ACP Multimedia Education

Game Plan Refresh Series for Trained WBCs Marion McCrary, MD, FACP, and NC Well-being Champion (WBC), revisits strategies learned during your WBC training and new skills to grow your toolkit to support you and your colleagues. Revisit Coaching Skills of GROW and Appreciative Inquiry Watch Video

January 20, 2023

Coaching Resources for Well-being Champions

Patients Before Paperwork

Advocacy in Action Now available: ACP's 2023 end-of-year graphic demonstrating ACP's advocacy in action. View here! ACP and the AMA AMA House of Delegates Takes Action on Medicare Payment, Prior Authorization, Physician Network Inadequacies and More

Noteworthy Resources

How to Ask Coaching Questions Carol Kauffman, PhD, ABPP, PCC, founder and co-chair of the Institute of Coaching at McLean, Affiliate of Harvard Medical School, shares an overview of and foundational skills for asking coaching questions. View here!

In the News

Benefits of Coaching for Individuals and Organizations by Institute of Coaching McLean, Affiliate of Harvard Medical School Explore evidence-based coaching research and the benefits of coaching for individuals and organizations. Read Now! Research IDs Factors Linked to Internal Medicine Resident Flourishing by Elana Gotkine

From the Trenches

Supporting a Colleague in Need by Kerri Palamara, MD, MACP Republished from the January 2023 issue of I.M. Thriving

ACP Multimedia Education

Mini But Mighty Skills for Well-being: Appreciative Inquiry (15 minutes) View here!

January 19, 2024

January 18, 2019

Announcements Dear ACP Well-being Champions:

Professional Fulfillment Zone

AVAILABLE NOW to ACP Members! The new year is the perfect time to prioritize your personal and professional growth. ACP's member-exclusive Physician Peer Coaching Program offers multiple opportunities to receive expert support to help you set a vision, create a plan, and achieve meaningful change in a sustainable way.

Cardiovascular Disease Mortality Among Native Hawaiian and Pacific Islander Adults Aged 35 Years or Older, 2018 to 2022

Background: Native Hawaiian and Pacific Islander (NHPI) adults have historically been grouped with Asian adults in U.S. mortality surveillance. Starting in 2018, the 1997 race and ethnicity standards from the U.S. Office of Management and Budget were adopted by all states on death certificates, enabling national-level estimates of cardiovascular disease (CVD) mortality for NHPI adults independent of Asian adults. Objective: To describe CVD mortality among NHPI adults. Design: Race-stratified age-standardized mortality rates (ASMRs) and rate ratios were calculated using final mortality data from the National Vital Statistics System for 2018 to 2022. Setting: Fifty states and the District of Columbia. Participants: Adults aged 35 years or older at the time of death. Measurements: CVD deaths were identified from International Classification of Diseases, 10th Revision codes indicating CVD (I00 to I99) as the underlying cause of death. Results: From 2018 to 2022, 10 870 CVD deaths (72.6% from heart disease; 19.0% from cerebrovascular disease) occurred among NHPI adults. The CVD ASMR for NHPI adults (369.6 deaths per 100 000 persons [95% CI, 362.4 to 376.7]) was 1.5 times higher than for Asian adults (243.9 deaths per 100 000 persons [CI, 242.6 to 245.2]). The CVD ASMR for NHPI adults was the third highest in the country, after Black adults (558.8 deaths per 100 000 persons [CI, 557.4 to 560.3]) and White adults (423.6 deaths per 100 000 persons [CI, 423.2 to 424.1]). Limitation: Potential misclassification of underlying cause of death or race group. Conclusion: NHPI adults have a high rate of CVD mortality, which was previously masked by aggregation of the NHPI population with the Asian population. The results of this study support the need for continued disaggregation of the NHPI population in public health research and surveillance to identify opportunities for intervention. Primary Funding Source: National Institute of General Medical Sciences, National Institutes of Health.

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.

How Would You Manage This Patient With Type 2 Diabetes and Chronic Kidney Disease? Grand Rounds Discussion From Beth Israel Deaconess Medical Center

Nearly 15% of U.S. adults have diabetes; type 2 diabetes (T2D) accounts for more than 90% of cases. Approximately one third of all patients with diabetes will develop chronic kidney disease (CKD). All patients with T2D should be screened annually for CKD with both a urine albumin–creatinine ratio and an estimated glomerular filtration rate. Research into strategies to slow the worsening of CKD and reduce renal and cardiovascular morbidity in patients with T2D and CKD has evolved substantially. In 2022, a consensus statement from the American Diabetes Association and the Kidney Disease: Improving Global Outcomes recommended prioritizing the use of sodium–glucose cotransporter-2 inhibitors and metformin and included guidance for add-on therapy with glucagon-like peptide 1 receptors agonists for most patients whose first-line therapy failed. It also recommended nonsteroidal mineralocorticoid receptor antagonists for patients with hypertension that is not adequately controlled with angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers. Here, an endocrinologist and a nephrologist discuss the care of patients with T2D and CKD and how they would apply the consensus statement to the care of an individual patient with T2D who is unaware that he has CKD.

Colorectal Cancer Screening Completion and Yield in Patients Aged 45 to 50 Years: An Observational Study: Annals of Internal Medicine: Vol 177, No 12

Background: Guidelines now recommend initiating colorectal cancer (CRC) screening at age 45 years rather than 50 years, but little is known about screening completion and yield among people aged 45 to 49 years. Objective: To evaluate fecal immunochemical test (FIT) completion and yield in patients aged 45 to 49 versus 50 years. Design: Retrospective cohort study. Setting: Kaiser Permanente Northern California, Washington, and Colorado. Patients: Those distributed a FIT kit during January to September 2022. Measurements: FIT completion within 3 months, FIT positivity, receipt of colonoscopy within 3 months after a positive FIT result, and colonoscopy yield. Results: A total of 267 732 FIT kits were distributed: 213 928 (79.9%) to patients aged 45 to 49 years, and 53 804 (20.1%) to those aged 50 years. Overall, FIT completion was slightly higher in patients aged 45 to 49 years (38.9% vs. 37.5%; adjusted risk ratio [aRR], 1.05 [95% CI, 1.04 to 1.06]), although at Colorado, those aged 45 to 49 years were substantially less likely to complete a FIT (30.7% vs. 40.2%; aRR, 0.77 [CI, 0.73 to 0.80]). Overall, FIT positivity was lower in patients aged 45 to 49 years (3.6% vs. 4.0%; aRR, 0.91 [CI, 0.84 to 0.98]), and receipt of colonoscopy after a positive FIT result was similar between groups (64.9% vs. 67.4%; aRR, 1.00 [CI, 0.94 to 1.05]). Adenoma detection was lower in the younger group (58.8% vs. 67.7%; aRR, 0.88 [CI, 0.83 to 0.95]). Yields were similar for adenoma with advanced histology (13.2% vs. 15.9%; aRR, 0.86 [CI, 0.69 to 1.07]), polyp with high-grade dysplasia (3.4% vs. 5.1%; aRR, 0.68 [CI, 0.44 to 1.04]), sessile serrated lesion (10.3% vs. 11.7%; aRR, 0.92 [CI, 0.71 to 1.21]), and CRC (2.8% vs. 2.7%; aRR, 1.10 [CI, 0.62 to 1.96]). Limitation: The small number of neoplasia events contributed to wide CIs. Conclusion: Similar FIT completion and yield rates in people aged 45 to 50 years support initiation of CRC screening at age 45 years. Primary Funding Source: Kaiser Permanente Sidney R. Garfield Memorial Fund.

Untangling the Benefits of Time-Restricted Eating: Is It the Calories or the Time Restriction?

Infectious Diseases: What You May Have Missed in 2023

In 2023, published research on COVID-19 remains prominent. The aim of this article is to highlight important developments in infectious disease evidence unrelated to COVID-19 that were published in 2023. The literature was screened for sound new evidence relevant to internal medicine specialists and subspecialists whose focus of practice is not infectious diseases. The highlighted publications relate to various organisms and patient populations. One article provides insight into the updated guidelines for the diagnosis and management of infective endocarditis. Several articles address the management of sepsis and bacteremia: comparison of cefepime versus piperacillin–tazobactam, ceftobiprole for the treatment of complicated Staphylococcus aureus bacteremia, and early switch from intravenous to oral antibiotics in patients with gram-negative bacteremia. Another article examines differences in all-cause mortality in patients with Clostridioides difficile infection who receive different treatments. Additional articles provide evidence about the treatment of patients with HIV infection: the utility of preexposure prophylaxis to prevent HIV infection, the efficacy of pitavastatin in reducing cardiovascular disease, and the efficacy of dexamethasone for the treatment of tuberculous meningitis in persons with HIV.

Rheumatology: What You May Have Missed in 2023

Many patients with rheumatologic conditions receive care from physicians other than rheumatologists. Here we note key findings from 6 studies in rheumatology published in 2023 that offer valuable insights for internal medicine specialists and subspecialists outside of rheumatology. The first study investigated the effect of low-dose glucocorticoids on patients with rheumatoid arthritis (RA) over 2 years and challenged existing perceptions about the risks of glucocorticoids in this setting. The second study focused on the updated guideline for preventing and treating glucocorticoid-induced osteoporosis. With the chronic and widespread use of glucocorticoids, the American College of Rheumatology emphasized the importance of assessing fracture risk and initiating pharmacologic therapy when appropriate. The third study explored the potential use of methotrexate in treating inflammatory hand osteoarthritis, suggesting a novel approach to managing this challenging and common condition. The results of the fourth article we highlight suggest that sarilumab has promise as an adjunct treatment of polymyalgia rheumatica relapse during glucocorticoid dosage tapering. The fifth study evaluated sublingual cyclobenzaprine for fibromyalgia treatment, noting both potential benefits and risks. Finally, the sixth article is a systematic review and meta-analysis that assessed the therapeutic equivalence of biosimilars and reference biologics in the treatment of patients with RA. Knowledge of this recent literature will be useful to clinicians regardless of specialty who care for patients with these commonly encountered conditions.

Long COVID Definitions and Models of Care: A Scoping Review: Annals of Internal Medicine: Vol 177, No 7

Background: Definitions of long COVID are evolving, and optimal models of care are uncertain. Purpose: To perform a scoping review on definitions of long COVID and provide an overview of care models, including a proposed framework to describe and distinguish models. Data Sources: English-language articles from Ovid MEDLINE, PsycINFO, the Cochrane Library, SocINDEX, Scopus, Embase, and CINAHL published between January 2021 and November 2023; gray literature; and discussions with 18 key informants. Study Selection: Publications describing long COVID definitions or models of care, supplemented by models described by key informants. Data Extraction: Data were extracted by one reviewer and verified for accuracy by another reviewer. Data Synthesis: Of 1960 screened citations, 38 were included. Five clinical definitions of long COVID varied with regard to timing since symptom onset and the minimum duration required for diagnosis; 1 additional definition was symptom score–based. Forty-nine long COVID care models were informed by 5 key principles: a core “lead” team, multidisciplinary expertise, comprehensive access to diagnostic and therapeutic services, a patient-centered approach, and providing capacity to meet demand. Seven characteristics provided a framework for distinguishing models: home department or clinical setting, clinical lead, collocation of other specialties, primary care role, population managed, use of teleservices, and whether the model was practice- or systems-based. Using this framework, 10 representative practice-based and 3 systems-based models of care were identified. Limitations: Published literature often lacked key model details, data were insufficient to assess model outcomes, and there was overlap between and variability within models. Conclusion: Definitions of long COVID and care models are evolving. Research is needed to optimize models and evaluate outcomes of different models. Primary Funding Source: Agency for Healthcare Research and Quality. (Protocol posted at https://effectivehealthcare.ahrq.gov/products/long-covid-models-care/protocol.)

Self-reflection on an Elevated BMI

Ethics and Academic Discourse, Scientific Integrity, Uncertainty, and Disinformation in Medicine: An American College of Physicians Position Paper

Respect for the scientific process and a diversity of views; open discourse and debate based on principles of ethics, best available evidence, and scientific inquiry and integrity; and an understanding of evidence gaps and uncertainty and how to communicate about them are important values in the advancement of science and the practice of medicine. Physicians often must make decisions about their recommendations to patients in the face of scarce or conflicting data. Are these characteristics of medicine and science widely understood and effectively communicated among members of the profession and to patients and the public? Issues of scientific integrity are longstanding, but COVID-19 brought them to the forefront, in an environment that was sometimes characterized by communication missteps as guidance came and went—or changed—quickly. Today, is open debate flourishing? Have some debates shed more heat than light? Are people losing confidence in science and medicine? In health care institutions? The American College of Physicians explores these issues and offers guidance in this position paper.

Advocacy as a core aspect of patient care

Put words in our mouth

Correction to “Drug Reactions a Risk with NOAC Treatment for Afib”

New ACP paper advises on how to be effective advocates through collective action

Opioid dose escalation, rapid tapering associated with all-cause mortality in older patients

MKSAP Quiz: 3-week history of fever, dyspnea on exertion

Military sexual trauma linked with later suicide attempts, death by suicide or overdose

Drug may lower flu transmission among households, industry trial finds

And the winner is …

Volunteers needed to answer ACP MKSAP pretest questions

Take a quiz about the Feb. 12 issue! | ACP Hospitalist

SEP-1 bundle hasn't been proven to reduce mortality, review finds | ACP Hospitalist

Rise in white blood cell count can be expected 48 hours after steroid dose, study finds | ACP Hospitalist

Pleural effusion may be indicator of mortality risk in certain conditions | ACP Hospitalist

On the threshold | ACP Hospitalist

Hammer and nails | ACP Hospitalist

Early stroke complications associated with poor outcomes after discharge | ACP Hospitalist

U.S. has higher CV hospitalization rate of older adults than Denmark | ACP Hospitalist

Thrombectomy fails to provide benefit in stroke with medium, distal occlusions | ACP Hospitalist

Take a quiz about the Feb. 5 issue! | ACP Hospitalist

Infection or Malignancy? A Novel Co-Diagnosis in a Patient After Hematopoietic Stem Cell Transplant | Annals of Internal Medicine: Clinical Cases

Patients undergoing hematopoietic stem cell transplant are susceptible to various opportunistic infections after transplantation, including reactivation of latent infections. We report a patient with acute neurologic worsening after allogeneic hematopoietic stem cell transplant complicated by chronic graft-versus-host disease who was concurrently diagnosed with cerebral toxoplasmosis and post-transplant lymphoproliferative disorder with central nervous system involvement, the first such reported co-diagnosis to our knowledge. Management of these patients can be challenging due to the continued need for immunosuppression to control graft-versus-host disease. Due to the high mortality associated with either condition, this co-diagnosis ultimately proved fatal in our patient.

Biceps Tendon Rupture as an Early Manifestation of Hereditary Transthyretin Amyloidosis | Annals of Internal Medicine: Clinical Cases

Amyloidosis is a protein-folding disorder that leads to extracellular fibrillar deposition, often resulting in multiorgan dysfunction and tissue damage. Although several organs are subject to amyloid deposition, early identification and treatment of cardiac disease is crucial for efficacy of therapy. Here, we describe the cases of 2 men who reported biceps tendon ruptures several years before their diagnosis of cardiac amyloidosis.

Increasing Representation in Clinical Images: Ludwig Angina | Annals of Internal Medicine: Clinical Cases

We describe an African American woman with uncontrolled diabetes who presented with 3 days of jaw pain, drooling, and dysphagia due to Ludwig angina. Images include her physical examination (trismus, poor dentition, and asymmetrical tissue swelling) and radiographic findings (developing abscess). This case also illustrates why the medical education field must continue to increase representation in patients with darker skin tones in clinical images.

Diagnosing Smoldering Multiple Myeloma and Light Chain Amyloidosis in the Setting of Severe Transthyretin Amyloid Cardiomyopathy and Extracardiac Sarcoidosis | Annals of Internal Medicine: Clinical Cases

Light chain (AL) amyloidosis involves deposition of monoclonal immunoglobulin light chain-derived amyloid fibrils, whereas ATTR amyloidosis involves deposition of insoluble antiparallel beta-pleated protein within tissues, leading to organ-specific damage. Regardless of ATTR amyloid status, serum protein electrophoresis with immunofixation is appropriate in cases of cardiac amyloidosis, as treatment of an underlying plasma cell dyscrasia drastically differs. This case illustrates the importance of universal screening for AL amyloidosis in the context of clinical findings for cardiac amyloidosis.

Nitrous Oxide–Induced Neurologic Deficits: A Case Report | Annals of Internal Medicine: Clinical Cases

A 22-year-old man presented to the emergency department with a 1-week history of severe ataxia, inability to walk, and symmetrical bilateral upper- and lower-extremity paresthesia. Magnetic resonance imaging of the C-spine showed diffuse elevated T2 signal in the dorsal columns. Axial view of the C-spine revealed a lesion in the dorsal column that was hyperintense on T2-weighted images; this finding is called the “inverted V sign,” that is typically seen in subacute combined degeneration.

Orbital Inflammatory Disease as Initial Presentation of Primary Sjögren Syndrome | Annals of Internal Medicine: Clinical Cases

Sjögren syndrome (SS) is a chronic inflammatory disorder characterized by diminished lacrimal and salivary gland functions. It also has been associated with musculoskeletal, dermatologic, respiratory, cardiac, nervous system, renal, gastrointestinal, and hematologic involvement. Neurologic involvement, when present, is more often pure sensory neuropathy. Orbital inflammation with abducens nerve (cranial nerve VI) palsy is a previously unreported complication of Sjögren syndrome (SS). A 61-year-old woman who presented with diplopia on lateral gaze, eye pain, and periorbital swelling was diagnosed with orbital inflammation and primary SS. She was treated successfully with high-dose steroids and cyclophosphamide.

Cytomegalovirus-Related Immune Thrombocytopenic Purpura in an Immunocompetent Adult | Annals of Internal Medicine: Clinical Cases

We present the case of a 42-year-old immunocompetent man who was diagnosed with acute immune thrombocytopenic purpura and had evidence of an acute cytomegalovirus infection, concerning for secondary immune thrombocytopenic purpura. The patient presented with diffuse petechial rash, epistaxis, and gingival bleeding after a prodromal flu-like illness. His initial laboratory test results were significant for transaminitis, a platelet count of 6 K/μL, and a cytomegalovirus viral load of 2030 copies. He was treated with dexamethasone, intravenous immunoglobulin, and valganciclovir, with improvement noted in his platelet count to 331 K/μL.

Murine Double Minute 2–Positive Primary Pulmonary Artery Intimal Sarcoma Diagnosed by Pulmonary Arterial Catheter Aspiration After Emergency Admission | Annals of Internal Medicine: Clinical Cases

We present a rare case of primary pulmonary artery intimal sarcoma diagnosed after emergency admission for respiratory failure in an 80-year-old man. Tumor cells were obtained through minimally invasive pulmonary arterial catheter aspiration at a high-intensity magnetic resonance–diffusion-weighted imaging–highlighted site. Despite the patient's poor overall condition, right heart catheterization confirmed the diagnosis and murine double minute 2 positivity. Palliative care was implemented, and the patient died 13 days after admission. Our case underscores the importance of recognizing this sarcoma in pulmonary artery abnormalities, highlighting complementary roles of magnetic resonance–diffusion-weighted imaging in increasing prediagnostic probability and right heart catheterization in facilitating minimally invasive murine double minute 2 assessment.

Watermelon-Induced Hyperkalemia: A Case Series | Annals of Internal Medicine: Clinical Cases

Hyperkalemia is a potentially life-threatening electrolyte disorder. In patients with stable chronic kidney disease, on stable doses of renin–angiotensin–aldosterone system inhibitors and with adequate distal sodium delivery, an exogenous source of increased potassium intake should be investigated in patients with new hyperkalemia. Watermelon is an under-recognized source of excess dietary potassium, with 2 wedges (1/8th of a watermelon) containing 16.4 mmol (640 mg) of potassium. This emphasizes the importance of dietary counseling in patients with advanced chronic kidney disease, including end-stage renal disease. We present a case series of 3 patients with excess watermelon consumption causing severe hyperkalemia.

Warfarin for Priapism With Primary Antiphospholipid Syndrome: From Culprit to Cure | Annals of Internal Medicine: Clinical Cases

Priapism is a hemodynamic disorder of penile circulation that results in persistent erection in the absence of sexual stimulation. It poses significant adverse effects on quality of life, and if left untreated, it can possibly lead to permanent erectile dysfunction. We present a case of a 38-year-old man with recurrent episodes of veno-occlusive priapism for 8 years, positive lupus anticoagulant antibody, and underlying antiphospholipid syndrome. Anticoagulant therapy was started, with considerable improvement in his symptoms. This report aims to highlight the atypical presentation of priapism, its pathophysiology, and the role of anticoagulation in patients with antiphospholipid syndrome.