Patients Before Paperwork

Advocacy in Action ACP Preps Advocacy To-Do List for New Trump Administration In the wake of the election of President-elect Donald Trump, there has been much media speculation about whom he will appoint to his Cabinet and what health care legislation may be repealed or dissected for parts; the American College of Physicians is currently working to make sure its voice will be heard.

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

Association of Work Control With Burnout and Career Intentions Among U.S. Physicians: A Multi-Institution Study Annals of Internal Medicine: Christine A. Sinsky, MD; Roger L. Brown, PhD; Lisa Rotenstein, MD; Lindsey E. Carlasare, MBA; Purva Shah, BS; and Tait D. Shanafelt, MD

From the Trenches

“Top 10 Tips to Beat Loneliness at Work” In this article from ACP's I.M. Matters, Kerri Palamara, MD, MACP, discusses how the challenge of isolation and loneliness at work can be exacerbated by personal and societal circumstances, workplace stressors, and technology. Read here!

January 17, 2025

Professional Fulfillment Zone: Internal Medicine Meeting 2026 Preview

The ACP Internal Medicine Meeting Heads to the West Coast April 16-18, 2026!Register now to join us at the Internal Medicine Meeting in San Francisco, CA!Register here!

Patients Before Paperwork

Advocacy in ActionACP: New Federal Changes to Student Loan Forgiveness Programs and Loan Limits Threaten the Physician Pipeline and Patient AccessACP is advocating against a new final rule on the Public Service Loan Forgiveness Program that will restrict program eligibility for certain nonprofit employers.

Noteworthy Resources for Well-being

New! WBC Social Share ZoneAttention all WBCs and ACP Chapter Leaders! Please take some time to explore our new Social Share Zone. We have compiled shareable graphics and resources highlighting well-being that you can use on social media, in presentations, or at your events. In addition, you will find resources on trauma education, physician suicide awareness, and ACP's Mini But Mighty Skills.Social Share Zone

In the News

Efficacy of Individual-Level Interventions to Mitigate the Risk for Burnout Among Health Care Professionals: A Systematic Review and Meta-analysis of Randomized Controlled TrialsAnnals of Internal Medicine: G. Collett, PhD; J. Gupta, MD; A. Eltayeb, MBBS, MPH; A. Korszun, MD, PhD; L. Sharples, PhD; K. Rice, PhD; A.K. Gupta, MD, PhD

From the Trenches

“The lake at night: Music helped solve a medical mystery.”Learn how music helped solve a medical mystery from a special issue of ACP Hospitalist.Read here!

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.

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

Annals publishes CDC immunization schedules, stresses the importance of vaccination

Drug reactions a risk with NOAC treatment for afib

MKSAP Quiz: Abdominal distention in cirrhosis

Digital intervention helped improve depression outcomes in primary care

Study charts rising rates of U.S. psilocybin use across age groups

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Register now for Internal Medicine Meeting 2026 in San Francisco

ACP calls for urgent policy action on rural health

Targeted screening for patients at highest genetic risk of prostate cancer increased clinical management, radical treatment

MKSAP Quiz: 3-month history of symmetric polyarthritis

Nonopioid approved for moderate to severe pain | ACP Hospitalist

Hospitalists lack knowledge about handling dysphagia in dementia, survey finds | ACP Hospitalist

Genotyping may help predict afib risk after stroke | ACP Hospitalist

A phone call is not enough | ACP Hospitalist

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

Women more likely to be hospitalized with TIA, have subsequent hemorrhage | ACP Hospitalist

Take a quiz about the Jan. 29 issue! | ACP Hospitalist

Rethinking AMA | ACP Hospitalist

Lending an ear | ACP Hospitalist

Home-based cardiac rehab noninferior to center-based for HF | ACP Hospitalist

Isolated Cranial Nerve VI Palsy in Granulomatosis With Polyangiitis | Annals of Internal Medicine: Clinical Cases

Granulomatosis with polyangiitis has many presentations and is known to cause optic neuropathies, but the mechanism of injury is usually related to mass effect from a space-occupying granuloma. In this case report, we present a patient with cranial nerve VI mononeuropathy from granulomatosis with polyangiitis secondary to inflammation alone. This underscores the importance of considering vasculitis in the setting of neuropathy even in the absence of space-occupying lesion.

Acute Kidney Injury From Acute Oxalate Nephropathy in Diabetic Ketoacidosis: A Case Report | Annals of Internal Medicine: Clinical Cases

Acute oxalate nephropathy is a rare cause of acute kidney injury. Most cases of hyperoxaluria and oxalate nephropathy have been due to increased oxalate absorption from enzymatic defects or malabsorption. Here, we describe a 60-year-old woman with long-standing diabetes who developed acute oxalate nephropathy during hospitalization due to renal hypoperfusion from diabetic ketoacidosis, nonsteroidal anti-inflammatory drug use, angiotensin-converting enzyme inhibitor use, and nephrotoxic antibiotics. The patient required hemodialysis briefly and improved with intravenous fluids with residual renal dysfunction on follow-up. Oxalate nephropathy causes severe renal failure, and it is an important differential diagnosis in patients with predisposing factors.

Tularemia in the Midwest: Perspectives on Diagnosis, Treatment, and Increasing Incidence | Annals of Internal Medicine: Clinical Cases

Tularemia, caused by Francisella tularensis, is an uncommon, reportable bacterial infection historically endemic to the South Central United States. We report a case of tularemia in a healthy 83-year-old man living in Michigan presenting with fevers, weight loss, and fatigue in addition to having an extensive exposure history. Despite reported efficacy with oral fluoroquinolone therapy, escalation to combination intravenous antibiotic therapy was required. As transmission of arthropod-borne pathogens appears to be increasing in historically unaffected regions, such as F tularensis in Michigan, physicians should consider tularemia in patients with fever of unknown cause and compatible exposure risk factors to ensure timely treatment and reporting.

Late Presentation of Myotonic Dystrophy Presenting With Dyspnea and Hypoxemia | Annals of Internal Medicine: Clinical Cases

Myotonic dystrophy type 1 (dystrophia myotonica, DM1) is a rare, heritable muscular dystrophy characterized by skeletal and smooth muscle weakness and myotonia. We present a case of a 34-year-old man with hypoxic respiratory failure found to have DM1. This case is noteworthy in 2 regards: first, it highlights an uncommon cause of hypoxic respiratory failure. Second, this presentation of DM1 is noteworthy, as the patient's diagnosis was made late in the disease course due to unique social factors.

Acute Calcific Tendonitis: A Rare Cause of Finger Pain | Annals of Internal Medicine: Clinical Cases

Acute calcific tendonitis rarely affects small joints of the hand. When it involves a finger, the presenting clinical features of swelling, redness, and tenderness often are misdiagnosed as felon or avulsion fractures. It is important to differentiate between these causes of finger pain to avoid unnecessary antibiotics and/or surgery.

Chronic Myelomonocytic Leukemia Associated With TAFRO Syndrome-Like Symptoms | Annals of Internal Medicine: Clinical Cases

Thrombocytopenia, anasarca, fever, reticulin fibrosis, renal dysfunction, and organomegaly (TAFRO) syndrome is a recent disease concept whose physiopathology remains largely unknown. Association of TAFRO syndrome features with immune-mediated or hematologic disorders have been reported but have not been reported with chronic myelomonocytic leukemia. Chronic myelomonocytic leukemia (CMML) is a myeloproliferative/myelodysplastic syndrome that is frequently associated with autoimmune or autoinflammatory features. Herein, we report 2 cases of CMML-associated TAFRO syndrome-like symptoms. The first one was fatal, and the second one was successfully treated with siltuximab. These reports question the Masaki criteria for TAFRO syndrome diagnosis, which require excluding an autoimmune, neoplastic, or infectious condition beforehand.

Constrictive Pericarditis After a Stab Wound of the Chest | Annals of Internal Medicine: Clinical Cases

Constrictive pericarditis is an uncommon cause of diastolic heart failure resulting by impaired cardiac filling from an inelastic pericardium. We present a case of constrictive pericarditis in a 39-years-old man following thoracic penetrating trauma in which histologic specimens have shown pericardial layer invasion by squamous cells from the skin. Moreover, the multimodality imaging approach has been essential for diagnosis and case management.

Ingested Denture as an Esophageal Foreign Body | Annals of Internal Medicine: Clinical Cases

A 74-year-old man presented with shortness of breath and sore throat and was admitted for an acute exacerbation of chronic obstructive pulmonary disease. He developed severe sore throat, stridor, and hoarseness over the subsequent 72 hours and was found to have an upper denture lodged in his upper esophagus that was missed on admission radiograph of the chest. Dentures are the second most common foreign body ingested after fish and animal bones and usually require flexible or rigid endoscopic intervention.

Recurrent Intracranial Hemorrhages in a Patient With Hb Tak and Hb E | Annals of Internal Medicine: Clinical Cases

Although several hemoglobin variants have been characterized, many have poorly understood clinical significance. We report the case of a 34-year-old Thai man who was found to have Hb Tak and Hb E after presenting with polycythemia and intracranial hemorrhages. His clinical condition improved after the evacuation of an intraparenchymal hematoma, and he received counseling on smoking cessation, antihypertensive therapy, and phlebotomies. Neither Hb Tak nor Hb E were previously associated with cerebrovascular disease. Clinicians should consider using hemoglobin electrophoresis to identify hemoglobin variants in the work-up of polycythemia and closely follow these patients while mitigating risk factors to prevent such adverse events.

A Case Series of Recreational Ketamine-Induced Cholangiopathy | Annals of Internal Medicine: Clinical Cases

Ketamine, a dissociative anesthetic, is growing in popularity among young adults as a “club drug” in the U.S. Chronic use may lead to dependence and withdrawal symptoms, but ketamine also has been associated with ulcerative cystitis. We describe severe cholestasis and cholangiopathy in 6 young adults with chronic recreational ketamine use. All presented with progressive abdominal pain and cholestasis, sometimes with concomitant urinary symptoms and weight loss. In each case, there was marked biliary duct dilatation without evidence of obstruction, suggestive of sclerosing cholangitis. In some cases, the biliary duct dilatation was reversible with cessation of ketamine use.