The ABCs of Atrial Fibrillation

The Annals Consult Guys return to the topic of atrial fibrillation and review the Atrial fibrillation Better Care (ABC) pathway for integrated care management of atrial fibrillation.

Teaching Diagnostic Reasoning

In this episode of Annals On Call, Dr. Centor discusses teaching diagnostic reasoning with Drs. Rabih Geha and Reza Manesh. First, listen to the podcast. After listening, ACP members can take the CME/MOC quiz for free.

Talking With Patients About Health-Related Mis- and Dis-information

The most powerful current threat to public health is not an infectious disease or climate change; it is the rampant spread of health-related misinformation and disinformation (1). Social media has fostered an environment in which misleading health claims spread rapidly.

Suspected Bronchiectasis in People Who Smoke

In this episode of Annals On Call, Dr. Centor discusses suspected bronchiectasis and mortality in people who smoke with and without normal lung function with Dr. Alejandro Diaz. First, listen to the podcast. After listening, ACP members can take the CME/MOC quiz for free.

Surgery After Thromboembolic Stroke

The Annals Consult Guys discuss the vexing problem of appropriate timing of surgery after a thromboembolic stroke.

Substance Use Disorder & the Medical Record

Rules promulgated in the 1970s protected the information of patients who were assessed or treated for a substance use disorder (SUD) in a federally funded health care setting by a substance abuse specialist by requiring the patient’s written authorization for each disclosure of information to health care professionals in other treatment settings, hampering care coordination and potentially putting patients at risk. Updated "Part 2" rules published in 2024 allow patients to give a single consent for disclosure that enables any physician treating them to access information about SU

Substance Use Disorder (SUD) Presentations from 2023 Internal Medicine Meeting

Captured from Internal Medicine Meeting 2023, this video bundle package provides 2.5 hours of high-yield video content covering strategies and management options for treating substance use disorder. To purchase for credit, ACP members pay $24 while non-members pay $59. Note: 2023 Premium registrants or CME 160 purchasers can find this content here.

Substance Use Disorder (SUD) Presentations from 2022 Internal Medicine Meeting

Captured from Internal Medicine Meeting 2022, this video bundle package provides 3 hours of high-yield video content covering strategies and management options for treating substance use disorder. To purchase for credit, ACP members pay $29 while non-members pay $59.

Subclinical Coronary Atherosclerosis

In this episode of Annals On Call, Dr. Centor discusses subclinical atherosclerosis and the risk for myocardial infarction with Dr. Klaus Fuglsang Kofoed. First, listen to the podcast. After listening, ACP members can take the CME/MOC quiz for free.

Striving for Diagnostic Excellence

In this episode of Annals On Call, Dr. Centor discusses strategies for improving diagnostic skills with Dr. Gurpreet Dhaliwal. First, listen to the podcast. After listening, ACP members can take the CME/MOC quiz for free.

Risk Model–Based Lung Cancer Screening: A Cost-Effectiveness Analysis: Annals of Internal Medicine: Vol 176, No 3

Background: In their 2021 lung cancer screening recommendation update, the U.S. Preventive Services Task Force (USPSTF) evaluated strategies that select people based on their personal lung cancer risk (risk model–based strategies), highlighting the need for further research on the benefits and harms of risk model–based screening. Objective: To evaluate and compare the cost-effectiveness of risk model–based lung cancer screening strategies versus the USPSTF recommendation and to explore optimal risk thresholds. Design: Comparative modeling analysis. Data Sources: National Lung Screening Trial; Surveillance, Epidemiology, and End Results program; U.S. Smoking History Generator. Target Population: 1960 U.S. birth cohort. Time Horizon: 45 years. Perspective: U.S. health care sector. Intervention: Annual low-dose computed tomography in risk model–based strategies that start screening at age 50 or 55 years, stop screening at age 80 years, with 6-year risk thresholds between 0.5% and 2.2% using the PLCOm2012 model. Outcome Measures: Incremental cost-effectiveness ratio (ICER) and cost-effectiveness efficiency frontier connecting strategies with the highest health benefit at a given cost. Results of Base-Case Analysis: Risk model–based screening strategies were more cost-effective than the USPSTF recommendation and exclusively comprised the cost-effectiveness efficiency frontier. Among the strategies on the efficiency frontier, those with a 6-year risk threshold of 1.2% or greater were cost-effective with an ICER less than $100 000 per quality-adjusted life-year (QALY). Specifically, the strategy with a 1.2% risk threshold had an ICER of $94 659 (model range, $72 639 to $156 774), yielding more QALYs for less cost than the USPSTF recommendation, while having a similar level of screening coverage (person ever-screened 21.7% vs. USPSTF's 22.6%). Results of Sensitivity Analyses: Risk model–based strategies were robustly more cost-effective than the 2021 USPSTF recommendation under varying modeling assumptions. Limitation: Risk models were restricted to age, sex, and smoking-related risk predictors. Conclusion: Risk model–based screening is more cost-effective than the USPSTF recommendation, thus warranting further consideration. Primary Funding Source: National Cancer Institute (NCI).

Outpatient Treatment of Confirmed COVID-19: A Living, Rapid Review for the American College of Physicians

An update is available for this article. This article has been corrected. The original version of the article and supplement (PDF) is appended to this article as a Supplement. Background: Clinicians and patients want to know the benefits and harms of outpatient treatment options for SARS-CoV-2 infection. Purpose: To assess the benefits and harms of 12 different COVID-19 treatments in the outpatient setting. Data Sources: Epistemonikos COVID-19 L·OVE Platform, searched on 4 April 2022. Study Selection: Two reviewers independently screened abstracts and full texts against a priori–defined criteria. Randomized controlled trials (RCTs) that compared COVID-19 treatments in adult outpatients with confirmed SARS-CoV-2 infection were included. Data Extraction: One reviewer extracted data and assessed risk of bias and certainty of evidence (COE). A second reviewer verified data abstraction and assessments. Data Synthesis: The 26 included studies collected data before the emergence of the Omicron variant. Nirmatrelvir–ritonavir and casirivimab–imdevimab probably reduced hospitalizations (1% vs. 6% [1 RCT] and 1% vs. 4% [1 RCT], respectively; moderate COE). Nirmatrelvir–ritonavir probably reduced all-cause mortality (0% vs. 1% [1 RCT]; moderate COE), and regdanvimab probably improved recovery (87% vs. 72% [1 RCT]; moderate COE). Casirivimab–imdevimab reduced time to recovery by a median difference of 4 days (10 vs. 14 median days [1 RCT]; high COE). Molnupiravir may reduce all-cause mortality, sotrovimab and remdesivir may reduce hospitalization, and remdesivir may improve recovery (low COE). Lopinavir–ritonavir and azithromycin may have increased harms, and hydroxychloroquine may result in lower recovery rates (low COE). Other treatments had insufficient evidence or no statistical difference in efficacy and safety versus placebo. Limitation: Many outcomes had few events and small samples. Conclusion: Some antiviral medications and monoclonal antibodies may improve outcomes for outpatients with mild to moderate COVID-19. However, the generalizability of the findings to the currently dominant Omicron variant is limited. Primary Funding Source: American College of Physicians. (PROSPERO: CRD42022323440)

In These Uncaring Times, Will Physicians Lead Us Back to Our Better Angels?

Cold Versus Hot Snare Polypectomy for Small Colorectal Polyps: A Pragmatic Randomized Controlled Trial: Annals of Internal Medicine: Vol 176, No 3

Background: Although cold snare polypectomy (CSP) is considered effective in reducing delayed postpolypectomy bleeding risk, direct evidence supporting its safety in the general population remains lacking. Objective: To clarify whether CSP would reduce delayed bleeding risk after polypectomy compared with hot snare polypectomy (HSP) in the general population. Design: Multicenter randomized controlled study. (ClinicalTrials.gov: NCT03373136) Setting: 6 sites in Taiwan, July 2018 through July 2020. Participants: Participants aged 40 years or older with polyps of 4 to 10 mm. Intervention: CSP or HSP to remove polyps of 4 to 10 mm. Measurements: The primary outcome was the delayed bleeding rate within 14 days after polypectomy. Severe bleeding was defined as a decrease in hemoglobin concentration of 20 g/L or more, requiring transfusion or hemostasis. Secondary outcomes included mean polypectomy time, successful tissue retrieval, en bloc resection, complete histologic resection, and emergency service visits. Results: A total of 4270 participants were randomly assigned (2137 to CSP and 2133 to HSP). Eight patients (0.4%) in the CSP group and 31 (1.5%) in the HSP group had delayed bleeding (risk difference, −1.1% [95% CI, −1.7% to −0.5%]). Severe delayed bleeding was also lower in the CSP group (1 [0.05%] vs. 8 [0.4%] events; risk difference, −0.3% [CI, −0.6% to −0.05%]). Mean polypectomy time (119.0 vs. 162.9 seconds; difference in mean, −44.0 seconds [CI, −53.1 to −34.9 seconds]) was shorter in the CSP group, although successful tissue retrieval, en bloc resection, and complete histologic resection did not differ. The CSP group had fewer emergency service visits than the HSP group (4 [0.2%] vs. 13 [0.6%] visits; risk difference, −0.4% [CI, −0.8% to −0.04%]). Limitation: An open-label, single-blind trial. Conclusion: Compared with HSP, CSP for small colorectal polyps significantly reduces the risk for delayed postpolypectomy bleeding, including severe events. Primary Funding Source: Boston Scientific Corporation.

Detection of Monkeypox Virus in Anorectal Swabs From Asymptomatic Men Who Have Sex With Men in a Sexually Transmitted Infection Screening Program in Paris, France

Get Out the Vote: A Framework to Mobilize Medical Professionals to Vote

Poser

Effectiveness of Opioid Analgesic Medicines Prescribed in or at Discharge From Emergency Departments for Musculoskeletal Pain: A Systematic Review and Meta-analysis: Annals of Internal Medicine: Vol 175, No 11

Background: The comparative benefits and harms of opioids for musculoskeletal pain in the emergency department (ED) are uncertain. Purpose: To evaluate the comparative effectiveness and harms of opioids for musculoskeletal pain in the ED setting. Data Sources: Electronic databases and registries from inception to 7 February 2022. Study Selection: Randomized controlled trials of any opioid analgesic compared with placebo or a nonopioid analgesic administered or prescribed to adults in or on discharge from the ED. Data Extraction: Pain and disability were rated on a scale of 0 to 100 and pooled using a random-effects model. Certainty of evidence was assessed using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) framework. Data Synthesis: Forty-two articles were included (n = 6128). In the ED, opioids were statistically but not clinically more effective in reducing pain in the short term (about 2 hours) than placebo and paracetamol (acetaminophen) but were not clinically or statistically more effective than nonsteroidal anti-inflammatory drugs (NSAIDs) or local or systemic anesthetics. Opioids may carry higher risk for harms than placebo, paracetamol, or NSAIDs, although evidence is very uncertain. There was no evidence of difference in harms associated with local or systemic anesthetics. Limitations: Low or very low GRADE ratings for some outcomes, unexplained heterogeneity, and little information on long-term outcomes. Conclusion: The risk–benefit balance of opioids versus placebo, paracetamol, NSAIDs, and local or systemic anesthetics is uncertain. Opioids may have equivalent pain outcomes compared with NSAIDs, but evidence on comparisons of harms is very uncertain and heterogeneous. Although factors such as route of administration or dosage may explain some heterogeneity, more work is needed to identify which subgroups will have a more favorable benefit–risk balance for one analgesic over another. Longer-term pain management once dose thresholds are reached is also uncertain. Primary Funding Source: None. (PROSPERO: CRD42021275293)

Nirmatrelvir Plus Ritonavir for Early COVID-19 in a Large U.S. Health System: A Population-Based Cohort Study: Annals of Internal Medicine: Vol 176, No 1

Background: In the EPIC-HR (Evaluation of Protease Inhibition for Covid-19 in High-Risk Patients) trial, nirmatrelvir plus ritonavir led to an 89% reduction in hospitalization or death among unvaccinated outpatients with early COVID-19. The clinical impact of nirmatrelvir plus ritonavir among vaccinated populations is uncertain. Objective: To assess whether nirmatrelvir plus ritonavir reduces risk for hospitalization or death among outpatients with early COVID-19 in the setting of prevalent SARS-CoV-2 immunity and immune-evasive SARS-CoV-2 lineages. Design: Population-based cohort study analyzed to emulate a clinical trial using inverse probability–weighted models to account for anticipated bias in treatment. Setting: A large health care system providing care for 1.5 million patients in Massachusetts and New Hampshire during the Omicron wave (1 January to 17 July 2022). Patients: 44 551 nonhospitalized adults (90.3% with ≥3 vaccine doses) aged 50 years or older with COVID-19 and no contraindications for nirmatrelvir plus ritonavir. Measurements: The primary outcome was a composite of hospitalization within 14 days or death within 28 days of a COVID-19 diagnosis. Results: During the study period, 12 541 (28.1%) patients were prescribed nirmatrelvir plus ritonavir, and 32 010 (71.9%) were not. Patients prescribed nirmatrelvir plus ritonavir were more likely to be older, have more comorbidities, and be vaccinated. The composite outcome of hospitalization or death occurred in 69 (0.55%) patients who were prescribed nirmatrelvir plus ritonavir and 310 (0.97%) who were not (adjusted risk ratio, 0.56 [95% CI, 0.42 to 0.75]). Recipients of nirmatrelvir plus ritonavir had lower risk for hospitalization (adjusted risk ratio, 0.60 [CI, 0.44 to 0.81]) and death (adjusted risk ratio, 0.29 [CI, 0.12 to 0.71]). Limitation: Potential residual confounding due to differential access to COVID-19 vaccines, diagnostic tests, and treatment. Conclusion: The overall risk for hospitalization or death was already low (1%) after an outpatient diagnosis of COVID-19, but nirmatrelvir plus ritonavir reduced this risk further. Primary Funding Source: National Institutes of Health.

Temporal Improvements in COVID-19 Outcomes for Hospitalized Adults: A Post Hoc Observational Study of Remdesivir Group Participants in the Adaptive COVID-19 Treatment Trial

Background: The COVID-19 standard of care (SOC) evolved rapidly during 2020 and 2021, but its cumulative effect over time is unclear. Objective: To evaluate whether recovery and mortality improved as SOC evolved, using data from ACTT (Adaptive COVID-19 Treatment Trial). Design: ACTT is a series of phase 3, randomized, double-blind, placebo-controlled trials that evaluated COVID-19 therapeutics from February 2020 through May 2021. ACTT-1 compared remdesivir plus SOC to placebo plus SOC, and in ACTT-2 and ACTT-3, remdesivir plus SOC was the control group. This post hoc analysis compared recovery and mortality between these comparable sequential cohorts of patients who received remdesivir plus SOC, adjusting for baseline characteristics with propensity score weighting. The analysis was repeated for participants in ACTT-3 and ACTT-4 who received remdesivir plus dexamethasone plus SOC. Trends in SOC that could explain outcome improvements were analyzed. (ClinicalTrials.gov: NCT04280705 [ACTT-1], NCT04401579 [ACTT-2], NCT04492475 [ACTT-3], and NCT04640168 [ACTT-4]) Setting: 94 hospitals in 10 countries (86% U.S. participants). Participants: Adults hospitalized with COVID-19. Intervention: SOC. Measurements: 28-day mortality and recovery. Results: Although outcomes were better in ACTT-2 than in ACTT-1, adjusted hazard ratios (HRs) were close to 1 (HR for recovery, 1.04 [95% CI, 0.92 to 1.17]; HR for mortality, 0.90 [CI, 0.56 to 1.40]). Comparable patients were less likely to be intubated in ACTT-2 than in ACTT-1 (odds ratio, 0.75 [CI, 0.53 to 0.97]), and hydroxychloroquine use decreased. Outcomes improved from ACTT-2 to ACTT-3 (HR for recovery, 1.43 [CI, 1.24 to 1.64]; HR for mortality, 0.45 [CI, 0.21 to 0.97]). Potential explanatory factors (SOC trends, case surges, and variant trends) were similar between ACTT-2 and ACTT-3, except for increased dexamethasone use (11% to 77%). Outcomes were similar in ACTT-3 and ACTT-4. Antibiotic use decreased gradually across all stages. Limitation: Unmeasured confounding. Conclusion: Changes in patient composition explained improved outcomes from ACTT-1 to ACTT-2 but not from ACTT-2 to ACTT-3, suggesting improved SOC. These results support excluding nonconcurrent controls from analysis of platform trials in rapidly changing therapeutic areas. Primary Funding Source: National Institute of Allergy and Infectious Diseases.

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