Future I.M. Experience Story Slam: Resilience During COVID-19

ACP asked trainees to explain how the COVID-19 pandemic affected their training. We are proud to present these inspiring stories. Resilience During COVID-19 William Butler - Bright Eyes During the Pandemic Florida State University College of Medicine

Providers’ Clinical Support System for Opioid Therapies

Through funding from the Department of Health and Human Services Substance Abuse and Mental Health Services Administration (SAMSHA), ACP is collaborating with 12 other consortium partners to create and deliver resources to educate providers on practice-based approaches to improving chronic pain management and discussing tactics for implementing the best practices.

Practical POCUS Skills for Internal Medicine Physicians

Unlock advanced POCUS skills for outpatient practice in internal medicine. Sign up today to get focused training, techniques, & insights in point-of-care ultrasound.

ACP Members Eligible for POCUS Mentorship Program

Contact information for ACP Members can be found in the Membership Directory.

Point-of-Care Ultrasound Mentorship Program (POCUS) | ACP

Continue your point-of-care ultrasound learning and become more proficient in practice with this live, virtual course. Learn about POCUS training today.

Point of Care Ultrasound (POCUS) Training: Foundational Skills | ACP

Master foundational POCUS skills for your internal medicine practice with hands-on training, guidelines, and techniques. Register for upcoming sessions today.

POCUS Online Learning Activities

This training series consists of 13 online, self-paced activities based on common applications for POCUS in internal medicine and with an emphasis on image analysis.

In-Person Courses for Physicians

Elevate patient care through hands-on training and advanced ultrasound techniques with in-person POCUS courses for physicians. View dates and register today.

Acquiring POCUS Equipment: Considerations and Advice

Webinar on Acquiring POCUS Equipment: Considerations and Advice.

Our Statement in Support of Point-of-Care Ultrasound in Internal Medicine | ACP

The American College of Physicians is formally acknowledging the important role of point-of-care ultrasound (POCUS) in internal medicine. Read our statement here.

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).

On the Labels We Carry

2022 Clinical Practice Guideline Update for Diabetes Management of Chronic Kidney Disease: An Important First Step, More Work to Do

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Risk for Chronic Kidney Disease Progression After Acute Kidney Injury: Findings From the Chronic Renal Insufficiency Cohort Study

Background: Prior studies associating acute kidney injury (AKI) with more rapid subsequent loss of kidney function had methodological limitations, including inadequate control for differences between patients who had AKI and those who did not. Objective: To determine whether AKI is independently associated with subsequent kidney function trajectory among patients with chronic kidney disease (CKD). Design: Multicenter prospective cohort study. Setting: United States. Participants: Patients with CKD (n = 3150). Measurements: Hospitalized AKI was defined by a 50% or greater increase in inpatient serum creatinine (SCr) level from nadir to peak. Kidney function trajectory was assessed using estimated glomerular filtration rate (eGFR) based on SCr level (eGFRcr) or cystatin C level (eGFRcys) measured at annual study visits. Results: During a median follow-up of 3.9 years, 433 participants had at least 1 AKI episode. Most episodes (92%) had stage 1 or 2 severity. There were decreases in eGFRcr (−2.30 [95% CI, −3.70 to −0.86] mL/min/1.73 m2) and eGFRcys (−3.61 [CI, −6.39 to −0.82] mL/min/1.73 m2) after AKI. However, in fully adjusted models, the decreases were attenuated to −0.38 (CI, −1.35 to 0.59) mL/min/1.73 m2 for eGFRcr and −0.15 (CI, −2.16 to 1.86) mL/min/1.73 m2 for eGFRcys, and the CI bounds included the possibility of no effect. Estimates of changes in eGFR slope after AKI determined by either SCr level (0.04 [CI, −0.30 to 0.38] mL/min/1.73 m2 per year) or cystatin C level (−0.56 [CI, −1.28 to 0.17] mL/min/1.73 m2 per year) also had CI bounds that included the possibility of no effect. Limitations: Few cases of severe AKI, no adjudication of AKI cause, and lack of information about nephrotoxic exposures after hospital discharge. Conclusion: After pre-AKI eGFR, proteinuria, and other covariables were accounted for, the association between mild to moderate AKI and worsening subsequent kidney function in patients with CKD was small. Primary Funding Source: National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health.

Self-Rated Health and Ability to Climb Stairs: A Pragmatic Health Assessment Before Lung Cancer Screening

Drug Repurposing and Observational Studies: The Case of Antivirals for the Treatment of COVID-19

Remdesivir and molnupiravir were the only 2 repurposed antivirals that were approved for emergency use during the COVID-19 pandemic. Both drugs received their emergency use authorization on the basis of a single industry-funded phase 3 trial, which was launched after evidence of in vitro activity against SARS-CoV-2. In contrast, for tenofovir disoproxil fumarate (TDF), little in vitro evidence was generated, no randomized trials for early treatment were done, and the drug was not considered for authorization. Yet, by the summer of 2020, observational evidence suggested a substantially lower risk for severe COVID-19 in TDF users compared with nonusers. The decision-making process for the launching of randomized trials for these 3 drugs is reviewed. Observational data in favor of TDF was systematically dismissed, even though no viable alternative explanations were proposed for the lower risk for severe COVID-19 among TDF users. Lessons learned from the TDF example during the first 2 years of the COVID-19 pandemic are described, and the use of observational clinical data to guide decisions about the launch of randomized trials during the next public health emergency is proposed. The goal is that gatekeepers of randomized trials make better use of the available observational evidence for the repurposing of drugs without commercial value.

Osteoporosis Treatment: Not Easy

Indefinite Anticoagulant Therapy for First Unprovoked Venous Thromboembolism: A Cost-Effectiveness Study: Annals of Internal Medicine: Vol 176, No 7

Background: Clinical practice guidelines recommend indefinite anticoagulation for a first unprovoked venous thromboembolism (VTE). Objective: To estimate the benefit–harm tradeoffs of indefinite anticoagulation in patients with a first unprovoked VTE. Design: Markov modeling study. Data Sources: Systematic reviews and meta-analyses for the long-term risks and case-fatality rates of recurrent VTE and major bleeding. Published literature for costs, quality of life, and other clinical events. Target Population: Patients with a first unprovoked VTE who have completed 3 to 6 months of initial anticoagulant treatment. Time Horizon: Lifetime. Perspective: Canadian health care public payer. Intervention: Indefinite anticoagulation with direct oral anticoagulants. Outcome Measures: Recurrent VTE events, major bleeding events, costs in 2022 Canadian dollars (CAD), and quality-adjusted life-years (QALYs). Results of Base-Case Analysis: When compared with discontinuing anticoagulation after initial treatment in a hypothetical cohort of 1000 patients aged 55 years, indefinite anticoagulation prevented 368 recurrent VTE events, which included 14 fatal pulmonary emboli, but induced an additional 114 major bleeding events, which included 30 intracranial hemorrhages and 11 deaths from bleeding. Indefinite anticoagulation cost CAD $16 014 more per person and did not increase QALYs (−0.075 per person). Results of Sensitivity Analysis: Model results were most sensitive to the case-fatality rate of major bleeding and the annual risk for major bleeding during extended anticoagulation. Limitation: The model assumed that risks for recurrent VTE and major bleeding measured in clinical trials at 1 year remained constant during extended anticoagulation. Conclusion: Clinicians should use shared decision making to incorporate individual patient preferences and values when considering treatment duration for unprovoked VTE. Primary Funding Source: Canadian Institutes of Health Research.

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