List of Sessions - ACP CME 165

Over 165 hours of high-yield recorded sessions Order ACP CME 165 Alphabetical by Title The 5 Ms: Five Simple Words to Guide the Care of Complex Older Adults Speaker: Mary Tinetti, MD

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X-Express: The ABCs of Prescribing Buprenorphine

This highly practical one-hour course, presented by Ann Garment, MD, FACP provides an overview of the role buprenorphine plays in the management of opioid use disorder. Since the previously required 8-hour training for buprenorphine prescribing has been eliminated, the goal of this course is to increase prescribing confidence among attendees.

Would You Screen This Patient for Cognitive Impairment?

Dementia, according to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, is defined by a significant decline in 1 or more cognitive domains that interferes with a person’s independence in daily activities. Mild cognitive impairment (MCI) differs from dementia in that the impairment is not sufficient to interfere with independence. For the purposes of this discussion, cognitive impairment (CI) includes both dementia and MCI. Various screening tests are available for CI.

“Why Can’t I Be There?” Ethics Regarding Restrictions on Visitation/Family Caregiver Presence

Early in the COVID-19 pandemic unprecedented restrictions on allowing visitors in medical settings were deemed necessary to protect patients and healthcare workers (HCWs) in the face of a novel pathogen with unknown transmission risks, high morbidity/mortality, overwhelmed healthcare systems, and limited personal protective equipment (PPE). As time went on, however, clear evidence emerged regarding the unintended harms of visitor restrictions, while evidence demonstrating the necessity of such restrictions for protecting the health of patients and HCWs remained lacking (1).

Comparative Safety Analysis of Oral Antipsychotics for In-Hospital Adverse Clinical Events in Older Adults After Major Surgery: A Nationwide Cohort Study: Annals of Internal Medicine: Vol 176, No 9

Background: Antipsychotics are commonly used to manage postoperative delirium. Recent studies reported that haloperidol use has declined, and atypical antipsychotic use has increased over time. Objective: To compare the risk for in-hospital adverse events associated with oral haloperidol, olanzapine, quetiapine, and risperidone in older patients after major surgery. Design: Retrospective cohort study. Setting: U.S. hospitals in the Premier Healthcare Database. Patients: 17 115 patients aged 65 years and older without psychiatric disorders who were prescribed an oral antipsychotic drug after major surgery from 2009 to 2018. Interventions: Haloperidol (≤4 mg on the day of initiation), olanzapine (≤10 mg), quetiapine (≤150 mg), and risperidone (≤4 mg). Measurements: The risk ratios (RRs) for in-hospital death, cardiac arrhythmia events, pneumonia, and stroke or transient ischemic attack (TIA) were estimated after propensity score overlap weighting. Results: The weighted population had a mean age of 79.6 years, was 60.5% female, and had in-hospital death of 3.1%. Among the 4 antipsychotics, quetiapine was the most prescribed (53.0% of total exposure). There was no statistically significant difference in the risk for in-hospital death among patients treated with haloperidol (3.7%, reference group), olanzapine (2.8%; RR, 0.74 [95% CI, 0.42 to 1.27]), quetiapine (2.6%; RR, 0.70 [CI, 0.47 to 1.04]), and risperidone (3.3%; RR, 0.90 [CI, 0.53 to 1.41]). The risk for nonfatal clinical events ranged from 2.0% to 2.6% for a cardiac arrhythmia event, 4.2% to 4.6% for pneumonia, and 0.6% to 1.2% for stroke or TIA, with no statistically significant differences by treatment group. Limitation: Residual confounding by delirium severity; lack of untreated group; restriction to oral low-to-moderate dose treatment. Conclusion: These results suggest that atypical antipsychotics and haloperidol have similar rates of in-hospital adverse clinical events in older patients with postoperative delirium who receive an oral low-to-moderate dose antipsychotic drug. Primary Funding Source: National Institute on Aging.

Chess Lessons: Harnessing Collective Human Intelligence and Imitation Learning to Support Clinical Decisions

Moving From Idealism to Realism With Data Sharing

Retiring the “Against Medical Advice” Discharge

Facilitating Shared Decision Making Among Black Patients at Risk for Sudden Cardiac Arrest: A Randomized Clinical Trial: Annals of Internal Medicine: Vol 176, No 5

Background: Racial disparities in implantable cardioverter-defibrillator (ICD) implantation are multifactorial and are partly explained by higher refusal rates. Objective: To assess the effectiveness of a video decision support tool for Black patients eligible for an ICD. Design: Multicenter, randomized clinical trial conducted between September 2016 and April 2020. (ClinicalTrials.gov: NCT02819973) Setting: Fourteen academic and community-based electrophysiology clinics in the United States. Participants: Black adults with heart failure who were eligible for a primary prevention ICD. Intervention: An encounter-based video decision support tool or usual care. Measurements: The primary outcome was the decision regarding ICD implantation. Additional outcomes included patient knowledge, decisional conflict, ICD implantation within 90 days, the effect of racial concordance on outcomes, and the time patients spent with clinicians. Results: Of the 330 randomly assigned patients, 311 contributed data for the primary outcome. Among those randomly assigned to the video group, assent to ICD implantation was 58.6% compared with 59.4% in the usual care group (difference, −0.8 percentage point [95% CI, −13.2 to 11.1 percentage points]). Compared with usual care, participants in the video group had a higher mean knowledge score (difference, 0.7 [CI, 0.2 to 1.1]) and a similar decisional conflict score (difference, −2.6 [CI, −5.7 to 0.4]). The ICD implantation rate within 90 days was 65.7%, with no differences by intervention. Participants randomly assigned to the video group spent less time with their clinician than those in the usual care group (mean, 22.1 vs. 27.0 minutes; difference, −4.9 minutes [CI, −9.4 to −0.3 minutes]). Racial concordance between video and study participants did not affect study outcomes. Limitation: The Centers for Medicare & Medicaid Services implemented a requirement for shared decision making for ICD implantation during the study. Conclusion: A video-based decision support tool increased patient knowledge but did not increase assent to ICD implantation. Primary Funding Source: Patient-Centered Outcomes Research Institute.

Lessons From Implementation of the U.S. Preventive Services Task Force Recommendations for Lung Cancer Screening

What Follows From State-Mandated Pregnancy?

Of Pandemics and Renewals

Forgiving Physician Debt

How Would You Manage This Patient With Chronic Insomnia?: Grand Rounds Discussion From Beth Israel Deaconess Medical Center: Annals of Internal Medicine: Vol 175, No 12

Insomnia, which is characterized by persistent sleep difficulties in association with daytime dysfunction, is a common concern in clinical practice. Chronic insomnia disorder is defined as symptoms that occur at least 3 times per week and persist for at least 3 months. The American Academy of Sleep Medicine (AASM) published recent guidelines on behavioral and psychological treatment as well as pharmacologic therapy for chronic insomnia disorder. Regarding behavioral and psychological approaches, the only intervention strongly recommended was multicomponent cognitive behavioral therapy for insomnia. Regarding pharmacologic treatment, the AASM, based on weak evidence, suggested a limited number of medications that might be useful and others that probably are not. Here, 2 clinicians with expertise in sleep disorders—one a clinical psychologist and the other a physician—debate the management of a patient with chronic insomnia who has been treated with medications. They discuss the role of behavioral and psychological interventions and pharmacologic therapy for chronic insomnia and how the primary care practitioner should approach such a patient.

Long-term PPI use associated with higher incidence of dementia

Social determinants of health associated with higher CVD mortality rates in Black persons

Put words in our mouth

Now available: ACP's Internal Medicine Meeting 2023 highlights video

Aortic stenosis risk elevated in patients with rheumatoid arthritis, study finds

MKSAP Quiz: Evaluation for daytime sleepiness

Statins underused in patients with cardiovascular disease, study finds

Breast cancer overdiagnosis common among older women

Put words in our mouth

Call for spring 2024 Board of Governors resolutions

Few guidelines address inpatient blood pressure management | ACP Hospitalist

Early dapagliflozin initiation in acute heart failure reduced diuretic doses for inpatients | ACP Hospitalist

Disseminated varicella infection in an immunocompromised patient | ACP Hospitalist

Delirium in the hospital may have a dose-response association with dementia | ACP Hospitalist

Lower oxygen target led to better outcomes in ICU patients with COVID-19 | ACP Hospitalist

Inappropriate CAP diagnosis common in hospitalized adults | ACP Hospitalist

High-sensitivity troponin-based pathway safe, effective for chest pain patients without CAD | ACP Hospitalist

Clarifying criteria for acute respiratory failure | ACP Hospitalist

Antipsychotic medications not effective in ICU patients with delirium | ACP Hospitalist

A peek at your peers | ACP Hospitalist