Noteworthy Resources

Well-being Champion Training: Coaching Revisit your coaching curriculum for a refresher. This training explains coaching and the role you may decide to assume as an ACP Well-being Champion (WBC) peer coach. Even if you decide not to be a peer coach, the techniques you will learn in this training will help you succeed in your role as a WBC.

In the News

“I Cry and No One Cares”: Medscape Survey Shows Doctor Burnout, Depression Is Getting Worse by Anastassia Gliadkovskaya More than a third of doctors said they would rather not tell others about their depression, highlighting ongoing stigma for physicians seeking mental health support. Four in 10 believe people will think less of their professional abilities and fear the medical board or their employer will find out.

From the Trenches

What Does Well-being Mean to You Today? Supplement Resource to Coaching Practice by Kerri Palamara, MD, MACP Well-being Wheel Exercise Video We talk a lot about well-being, but it is often hard to define for others and for ourselves.

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. You Don't Need All of the Answers! Three Steps to Better Connect With a Colleague Who Needs You Watch Video

March 17, 2023

ACP Internal Medicine Meeting 2023 Well-being Activities and Career and Professional Development Opportunities

WBCs in Their Community: Promoting Positive Working and Learning Environments

Patients Before Paperwork

Recently Proposed Changes to Race and Ethnicity Standards Will Have Important Impact on Research and Data Collection The Office of Management and Budget is proposing an update to the Race and Ethnicity Statistical Standards to expand the number of categories and make them more specific. View Here!

Noteworthy Resources

Team-Based Care Toolkit ACP has developed this toolkit to share best practices and real-life examples of successful team-based clinical care models that include internal medicine physicians working with nurse practitioners, physician assistants, and other members of the clinical care team. This toolkit includes resources to help foster productive and purposeful internal medicine teams. View here!

In the News

You're Not Alone in Feeling Lonely By Dr. Vivek Murthy, U.S. Surgeon General Loneliness is an experience so many of us have. But what's surprising is how loneliness impacts both our mental and physical health. To mark the release of a groundbreaking new Surgeon General's advisory on loneliness and social connection, Dr. Murthy answers the most common questions he's asked about loneliness. He also shares some of the surprising science around the positive health effects of social connection. This episode is one worth sharing with a friend.

From the Trenches

WBCs in Their Community: Promoting Positive Working and Learning EnvironmentsPuerto Rico WBC Melba Feliciano, MD, FACP, and her team in action. Check out photos from well-being activities at their chapter and in the community. Photo story here!Loneliness & BelongingBy Kerri Palamara, MD, MACP

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.

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.

Put words in our mouth

Article, podcast discuss medical school students, career choices, and challenges

Intensive BP control improved outcomes in patients with type 2 diabetes, trial finds

MKSAP Quiz: Treatment of deep venous thrombosis

Endometriosis linked with increased risk of premature death

Diabetes drugs associated with a lower rate of asthma attacks

Put words in our mouth

ACP offers upcoming webinars on health policy, health care mergers

Co-locating postpartum primary care with pediatrics increased timely uptake of care

MKSAP Quiz: 2-week history of vaginal discharge, itching

Bacterial infection unlikely in almost a third who got extended-spectrum antibiotics in ED | ACP Hospitalist

Take action on anaphylaxis | ACP Hospitalist

Take a quiz about the April 9 issue! | ACP Hospitalist

Poor communication involved in almost a quarter of patient safety incidents | ACP Hospitalist

Optimal medical therapy for HFrEF associated with lower 30-day readmissions | ACP Hospitalist

Intervention reduced antibiotic overuse for skin and soft-tissue infections | ACP Hospitalist

Choices in C. diff care | ACP Hospitalist

Beta-lactams noninferior to fluoroquinolones, trim-sulfa for uncomplicated gram-negative bacteremia | ACP Hospitalist

Thoracentesis didn't improve outcomes in heart failure with pleural effusion | ACP Hospitalist

Take a quiz about the April 2 issue! | ACP Hospitalist

Homozygous Familial Hypobetalipoproteinemia Diagnosed in Adulthood With a New Splicing Variant of the APOB Gene | Annals of Internal Medicine: Clinical Cases

We report a case of familial hypobetalipoproteinemia presenting with severe fat malabsorption, diagnosed in adulthood, with a new splicing variant of the APOB gene.

Ciprofloxacin-Induced Crystal Nephropathy and Allergic Interstitial Nephritis: Case Report and Review of Literature | Annals of Internal Medicine: Clinical Cases

Ciprofloxacin is a commonly used antibiotic that has the potential to cause acute kidney injury (AKI) secondary to interstitial injury or vasculitis. Of all causes, allergic interstitial nephritis is the most common of ciprofloxacin-induced AKI. There have been very few case reports of crystal nephropathy resulting from ciprofloxacin. Most patients with crystal nephropathy respond well to conservative management, but some require hemodialysis and glucocorticoids treatment. We describe a patient case of a 67-year-old woman who developed AKI secondary to ciprofloxacin-induced crystal nephropathy and allergic interstitial nephritis who was successfully managed with hemodialysis and a short course of glucocorticoids.

Pyoderma Gangrenosum Mimicking Necrotizing Fasciitis in a Marathon Runner With Myelodysplastic Syndrome | Annals of Internal Medicine: Clinical Cases

A 62-year-old man with myelodysplastic syndrome presented with fever, leukocytosis, and a violaceous lesion on his right leg. His skin lesion worsened, and his fever persisted despite him receiving broad-spectrum antibiotics and multiple surgical debridements for a presumptive diagnosis of necrotizing fasciitis. Through careful review of histopathologic findings and his clinical presentation, he was subsequently diagnosed with pyoderma gangrenosum (PG). This case highlights an important diagnostic challenge. PG should be suspected in cases of nonresolving soft-tissue infection, particularly in the context of associated systemic disease, negative microbiological results, and negative work-up for autoimmune and malignant conditions.

Eosinophilic Fasciitis: Clinical Signs Leading to Diagnosis | Annals of Internal Medicine: Clinical Cases

Eosinophilic fasciitis is a rare disease characterized by peripheral eosinophilia and inflammatory infiltrate on muscular fascia and subcutaneous tissue. Patients present with edema and stiffening of limbs, progressing rapidly to fibrosis. The Groove sign is a classical physical examination finding. A skin–fascia–muscle biopsy is the gold standard for diagnosis, but nuclear magnetic resonance imaging is also useful. Glucocorticoids in high doses are the initial treatment of choice. We report the patient case of a 22-year-old man with expressive eosinophilia and whose clinical findings (Groove sign and others) led to the diagnosis.

Pediatric COVID-19–Associated Cavernous Sinus Thrombosis | Annals of Internal Medicine: Clinical Cases

This report details the physical and imaging findings associated with a pediatric case of cavernous sinus thrombosis (CST) that developed in the setting of COVID-19 infection, sinusitis, and orbital cellulitis. COVID-19 is rarely associated with CST but may contribute to the development by inducing hypercoagulability.

Deep Rectal Ulceration Associated With Hydrogel Spacer for Prostate Radiation Therapy | Annals of Internal Medicine: Clinical Cases

The report highlights the importance of having a high suspicion of rectal ulceration in patients after radiation therapy. We present a case of 57-year-old man with a history of stage IIIc prostate cancer who developed a solitary rectal ulcer after radiation therapy with a hydrogel spacer. He was diagnosed during colonoscopy and responded well to a course of hyperbaric oxygen therapy.

Human Disease Caused by Kalamiella piersonii | Annals of Internal Medicine: Clinical Cases

Rare or unusual bacteria in blood cultures can be a diagnostic challenge. Here, we report a case of Kalamiella piersonii, a novel gram-negative Enterobacterales belonging to the proposed genus Kalamiella gen nov in the Erwiniaceae family. A 56-year-old woman with a medical history of end-stage nonischemic cardiomyopathy, receiving milrinone through a tunneled catheter, presented to our emergency department with chills and was found to be bacteremic with gram-negative bacilli identified as K piersonii. She was treated with 14 days of intravenous piperacillin-tazobactam without complications.

Severe Rhabdomyolysis After COVID-19 Vaccine | Annals of Internal Medicine: Clinical Cases

A 65-year-old man presented with muscle pain and muscle weakness lasting 1 week that started after his second BNT162b2 COVID-19 vaccine. He had been taking rosuvastatin and gemfibrozil for several years. He was diagnosed with acute kidney failure caused by rhabdomyolysis resulting from a statin-fibrate interaction from a COVID-19 vaccination and was admitted for continuous venovenous hemodiafiltration. Rhabdomyolysis following messenger RNA COVID-19 vaccination is a rare but important adverse event in patients using high-dose statins combined with fibrates. Such patients should be warned to seek medical attention in case of ongoing muscle symptoms after vaccination.

Immune Checkpoint Inhibitor Use in Microscopic Colitis | Annals of Internal Medicine: Clinical Cases

Immune checkpoint inhibitors (ICIs) are a novel class of anticancer therapies that can result in autoimmune pathology known as immune-related adverse events (irAEs). Because of the risk for irAEs, patients with preexisting autoimmune diseases have been excluded from safety trials for ICIs. Although the pathophysiology of microscopic colitis is not fully understood, it is considered part of the spectrum of immune-mediated gastrointestinal diseases. Little is known about the effects of ICIs on patients with microscopic colitis. This case series describes 4 patients with microscopic colitis requiring ICIs for cancer therapy and gastrointestinal-related outcomes after ICI therapy.

Ileitis in Adult Multisystem Inflammatory Syndrome: A Case Report | Annals of Internal Medicine: Clinical Cases

Multisystem inflammatory syndrome (MIS) can manifest with nonspecific gastrointestinal symptoms, fever, shock, and cardiovascular dysfunction. Compared with children, MIS in adults (MIS-A) is rare. We present a definitive case of MIS-A (based on the Brighton criteria) in a young adult with fever, erythematous rash, and prominent gastrointestinal (ileitis) features, elevated inflammatory markers with evidence of cardiac involvement, and renal injury 4 weeks after confirmed SARS-CoV-2 infection. We highlight the histopathologic features from an ileal biopsy, which demonstrated reactive lymphocytic infiltrates. To our knowledge, this is the first report describing intestinal histopathologic findings in MIS-A.