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Displaying 731 - 740 of 6848 in Annals of Internal Medicine
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Blood Pressure Level in Late Adolescence and Risk for Cardiovascular Events: A Cohort Study: Annals of Internal Medicine: Vol 176, No 10
Background: Not enough is known about the association between blood pressure (BP) in adolescence and future cardiovascular events. Objective: To measure this association using the 2017 American College of Cardiology/American Heart Association guidelines for classifying BP elevation. Design: Cohort study. Setting: Sweden. Participants: Males in late adolescence who were conscripted into the military from 1969 to 1997. Measurements: Baseline BP was measured at conscription. The primary outcome was a composite of cardiovascular death or first hospitalization for myocardial infarction, heart failure, ischemic stroke, or intracerebral hemorrhage. Results: The study included 1 366 519 males with a mean age of 18.3 years. The baseline BP was classified as elevated (120 to 129/<80 mm Hg) for 28.8% of participants and hypertensive (≥130/80 mm Hg) for 53.7%. During a median follow-up of 35.9 years, 79 644 had a primary outcome. The adjusted hazard ratio was 1.10 for elevated BP (95% CI, 1.07 to 1.13), 1.15 for stage 1 isolated systolic hypertension (ISH) (CI, 1.11 to 1.18), 1.23 for stage 1 isolated diastolic hypertension (IDH) (CI, 1.18 to 1.28), 1.32 for stage 1 systolic–diastolic hypertension (SDH) (CI, 1.27 to 1.37), 1.31 for stage 2 ISH (CI, 1.28 to 1.35), 1.55 for stage 2 IDH (CI, 1.42 to 1.69), and 1.71 for stage 2 SDH (CI, 1.58 to 1.84). The cumulative risk for cardiovascular events also increased gradually across BP stages, ranging from 14.7% for normal BP to 24.3% for stage 2 SDH at age 68 years. Limitation: This was an observational study of Swedish men. Conclusion: Increasing BP levels in late adolescence are associated with gradually increasing risks for major cardiovascular events, beginning at a BP level of 120/80 mm Hg. Primary Funding Source: Västerbotten County Council, Swedish Society for Medical Research, and Heart Foundation of Northern Sweden.
Incidence of and Factors Associated With Recurrent Firearm Injury Among Patients Presenting to St. Louis Trauma Centers, 2010 to 2019: A Cohort Study: Annals of Internal Medicine: Vol 176, No 9
Background: Firearm injuries are a public health crisis in the United States. Objective: To examine the incidence and factors associated with recurrent firearm injuries and death among patients presenting with an acute (index), nonfatal firearm injury. Design: Multicenter, observational, cohort study. Setting: Four adult and pediatric level I trauma hospitals in St. Louis, Missouri, 2010 to 2019. Participants: Consecutive adult and pediatric patients (n = 9553) presenting to a participating hospital with a nonfatal acute firearm injury. Measurements: Data on firearm-injured patient demographics, hospital and diagnostic information, health insurance status, and death were collected from the St. Louis Region-Wide Hospital-Based Violence Intervention Program Data Repository. The Centers for Disease Control and Prevention (CDC) 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 probability of experiencing a recurrent firearm injury. Results: We identified 10 293 acutely firearm-injured patients of whom 9553 survived the injury and comprised the analytic sample. Over a median follow-up of 3.5 years (IQR, 1.5 to 6.4 years), 1155 patients experienced a recurrent firearm injury including 5 firearm suicides and 149 fatal firearm injuries. Persons experiencing recurrent firearm injury were young (25.3 ± 9.5 years), predominantly male (93%), Black (96%), and uninsured (50%), and resided in high social vulnerability regions (65%). The estimated risk for firearm reinjury was 7% at 1 year and 17% at 8 years. Limitations: Limited data on comorbidities and patient-level social determinants of health. Inability to account for recurrent injuries presenting to nonstudy hospitals. Conclusion: Recurrent injury and death are frequent among survivors of firearm injury, particularly among patients from socially vulnerable areas. Our findings highlight the need for interventions to prevent recurrence. Primary Funding Source: Emergency Medicine Foundation–AFFIRM and Missouri Foundation for Health.
Effects of U.S. State Medical Cannabis Laws on Treatment of Chronic Noncancer Pain
Background: State medical cannabis laws may lead patients with chronic noncancer pain to substitute cannabis in place of prescription opioid or clinical guideline–concordant nonopioid prescription pain medications or procedures. Objective: To assess effects of state medical cannabis laws on receipt of prescription opioids, nonopioid prescription pain medications, and procedures for chronic noncancer pain. Design: Using data from 12 states that implemented medical cannabis laws and 17 comparison states, augmented synthetic control analyses estimated laws’ effects on receipt of chronic noncancer pain treatment, relative to predicted treatment receipt in the absence of the law. Setting: United States, 2010 to 2022. Participants: 583 820 commercially insured adults with chronic noncancer pain. Measurements: Proportion of patients receiving any opioid prescription, nonopioid prescription pain medication, or procedure for chronic noncancer pain; volume of each treatment type; and mean days’ supply and mean morphine milligram equivalents per day of prescribed opioids, per patient in a given month. Results: In a given month during the first 3 years of law implementation, medical cannabis laws led to an average difference of 0.05 percentage points (95% CI, −0.12 to 0.21 percentage points), 0.05 percentage points (CI, −0.13 to 0.23 percentage points), and −0.17 percentage points (CI, −0.42 to 0.08 percentage points) in the proportion of patients receiving any opioid prescription, any nonopioid prescription pain medication, or any chronic pain procedure, respectively, relative to what we predict would have happened in that month had the law not been implemented. Limitations: This study used a strong nonexperimental design but relies on untestable assumptions involving parallel counterfactual trends. Statistical power is limited by the finite number of states. Results may not generalize to noncommercially insured populations. Conclusion: This study did not identify important effects of medical cannabis laws on receipt of opioid or nonopioid pain treatment among patients with chronic noncancer pain. Primary Funding Source: National Institute on Drug Abuse.
Comparison of Hospital Outcomes for Patients Treated by Allopathic Versus Osteopathic Hospitalists: An Observational Study: Annals of Internal Medicine: Vol 176, No 6
Background: The United States has 2 types of degree programs that educate physicians: allopathic and osteopathic medical schools. Objective: To determine whether quality and costs of care differ between hospitalized Medicare patients treated by allopathic or osteopathic physicians. Design: Retrospective observational study. Setting: Medicare claims data. Patients: 20% random sample of Medicare fee-for-service beneficiaries hospitalized with a medical condition during 2016 to 2019 and treated by hospitalists. Measurements: The primary outcome was 30-day patient mortality. The secondary outcomes were 30-day readmission, length of stay (LOS), and health care spending (Part B spending). Multivariable regression models adjusted for patient and physician characteristics and their hospital-level averages (to effectively estimate differences within hospitals) were estimated. Results: Of 329 510 Medicare admissions, 253 670 (77.0%) and 75 840 (23.0%) received care from allopathic and osteopathic physicians, respectively. The results can rule out important differences in quality and costs of care between allopathic versus osteopathic physicians for patient mortality (adjusted mortality, 9.4% for allopathic physicians vs. 9.5% [reference] for osteopathic hospitalists; average marginal effect [AME], −0.1 percentage point [95% CI, −0.4 to 0.1 percentage point]; P = 0.36), readmission (15.7% vs. 15.6%; AME, 0.1 percentage point [CI, −0.4 to 0.3 percentage point; P = 0.72), LOS (4.5 vs. 4.5 days; adjusted difference, −0.001 day [CI, −0.04 to 0.04 day]; P = 0.96), and health care spending ($1004 vs. $1003; adjusted difference, $1 [CI, −$8 to $10]; P = 0.85). Limitation: Data were limited to elderly Medicare patients hospitalized with medical conditions. Conclusion: The quality and costs of care were similar between allopathic and osteopathic hospitalists when they cared for elderly patients and worked as the principal physician in a team of health care professionals that often included other allopathic and osteopathic physicians. Primary Funding Source: National Institutes of Health/National Institute on Aging.
Cases in Precision Medicine: Is There an Obligation to Return Reinterpreted Genetic Results to Former Patients?
Interpretation of many genetic test results can change over time as new data accumulate. Hence, physicians who order genetic tests may subsequently receive revised reports with important implications for patients' medical treatment—even for patients who are no longer in their care. Several of the ethical principles underlying medical practice suggest an obligation to reach out to former patients with this information. Discharging that obligation can be accomplished, at a minimum, by attempting to contact the former patient with their last known contact information.
Effects of Implementation of a Supervised Walking Program in Veterans Affairs Hospitals: A Stepped-Wedge, Cluster Randomized Trial: Annals of Internal Medicine: Vol 176, No 6
Background: In trials, hospital walking programs have been shown to improve functional ability after discharge, but little evidence exists about their effectiveness under routine practice conditions. Objective: To evaluate the effect of implementation of a supervised walking program known as STRIDE (AssiSTed EaRly MobIlity for HospitalizeD VEterans) on discharge to a skilled-nursing facility (SNF), length of stay (LOS), and inpatient falls. Design: Stepped-wedge, cluster randomized trial. (ClinicalTrials.gov: NCT03300336) Setting: 8 Veterans Affairs hospitals from 20 August 2017 to 19 August 2019. Patients: Analyses included hospitalizations involving patients aged 60 years or older who were community dwelling and admitted for 2 or more days to a participating medicine ward. Intervention: Hospitals were randomly assigned in 2 stratified blocks to a launch date for STRIDE. All hospitals received implementation support according to the Replicating Effective Programs framework. Measurements: The prespecified primary outcomes were discharge to a SNF and hospital LOS, and having 1 or more inpatient falls was exploratory. Generalized linear mixed models were fit to account for clustering of patients within hospitals and included patient-level covariates. Results: Patients in pre-STRIDE time periods (n = 6722) were similar to post-STRIDE time periods (n = 6141). The proportion of patients with any documented walk during a potentially eligible hospitalization ranged from 0.6% to 22.7% per hospital. The estimated rates of discharge to a SNF were 13% pre-STRIDE and 8% post-STRIDE. In adjusted models, odds of discharge to a SNF were lower among eligible patients hospitalized in post-STRIDE time periods (odds ratio [OR], 0.6 [95% CI, 0.5 to 0.8]) compared with pre-STRIDE. Findings were robust to sensitivity analyses. There were no differences in LOS (rate ratio, 1.0 [CI, 0.9 to 1.1]) or having an inpatient fall (OR, 0.8 [CI, 0.5 to 1.1]). Limitation: Direct program reach was low. Conclusion: Although the reach was limited and variable, hospitalizations occurring during the STRIDE hospital walking program implementation period had lower odds of discharge to a SNF, with no change in hospital LOS or inpatient falls. Primary Funding Source: U.S. Department of Veterans Affairs Quality Enhancement Research Initiative (Optimizing Function and Independence QUERI).