Institutionalize well-being as a long-term value

Implement recommendations from the Surgeon General Advisory on Health Worker Burnout and Resignation.

From the Trenches

Opportunities to Connect:Topic: Small Feedings of the Soul: Readings and Reflections Series

Create and sustain positive work and learning environments and culture in medicine

Apply positive systems changes skills in 2 mins. or less with ACP’s unique mobile-friendly microlearning resources. Learn about Promoting Psychological Safety, Your Circles of Control and Influence, and Standing Up to Bias and Harassment.

July 15, 2022

Take Steps Toward Promoting Belonging“We all belong in the circle of human concern” - Othering & Belonging Institute

Patients Before Paperwork

ACP Advocate Newsletter Feature: ACP Joins Amicus Briefs in Support of Vaccine Mandates Ahead of special Supreme Court hearing, amicus briefs provide medical perspective for judges considering challenges to mandates for health care workers and employees at large companies.

Noteworthy Resources

COVID-19 Recovery: Promoting Well-being in Residency Programs through Quality Improvement Coaching This webinar recording features panel presentations from resident champions who share how working with a QI coach helped them achieve their quality goals and promoted well-being during the COVID-19 pandemic, followed by a moderated discussion. CME/MOC available. Watch Recording

In the News

Ten Changes That Could Keep Clinicians in the Workforce in a Pandemic By Marcia Frellick, MD Edge The 10-point, one-page checklist [in the Annals of Internal Medicine Getting Through Covid-19: Keeping Clinicians in the Workforce] includes providing “practical support in the areas that clinicians identify as causing emotional stress or moral injury,” such as managing anger and grief when patients have chosen not to be vaccinated or confronting misinformation.

From the Trenches

Opportunities to Connect:Topic: Game Plan Refresh Series for Trained ACP Well-being Champions “Revisit Coaching Skills of GROW and Appreciative Inquiry”

January 21, 2022

Patients Before Paperwork

Request for Information; National Directory of Healthcare Providers & Services [RIN 0938–ZB72] Updates provided by Nadia Daneshvar, ACP Advocacy team ACP responded to a request for information from CMS related to the creation of a “National Provider Directory,” which has some burden-reduction implications for ACP members. The letter was drafted with input from the Medical Informatics Committee (MIC) and came from the MIC chair on behalf of ACP.

Oncology: What You May Have Missed in 2023

Advances in oncology treatment methods have improved outcomes and quality of life for patients with cancer. However, care of these patients can be complex, and the contribution of physicians from different specialties is crucial. This article highlights important publications from 2023 on topics across a wide spectrum relating to the management of oncology patients. The literature was screened for significant new evidence that is relevant to internal medicine specialists and subspecialists whose focus is not oncology. Two articles address the importance of social interventions targeting end-of-life care for low-income and minority patients and the well-being of caregivers. Two additional articles address screening considerations in patients at risk for colorectal and lung cancer. Two more articles address safe use of hormone-related therapies to treat symptoms of menopause and prevent disease recurrence or progression in patients diagnosed with noninvasive breast neoplasia. Finally, several articles were included on topics related to COVID-19 vaccination in patients with cancer, use of cannabinoids for cancer pain control, chronic autoimmune adverse effects related to use of immune checkpoint inhibitors, and the incidence of second primary neoplasms.

Gastroenterology/Hepatology: What You May Have Missed in 2023

This article summarizes clinically important gastroenterology developments from 2023 for internal medicine specialists. In colorectal cancer screening, a new RNA fecal screening test is on the horizon, as well as a new analysis on the benefits of using artificial intelligence in screening colonoscopy to detect more polyps. There is new evidence for management of gastrointestinal bleeding, a new drug for treatment of recurrent small-intestinal angiodysplasia, and a new endoscopic treatment method in patients with gastrointestinal tumor bleeding. The authors feature a randomized trial about amitriptyline as treatment for patients with irritable bowel syndrome by primary care providers and bring you news about new biologic agents for inflammatory bowel disease and eosinophilic esophagitis. Finally, they review 2 important articles on new terminology and management of metabolic dysfunction–associated fatty liver disease.

Resurgence of Dengue in the Era of Genomic Surveillance and Vaccines

Annals Video Summary - Attention Among Health Care Professionals: A Scoping Review

Annals Video Summary - Effect of Weight Loss Interventions on the Symptomatic Burden and Biomarkers of Polycystic Ovary Syndrome

Factors Associated With Recurrent Pediatric Firearm Injury: A 10-Year Retrospective Cohort Analysis: Annals of Internal Medicine: Vol 177, No 10

Background: Firearm injuries are the leading cause of death among children aged 0 to 17 years in the United States. Objective: To examine the factors associated with recurrent firearm injury among children who presented with acute (index) nonfatal firearm injury in the St. Louis region. Design: Multicenter, observational, cohort study. Setting: 2 adult and 2 pediatric level I trauma hospitals in St. Louis, Missouri. Participants: Pediatric patients aged 0 to 17 years presenting with an index firearm injury between 2010 and 2019. Measurements: From the St. Louis Region-Wide Hospital-Based Violence Intervention Program Data Repository, we collected data on firearm-injured patient demographics, hospital and diagnostic information, health insurance status, and mortality. The Social Vulnerability Index was used to characterize the social vulnerability of the census tracts of patients’ residences. Analysis included descriptive statistics and time-to-event analyses estimating the cumulative incidence of experiencing a recurrent firearm injury. Results: During the 10-year study period, 1340 children presented with an index firearm injury. Most patients were Black (87%), non-Hispanic (99%), male (84%), and between the ages of 15 and 17 years (67%). The estimated risk for firearm reinjury was 6% at 1 year and 14% at 5 years after initial injury. Male children and those seen at an adult hospital were at increased risk for reinjury. Limitation: Our data set does not account for injuries occurring outside of the study period and for reinjuries presenting to nonstudy hospitals. Conclusion: Children who experience an initial firearm injury are at high risk for experiencing a recurrent firearm injury. Interventions are needed to reduce reinjury and address inequities in the demographic and clinical profiles within this cohort of children. Primary Funding Source: National Institutes of Health.

Aspirin Use Prevalence for Cardiovascular Disease Prevention Among U.S. Adults From 2012 to 2021

Cost-Effectiveness of Extending Human Papillomavirus Vaccination to Population Subgroups Older Than 26 Years Who Are at Higher Risk for Human Papillomavirus Infection in the United States

Background: In June 2019, the U.S. Advisory Committee on Immunization Practices recommended shared clinical decision making regarding potential human papillomavirus (HPV) vaccination of men and women aged 27 to 45 years (“mid-adults”). Objective: To examine the incremental cost-effectiveness ratios (ICERs) and number needed to vaccinate (NNV) to prevent 1 HPV-related cancer case of expanding HPV vaccination to subgroups of mid-adults at increased risk for HPV-related diseases in the United States. Design: Individual-based transmission dynamic modeling of HPV transmission and associated diseases using HPV-ADVISE (Agent-based Dynamic model for VaccInation and Screening Evaluation). Data Sources: Published data. Target Population: All U.S. mid-adults and higher-risk subgroups within this population. Time Horizon: 100 years. Perspective: Health care sector. Intervention: Expanding 9-valent HPV vaccination to mid-adults and higher-risk subgroups. Outcome Measures: ICERs and NNVs. Results of Base-Case Analysis: Expanding 9-valent HPV vaccination to all mid-adults, those with more lifetime partners, and those who have just separated was projected to cost an additional $2 005 000, $763 000, and $1 164 000 per quality-adjusted life-year (QALY) gained, respectively. The NNVs to prevent 1 additional HPV-related cancer case were 7670, 3190, and 5150, respectively, compared with 223 for vaccination of persons aged 9 to 26 years (vs. no vaccination). Results of Sensitivity Analysis: The mid-adult strategy with the lowest ICER and NNV was vaccinating infrequently screened mid-adult women who have just separated and have a higher number of lifetime sex partners (ICER, $86 000 per QALY gained; NNV, 470). Limitation: Uncertainty about rate of new sex partners and natural history of HPV among mid-adults. Conclusion: Vaccination of mid-adults against HPV is substantially less cost-effective and produces higher NNVs than vaccination of persons younger than 26 years under all scenarios investigated. However, cost-effectiveness and NNV are projected to improve when higher-risk mid-adult subgroups are vaccinated, such as mid-adults with more sex partners and who have recently separated, and women who are underscreened. Primary Funding Source: Centers for Disease Control and Prevention.

Severe Maternal and Neonatal Morbidity Among Gestational Carriers: A Cohort Study: Annals of Internal Medicine: Vol 177, No 11

Background: Use of a gestational (“surrogate”) carrier is increasingly common. Risk for maternal and neonatal adversity is largely unknown in this birthing population. Objective: To determine the risk for severe maternal morbidity (SMM) and severe neonatal morbidity (SNM) in gestational carriers. Design: Population-based cohort study. Setting: All of Ontario, Canada. Participants: All singleton births at more than 20 weeks’ gestation, from 2012 to 2021. Measurements: Exposure was type of conception, namely, gestational carriage (main exposure), unassisted conception (comparison group 1), and in vitro fertilization (IVF) (comparison group 2). Main composite outcomes were SMM and SNM. Modified Poisson regression models generated weighted relative risks (wRRs) using propensity score–based overlap weighting. Secondary outcomes included hypertensive disorders of pregnancy, cesarean delivery, preterm birth, and postpartum hemorrhage. Results: Of all eligible singleton births, 846 124 (97.6%) were by unassisted conception, 16 087 (1.8%) by IVF, and 806 (0.1%) by gestational carriage. Respective risks for SMM were 2.3%, 4.3%, and 7.8%. The wRRs were 3.30 (95% CI, 2.59 to 4.20) comparing gestational carriage with unassisted conception and 1.86 (CI, 1.36 to 2.55) comparing gestational carriage with IVF. Respective risks for SNM were 5.9%, 8.9%, and 6.6%, generating wRRs of 1.20 (CI, 0.92 to 1.55) for gestational carriage versus unassisted conception and 0.81 (CI, 0.61 to 1.08) for gestational carriage versus IVF. Hypertensive disorders, postpartum hemorrhage, and preterm birth at less than 37 weeks were also significantly higher contrasting gestational carriers to either comparison group. Limitation: Absence of information about indications for choosing a gestational carrier, and oocyte or sperm donor source. Conclusion: Among singleton births of more than 20 weeks’ gestation, a higher risk for SMM and adverse pregnancy outcomes was seen among gestational carriers compared with women who conceived with and without assistance. Although gestational carriage was associated with preterm birth, there was less clear evidence of severe neonatal morbidity. Potential mechanisms for higher maternal morbidity among gestational carriers require elucidation, alongside developing special care plans for gestational carriers. Primary Funding Source: The Canadian Institutes of Health Research.

Ho Ho Kam

Vitamin K2 reduced frequency, intensity, duration of nocturnal leg cramps

MKSAP Quiz: H. pylori eradication

Semaglutide-induced weight loss reduced knee osteoarthritis pain, industry trial finds

Weight loss interventions for PCOS associated with improved menstrual frequency, review finds

Put words in our mouth

Rosuvastatin appears better than atorvastatin for mortality, cardio, liver outcomes in large database

Broad-spectrum antibiotics dispensed to almost half of healthy adult outpatients with CAP

MKSAP Quiz: Sleeplessness in patient with panhypopituitarism

CDC revises pneumococcal, COVID-19 vaccine recommendations

New recommendations released on primary prevention of stroke

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

Analyzing academic nocturnists | ACP Hospitalist

AHA offers advice on blood culture-negative endocarditis | ACP Hospitalist

Take a quiz about the March 12 issue! | ACP Hospitalist

Antineutrophil Cytoplasmic Antibody–Associated Orbital Inflammatory Syndrome Without Extraocular Manifestations | Annals of Internal Medicine: Clinical Cases

The differential diagnosis of acute visual loss includes many ischemic, infiltrative, and rheumatologic etiologies. We present a case of antineutrophil cytoplasmic antibody (ANCA)-associated orbital inflammatory syndrome without extraocular manifestations. Initial complaints were vision loss and pain during mastication. Giant cell arteritis was suspected, but biopsy was negative. On withdrawal of steroids, symptoms returned and a head computed tomography scan showed an orbital pseudotumor. Testing showed strongly positive c-ANCA, and symptoms resolved after pulsed steroids. The patient was discharged with a probable diagnosis of ANCA-associated orbital inflammatory syndrome, prednisone, and methotrexate. This case highlights the importance of an extensive work-up in the evaluation of acute visual loss.

Alanine Aminotransferase Deficiency in a Patient With Hyperferritinemia, Steatosis Hepatis, and Hepatosplenomegaly | Annals of Internal Medicine: Clinical Cases

The glutamate pyruvate transaminase enzyme, also called alanine aminotransferase (ALT), plays an important role in gluconeogenesis and amino acid metabolism. It catalyzes the reversible transamination of L-alanine and α-ketoglutarate to pyruvate and L-glutamate. ALT is mostly located in the liver but is also present in other organs like kidney, heart, skeletal muscle, pancreas, and spleen. ALT deficiency was reported in a case of hepatitis B and hepatitis C infection, whereas complete absence of ALT, to our knowledge, has only been reported in 1 case of acute liver failure.

Hemophagocytic Lymphohistiocytosis in Refractory Celiac Disease Type II Transformed into Enteropathy-Associated T-Cell Lymphoma | Annals of Internal Medicine: Clinical Cases

Celiac disease (CD) can lead to small intestinal damage from gluten exposure. Refractory celiac disease type II (RCD2), a complication of CD, can transform to enteropathy-associated T-cell lymphoma (EATL). Hemophagocytic lymphohistiocytosis (HLH) is a rare complication that has been reported in patients with CD, RCD2, and EATL. We report the case of a 61-year-old man with a history of CD complicated by RCD2 that transformed into EATL with HLH as its presenting syndrome.

Hospital Stay Considerations in Hypermobile Ehlers-Danlos Syndrome: An Exemplary Case With Insights for Coexisting Symptoms | Annals of Internal Medicine: Clinical Cases

Ehlers-Danlos syndrome, hypermobility type, is a complex medical condition understood to be a genetic disorder resulting in abnormal collagen synthesis. It is characterized by joint hypermobility as well as skin laxity, poor wound healing, and other manifestations. It may present in conjunction with autonomic, neurologic, and immune abnormalities. Hypermobility spectrum disorder is similarly characterized by joint hypermobility but holds less extensive diagnostic criteria. When in the hospital setting, systemic differences resulting from hypermobility syndromes must be recognized to avoid harm. Here, we present the first case, to our knowledge, of a full hospital course with hypermobility syndrome–comorbidity-related complications described.

Deep Vein Thrombosis in a Patient With an Absent Infrarenal IVC | Annals of Internal Medicine: Clinical Cases

Absence of an infrarenal inferior vena cava is a rare anomaly that can be associated with deep venous thrombosis in young patients with no other provoking factors. Here, we present a patient case of a young man having groin pain and found to have gonadal vein and pampiniform plexus thromboses with an absent infrarenal inferior vena cava.

Peri-infarction Pericarditis: A Fading Complication of Myocardial Infarction | Annals of Internal Medicine: Clinical Cases

A 52-year-old man presenting with an anterior ST-segment elevation myocardial infarction (MI) had stent placement in the mid-left anterior descending coronary artery. A diagnosis of peri-infarction pericarditis (PIP) was made. The patient received acetaminophen and colchicine with complete symptom resolution and no complications. One of the diagnostic challenges with PIP is that the electrocardiographic changes are typically masked by the electrocardiographic changes seen in MI. Nonsteroidal anti-inflammatory drugs (except aspirin) and glucocorticoids should be avoided for 7 to 10 days after an acute MI because of the theory that impairment of collagen deposition and scarring can increase the risk for serious post-MI complications.

Sensing Error in Respironics Continuous Positive Airway Pressure Machine Risks Compromising Patient Compliance | Annals of Internal Medicine: Clinical Cases

We report a continuous positive airway pressure (CPAP) machine malfunction that may compromise patient compliance. A patient's Respironics DreamStation machine (Philips Respironics) was observed to sense “vibratory snore” events incorrectly, resulting in pressure increases that led to poor mask fit, large air leaks, and patient discomfort. A replacement machine developed the same problem. Once aware of the defect, we observed it in 2 other patients. The manufacturer acknowledges receiving a few similar reports, but our experience suggests that this may be an underreported defect. The resulting increased pressures reduce patient tolerance for CPAP. This may be an unrecognized cause for patients abandoning CPAP therapy.

Large Free-Floating Right Atrial Thrombus | Annals of Internal Medicine: Clinical Cases

We present the images of a 67-year-old man who came to the emergency department with bilateral lower extremity pain and shortness of breath. Our images include an intraoperative transesophageal echocardiogram that shows a large, continuous free-floating right atrial mass and a large 31 cm × 1 cm thrombus that was successfully extracted. The thrombus likely could not embolize because of the patient's severe heart failure.

Renal Sarcoidosis Presenting as Fanconi Syndrome | Annals of Internal Medicine: Clinical Cases

Fanconi syndrome is an extremely rare complication of renal sarcoidosis. We describe a case of biopsy-proven granulomatous interstitial nephritis secondary to sarcoidosis with the rare presenting feature of Fanconi syndrome. Our patient successfully received steroids initially, followed by mycophenolate and infliximab. These findings provide clinicians an important insight in recognizing this rare complication of sarcoidosis and opportunity to consider alternative regimens that can avoid or reduce side effects of first-line steroid therapy.

Concurrent Infective Endocarditis and Empyema From Salmonella arizonae | Annals of Internal Medicine: Clinical Cases

Although often associated with gastroenteritis, up to 30% of Salmonella infections are extraintestinal. Fewer than 50 cases of Salmonella empyema have been reported in the past century, and less than 2.9% of bacterial endocarditis cases are attributed to Salmonella species. Salmonella enterica subspecies arizonae generally causes mild disease and has been associated with reptiles or products containing rattlesnakes. We report the patient case of a 38-year-old man who presented to the hospital in septic shock and was found to have concurrent Salmonella bacteremia, endocarditis, and empyema with subspecies arizonae.