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Displaying 811 - 820 of 7495 in ACP Online
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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).
When Would You Screen This 39-Year-Old Woman for Breast Cancer? Grand Rounds Discussion From Beth Israel Deaconess Medical Center
Breast cancer is the second leading cause of cancer death among women in the United States. Screening mammography, which aims to detect asymptomatic breast cancers at earlier and more intervenable stages, has reduced breast cancer mortality, but not overall mortality, in randomized trials. As of 2024, the U.S. Preventive Services Task Force now recommends biennial screening mammography for women aged 40 to 74 years (grade B recommendation).
When Might Genomic Screening Be Cost-Effective?
In this episode of Annals On Call, Dr. Centor discusses the cost-effectiveness of genomic screening with Drs. Gregory Guzauskas and Josh Peterson. First, listen to the podcast. After listening, ACP members can take the CME/MOC quiz for free.
When Leg Cramps Suggest Peripheral Artery Disease
The Annals Consult Guys provide advice on the evaluation and management of a patient with leg cramps when walking.
Displaying 811 - 820 of 6736 in Annals of Internal Medicine
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Planning for Mpox on a College Campus: A Model-Based Decision-Support Tool
Background: In spring and summer 2022, an outbreak of mpox occurred worldwide, largely confined to men who have sex with men (MSM). There was concern that mpox could break swiftly into congregate settings and populations with high levels of regular frequent physical contact, like university campus communities. Objective: To estimate the likelihood of an mpox outbreak and the potential effect of mitigation measures in a residential college setting. Design: A stochastic dynamic SEIR (susceptible, exposed but not infectious, infectious, or recovered) model of mpox transmission in a study population was developed, composed of: a high-risk group representative of the population of MSM with a basic reproductive number (R 0) of 2.4 and a low-risk group with an R 0 of 0.8. Base input assumptions included an incubation time of 7.6 days and time to recovery of 21 days. Setting: U.S. residential college campus. Participants: Hypothetical cohort of 6500 students. Intervention: Isolation, quarantine, and vaccination of close contacts. Measurements: Proportion of 1000 simulations producing sustained transmission; mean cases given sustained transmission; maximum students isolated, quarantined, and vaccinated. All projections are estimated over a planning horizon of 100 days. Results: Without mitigation measures, the model estimated an 83% likelihood of sustained transmission, leading to an average of 183 cases. With detection and isolation of 20%, 50%, and 80% of cases, the average infections would fall to 117, 37, and 8, respectively. Reactive vaccination of contacts of detected cases (assuming 50% detection and isolation) reduced mean cases from 37 to 17, assuming 20 vaccinated contacts per detected case. Preemptive vaccination of 50% of the high-risk population before outbreak reduced cases from 37 to 14, assuming 50% detection and isolation. Limitation: A model is a stylized portrayal of behavior and transmission on a university campus. Conclusion: Based on our current understanding of mpox epidemiology among MSM in the United States, this model-based analysis suggests that future outbreaks of mpox on college campuses may be controlled with timely detection and isolation of symptomatic cases. Primary Funding Source: National Institutes of Health National Institute on Drug Abuse and National Institute of Allergy and Infectious Diseases.
Contact Tracing and Exposure Investigation in Response to the First Case of Monkeypox Virus Infection in the United States During the 2022 Global Monkeypox Outbreak
Background: In May 2022, the first case of monkeypox virus (MPXV) infection in the United States in the current global outbreak was identified. As part of the public health and health care facility response, a contact tracing and exposure investigation was done. Objective: To describe the contact tracing, exposure identification, risk stratification, administration of postexposure prophylaxis (PEP), and exposure period monitoring for contacts of the index patient, including evaluation of persons who developed symptoms possibly consistent with MPXV infection. Design: Contact tracing and exposure investigation. Setting: Multiple health care facilities and community settings in Massachusetts. Participants: Persons identified as contacts of the index patient. Intervention: Contact notification, risk stratification, and symptom monitoring; PEP administration in a subset of contacts. Measurements: Epidemiologic and clinical data collected through standard surveillance procedures at each facility and then aggregated and analyzed. Results: There were 37 community and 129 health care contacts identified, with 4 at high risk, 49 at intermediate risk, and 113 at low or uncertain risk. Fifteen health care contacts developed symptoms during the monitoring period. Three met criteria for MPXV testing, with negative results. Two community contacts developed symptoms. Neither met criteria for MPXV testing, and neither showed disease progression consistent with monkeypox. Among 4 persons with high-risk exposures offered PEP, 3 elected to receive PEP. Among 10 HCP with intermediate-risk exposures for which PEP was offered as part of informed clinical decision making, 2 elected to receive PEP. No transmissions were identified at the conclusion of the 21-day monitoring period, despite the delay in recognition of monkeypox in the index patient. Limitation: Descriptions of exposures are subject to recall bias, which affects risk stratification. Conclusion: In a contact tracing investigation involving 166 community and health care contacts of a patient with monkeypox, no secondary cases were identified. Primary Funding Source: None.
Monkeypox in Montréal: Epidemiology, Phylogenomics, and Public Health Response to a Large North American Outbreak
Background: Monkeypox, a viral zoonotic disease, is causing a global outbreak outside of endemic areas. Objective: To characterize the outbreak of monkeypox in Montréal, the first large outbreak in North America. Design: Epidemiologic and laboratory surveillance data and a phylogenomic analysis were used to describe and place the outbreak in a global context. Setting: Montréal, Canada. Patients: Probable or confirmed cases of monkeypox. Measurements: Epidemiologic, clinical, and demographic data were aggregated. Whole-genome sequencing and phylogenetic analysis were performed for a set of outbreak sequences. The public health response and its evolution are described. Results: Up to 18 October 2022, a total of 402 cases of monkeypox were reported mostly among men who have sex with men (MSM), most of which were suspected to be acquired through sexual contact. All monkeypox genomes nested within the B.1 lineage. Montréal Public Health worked closely with the affected communities to control the outbreak, becoming the first jurisdiction to offer 1 dose of the Modified Vaccinia Ankara-Bavarian Nordic vaccine as preexposure prophylaxis (PrEP) to those at risk in early June 2022. Two peaks of cases were seen in early June and July (43 and 44 cases per week, respectively) followed by a decline toward near resolution of the outbreak in October. Reasons for the biphasic peak are not fully elucidated but may represent the tempo of vaccination and/or several factors related to transmission dynamics and case ascertainment. Limitations: Clinical data are self-reported. Limited divergence among sequences limited genomic epidemiologic conclusions. Conclusion: A large outbreak of monkeypox occurred in Montréal, primarily among MSM. Successful control of the outbreak rested on early and sustained engagement with the affected communities and rapid offer of PrEP vaccination to at-risk persons. Primary Funding Source: None.
Implantable Defibrillator System Shock Function, Mortality, and Cause of Death After Magnetic Resonance Imaging
Background: Studies have shown that magnetic resonance imaging (MRI) does not have clinically important effects on the device parameters of non–MRI-conditional implantable cardioverter-defibrillators (ICDs). However, data on non–MRI-conditional ICD detection and treatment of arrhythmias after MRI are limited. Objective: To examine if non–MRI-conditional ICDs have preserved shock function of arrhythmias after MRI. Design: Prospective cohort study. (ClinicalTrials.gov: NCT01130896) Setting: 1 center in the United States. Patients: 629 patients with non–MRI-conditional ICDs enrolled consecutively between February 2003 and January 2015. Interventions: 813 total MRI examinations at a magnetic field strength of 1.5 Tesla using a prespecified safety protocol. Measurements: Implantable cardioverter-defibrillator interrogations were collected after MRI. Clinical outcomes included arrhythmia detection and treatment, generator or lead exchanges, adverse events, and death. Results: During a median follow-up of 2.2 years from MRI to latest available ICD interrogation before generator or lead exchange in 536 patients, 4177 arrhythmia episodes were detected, and 97 patients received ICD shocks. Sixty-one patients (10% of total) had 130 spontaneous ventricular tachycardia or fibrillation events terminated by ICD shocks. A total of 210 patients (33% of total) are known to have died (median, 1.7 years from MRI to death); 3 had cardiac arrhythmia deaths where shocks were indicated without direct evidence of device dysfunction. Limitations: Data were acquired at a single center and may not be generalizable to other clinical settings and MRI facilities. Implantable cardioverter-defibrillator interrogations were not available for a subset of patients; adjudication of cause of death relied solely on death certificate data in a subset. Conclusion: Non–MRI-conditional ICDs appropriately treated detected tachyarrhythmias after MRI. No serious adverse effects on device function were reported after MRI. Primary Funding Source: Johns Hopkins University and National Institutes of Health.
Developing Meaningful Health Care Quality Metrics: An Example From Colonoscopy and Adenoma Detection
Association Between Age and Low-Density Lipoprotein Cholesterol Response to Statins: A Danish Nationwide Cohort Study: Annals of Internal Medicine: Vol 176, No 8
Background: There is large patient-to-patient variability in the low-density lipoprotein cholesterol (LDL-C) response to statin treatment. The reduction in LDL-C may depend on the age of the patient treated—particularly in older adults, who have been substantially underrepresented in randomized controlled trials. Objective: To investigate the association between age and the LDL-C reduction by statins. Design: Nationwide, register-based cohort study. Setting: Denmark, 2008 to 2018. Participants: 82 958 simvastatin or atorvastatin initiators with LDL-C measurements before and during statin use. Measurements: Statin response, defined as percentage reduction in prestatin LDL-C level, and percentage reduction differences (PRDs) according to age and simvastatin or atorvastatin dose based on a longitudinal model for LDL-C. Results: Among 82 958 statin initiators, 10 388 (13%) were aged 75 years or older. With low- to moderate-intensity statins, initiators aged 75 years or older had greater mean LDL-C percentage reductions than initiators younger than 50 years—for example, 39.0% versus 33.8% for simvastatin, 20 mg, and 44.2% versus 40.2% for atorvastatin, 20 mg. The adjusted PRD for initiators aged 75 years compared with initiators aged 50 years was 2.62 percentage points. This association was consistent for primary prevention (2.54 percentage points) and secondary prevention (2.32 percentage points) but smaller for initiators of high-intensity statins (atorvastatin, 40 mg: 1.36 percentage points; atorvastatin, 80 mg: −0.58 percentage point). Limitation: Use of administrative data, observational pre–post comparison with a moderately high proportion of missing data, lack of information on body mass index, and the mainly White study population may limit generalizability. Conclusion: Low- to moderate-intensity statins were associated with a greater reduction in LDL-C levels in older persons than younger persons and may be more appealing as initial treatment in older adults who are at increased risk for adverse events. Primary Funding Source: The Independent Research Fund Denmark, Brødrene Hartmanns Fond, and Fonden til Lægevidenskabens Fremme.
Colinet–Caplan Syndrome: History of an Outbreak of Autoimmune Disease in Scouring Powder Workers
The first modern description linking rheumatoid arthritis to occupational dust exposure is generally attributed to the British physician Anthony Caplan. In 1953, Caplan reported on a “peculiar” nodular pattern on chest radiographs of Welsh coal miners with rheumatoid arthritis that differed from the typical coal workers' pneumoconiosis. However, as early as 1950, the Belgian rheumatologist Émile Colinet described a similar case of rheumatoid arthritis and concomitant pulmonary opacities in a 30-year-old woman with silica exposure. Soon after, he published a second case. Although this condition initially was called Colinet–Caplan syndrome in the Francophone biomedical literature, Colinet's name was later dropped from the eponym. Because Colinet never clearly described the specific occupational context of his cases, Caplan syndrome has been misconstrued as uniquely a disease of coal miners. We attempted to reconstruct the working conditions of Colinet's patients and found that they were packing Vim, a silica-based scouring powder, at the Savonneries Lever Frères factory in Brussels, Belgium. Colinet's cases were only the first 2 in a series of reports of rheumatoid arthritis and other autoimmune diseases, mainly among young women, in those who worked in the production of silica-based scouring powder between the 1930s and 1980s across Europe. The largest outbreak involved 32 cases of autoimmune disease among 50 former workers of a Spanish scouring powder manufacturing facility. After silica in scouring powders was replaced with less hazardous materials later in the 20th century, no further cases have been reported. Although scouring powder disease is a historical phenomenon, autoimmune disorders linked to occupational exposure to silica and coal dust have not disappeared but instead are reemerging among those who work with silica-based artificial stone and in other dusty trades.