What You May Have Missed in 2024: Part 3

In this episode of Annals On Call, Dr. Centor revisits information included in the Annals of Internal Medicine supplement “What You May Have Missed in 2024.”First, listen to the podcast. After listening, ACP members can take the CME/MOC quiz for free.

What You May Have Missed in 2024: Part 2

In this episode of Annals On Call, Dr. Centor revisits information included in the Annals of Internal Medicine supplement “What You May Have Missed in 2024.”First, listen to the podcast. After listening, ACP members can take the CME/MOC quiz for free.

What You May Have Missed in 2024: Part 1

In this episode of Annals On Call, Dr. Centor revisits information included in the Annals of Internal Medicine supplement “What You May Have Missed in 2024.”First, listen to the podcast. After listening, ACP members can take the CME/MOC quiz for free.

What Would You Recommend for This Patient Interested in a Total Knee Joint Arthroplasty? Grand Rounds Discussion From Beth Israel Deaconess Medical Center

Fourteen million people in the United States have symptomatic knee osteoarthritis (OA), a number that is expected to rise with an aging population. Patients with OA can benefit from nonoperative treatment. However, none of these treatments are disease modifying, and many patients eventually require total joint arthroplasty (TJA). The American College of Rheumatology and the American Association of Hip and Knee Surgeons recently issued a guideline on the optimal timing of TJA in patients with symptomatic moderate-to-severe OA for whom nonoperative therapy has been ineffective.

What Internal Medicine Physicians Need to Know About Contraception

Undesired pregnancy has potential negative effects on physical, mental, social, and financial well-being. Yet, internal medicine physicians too often do not consider contraception as a component of routine preventive health care. Contraception gets little, if any, emphasis during internal medicine residency training, and most internal medicine physicians have never prescribed long-acting contraception or inserted an intrauterine device. Many defer discussion of pregnancy intent and contraception to colleagues in obstetrics and gynecology.

Virtual Urgent Care: Artificial Intelligence Versus Physicians

In this episode of Annals On Call, Dr. Centor discusses artificial intelligence–assisted urgent care with Dr. Zehavi Kugler. First, listen to the podcast. After listening, ACP members can take the CME/MOC quiz for free.

Vaccines: Decision Making Amid Conflicting Recommendations

Vaccinations are among the most impactful of all public health interventions—protecting not only the vaccinee but also those around them. When polio vaccines were introduced, people clamored to receive them to avoid polio-related death and disability. Influenza vaccines have prevented countless lost days from school or work, hospitalizations, and deaths. Hepatitis B vaccines can prevent serious complications, including chronic liver damage and hepatocarcinoma. Some deadly infections such as smallpox have been virtually eliminated by vaccines.

Using Stories to Explore Identity and Enhance Well-being

Share your authentic story. Learn how narrative medicine can expand insight, creativity, compassion for self and others, and connection that supports inclusion and a sense of belonging. No MOC points available for this activity

Uptake of Newer Antibiotics for Resistant Infections

In this episode of Annals On Call, Dr. Centor discusses the uptake of newer antibiotics for difficult-to-treat resistant infections with Dr. Sameer Kadri. First, listen to the podcast. After listening, ACP members can take the CME/MOC quiz for free.

Understanding and Addressing Disparities in Diagnosis: Case 2

Understanding and Addressing Disparities in Diagnosis: Case 2 explores a case in the outpatient setting. The case focuses primarily on the difference in appearance of certain conditions on melanotic skin, as well as the differences in treatment some people of color may face as patients due to bias. This module offers both CME and MOC credit free to members and for a small fee to non-members.

Incremental Health Care Costs of Self-Reported Functional Impairments and Phenotypic Frailty in Community-Dwelling Older Adults: A Prospective Cohort Study: Annals of Internal Medicine: Vol 176, No 4

Background: Health care systems need better strategies to identify older adults at risk for costly care to select target populations for interventions to reduce health care burden. Objective: To determine whether self-reported functional impairments and phenotypic frailty are associated with incremental health care costs after accounting for claims-based predictors. Design: Prospective cohort study. Setting: Index examinations (2002 to 2011) of 4 prospective cohort studies linked with Medicare claims. Participants: 8165 community-dwelling fee-for-service beneficiaries (4318 women, 3847 men). Measurements: Weighted (Centers for Medicare & Medicaid Services Hierarchical Condition Category index) and unweighted (count of conditions) multimorbidity and frailty indicators derived from claims. Self-reported functional impairments (difficulty performing 4 activities of daily living) and frailty phenotype (operationalized using 5 components) derived from cohort data. Health care costs ascertained for 36 months after index examinations. Results: Average annualized costs (2020 U.S. dollars) were $13 906 among women and $14 598 among men. After accounting for claims-based indicators, average incremental costs of functional impairments versus no impairment in women (men) were $3328 ($2354) for 1 impairment increasing to $7330 ($11 760) for 4 impairments; average incremental costs of phenotypic frailty versus robust in women (men) were $8532 ($6172). Mean predicted costs adjusted for claims-based indicators in women (men) varied by both functional impairments and the frailty phenotype ranging from $8124 ($11 831) among robust persons without impairments to $18 792 ($24 713) among frail persons with 4 impairments. Compared with the model with claims-derived indicators alone, this model resulted in more accurate cost prediction for persons with multiple impairments or phenotypic frailty. Limitation: Cost data limited to participants enrolled in the Medicare fee-for-service program. Conclusion: Self-reported functional impairments and phenotypic frailty are associated with higher subsequent health care expenditures in community-dwelling beneficiaries after accounting for several claims-based indicators of costs. Primary Funding Source: National Institutes of Health.

Using Body Mass Index to Identify and Address Obesity in Asian Americans: One Size Does Not Fit All

Role of Artificial Intelligence in Colonoscopy Detection of Advanced Neoplasias: A Randomized Trial: Annals of Internal Medicine: Vol 176, No 9

Background: The role of computer-aided detection in identifying advanced colorectal neoplasia is unknown. Objective: To evaluate the contribution of computer-aided detection to colonoscopic detection of advanced colorectal neoplasias as well as adenomas, serrated polyps, and nonpolypoid and right-sided lesions. Design: Multicenter, parallel, randomized controlled trial. (ClinicalTrials.gov: NCT04673136) Setting: Spanish colorectal cancer screening program. Participants: 3213 persons with a positive fecal immunochemical test. Intervention: Enrollees were randomly assigned to colonoscopy with or without computer-aided detection. Measurements: Advanced colorectal neoplasia was defined as advanced adenoma and/or advanced serrated polyp. Results: The 2 comparison groups showed no significant difference in advanced colorectal neoplasia detection rate (34.8% with intervention vs. 34.6% for controls; adjusted risk ratio [aRR], 1.01 [95% CI, 0.92 to 1.10]) or the mean number of advanced colorectal neoplasias detected per colonoscopy (0.54 [SD, 0.95] with intervention vs. 0.52 [SD, 0.95] for controls; adjusted rate ratio, 1.04 [99.9% CI, 0.88 to 1.22]). Adenoma detection rate also did not differ (64.2% with intervention vs. 62.0% for controls; aRR, 1.06 [99.9% CI, 0.91 to 1.23]). Computer-aided detection increased the mean number of nonpolypoid lesions (0.56 [SD, 1.25] vs. 0.47 [SD, 1.18] for controls; adjusted rate ratio, 1.19 [99.9% CI, 1.01 to 1.41]), proximal adenomas (0.94 [SD, 1.62] vs. 0.81 [SD, 1.52] for controls; adjusted rate ratio, 1.17 [99.9% CI, 1.03 to 1.33]), and lesions of 5 mm or smaller (polyps in general and adenomas and serrated lesions in particular) detected per colonoscopy. Limitations: The high adenoma detection rate in the control group may limit the generalizability of the findings to endoscopists with low detection rates. Conclusion: Computer-aided detection did not improve colonoscopic identification of advanced colorectal neoplasias. Primary Funding Source: Medtronic.

The Dark Side of Rapid Reviews: A Retreat From Systematic Approaches and the Need for Clear Expectations and Reporting

Adrenal Incidentalomas: Insights Into Prevalence

Cancer Screening Guidelines Are Not Simple, But They Could Be Less Complex

Short-Term Adverse Outcomes After Mifepristone–Misoprostol Versus Procedural Induced Abortion: A Population-Based Propensity-Weighted Study: Annals of Internal Medicine: Vol 176, No 2

Background: Prior studies comparing first-trimester pharmaceutical induced abortion (IA) with procedural IA were prone to selection bias, were underpowered to assess serious adverse events (SAEs), and did not account for confounding by indication. Starting in 2017, mifepristone–misoprostol was dispensed at no cost in outpatient pharmacies across Ontario, Canada. Objective: To compare short-term risk for adverse outcomes after early IA by mifepristone–misoprostol versus by procedural IA. Design: Population-based cohort study. Setting: Ontario, Canada. Patients: All women who had first-trimester IA. Measurements: A total of 39 856 women dispensed mifepristone–misoprostol as outpatients were compared with 65 176 women undergoing procedural IA at 14 weeks' gestation or earlier within nonhospital outpatient clinics (comparison 1). A total of 39 856 women prescribed mifepristone–misoprostol were compared with 8861 women undergoing ambulatory hospital-based procedural IA at an estimated 9 weeks' gestation or less (comparison 2). The primary composite outcome was any SAE within 42 days after IA, including severe maternal morbidity, end-organ damage, intensive care unit admission, or death. A coprimary broader outcome comprised any SAE, hemorrhage, retained products of conception, infection, or transfusion. Stabilized inverse probability of treatment weighting accounted for confounding between exposure groups. Results: Mean age at IA was about 29 years (SD, 7); 33% were primigravidae. Six percent resided in rural areas, and 25% resided in low-income neighborhoods. In comparison 1, SAEs occurred among 133 women after mifepristone–misoprostol IA (3.3 per 1000) versus 114 after procedural IA (1.8 per 1000) (relative risk [RR], 1.87 [95% CI, 1.44 to 2.43]; absolute risk difference [ARD], 1.5 per 1000 [CI, 0.9 to 2.2]). The respective rates of any adverse event were 28.9 versus 12.4 per 1000 (RR, 2.33 [CI, 2.11 to 2.57]; ARD, 16.5 per 1000 [CI, 14.5 to 18.4]). In comparison 2, SAEs occurred among 133 (3.4 per 1000) and 27 (3.3 per 1000) women, respectively (RR, 1.04 [CI, 0.61 to 1.78]). The respective rates of any adverse event were 31.2 versus 24.9 per 1000 (RR, 1.25 [CI, 1.04 to 1.51]). Limitation: A woman prescribed mifepristone–misoprostol may not have taken the medication, and the exact gestational age at IA was not always known. Conclusion: Although rare, short-term adverse events are more likely after mifepristone–misoprostol IA than procedural IA, especially for less serious adverse outcomes. Primary Funding Source: Canadian Institutes of Health Research.

Effect of Yoga on Frailty in Older Adults: A Systematic Review: Annals of Internal Medicine: Vol 176, No 4

Background: Yoga, a multicomponent mind–body practice, improves several domains of physical and psychological health and may affect frailty in older adults. Purpose: To evaluate the available trial evidence on the effect of yoga-based interventions on frailty in older adults. Data Sources: MEDLINE, EMBASE, and Cochrane Central from their inception to 12 December 2022. Study Selection: Randomized controlled trials evaluating the effect of yoga-based interventions, including at least 1 session of physical postures, on a validated frailty scale or single-item markers of frailty in adults aged 65 years or older. Data Extraction: Two authors independently screened articles and extracted data; 1 author assessed risk of bias with review from a second author. Disagreements were resolved through consensus and as-needed input from a third author. Data Synthesis: Thirty-three studies (n = 2384 participants) were identified in varied populations, including community dwellers, nursing home residents, and those with chronic disease. Yoga styles were primarily based on Hatha yoga and most often included Iyengar or chair-based methods. Single-item frailty markers included measures of gait speed, handgrip strength, balance, lower-extremity strength and endurance, and multicomponent physical performance measures; no studies included a validated definition of frailty. When compared with education or inactive control, there was moderate-certainty evidence that yoga improved gait speed and lower-extremity strength and endurance, low-certainty evidence for balance and multicomponent physical function measures, and very low-certainty evidence for handgrip strength. Limitation: Heterogeneity in study design and yoga style, small sample sizes, and reporting deficiencies leading to concerns for selection bias. Conclusion: Yoga may affect frailty markers that are associated with clinically meaningful outcomes in older adult populations but may not offer benefit over active interventions (for example, exercise). Primary Funding Source: None. (PROSPERO: CRD42020130303)

Physician Turnover in the United States

Background: Medical groups, health systems, and professional associations are concerned about potential increases in physician turnover, which may affect patient access and quality of care. Objective: To examine whether turnover has changed over time and whether it is higher for certain types of physicians or practice settings. Design: The authors developed a novel method using 100% of traditional Medicare billing to create national estimates of turnover. Standardized turnover rates were compared by physician, practice, and patient characteristics. Setting: Traditional Medicare, 2010 to 2020. Participants: Physicians billing traditional Medicare. Measurements: Indicators of physician turnover—physicians who stopped practicing and those who moved from one practice to another—and their sum. Results: The annual rate of turnover increased from 5.3% to 7.2% between 2010 and 2014, was stable through 2017, and increased modestly in 2018 to 7.6%. Most of the increase from 2010 to 2014 came from physicians who stopped practicing increasing from 1.6% to 3.1%; physicians moving increased modestly from 3.7% to 4.2%. Modest but statistically significant (P < 0.001) differences existed across rurality, physician sex, specialty, and patient characteristics. In the second and third quarters of 2020, quarterly turnover was slightly lower than in the corresponding quarters of 2019. Limitation: Measurement was based on traditional Medicare claims. Conclusion: Over the past decade, physician turnover rates have had periods of increase and stability. These early data, covering the first 3 quarters of 2020, give no indication yet of the COVID-19 pandemic increasing turnover, although continued tracking of turnover is warranted. This novel method will enable future monitoring and further investigations into turnover. Primary Funding Source: The Physicians Foundation Center for the Study of Physician Practice and Leadership.

Effects of Cognitive Behavioral Therapy and Cash Transfers on Older Persons Living Alone in India: A Randomized Trial: Annals of Internal Medicine: Vol 176, No 5

Background: A growing number of older persons in developing countries live entirely alone and are physically, mentally, and financially vulnerable. Objective: To determine whether phone-based cognitive behavioral therapy (CBT) or a cash transfer reduce functional impairment, depression, or food insecurity in this population. Design: Randomized controlled trial. (ClinicalTrials.gov: NCT04225845; American Economic Association RCT Registry: AEARCTR-0007582). Setting: Tamil Nadu, India, 2021. Participants: 1120 people aged 55 years and older and living alone. Interventions: A 6-week, phone-based CBT and a 1-time cash transfer of 1000 rupees (U.S. $12 at market exchange rates) were evaluated in a factorial design. Measurements: The World Health Organization Disability Assessment Schedule (WHODAS), the Geriatric Depression Scale, and food security, all measured 3 weeks after CBT for 977 people and 3 months after for 932. Surveyors were blind to treatment assignment. Results: The WHODAS score (scale 0 to 48, greater values representing more impairment) decreased between baseline and the 3-week follow-up by 2.92 more (95% CI, −5.60 to −0.23) in the group assigned cash only than in the control group, and the depression score (ranging from 0 to 15, higher score indicating more depressive symptoms) decreased by 1.01 more (CI, −2.07 to 0.06). These effects did not persist to the 3-month follow-up, and CBT alone and the 2 together had no significant effects. There were no effects on food security. Limitations: The study cannot say whether more sustained or in-person therapy would have been effective, how results would translate outside of the COVID-19 period, or whether results in the consented sample differ from those in a larger population. Primary outcomes were self-reported. Conclusion: Among older people living alone, a small cash transfer was effective in alleviating short-term (3 weeks) functional impairment, produced a small but not clinically or statistically significant reduction in depression, and had no effect on food security. There were no short-term effects from CBT or the 2 interventions together. None of the interventions showed any effect at 3 months. Primary Funding Source: National Institute on Aging (NIA).

ACP recommends an evidence-based public health approach to excessive alcohol use

USPSTF recommends biennial breast cancer screening for women ages 40 to 74 years

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Spotlight on internal medicine physician leaders

New audio versions available for ACP Online Learning Center content

Lixisenatide linked with moderate symptom improvement in early Parkinson's

MKSAP Quiz: 2-week history of daily palpitations

New research evaluates strategies for prostate cancer screening

Salt substitution associated with lower mortality

Put words in our mouth

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