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Displaying 401 - 410 of 7510 in ACP Online
August 16, 2019
Announcements ACP Supports National Physician Suicide Awareness Day, September 17 (National Suicide Prevention Lifeline: 1-800-273-8255 and crisis text line at 741-741)
April 19, 2019
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Displaying 401 - 410 of 6736 in Annals of Internal Medicine
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How Would You Manage HIV Pre-exposure Prophylaxis in This Patient With Medical Comorbidities?: Grand Rounds Discussion From Beth Israel Deaconess Medical Center: Annals of Internal Medicine: Vol 177, No 4
Despite advances in treatment, HIV infection remains an important cause of morbidity and mortality, with more than 30 000 new cases diagnosed in the United States each year. There are several interventions traditionally used to prevent HIV transmission, but these vary in effectiveness and there are challenges to their implementation. In 2014, the Centers for Disease Control and Prevention published initial guidance on the use of antiretroviral pre-exposure prophylaxis (PrEP) to prevent transmission of HIV infection in persons at risk based on multiple studies that showed it to be highly efficacious in various populations. It was updated in 2021 to reflect new drug options. The U.S. Preventive Services Task Force also recently updated its recommendations for PrEP, which strongly support its use in persons at risk. Despite its well-established effectiveness, the implementation of PrEP in clinical practice has been variable, especially among populations underserved by the medical system and marginalized by society. Fewer than one third of persons in the United States who are eligible for PrEP currently receive it. Here, 2 physicians experienced in HIV PrEP debate how best to identify patients who might benefit from PrEP, how to decide what regimen to use, and how to monitor therapy.
Extracorporeal Shock-Wave Lithotripsy and Endoscopy for the Treatment of Pain in Chronic Pancreatitis: A Sham-Controlled, Randomized Trial: Annals of Internal Medicine: Vol 177, No 6
Background: No randomized controlled trials have substantiated endoscopic decompression of the pancreatic duct in patients with painful chronic pancreatitis. Objective: To investigate the pain-relieving effect of pancreatic duct decompression in patients with chronic pancreatitis and intraductal stones. Design: 24-week, parallel-group, randomized controlled trial (ClinicalTrials.gov: NCT03966781) Setting: Asian Institute of Gastroenterology in India from February 2021 to July 2022. Participants: 106 patients with chronic pancreatitis. Intervention: Combined extracorporeal shock-wave lithotripsy (ESWL) and endoscopic retrograde pancreatography (ERP) compared with sham procedures. Measurements: The primary end point was pain relief on a 0- to 10-point visual analog scale (VAS) at 12 weeks. Secondary outcomes were assessed after 12 and 24 weeks and included 30% pain relief, opioid use, pain-free days, questionaries, and complications to interventions. Results: 52 patients in the ESWL/ERP group and 54 in the sham group were included. At 12 weeks, the ESWL/ERP group showed better pain relief compared with the sham group (mean difference in change, −0.7 [95% CI, −1.3 to 0] on the VAS; P = 0.039). The difference between groups was not sustained at the 24-week follow-up, and no differences were seen for 30% pain relief at 12- or 24-week follow-up. The number of pain-free days was increased (median difference, 16.2 days [CI, 3.9 to 28.5 days]), and the number of days using opioids was reduced (median difference, −5.4 days [CI, −9.9 to −0.9 days]) in the ESWL/ERP group compared with the sham group at 12-week follow-up. Safety outcomes were similar between groups. Limitation: Single-center study and limited duration of follow-up. Conclusion: In patients with chronic pancreatitis and intraductal stones, ESWL with ERP provided modest short-term pain relief. Primary Funding Source: Asian Institute of Gastroenterology and Aalborg University Hospital.
Morbidity and Mortality of Hospital-Onset SARS-CoV-2 Infections Due to Omicron Versus Prior Variants: A Propensity-Matched Analysis: Annals of Internal Medicine: Vol 177, No 8
Background: Many hospitals have scaled back measures to prevent nosocomial SARS-CoV-2 infection given large decreases in the morbidity and mortality of SARS-CoV-2 infections for most people. Little is known, however, about the morbidity and mortality of nosocomial SARS-CoV-2 infections for hospitalized patients in the Omicron era. Objective: To estimate the effect of nosocomial SARS-CoV-2 infection on hospitalized patients’ outcomes during the pre-Omicron and Omicron periods. Design: Retrospective matched cohort study. Setting: 5 acute care hospitals in Massachusetts, December 2020 to April 2023. Patients: Adults testing positive for SARS-CoV-2 on or after hospital day 5, after negative SARS-CoV-2 test results on admission and on hospital day 3, were matched to control participants by hospital, service, time period, days since admission, and propensity scores that incorporated demographics, comorbid conditions, vaccination status, primary diagnosis category, vital signs, and laboratory test values. Measurements: Primary outcomes were hospital mortality and time to discharge. Secondary outcomes were intensive care unit (ICU) admission, need for advanced oxygen support, discharge destination, hospital-free days, and 30-day readmissions. Results: There were 274 cases of hospital-onset SARS-CoV-2 infection during the pre-Omicron period and 1037 cases during the Omicron period (0.17 vs. 0.49 cases per 100 admissions). Patients with hospital-onset SARS-CoV-2 infection were older and had more comorbid conditions than those without. During the pre-Omicron period, hospital-onset SARS-CoV-2 infection was associated with increased risk for ICU admission, increased need for high-flow oxygen, longer time to discharge (median difference, 4.7 days [95% CI, 2.9 to 6.6 days]), and higher mortality (risk ratio, 2.0 [CI, 1.1 to 3.8]) versus matched control participants. During the Omicron period, hospital-onset SARS-CoV-2 infection remained associated with increased risk for ICU admission and increased time to discharge (median difference, 4.2 days [CI, 3.6 to 5.0 days]). The association with increased hospital mortality was attenuated but still significant (risk ratio, 1.6 [CI, 1.2 to 2.3]). Limitation: Residual confounding may be present. Conclusion: Hospital-onset SARS-CoV-2 infection during the Omicron period remains associated with increased morbidity and mortality. Primary Funding Source: Harvard Medical School Department of Population Medicine.
Trends in Diet Quality Among U.S. Adults From 1999 to 2020 by Race, Ethnicity, and Socioeconomic Disadvantage
Background: Few data have assessed trends in diet quality among U.S. adults. Objective: To evaluate trends in diet quality by race, ethnicity, and socioeconomic disadvantage. Design: Repeated cross-sectional study. Setting: United States. Participants: Noninstitutionalized adults aged 20 years or older who responded to the 1999–2020 National Health and Nutrition Examination Survey (NHANES). Measurements: The proportion of participants meeting the targets of the validated American Heart Association (AHA) 2020 continuous diet score (based on higher intake of fruits, vegetables, whole grains, fish and shellfish, and nuts, seeds, and legumes and lower intake of sugar-sweetened beverages, processed meat, saturated fat, and sodium) and the Healthy Eating Index (HEI)-2015, and energy-adjusted consumption of their components and other individual food groups and nutrients. Poor diet was defined as less than 40% adherence to the AHA score, intermediate as 40% to 79.9% adherence, and ideal as at least 80% adherence. Results: A total of 51 703 adults were included. From 1999 to 2020, the proportion of U.S. adults with poor diet quality decreased from 48.8% to 37.4% (difference, −11.4 percentage points [95% CI, −16.8 to −5.96 percentage points]), the proportion with intermediate quality increased from 50.6% to 61.1% (difference, 10.5 percentage points [CI, 5.20 to 16.1 percentage points]), and the proportion with ideal quality increased from 0.66% to 1.58% (difference, 0.93 percentage points [CI, 0.35 to 1.51 percentage points]) (P for trend < 0.001 for each). Persistent or worsening disparities in diet quality were observed by age, sex, race and ethnicity, education, income, food security, Supplemental Nutrition Assistance Program participation, and health insurance coverage. For example, the proportion of adults with poor diet quality decreased from 47.9% to 33.0% among those with food security (P for trend < 0.001) but did not change (51.3% to 48.2%) among those experiencing food insecurity (P for trend = 0.140) (P for interaction = 0.001). Findings were similar for HEI-2015. Limitations: Self-reported diet; cross-sectional study design. Conclusion: Diet quality among U.S. adults improved modestly between 1999 and 2020, but the proportion with poor diet quality remains high, and dietary disparities persist or are worsening. Primary Funding Source: National Institutes of Health.
Comparative Effectiveness and Safety of Atorvastatin Versus Rosuvastatin: A Multi-database Cohort Study: Annals of Internal Medicine: Vol 177, No 12
Background: Rosuvastatin and atorvastatin are the most widely prescribed moderate- to high-intensity statins. However, evidence on their efficacy and safety during actual use is limited. Objective: To compare the real-world effectiveness and safety of rosuvastatin and atorvastatin. Design: Active comparator cohort study using target trial emulation. Setting: The China Renal Data System (CRDS) and UK Biobank (UKB) databases. Participants: Adults newly prescribed rosuvastatin or atorvastatin. Measurements: The primary outcome was all-cause mortality. Cox proportional hazards regressions were used after 1:1 multilevel propensity score matching. Results: Among the 285 680 eligible participants in both databases, 6-year all-cause mortality was lower for rosuvastatin than for atorvastatin (2.57 vs. 2.83 per 100 person-years in the CRDS database and 0.66 vs. 0.90 per 100 person-years in the UKB database), with differences in cumulative incidence of −1.03% (95% CI, −1.44% to −0.46%) in the CRDS database and −1.38% (CI, −2.50% to −0.21%) in the UKB database. For secondary outcomes in both databases, rosuvastatin conferred lower risks for major adverse cardiovascular events and major adverse liver outcomes. In the UKB database, the risk for development of type 2 diabetes mellitus was higher with rosuvastatin, and the 2 medications carried similar risks for development of chronic kidney disease and other statin-related adverse effects. Limitation: Possible residual confounding. Conclusion: This study found differences in risks for some important outcomes associated with rosuvastatin and atorvastatin. The differences were relatively small, and many did not meet traditional standards for statistical significance. Further research is needed to understand whether these findings can be used with confidence in clinical practice. Primary Funding Source: National Key R&D Program of China and National Natural Science Foundation of China.
Displaying 401 - 410 of 4549 in IM Matters
Displaying 401 - 410 of 2336 in ACP Hospitalist
Displaying 401 - 410 of 500 in Annals of Internal Medicine: Clinical Cases
Stimuli-Induced Decorticate Rigidity in Bickerstaff Brainstem Encephalitis | Annals of Internal Medicine: Clinical Cases
Bickerstaff brainstem encephalitis (BBE) is an immune-mediated disorder characterized by external ophthalmoplegia, ataxia, and altered consciousness. It is often triggered by preceding infection. Herein, a case of BBE with positive anti-GM1 and anti-GD1a antibodies, which exhibited the characteristic decorticate rigidity at the most severe stage, was reported. This case elucidates the pathophysiologic mechanism of BBE targeting the brainstem.
Antineutrophil Cytoplasmic Antibody–Associated Vasculitis Masquerading as Giant Cell Arteritis | Annals of Internal Medicine: Clinical Cases
The triad of temporal artery tenderness, monocular vision loss, and raised inflammatory markers is suggestive of giant cell arteritis (GCA). We encountered a 76-year-old woman who presented with acute right eye vision loss, temporal tenderness, jaw claudication, and markedly raised inflammatory markers, all suggestive of GCA. After a negative right temporal artery biopsy, serologic work-up revealed elevated proteinase 3 and myeloperoxidase titers. Pathology from a renal biopsy pursued for work-up of acute kidney injury demonstrated pauci-immune glomerulonephritis, leading to a diagnosis of granulomatosis with polyangiitis (GPA). This case underscores the importance of acknowledging and avoiding anchoring bias early in the diagnostic process.
Brucellar Granulomas as Focal Parenchymal Central Nervous System Lesions: A Case Series | Annals of Internal Medicine: Clinical Cases
Brucella spp. is a known cause of necrotizing granulomas that can involve any organ in the body. Central nervous system involvement is a rare form of presentation for Brucella infection; however, it may occur due to hematogenous spread of the bacteria. The most common presentation of neurobrucellosis is meningoencephalitis; however, in some cases Brucella may form granulomas in the brain parenchyma in the absence of meningeal involvement or characteristic systemic involvement such as fever and arthralgias. We present 2 cases of patients with brucellar granulomas who presented with focal central nervous system lesions in the absence of meningeal signs or any systemic sign of infection.
Persistent Chylothorax in an Immunocompromised Patient Possibly From Superior Mesenteric Vein Occlusion | Annals of Internal Medicine: Clinical Cases
A 35-year-old man with AIDS presented with shortness of breath due to chylothorax requiring chest tube placement. He had no cardiopulmonary history but was previously treated for an intra-abdominal Mycobacterium avium-intracellulare infection. Pleural cytology was negative for mesothelial cells, and cardiopulmonary and infectious work-up was negative. Unsuccessful attempts were made to recannulate the thoracic duct, and he had daily 2 to 4 L of chylous output despite decortication and pleurodesis. Computed tomography of the abdomen/pelvis revealed superior mesenteric vein thrombosis, for which a deployed stent ultimately led to chylothorax resolution. The patient was discharged with the possible theory of superior mesenteric vein occlusion causing retrograde lymphatic flow.
Lipoprotein X in the Setting of COVID-19–Induced Cholangiopathy: An Unforeseen Event | Annals of Internal Medicine: Clinical Cases
Elevated low-density lipoprotein cholesterol (LDL-C) is a well-known culprit for atherosclerosis; however, elevated lipoprotein X (LpX), an abnormal lipoprotein as dense as LDL-C, may confound differentiation between true hyperlipidemia and cholestasis-induced hyperlipidemia. We present the case of a 34-year-old man diagnosed with COVID-19–induced cholangiopathy with LpX. Despite treatment with evolocumab and plasmapheresis, the patient had persistent cholestasis and ultimately received a liver transplant, resulting in the resolution of hyperlipidemia. This case highlights the potential association between LpX and COVID-19–induced cholangiopathy, emphasizing the need for further research to better understand the underlying mechanisms and treatment options for this complex disease.
Giant Hepatic Cyst Inducing Near Syncope | Annals of Internal Medicine: Clinical Cases
Hepatic cysts occasionally produce complications associated with severe morbidity and mortality (<1% of all identified cases). Compression of the vasculature leading to syncope, however, is rare. We present a striking case of inferior vena cava compression by a large hepatic cyst, likely inducing near-syncope.
Resolution of Noncardiac Chest Pain With Corrective Exercises for Neck and Upper Thoracic Spine | Annals of Internal Medicine: Clinical Cases
Noncardiac chest pain (NCCP) is difficult to diagnose and often leads to excessive tests, negatively affecting patients’ lives. This case series presents 3 patients with severe NCCP who had extensive investigations with no definitive diagnosis. They then received a structured assessment using the Mechanical Diagnosis and Therapy approach. Through specific corrective exercises for the cervical and upper thoracic spine, all 3 patients experienced complete resolution of NCCP and remained symptom-free for 6 months. This study emphasizes the importance of recognizing spinal abnormalities as potential causes of NCCP and highlights the effectiveness of Mechanical Diagnosis and Therapy in managing this condition.
Immune-Mediated Liver Injury From Checkpoint Inhibitors Requiring Supratherapeutic Corticosteroid and Mycophenolate Treatment | Annals of Internal Medicine: Clinical Cases
A 43-year-old woman with metastatic adrenocortical carcinoma from the left adrenal gland for which she was prescribed therapeutic mitotane was found to have grade 4 immune-mediated liver injury caused by checkpoint inhibitors that was unresponsive to standard-dose corticosteroids. Mitotane inhibits steroidogenesis, induces CYP3A4, increasing steroid metabolism, and can cause adrenal insufficiency. Thus, supratherapeutic steroid doses were required for anti-inflammatory response along with mycophenolate. To our knowledge, this is the first case to describe a patient concurrently receiving mitotane and pembrolizumab with an immune-related adverse event requiring interdisciplinary care, with insights into steroid physiology and immune-mediated liver injury caused by checkpoint inhibitors necessitating a customized treatment plan.
Mycobacterium avium–intracellulare Complex Pleurisy in a Patient With Lupus–Dermatomyositis Overlap Syndrome | Annals of Internal Medicine: Clinical Cases
Mycobacterium avium–intracellulare complex (MAC) infrequently leads to pleural involvement in individuals with lung disease, but it forecasts increased mortality. In this case, a 26-year-old man diagnosed with systemic lupus erythematosus and dermatomyositis first presented with pulmonary nodules and a mild pleural effusion. The initial investigation for infection yielded negative results, suggesting the likelihood of lupus serositis. However, 7 months later, he was readmitted due to worsening pleural effusions. Analysis of the left pleural fluid led to the diagnosis of empyema. Its culture revealed the growth of MAC. Although uncommon, MAC pleuritis can occur in individuals with diverse comorbid conditions and varying degrees of immune competence.
Endogenous Endophthalmitis as a Complication of a Systemic Infection by Brucella Species | Annals of Internal Medicine: Clinical Cases
Endogenous endophthalmitis by Brucella species is a rare, serious ocular disease with a challenging diagnosis due to its poor clinical manifestations. In this clinical case, a 69-year-old woman with septic urinary shock and abdominal pain was hospitalized and initially treated for Klebsiella pneumoniae infection. Subsequently, she developed visual alterations characterized by a cloudy anterior chamber, ultimately leading to enucleation of her left eye. Brucella species was identified in the left eye, prompting proper antibiotic treatment. Integrating organ-specific symptoms as part of a systemic disease may aid in the identification of rare diseases, enabling timely and appropriate treatment while preventing significant complications.