New ACP Webinars

Mini Z Data Analysis Mark Linzer, MD, MACP, and Sara Poplau March 2, 1:00-2:00 p.m. ET

In the News

What medicine can learn from the fire department about team-based care By Pooja Desai; Kevin MD Blog Teamwork is sewn into the fabric of the fire department. Each firefighter and paramedic has clearly delineated responsibilities; they work efficiently, communicate well, and interface with other organizations (ambulance, police, trauma doctors, etc.) with little tension. Best of all, they have a great time doing it.

From the Trenches

Sowing Seeds and Cultivating Connections for Well-being By Tiffany Leung, MD, MPH, FACP, Honorary ACP Well-being Champion

February 21, 2020

Strengthening Well-being and Professional Fulfillment Through Collaboration

February 15, 2019

Announcements Hello Well-being Champions!

Patients Before Paperwork

ACP provided feedback on two CMS requests for information regarding how to improve and streamline the CMS Center for Program Integrity. Within our feedback, we highlighted our previous recommendations to CMS that more clarity is needed around what they will actually accept as far as the updated documentation requirements.

Noteworthy Resources

The Curbsiders Podcast #166 Advocacy and Hot Topics in Health Care Policy With Robert McLean MD, FACP

New ACP Webinars

Appreciative Inquiry Kerri Palamara, MD, FACP January 23, 9:00–10:00 a.m. ET

In the News

Physician-Friendly States for Mental Health: A Review of Medical Boards By Pamela Wibble, MD, and Arianna Palermini, OMS2; Pamela Wibble, MD Blog

December 20, 2019

Announcements Helping in our own way through advocacy

Ho Ho Kam

Heterogeneity of Sepsis Presentations and Mortality Rates

Viral Load–Based Prediction of Hepatocellular Carcinoma Risk in Noncirrhotic Patients With Chronic Hepatitis B: A Multinational Study for the Development and External Validation of a New Prognostic Model: Annals of Internal Medicine: Vol 177, No 10

Background: A nonlinear association between serum hepatitis B virus (HBV) DNA levels and hepatocellular carcinoma (HCC) risk has been suggested in patients with chronic hepatitis B (CHB). Objective: To develop and externally validate a prognostic model for HCC risk in noncirrhotic adult patients with CHB and no notable alanine aminotransferase (ALT) elevation. Design: Multinational cohort study. Setting: A community-based cohort in Taiwan (REVEAL-HBV [Risk Evaluation of Viral Load Elevation and Associated Liver Disease/Cancer-Hepatitis B Virus]; REACH-B [Risk Estimation for HCC in CHB] model cohort) and 8 hospital-based cohorts from Korea and Hong Kong (GAG-HCC [Guide with Age, Gender, HBV DNA-HCC] and CU-HCC [Chinese University-HCC] cohorts). Participants: Model development: 6949 patients with CHB from a Korean hospital-based cohort. External validation: 7429 patients with CHB combined from the Taiwanese cohort and 7 cohorts from Korea and Hong Kong. Measurements: Incidence of HCC. Results: Over median follow-up periods of 10.0 and 12.2 years, the derivation and validation cohorts identified 435 and 467 incident HCC cases, respectively. Baseline HBV DNA level was one of the strongest predictors of HCC development, demonstrating a nonlinear parabolic association in both cohorts, with moderate viral loads (around 6 log10 IU/mL) showing the highest HCC risk. Additional predictors included in the new model (Revised REACH-B) were age, sex, platelet count, ALT levels, and positive hepatitis B e antigen result. The model exhibited satisfactory discrimination and calibration, with c-statistics of 0.844 and 0.813 in the derivation and validation cohorts with multiple imputation, respectively. The model yielded a greater positive net benefit compared with other strategies in the 0% to 18% threshold. Limitation: Validation in cohorts of other races and receiving antiviral treatment was lacking. Conclusion: Our new prognostic model, based on the nonlinear association between HBV viral loads and HCC risk, provides a valuable tool for predicting and stratifying HCC risk in noncirrhotic patients with CHB who are not currently indicated for antiviral treatment. Primary Funding Source: Korean government.

The Ethics of Cancer Screening Based on Race and Ethnicity

Racial and ethnic disparities in incidence and mortality are well documented for many types of cancer. As a result, there is understandable policy and clinical interest in race- and ethnicity-based clinical screening guidelines to address cancer health disparities. Despite the theoretical benefits, such proposals do not typically address associated ethical considerations. Using the examples of gastric cancer and esophageal adenocarcinoma, which have demonstrated disparities according to race and ethnicity, this article examines relevant ethical arguments in considering screening based on race and ethnicity. Race- and ethnicity-based clinical preventive care services have the potential to improve the balance of harms and benefits of screening. As a result, programs focused on high-risk racial or ethnic groups could offer a practical alternative to screening the general population, in which the screening yield may be too low to demonstrate sufficient effectiveness. However, designing screening according to socially based categorizations such as race or ethnicity is controversial and has the potential for intersectional stigma related to social identity or other structurally mediated environmental factors. Other ethical considerations include miscategorization, unintended negative effects on health disparities, disregard for underlying risk factors, and the psychological costs of being assigned higher risk. Given the ethical considerations, the practical application of race and ethnicity in cancer screening is most relevant in multicultural countries if and only if alternative proxies are not available. Even in those instances, policymakers and clinicians should carefully address the ethical considerations within the historical and cultural context of the intended population. Further research on alternative proxies, such as social determinants of health and culturally based characteristics, could provide more adequate factors for risk stratification.

The Annual Cost of Cancer Screening in the United States

Background: Cancer has substantial health, quality-of-life, and economic impacts. Screening may decrease cancer mortality and treatment costs, but the cost of screening in the United States is unknown. Objective: To estimate the annual cost of initial cancer screening (that is, screening without follow-up costs) in the United States in 2021. Design: Model using national health care survey and cost resources data. Setting: U.S. health care systems and institutions. Participants: People eligible for breast, cervical, colorectal, lung, and prostate cancer screening with available data. Measurements: The number of people screened and associated health care system costs by insurance status in 2021 dollars. Results: Total health care system costs for initial cancer screenings in the United States in 2021 were estimated at $43 billion. Approximately 88.3% of costs were attributable to private insurance; 8.5% to Medicare; and 3.2% to Medicaid, other government programs, and uninsured persons. Screening for colorectal cancer represented approximately 64% of the total cost; screening colonoscopy represented about 55% of the total. Facility costs (amounts paid to facilities where testing occurred) were major drivers of the total estimated costs of screening. Limitations: All data on receipt of cancer screening are based on self-report from national health care surveys. Estimates do not include costs of follow-up for positive or abnormal screening results. Variations in costs based on geography and provider or health care organization are not fully captured. Conclusion: The $43 billion estimated annual cost for initial cancer screening in the United States in 2021 is less than the reported annual cost of cancer treatment in the United States in the first 12 months after diagnosis. Identification of cancer screening costs and their drivers is critical to help inform policy and develop programmatic priorities, particularly for enhancing access to recommended cancer screening services. Primary Funding Source: None.

Glucagon-Like Peptide-1 Receptor Agonists and Risk for Suicidal Ideation and Behaviors in U.S. Older Adults With Type 2 Diabetes: A Target Trial Emulation Study: Annals of Internal Medicine: Vol 177, No 8

Background: A major concern has recently emerged about a potential link between glucagon-like peptide-1 receptor agonists (GLP-1 RAs) and increased risk for suicidal ideation and behaviors based on International Classification of Diseases codes. Objective: To investigate the association between GLP-1 RAs, compared with sodium–glucose cotransporter-2 inhibitors (SGLT2is) or dipeptidyl peptidase-4 inhibitors (DPP4is), and risk for suicidal ideation and behaviors in older adults with type 2 diabetes (T2D). Design: Two target trial emulation studies comparing propensity score (PS)–matched cohorts for GLP-1 RAs versus SGLT2is and GLP-1 RAs versus DPP4is. Setting: U.S. national Medicare administrative data from January 2017 to December 2020. Patients: Older adults (≥66 years) with T2D; no record of suicidal ideation or behaviors; and a first prescription for a GLP-1 RA, SGLT2i, or DPP4i. Measurements: The primary end point was a composite of suicidal ideation and behaviors. New GLP-1 RA users were matched 1:1 on PS to new users of an SGLT2i or DPP4i in each pairwise comparison. A Cox proportional hazards regression was used to estimate the hazard ratio (HR) and 95% CIs within matched groups. Results: This study included 21 807 pairs of patients treated with a GLP-1 RA versus an SGLT2i and 21 402 pairs of patients treated with a GLP-1 RA versus a DPP4i. The HR of suicidal ideation and behaviors associated with GLP-1 RAs relative to SGLT2is was 1.07 (95% CI, 0.80 to 1.45; rate difference, 0.16 [CI, −0.53 to 0.86] per 1000 person-years); the HR relative to DPP4is was 0.94 (CI, 0.71 to 1.24; rate difference, −0.18 [CI, −0.92 to 0.57] per 1000 person-years). Limitations: Low event rate; imprecise estimates; unmeasured confounders, such as body mass index; and potential misclassification of outcomes. Conclusion: Among Medicare beneficiaries with T2D, this study found no clear increased risk for suicidal ideation and behaviors with GLP-1 RAs, although estimates were imprecise and a modest adverse risk could not be ruled out. Primary Funding Source: American Foundation for Pharmaceutical Education, Pharmaceutical Research and Manufacturers of America Foundation, National Institute on Aging, and National Institute of Diabetes and Digestive and Kidney Diseases.

Pain Reduction With Oral Methotrexate in Knee Osteoarthritis: A Randomized, Placebo-Controlled Clinical Trial: Annals of Internal Medicine: Vol 177, No 9

Background: Treatments for osteoarthritis (OA) are limited. Previous small studies suggest that the antirheumatic drug methotrexate may be a potential treatment for OA pain. Objective: To assess symptomatic benefits of methotrexate in knee OA (KOA). Design: A multicenter, randomized, double-blind, placebo-controlled trial done between 13 June 2014 and 13 October 2017. (ISRCTN77854383; EudraCT: 2013-001689-41) Setting: 15 secondary care musculoskeletal clinics in the United Kingdom. Participants: A total of 207 participants with symptomatic, radiographic KOA and knee pain (severity ≥4 out of 10) on most days in the past 3 months with inadequate response to current medication were approached for inclusion. Intervention: Participants were randomly assigned 1:1 to oral methotrexate once weekly (6-week escalation 10 to 25 mg) or matched placebo over 12 months and continued usual analgesia. Measurements: The primary end point was average knee pain (numerical rating scale [NRS] 0 to 10) at 6 months, with 12-month follow-up to assess longer-term response. Secondary end points included knee stiffness and function outcomes and adverse events (AEs). Results: A total of 155 participants (64% women; mean age, 60.9 years; 50% Kellgren–Lawrence grade 3 to 4) were randomly assigned to methotrexate (n = 77) or placebo (n = 78). Follow-up was 86% (n = 134; methotrexate: 66, placebo: 68) at 6 months. Mean knee pain decreased from 6.4 (SD, 1.80) at baseline to 5.1 (SD, 2.32) at 6 months in the methotrexate group and from 6.8 (SD, 1.62) to 6.2 (SD, 2.30) in the placebo group. The primary intention-to-treat analysis showed a statistically significant pain reduction of 0.79 NRS points in favor of methotrexate (95% CI, 0.08 to 1.51; P = 0.030). There were also statistically significant treatment group differences in favor of methotrexate at 6 months for Western Ontario and McMaster Universities Osteoarthritis Index stiffness (0.60 points [CI, 0.01 to 1.18]; P = 0.045) and function (5.01 points [CI, 1.29 to 8.74]; P = 0.008). Treatment adherence analysis supported a dose-response effect. Four unrelated serious AEs were reported (methotrexate: 2, placebo: 2). Limitation: Not permitting oral methotrexate to be changed to subcutaneous delivery for intolerance. Conclusion: Oral methotrexate added to usual medications demonstrated statistically significant reduction in KOA pain, stiffness, and function at 6 months. Primary Funding Source: Versus Arthritis.

Why Hospitals Must Provide Abortions in Pregnancy Emergencies

En Garde or On Board? Travel Medicine for Immunocompromised Patients in the COVID-19 Era

Shedding Light on the Health of Latino Populations in the United States

Living a longer life with HIV

Lessening EHR burden through alert, message settings

Latest updates on ACP's priorities, initiatives

Get involved in advocacy early and often

From head to toe

First rapid-acting insulin biosimilar approved

Put words in our mouth

Dr. Jokela talks Match Day on KevinMD

ACP offers new AI Resource Hub

Childhood cancer survivors at earlier risk for aging-related disease

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Intervention reduced low-value preoperative testing with decision support, other steps | ACP Hospitalist

Finding feedback | ACP Hospitalist

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Take a quiz about the Jan. 8 issue! | ACP Hospitalist

Short-acting, full-agonist opioids linked with less severe withdrawal after admission | ACP Hospitalist

Private equity hospital acquisition associated with lower patient experience ratings | ACP Hospitalist

Suspected Levamisole-Induced Antineutrophil Cytoplasmic Antibody Vasculitis and Diffuse Alveolar Hemorrhage in a Person Who Uses Cocaine | Annals of Internal Medicine: Clinical Cases

Known for its stimulatory effects and serious health risks, cocaine is among the most widely abused substances in the United States. Levamisole, a veterinary drug, is a commonly used cutting agent in cocaine. Levamisole has been associated with the development of antineutrophil cytoplasmic antibody vasculitis, which may present with a spectrum of multiorgan pathologies, including diffuse alveolar hemorrhage, although this is less well documented in the literature. We present a case of diffuse alveolar hemorrhage suspected to be related to levamisole-associated antineutrophil cytoplasmic antibody vasculitis.

Hemolytic Anemia in Cirrhosis: A Case of Spur-Cell Anemia | Annals of Internal Medicine: Clinical Cases

Anemia is a common complication of cirrhosis; therefore, its evaluation must be thorough and tailored to a patient's history. In this case, a 67-year-old woman with metabolic dysfunction–associated cirrhosis presented with transfusion-refractory hemolytic anemia. The differential diagnosis for hemolytic anemia associated with liver disease includes autoimmune hepatitis, Wilson disease, Zieve syndrome, and spur-cell anemia. Spur-cell anemia should be considered in all hemolytic anemias with a peripheral blood smear revealing the presence of 5% spur cells or greater, with prompt referral for liver transplant evaluation because of its median survival of 1.9 months.

Slow-Growing Lung Mass in a Patient With Multiple Endocrine Neoplasia Type I: Consider Carcinoid Tumor | Annals of Internal Medicine: Clinical Cases

A 23-year-old man with multiple endocrine neoplasia type 1 (MEN 1) with pancreatic tail masses and Cushing syndrome (status after transsphenoidal adenomectomy) presented with a slow-growing, asymptomatic right lower lung lobe mass confirmed to be an atypical carcinoid tumor by pathologic staging following successful basilar segmentectomy with mediastinal lymphadenectomy. Pulmonary carcinoid tumor (PCT) is a rare neoplasm in patients with MEN 1, but there is limited data on trends in atypical versus typical carcinoid tumors in these patients. This case emphasizes the need to characterize these trends given the implications for metastatic potential and 5-year survival, which can help guide screening recommendations in these patients.

Dobutamine-Induced Myoclonus: Acute Myoclonus With Continuous Dobutamine and Chronic Kidney Disease | Annals of Internal Medicine: Clinical Cases

A 73-year-old woman with systolic heart failure and stage 4 chronic kidney disease developed a rare complication of myoclonus 24 hours after intravenous dobutamine infusion. Upon discontinuation of dobutamine, the patient's myoclonus ceased within 24 hours.

Loperamide Misuse Presenting With Pancreatitis | Annals of Internal Medicine: Clinical Cases

Epidemiologic studies demonstrate increasing reports of loperamide misuse for euphoria or as a methadone equal. Misuse dysregulates cardiac myocytes and often is manifested by ventricular dysrhythmias. To our knowledge, we report the first documented case of loperamide misuse associated with acute pancreatitis. Given loperamide's mu agonism, we suspect supratherapeutic doses induce sphincter of Oddi dysfunction and predispose to pancreatitis.

SARS-CoV-2–Induced Angioedema—A Novel Case Report | Annals of Internal Medicine: Clinical Cases

We present a case of a 61-year-old hypertensive woman who developed angioedema during a COVID-19 infection. She presented with tongue and lip swelling, as well as difficulty breathing. Flexible nasolaryngoscopy revealed edema in the uvula, epiglottis, and bilateral arytenoids, indicating a potential airway compromise. The patient received intravenous methylprednisolone, epinephrine, and antihistamines, leading to improvement and resolution of the angioedema and hypoxemia. This case adds to the limited literature on angioedema associated with COVID-19 and highlights the possible link between SARS-CoV-2 and angiotensin-converting enzyme 2.

Oral Pemphigus Vulgaris After SARS-CoV-2 Vaccine: A Case Report and Review of Literature | Annals of Internal Medicine: Clinical Cases

Pemphigus vulgaris is an antibody-mediated autoimmune disease that causes blistering of the skin and mucus membranes. A variety of environmental factors have been suggested as triggers to pemphigus exacerbations, including ultraviolet radiation, trauma, drugs, viral and bacterial vaccination. We present a patient who developed oral lesions shortly after the administration of the SARS-CoV-2 vaccine. Biopsy of the oral mucosa revealed pemphigus vulgaris, and the patient was managed with immunosuppressants.

Metronidazole-Induced Encephalopathy in a Patient Treated for Osteomyelitis | Annals of Internal Medicine: Clinical Cases

Metronidazole-induced encephalopathy (MIE) is a rare treatment complication associated with higher cumulative doses of metronidazole. Patients with underlying renal or hepatic dysfunction are at highest risk. Patients with MIE present with cerebellar dysfunction (for example, dysarthria, gait ataxia, and dysmetria) or encephalopathic symptoms, such as confusion. MIE is suspected when a patient presents with unexplained cerebellar dysfunction after prolonged metronidazole use, and it is confirmed on magnetic resonance imaging displaying lesions affecting the dentate nuclei or the corpus callosum. Herein, we present a case of MIE in a 73-year-old man with cirrhosis after receipt of a prolonged metronidazole course for bacterial spinal osteomyelitis.

Coronary Arteritis and Aneurysm in a Young Adult Revealing Systemic IgG4-Related Disease | Annals of Internal Medicine: Clinical Cases

We present here a rare and atypical case of IgG4-related disease (IgG4-RD) in a young adult. A 22-year-old man presented with recurrent ST-segment elevation myocardial infarction ultimately revealing a systemic IgG4-RD. Multimodal imagery enabled the diagnosis of IgG4-RD coronaritis with aneurysmal complication. The patient was successfully treated with B-cell–depleting therapy associated with coronary revascularization. A multidisciplinary approach enabled appropriate diagnosis and successful treatment.

Aortic Thrombus in Severe Disseminated Lyme Disease | Annals of Internal Medicine: Clinical Cases

Lyme carditis with atrioventricular dissociation is a rare yet well-recognized complication of disseminated Lyme disease. Other cardiac and noncardiovascular conditions have been reported with disseminated Lyme disease. We present a case of severe disseminated Lyme carditis with an acute arterial thrombus, in the absence of an alternative or more common cause, which required urgent surgical intervention. To our knowledge, arterial thrombus is a previously unreported complication of disseminated Lyme carditis.