarction: Findings From the MINT Trial

Billing for preventive services in Medicare

Address pain during sex as a normal part of care

Put words in our mouth

ACP review of performance measures for diabetes finds many inadequate

ACP releases new online modules on continuous glucose monitoring

Adding budesonide may reduce exacerbations in mild asthma, industry trial finds

MKSAP Quiz: Evaluation for an episode of dizziness

Chiropractic care for low back pain may decrease later opioid prescriptions

Tomosynthesis may be better than digital mammography in patients with family history of breast cancer

And the winner is …

Hospital tested providing zoledronic acid to inpatients with hip fracture | ACP Hospitalist

Have scope—will travel | ACP Hospitalist

Deprescribing sedatives during hospitalization may reduce adverse events, study finds | ACP Hospitalist

Be alert to elder abuse | ACP Hospitalist

Arterial blood gas testing in ICU patients varies by race, sex | ACP Hospitalist

Take a quiz about the March 19 issue! | ACP Hospitalist

Secure messaging drives increases in EHR use, attention switching | ACP Hospitalist

Nudging physicians about communication with ICU patients did not reduce LOS | ACP Hospitalist

Give patients a rest | ACP Hospitalist

‘Broken heart syndrome’ poses risk of readmission comparable to myocardial infarction | ACP Hospitalist

Unmasking Atrial Septal Defect by Paradoxical Ventilator Response in a Patient With Pulmonary Embolism | Annals of Internal Medicine: Clinical Cases

Positive end-expiratory pressure (PEEP) is used in mechanical ventilation to improve Pao2. Rarely will increasing PEEP result in a reduction of Pao2. Whenever hypoxemia worsens in response to increased PEEP, one must consider the presence of a cardiac or pulmonary shunt. A coexisting pulmonary embolism further exacerbates the effect of PEEP and potentially reveals the presence of a shunt. We present one such case with pneumonia complicated by acute hypoxic respiratory failure necessitating mechanical ventilation with paradoxical hypoxemia despite escalating PEEP. Work-up revealed pulmonary embolism and atrial septal defect in a 69-year-old patient. Successfully managed with airway pressure release ventilation, this case emphasizes the importance of understanding physiology in the management of paradoxical hypoxia.

New Presentation of Takayasu Arteritis in a Patient With Preexisting Ulcerative Colitis | Annals of Internal Medicine: Clinical Cases

Takayasu arteritis (TA) is a rare, large-vessel vasculitis involving the aorta and its primary branches. Associations between TA and ulcerative colitis (UC) have been reported; however, the exact pathophysiologic mechanisms behind this association remain unclear. This case report highlights the new diagnosis of TA, including cardiac involvement, in a young woman with underlying UC that developed while she was receiving anti-tumor necrosis factor-α treatment of her UC.

An Uncommon Case of Eosinophilic Myocarditis in a Patient With Autoimmune Lymphoproliferative Syndrome | Annals of Internal Medicine: Clinical Cases

Eosinophilic myocarditis is a rare but well-described inflammatory condition with high morbidity and mortality but is not reported as caused by underlying autoimmune lymphoproliferative disorder. We describe the case of a patient with left ventricular systolic dysfunction caused by eosinophilic myocarditis in the setting of hypereosinophilic syndrome attributable to autoimmune lymphoproliferative disorder in the absence of other identified causes. In our case, eosinophilic myocarditis occurred as a consequence of hypereosinophilic syndrome after an untreated autoimmune lymphoproliferative disorder. Further surveillance and evaluation of eosinophilic myocarditis in patients with systolic dysfunction and autoimmune lymphoproliferative disorders is warranted.

Effusive Constrictive Pericarditis in the Era of COVID-19 | Annals of Internal Medicine: Clinical Cases

Effusive-constrictive pericarditis is a rare condition in which the visceral pericardium compresses the heart, with fluid accumulation in the pericardial space leading to cardiac tamponade. We present a case of 59-year-old man with effusive-constrictive pericarditis that was refractory to standard therapy. The symptoms appeared after he received a Moderna COVID-19 booster, with electrocardiogram findings showing PR depression and ST-segment elevation and cardiac imaging findings revealing abnormalities including thickened pericardium, ventricular interdependence, and septal bounce. Given the patient's abnormal hemodynamics and intolerance to high-dose nonsteroidal anti-inflammatory drugs, he was prescribed rilonacept. Because of the recalcitrant nature of his disease, pericardial stripping was done to prevent worsening of heart failure.

Checkpoint Inhibitor Myocarditis–Mediated Conduction Abnormalities Reversed With Early Intravenous Steroid Administration: A Case Report | Annals of Internal Medicine: Clinical Cases

A man receiving nivolumab and ipilimumab presented to urgent care following a syncopal episode with troponin elevation before rapidly developing progressive conduction abnormalities from checkpoint inhibitor–mediated myocarditis, which initially required pacing. His arrhythmia resolved with a prompt regimen of steroids. There is a paucity of literature supporting treatment strategies for heart block related to immune checkpoint inhibitor–mediated myocarditis. Most cases have not been treated promptly with aggressive steroid therapy, and rarely have patients been liberated from pacemaker dependence following treatment. This case demonstrates the potentially devastating adverse effects of checkpoint inhibition and emphasizes the necessity of timely diagnosis and treatment.

Diabetic Striatopathy: A Rare Case Report of Chorea, Hyperglycemia, Basal Ganglia (C-H-BG) Syndrome | Annals of Internal Medicine: Clinical Cases

Chorea-hyperglycemia-basal ganglia syndrome is a rare complication of hyperglycemia and unilateral hemichorea-hemiballismus syndrome. Synonyms include diabetic striatopathy and non-ketotic hyperglycemic hemichorea. This occurs in 90% of individuals of Asian descent, particularly female patients with type 2 diabetes. Diagnosis is made when the mean serum glucose level is 481.5 mg/dL, HbA1c level 14.4%, and serum osmolarity of 305.9 mmol/kg. It is managed with antipsychotic drugs and insulin. We report an 80-year-old man with diabetes who presented with disabling unintentional movements of his left extremities affecting his quality of life. Computed tomography and magnetic resonance imaging of the head demonstrated findings of diabetic striatopathy. Risperidone and glycemic control resolved the chorea like-movements.

Severe Polyarticular Gout Flare Inducing Diabetic Ketoacidosis: A Case Report | Annals of Internal Medicine: Clinical Cases

Diabetic ketoacidosis (DKA) is a serious condition that is triggered by multiple stressors, including processes linked to inflammation. Gout is an inflammatory process that has not been directly linked to DKA, but it affects similar pathways, affecting glycemic control. This case illustrates the link between DKA and gout flares with emphasis on the nuanced management of gout in the setting of DKA.

A Case of Hereditary Hemorrhagic Telangiectasia With Gastrointestinal Tract Involvement | Annals of Internal Medicine: Clinical Cases

Hereditary hemorrhagic telangiectasia involves the development of arteriovenous malformations which can occur in various organ systems, including the skin and gastrointestinal tract. These small arteriovenous malformations, known as telangiectasias, are most notable on the nose, lips, oral cavity, and fingers. They lead to recurrent bleeds, commonly presenting as epistaxis before age 20 and, less frequently, as gastrointestinal bleeds after the age of 40. We present the case of a patient with anemia who met the criteria for definite hereditary hemorrhagic telangiectasia.

An Unusual Case of Acute-on-Chronic Liver Failure Leading to Liver Transplantation: Case Report | Annals of Internal Medicine: Clinical Cases

We report a case of acute-on-chronic liver failure manifesting as fulminant hepatitis caused by acute infection with hepatitis C virus in a patient with chronic cirrhosis secondary to former alcohol use. As a treatable cause with readily accessible testing, acute infection should be considered as a possible cause in all cases of acute-on-chronic liver failure. Hepatitis C virus viral load testing should be the test of choice to avoid missing a diagnosis in the window period of acute infection.

Severe Hypercalcemia as Presentation of Atypical Cystic Parathyroid Adenoma: A Case Report | Annals of Internal Medicine: Clinical Cases

Because of their similarities with parathyroid carcinomas, atypical parathyroid adenomas constitute a challenge for pathologists. The diagnosis of this kind of parathyroid tumor also can be difficult for clinicians because of the low accuracy of imaging techniques such as scintigraphy with technetium (Tc)-99m-sestamibi or ultrasonography of the neck, severe hypercalcemia, and high serum levels of intact parathyroid hormone. We present an unusual case of hyperparathyroidism caused by an atypical cystic parathyroid adenoma with hypercalcemia and negative scintigraphy that required dialysis and presented with several postoperative complications. The clinical presentation may have indicated a parathyroid carcinoma; however, a histopathologic diagnosis was key to the diagnosis.