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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 the Answers! 3 Steps to Better Connect With a Colleague Who Needs You Watch Video

July 21, 2023

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

From the Trenches

“National Physician Burnout Study: Latest Statistics on Burnout in Healthcare and Doctor Well-Being” Burnout in medicine: When was burnout at its peak for doctors? Why are doctors so burnt out? What causes burnout in health care? Is there a National Burnout Study? From the latest episode of AMA Update, Michael Tutty, PhD, group vice president of Professional Satisfaction and Practice Sustainability at the American Medical Association.

July 18, 2025

ACP Well-being Champions: Cultivating Connections in Uncertain Times

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Patients Before Paperwork

ACP Advocate Newsletter Advocacy in Action: ACP Strengthens Advocacy to Prevent Firearm Violence Amid Recurrence of Mass Shootings The American College of Physicians continues to press legislators to take action to prevent firearm violence.

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.

Nephrology: What You May Have Missed in 2023

This article highlights a selection of important nephrology studies published in 2023 that have relevance for nonnephrologist physicians. Four studies examined progression of chronic kidney disease or cardiovascular disease with respect to finerenone use, magnesium supplementation, iron markers, and COVID-19. Two studies examined treatments to improve specific aspects of chronic kidney disease management, including daprodustat to address anemia and patiromer to address hyperphosphatemia. One study showed that acetazolamide added to loop diuretics increased diuresis in acute decompensated heart failure across a wide range of renal function. Another study found that once-daily hydrochlorothiazide did not prevent kidney stone recurrence. Finally, an antibiotic stewardship intervention safely reduced antibiotic prescribing for suspected urinary tract infection in frail older adults.

Denial, Old Friend

Cardiology: What You May Have Missed in 2023

Cardiology and all its subspecialties continue to push the envelope in developing new treatment strategies for a wide variety of diseases. After screening more than 1300 articles, we highlight a selection of important cardiology articles published in 2023. Starting with prevention, we note articles that look at the effect of semaglutide in patients with obesity as well as a first-in-class drug, bempedoic acid, on cardiovascular outcomes. We have also examined new evidence comparing conservative management with invasive management of frail, older patients with non–ST-segment elevation myocardial infarction (NSTEMI). In patients with cardiac arrest secondary to NSTEMI, another article examines the rationale for expedited transfer to a cardiac arrest center. The STREAM-2 (Strategic Reperfusion in Elderly Patients Early After Myocardial Infarction) trial builds on looking at half-dose thrombolysis in older populations with STEMI. Emphasis is placed on guideline-directed medical therapy before hospital discharge in those with heart failure. In addition, in patients with stable symptomatic coronary artery disease, initial noninvasive testing using coronary computed tomography angiography may be a viable option compared with invasive strategies. More details have emerged on anticoagulation strategies in those with device-detected atrial fibrillation. Finally, transcatheter approaches to treat both mitral and tricuspid regurgitation have also been included.

Body Surface Area in Obesity: Clinical Challenges and Call for Improvements

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.

Critical Care: What You May Have Missed in 2023

Critical care medicine is a specialty that brings together a truly wide spectrum of patient populations, disease states, and treatment methods. This article highlights 10 important pieces of research from 2023 (and 1 from 2022) in critical care. The literature was screened for new evidence relevant to internal medicine physicians and hospitalists whose focus of practice is not critical care but who may be taking care of seriously ill patients. The articles highlight the diverse spectrum of pathology and interplay of various specialties that go into critical care. Topics include transfusion medicine, fluid resuscitation, safe intubation practices and respiratory failure, and the management of acute ischemic stroke. Several trials are groundbreaking, forcing clinicians to reconsider preexisting dogma and likely adopt new treatment strategies.

Race, Health Care Algorithms, and Precision Health Equity

Beyond the Bacillus: Closing Gaps in Tuberculosis Health Disparities Requires Targeting Social Determinants

Moving Beyond Central Line–Associated Bloodstream Infections

Beta-blockers associated with worse outcomes in new PAH

Denosumab associated with hypocalcemia requiring treatment in patients with advanced CKD

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CNS polypharmacy common in older U.S. adults with dementia

Nearly half of deaths among patients hospitalized for flu occur postdischarge

MKSAP Quiz: 2-month history of neck pain

Daytime sleepiness associated with cognitive issues, slow gait speed

Increase in alcohol use during pandemic persisted through 2022

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New edition of ACP's The Works released

Parenteral, enteral, and malnutrition in the hospital | ACP Hospitalist

New studies highlight importance of intervening on OUD during hospitalization | ACP Hospitalist

Invasive group A strep incidence up sharply in the U.S. over last decade | ACP Hospitalist

First national practice standards for hospital at home developed | ACP Hospitalist

Beefing up on BCNE | ACP Hospitalist

Take a quiz about the March 26 issue! | ACP Hospitalist

Hospitalizations common among patients with substance use disorder | ACP Hospitalist

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

Malignant Melanoma Disguised as Biliary Obstruction | Annals of Internal Medicine: Clinical Cases

In melanoma, symptomatic involvement of the small bowel is exceedingly rare. When melanoma spreads to the gastrointestinal tract, the prognosis worsens significantly. We present the case of a 70-year-old woman with secondary malignant melanoma of the gastrointestinal tract. Our patient, who had been treated for a stage I melanoma 4 years prior, presented with symptoms of frequent constipation, heartburn, and nausea. A biopsy of the masses on her back and axilla showed malignant melanoma. Computed tomography showed marked dilation of the common bile duct. Endoscopic retrograde cholangiopancreatography was unsuccessful owing to malignant infiltration of the ampulla. Biliary drainage via percutaneous port placement and immunotherapy were initiated.

Acute Localized Abdominal Pain From Primary Epiploic Appendagitis | Annals of Internal Medicine: Clinical Cases

This report describes primary epiploic appendagitis in a 40-year-old man. He had the classic physical finding of highly localized abdominal pain and the classic computed tomography findings of a hyperattenuating ring sign and a central dot sign.

Male Mammary Myofibroblastoma | Annals of Internal Medicine: Clinical Cases

Mammary myofibroblastoma is a rare mesenchymal neoplasm that represents less than 1% of breast tumors. It is a benign lesion first described in 1987 and to date has a minimal number of reported cases. Clinical knowledge of its presence is important as it can strongly resemble malignant tumors owing to its nonspecific imaging findings and morphologically similar appearance to its aggressive counterparts. We present a case of a unilateral myofibroblastoma in a late 50-year-old male. The rare tumor was found incidentally during a cardiac work-up, which led to extensive imaging and immunohistochemical analysis to definitively make the diagnosis.

An Uncommon Cause of Cardiac Arrest: Tamponade Secondary to Malignant Pericardial Effusion From Myxoid Sarcoma | Annals of Internal Medicine: Clinical Cases

Primary tumors involving the pericardium are rare and often are incidentally discovered with transthoracic echocardiography. These tumors cause complications from obstruction of cardiac function with hemodynamic instability. We present a case of a 30-year-old man with primary myxoid sarcoma that resulted in cardiac arrest from malignant pericardial effusion. Despite partial resection and chemotherapy, the patient died. Despite being rare, with a 2-year survival of 60%, it is important for clinicians to be able to recognize complications from this tumor. Although no formal guidelines exist, performing surveillance echocardiography in this patient population could prevent some complications.

Lacrimal Gland Enlargement as an Extraintestinal Manifestation of Crohn Disease: A Case Report | Annals of Internal Medicine: Clinical Cases

A 29-year-old woman was referred for a 3-month history of recurrent fever, abdominal pain, and diarrhea. Abdominal computed tomography (CT) scans revealed diffuse intestinal wall thickening involving the transverse colon. When her abdominal pain recurred 1 month later, she noticed bilateral upper eyelid edema with an “S-shaped” contour. Lacrimal gland CT scans revealed enlarged lacrimal glands. Crohn disease sometimes presents with extraintestinal symptoms including ocular complications. Dacryoadenitis is rarely associated with ocular complications. Enteroscopy revealed a noncaseating granuloma in the small intestine, and Crohn disease was diagnosed. We report the characteristics of dacryoadenitis resulting from Crohn disease and review published case reports.

Muscular Polyarteritis Nodosa: A Case Series Study of 6 Patients | Annals of Internal Medicine: Clinical Cases

A subset of polyarteritis nodosa known as muscular polyarteritis nodosa (MPAN) is a disease process that remains mostly limited to the muscle. Here, we report 6 patient cases of MPAN for which we investigated the clinical features. We examined 6 patients who visited our department between April 2010 and October 2019 and had a confirmed diagnosis of MPAN. The clinical features of MPAN include fever, myalgia, muscle tenderness without restricted joint range of motion, elevated C-reactive protein levels, and normal creatine kinase levels. In the presence of such features, MPAN should be suspected and magnetic resonance imaging and biopsy be performed.

Pylephlebitis With Concomitant Fusobacterium Bacteremia: Lemierre's Syndrome Variant of the Gut | Annals of Internal Medicine: Clinical Cases

Pylephlebitis is a rare complication of intra-abdominal infections, and Fusobacterium, traditionally associated with thrombophlebitis of the internal jugular vein, is an extremely rare causative organism. This infection is associated with high morbidity and mortality, and there is still some controversy about management. Here, we report a patient who presented with pylephlebitis and Fusobacterium bacteremia and responded well to a short course of intravenous antibiotics, finished therapy in the outpatient setting, and made a full recovery. We also review relevant literature on treatment strategies including antibiotics, anticoagulation, and screening endoscopy.

Unstable Atrial Fibrillation RVR and DNR: A Challenging Ethical Dilemma | Annals of Internal Medicine: Clinical Cases

An 82-year-old man with history of dementia and atrial fibrillation (AF) was admitted for sepsis and subsequently developed AF with rapid ventricular response (RVR). Given a recent do not resuscitate (DNR) order, there was disagreement among providers regarding the use of direct current cardioversion (DCCV). This patient case reveals the ethical challenges faced by providers when patients with a DNR order develop unstable AF with RVR and discusses an ethical framework for decision-making regarding DCCV in patients with a DNR order. This case also promotes changes to clinical practice, such as discussing DCCV when discussing code status and replacing DNR with “no cardiopulmonary resuscitation.”

Cryoglobulinemic Glomerulonephritis Presenting as Acute Kidney Injury on Chronic Kidney Disease in Rheumatoid Arthritis | Annals of Internal Medicine: Clinical Cases

Cryoglobulinemic vasculitis (CV) is one of the manifestations of rheumatoid arthritis (RA). Here, we present a case of a 69-year-old woman with uncontrolled long-standing RA who presented with heart failure exacerbation and had an incidental finding of persistent acute kidney injury, which led to the diagnosis of CV. The rarity of its co-occurrence with RA and the serious consequences from progressive kidney damage makes this case a key learning encounter.

Paget-Schroetter Syndrome in Nonathletic 31-Year-Old Female Without Hypercoagulopathy | Annals of Internal Medicine: Clinical Cases

Paget-Schroetter syndrome is an infrequent event in which an upper-extremity thrombosis forms typically after strenuous overhead activities, such as weight-lifting, swimming, pitching, and wrestling. This occurs most frequently in athletic men in their second or third decade of life and may be associated with thoracic outlet anatomical abnormalities that result in venous compression and increased risk for repetitive microtrauma leading to thrombosis. An atypical presentation in a 31-year-old nonathletic woman information technology worker without hypercoagulability is presented here.