January 19, 2024

Professional Fulfillment Zone

AVAILABLE NOW to ACP Members!The new year is the perfect time to prioritize your personal and professional growth. ACP's member-exclusive Physician Peer Coaching Program offers multiple opportunities to receive expert support to help you set a vision, create a plan, and achieve meaningful change in a sustainable way.

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there has been much media speculation about whom he will appoint to his Cabinet and what health care legislation may be repealed or dissected for parts; the American College of Physicians is currently working to make sure its voice will be heard.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

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.

Creating Incentives to Move Specialists Into the Medical Neighborhood

New Antibiotics for Resistant Infections: What Happens After Approval?

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.

Condition H

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.

Healing the Sick: A Timeline of Altruism

Body Mass Index Thresholds for Asians: A Race Correction in Need of Correction?

Native Hawaiian Pacific Islanders have third highest CVD mortality rate in U.S.

Improper arm position results in significantly higher blood pressure readings

Vote for your favorite entry

Physician peer coaching service now available for ACP members

How ACP members can support Hurricane Helene aid efforts

Women less likely to receive guideline-directed medical therapy after ischemic stroke

MKSAP Quiz: Follow-up examination for COPD

Industry-funded study identifies risk factors for UTI treatment failure

Statin therapy alone does not appear to increase diabetes risk in patients with HIV

Put words in our mouth

Forgoing fasting before PCI or angiography is safe, acceptable, meta-analysis finds | ACP Hospitalist

First rapid-acting insulin biosimilar approved | ACP Hospitalist

Finerenone is effective for heart failure with mildly reduced or preserved ejection fraction | ACP Hospitalist

Updated guidelines advise managing sedation, mobilization, sleep in ICU | ACP Hospitalist

Take a quiz about the Feb. 26 issue! | ACP Hospitalist

Studies assess effects of cardiac rehab, PT, OT on later health care use | ACP Hospitalist

Risk score accurately predicts major bleeding risk in COVID-19 patients, study finds | ACP Hospitalist

Pressure injuries | ACP Hospitalist

New guidance issued on acute coronary syndromes | ACP Hospitalist

Get up to speed on skin failure | ACP Hospitalist

Acute Limb Ischemia After Cardiac Surgery: Looking for the White Clot Syndrome | Annals of Internal Medicine: Clinical Cases

Two weeks after undergoing cardiac surgery with cardiopulmonary bypass, a 59-year-old patient presented with acute right-limb ischemia. The probability of heparin-induced thrombocytopenia was high and heparin antibody immunoassays were positive, so heparin anticoagulation was replaced by argatroban. An emergency right femoral thrombectomy yielded a macroscopically white thrombus that was rich in platelets and leukocytes on histopathological and immunologic analysis. Given that the serotonin-release assay is the gold standard and is technically demanding, type 2 heparin-induced thrombopenia is challenging to diagnose with certainty after cardiac surgery, so the white appearance of a thrombus obtained by emergency thrombectomy may help in decision-making.

Why So Salty? Transient Diabetes Insipidus After Discontinuation of Vasopressin | Annals of Internal Medicine: Clinical Cases

In recent years, vasopressin has been increasingly used as an early treatment of vasopressor-refractory septic shock. In this article, we describe 2 episodes of transient diabetes insipidus after vasopressin for the treatment of septic shock was discontinued, which adds to a modest number of case studies reporting the same phenomenon. With the anticipated continued use of vasopressin in intensive care units, it can be expected that this adverse effect will occur with some frequency. Awareness and early recognition of this phenomenon can lead to prompt diagnosis and treatment.

Successful Peripartum Venoarterial Extracorporeal Membrane Oxygenation for Pheochromocytoma-Induced Cardiogenic Shock | Annals of Internal Medicine: Clinical Cases

We describe a 37-year-old multiparous woman with cardiogenic shock resulting from pheochromocytoma crisis. She had term labor induction after developing hypertension attributed to preeclampsia. Severe hemodynamic instability followed on postpartum day 2 requiring venoarterial extracorporeal membrane oxygenation (VA-ECMO). Suspicion for pheochromocytoma arose after a computed tomography scan showed a large adrenal mass, and the diagnosis was confirmed with plasma and 24-hour urine metanephrine levels. She initially had cardiomyopathy with left ventricular ejection fraction less then 10%, which rapidly improved, and she was successfully weaned off VA-ECMO. This patient case illustrates the clinical challenges concerning pheochromocytoma during pregnancy.

IgG4-Related Disease Masquerading as Culture-Negative Endocarditis | Annals of Internal Medicine: Clinical Cases

We detail an extremely rare case of noninfective endocarditis secondary to IgG4-related disease on the mitral valve. A 75-year-old-woman with mitral valve ring annuloplasty presented with subacute, intermittent, self-limiting neurologic deficits. Magnetic resonance imaging of her brain revealed multiple small infarcts consistent with a cardioembolic phenomenon. Transesophageal echocardiogram revealed mobile, strand-like vegetations. She was taken for surgical repair of her mitral valve and tissue biopsy confirmed the diagnosis of IgG4-related disease. Our knowledge of this rare disease is continuously evolving, and this case highlights an exceptionally rare manifestation of this poorly understood disease.

Incidental Krukenberg Tumor During Cesarean Section | Annals of Internal Medicine: Clinical Cases

We present the case of a 29-year-old woman in her 30th week of pregnancy admitted for preterm contractions. She had an emergent cesarean delivery and was noted to have a large ovarian mass diagnosed on pathology as a Krukenberg tumor. Subsequent upper gastrointestinal endoscopy revealed gastric signet ring cell adenocarcinoma as the primary cancer. The patient received palliative chemotherapy and immunotherapy and is pending clinical trial participation. Pregnancy-associated gastric cancer is a rare condition with a poor prognosis as most symptoms may be attributed to a normal pregnancy. This misinterpretation often leads to a late diagnosis and poor outcomes.

Antibiotic and Surgical Treatment of a Ventriculoperitoneal Shunt-Related Soft Tissue Abscess Caused by Brucella melitensis | Annals of Internal Medicine: Clinical Cases

We report on the antibiotic and surgical treatment of a woman who presented with an abscess caused by Brucella melitensis related to a ventriculoperitoneal shunt, which is an atypical presentation of brucellosis. There were no signs of neurologic, osteoarticular, or peritoneal infection. The abscess initially healed after ultrasound-guided drainage and antibiotic treatment with gentamycin/doxycycline for 5 days, followed by doxycycline/ciprofloxacin for 8 weeks, allowing shunt preservation. Three months after treatment ended, however, a relapse occurred that required partial surgical shunt revision and readministration of antibiotics. Seven months after surgery and 12 months after the initial diagnosis, the patient's remission status has been maintained.

A Case Report of Postheart Transplant Epicardial Adipose Deposition in a Patient With Dunnigan Syndrome | Annals of Internal Medicine: Clinical Cases

Dunnigan syndrome is a rare genetic disorder that is a type of familial partial lipodystrophy. In some patients, severe cardiomyopathy and heart transplantation have been reported in this syndrome. Here, we describe a 40-year-old patient with Dunnigan syndrome who underwent heart transplantation for end-stage heart failure. Post-transplantation, routine imaging showed an accumulation of epicardial adipose tissue around the heart. In general, in Dunnigan syndrome, epicardial fat accumulation is not different compared with that of the general population. This is the first case report of exaggerated accumulation of adipose tissue around the heart causing subtle pericardial tamponade physiology.

Successful Extracorporeal Membrane Oxygenation After a Challenging Cannulation in a Pregnant Patient With COVID-19 | Annals of Internal Medicine: Clinical Cases

Veno-venous extracorporeal membrane oxygenation (V-V ECMO) support for fulminant COVID-19 pneumonia in a person with a viable pregnancy is controversial because many experts recommend delivery of the fetus before maternal ECMO. We describe V-V ECMO use for COVID-19 in a pregnant person at 28 weeks gestation. An inability to pass a guidewire from the jugular vein to the inferior vena cava complicated bedside ECMO cannulation, mandating a jugular-femoral 2-cannula approach that involves risk near a gravid uterus. In this case, procedural flexibility and multispecialty collaboration led to good maternal and fetal outcomes after 6 days of ECMO support.

Painless Neck Mass in a 47-Year-Old Man | Annals of Internal Medicine: Clinical Cases

A 47-year-old man presents for evaluation of a painless neck mass.

Refractory Premature Ventricular Complex Triggered Ventricular Fibrillation Responsive to Cardiac Sympathetic Denervation | Annals of Internal Medicine: Clinical Cases

A healthy 34-year-old woman sustained refractory idiopathic ventricular fibrillation (IVF) secondary to premature ventricular contractions (PVCs). Ischemic, structural, and genetic evaluations did not identify an attributable pathology. Here, we review the epidemiology, prognosis, and management of PVC-induced IVF. We additionally highlight the utility of cardiac sympathetic denervation.