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Displaying 861 - 870 of 7495 in ACP Online
Steroids: 5 Pearls Segment
Steroids are commonly used in clinical practice to treat a wide range of diseases. Despite widespread use, there are common pitfalls related to their selection, dosing, and discontinuation. Understanding the rationale behind steroid selection and usage is crucial for tailoring therapy to each patient and their specific disease. In this episode of Core IM, the team aims to address the common questions encountered by internists when caring for patients.
Spontaneous Coronary Artery Dissection
The Annals Consult Guys discuss a patient who had a myocardial infarction due to spontaneous coronary artery dissection. Why did this happen? Can anything be done to reduce the risk of it happening again?
Should Antihypertensive Therapy Be Optimized Before Hospital Discharge?
The Annals Consult Guys review the management of hypertension before hospital discharge.
Semaglutide Versus Dulaglutide or Empagliflozin: Death and Cardiovascular Outcomes for Patients With Type 2 Diabetes
In this episode of Annals On Call, Dr. Centor discusses outcomes in patients with type 2 diabetes when treated with semaglutide or dulaglutide versus empagliflozin with Drs. Kevin Kip and Anum Saeed. First, listen to the podcast. After listening, ACP members can take the CME/MOC quiz for free.
Seadragon
This episode of Bedside Rounds, the first in a series of three episodes, is on the development of clinical decision support (CDS) systems, the role they play in medical decision making, and how this will change in the future with artificial intelligence. This first episode, Seadragon, goes over the history of high stakes abdominal surgeries, which led to the development of the "model" CDS, AAPHELP, also known as the Leeds Abdominal Pain Scale. You’re invited to join Dr.
Rhythm Control in Afib: 5 Pearls Segment
The Core IM team dives into Rhythm Control in Afib: 5 Pearls Segment with the recognition of paradigm shift and the latest guidelines in atrial fibrillation management. Specifically the guests for this episode will examine the indications for antiarrhythmic strategies, pathophysiology of atrial fibrillation progression, and indications for rate control.
Reviving Humility in Physicians
In this episode of Annals On Call, Dr. Centor discusses the importance of physician humility with Dr. Caroline Matchett. First, listen to the podcast. After listening, ACP members can take the CME/MOC quiz for free.
Reversals of Care Started After a Myocardial Infarction
The Annals Consult Guys discuss the modification of medication regimens initiated in the setting of an acute myocardial infarction.
Responding to Medical Misinformation and Disinformation and Protecting Scientific Discourse and Integrity
Communicating clearly to the public about the scientific process and the uncertainty inherent in science and medicine can be challenging. Patients and the public are often not prepared to understand why scientific knowledge and recommendations change, especially in fast-evolving fields. Patients can become confused and distrustful in the face of differing views and disagreement in the professional community.
Renin–Angiotensin System Blockade in Persons With Advanced Chronic Kidney Disease
In this episode of Annals On Call, Dr. Centor discusses renin–angiotensin system blockade in persons with advanced chronic kidney disease with Drs. Elaine Ku and Mark Sarnak. First, listen to the podcast. After listening, ACP members can take the CME/MOC quiz for free.
Displaying 861 - 870 of 6736 in Annals of Internal Medicine
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Effects of Dapagliflozin on Hospitalizations in Patients With Chronic Kidney Disease: A Post Hoc Analysis of DAPA-CKD: Annals of Internal Medicine: Vol 176, No 1
Background: Acute hospitalizations are common in patients with chronic kidney disease (CKD) and often lead to decreases in health-related quality of life and increased care costs. Objective: To determine the effects of dapagliflozin on first hospitalizations and all (first and subsequent) hospitalizations and to explore effects on cause-specific hospitalizations. Design: Post hoc analysis of a randomized, double-blind, placebo-controlled clinical trial. (ClinicalTrials.gov: NCT03036150) Setting: 386 ambulatory practice sites in 21 countries from 2 February 2017 through 12 June 2020. Participants: Adults with an estimated glomerular filtration rate of 25 to 75 mL/min/1.73 m2 and a urinary albumin–creatinine ratio of 200 to 5000 mg/g, with and without type 2 diabetes. Intervention: Dapagliflozin, 10 mg once daily, or matching placebo (1:1 ratio). Measurements: The effects of dapagliflozin on first hospitalizations for any cause, all hospitalizations, and cause-specific (first and recurrent) hospitalizations were determined. The reported system organ class was used to evaluate reasons for admission. Hospitalizations were analyzed using Cox proportional hazards regression models (first hospitalization), the Lin–Wei–Yang–Ying method (all hospitalizations or death), and negative binomial models (cause-specific hospitalizations). Results: The study included 4304 patients (mean age, 61.8 years; 33.1% women). During a median follow-up of 2.4 years, 2072 hospitalizations were reported among 1224 (28.4%) participants. Compared with placebo, dapagliflozin reduced risk for a first hospitalization (hazard ratio, 0.84 [95% CI, 0.75 to 0.94]) and all hospitalizations or death (rate ratio, 0.79 [CI, 0.70 to 0.89]). There was no evidence that the effects of dapagliflozin on first and all hospitalizations varied by baseline presence of type 2 diabetes (P for interaction = 0.60 for each). Compared with placebo, dapagliflozin reduced the rate of admissions due to cardiac disorders, renal and urinary disorders, metabolism and nutrition disorders, and neoplasms. Limitations: This was a post hoc analysis and should be viewed as hypothesis-generating. Hospitalizations and causes were reported by site investigators and were not centrally adjudicated. Conclusion: Dapagliflozin reduced the risk for hospitalization for any cause in patients with CKD with and without type 2 diabetes. Primary Funding Source: AstraZeneca.
Total Ankle Replacement Versus Arthrodesis for End-Stage Ankle Osteoarthritis: A Randomized Controlled Trial: Annals of Internal Medicine: Vol 175, No 12
Background: End-stage ankle osteoarthritis causes severe pain and disability. There are no randomized trials comparing the 2 main surgical treatments: total ankle replacement (TAR) and ankle fusion (AF). Objective: To determine which treatment is superior in terms of clinical scores and adverse events. Design: A multicenter, parallel-group, open-label randomized trial. (ISRCTN registry number: 60672307) Setting: 17 National Health Service trusts across the United Kingdom. Patients: Patients with end-stage ankle osteoarthritis, aged 50 to 85 years, and suitable for either procedure. Intervention: Patients were randomly assigned to TAR or AF surgical treatment. Measurements: The primary outcome was change in Manchester–Oxford Foot Questionnaire walking/standing (MOXFQ-W/S) domain scores between baseline and 52 weeks after surgery. No blinding was possible. Results: Between 6 March 2015 and 10 January 2019, a total of 303 patients were randomly assigned; mean age was 68 years, and 71% were men. Twenty-one patients withdrew before surgery, and 281 clinical scores were analyzed. At 52 weeks, the mean MOXFQ-W/S scores improved for both groups. The adjusted difference in the change in MOXFQ-W/S scores from baseline was −5.6 (95% CI, −12.5 to 1.4), showing that TAR improved more than AF, but the difference was not considered clinically or statistically significant. The number of adverse events was similar between groups (109 vs. 104), but there were more wound healing issues in the TAR group and more thromboembolic events and nonunion in the AF group. The symptomatic nonunion rate for AF was 7%. A post hoc analysis suggested superiority of fixed-bearing TAR over AF (−11.1 [CI, −19.3 to −2.9]). Limitation: Only 52-week data; pragmatic design creates heterogeneity of implants and surgical techniques. Conclusion: Both TAR and AF improve MOXFQ-W/S and had similar clinical scores and number of harms. Total ankle replacement had greater wound healing complications and nerve injuries, whereas AF had greater thromboembolism and nonunion, with a symptomatic nonunion rate of 7%. Primary Funding Source: National Institute for Health and Care Research Heath Technology Assessment Programme.
Nonpharmacologic and Pharmacologic Treatments of Adults in the Acute Phase of Major Depressive Disorder: A Living Clinical Guideline From the American College of Physicians
An update is available for this article. Description: The purpose of this guideline from the American College of Physicians (ACP) is to present updated clinical recommendations on nonpharmacologic and pharmacologic interventions as initial and second-line treatments during the acute phase of a major depressive disorder (MDD) episode, based on the best available evidence on the comparative benefits and harms, consideration of patient values and preferences, and cost. Methods: The ACP Clinical Guidelines Committee based these recommendations on an updated systematic review of the evidence. Audience and Patient Population: The audience for this guideline includes clinicians caring for adult patients in the acute phase of MDD in ambulatory care. The patient population includes adults in the acute phase of MDD. Recommendation 1a: ACP recommends monotherapy with either cognitive behavioral therapy or a second-generation antidepressant as initial treatment in patients in the acute phase of moderate to severe major depressive disorder (strong recommendation; moderate-certainty evidence). Recommendation 1b: ACP suggests combination therapy with cognitive behavioral therapy and a second-generation antidepressant as initial treatment in patients in the acute phase of moderate to severe major depressive disorder (conditional recommendation; low-certainty evidence). The informed decision on the options of monotherapy with cognitive behavioral therapy versus second-generation antidepressants or combination therapy should be personalized and based on discussion of potential treatment benefits, harms, adverse effect profiles, cost, feasibility, patients' specific symptoms (such as insomnia, hypersomnia, or fluctuation in appetite), comorbidities, concomitant medication use, and patient preferences. Recommendation 2: ACP suggests monotherapy with cognitive behavioral therapy as initial treatment in patients in the acute phase of mild major depressive disorder (conditional recommendation; low-certainty evidence). Recommendation 3: ACP suggests one of the following options for patients in the acute phase of moderate to severe major depressive disorder who did not respond to initial treatment with an adequate dose of a second-generation antidepressant: • Switching to or augmenting with cognitive behavioral therapy (conditional recommendation; low-certainty evidence) • Switching to a different second-generation antidepressant or augmenting with a second pharmacologic treatment (see Clinical Considerations) (conditional recommendation; low-certainty evidence) The informed decision on the options should be personalized and based on discussion of potential treatment benefits, harms, adverse effect profiles, cost, feasibility, patients' specific symptoms (such as insomnia, hypersomnia, or fluctuation in appetite), comorbidities, concomitant medication use, and patient preferences.
How Would You Screen This Patient for Colorectal Cancer?: Grand Rounds Discussion From Beth Israel Deaconess Medical Center: Annals of Internal Medicine: Vol 175, No 10
Colorectal cancer (CRC) is the third leading cause of cancer death for men and women in the United States, with an estimated 52 580 people expected to die in 2022. Most frequently, CRC is diagnosed among persons aged 65 to 74 years. However, among persons younger than 50 years, incidence rates have been increasing since the mid-1990s. In 2021, partially because of the rising incidence, the U.S. Preventive Services Task Force (USPSTF) recommended CRC screening for adults aged 45 to 49 years (Grade B recommendation). Options for CRC screening include stool-based and direct visualization tests. The USPSTF did not recommend a specific screening test; rather, its guidance was to select a test after a discussion with the patient. Here, a primary care physician and a gastroenterologist discuss the recommendation to begin CRC screening at age 45, review options for CRC screening, and discuss how to choose among the available options.
Comparative Effectiveness of Team-Based Care With and Without a Clinical Decision Support System for Diabetes Management: A Cluster Randomized Trial: Annals of Internal Medicine: Vol 176, No 1
Background: Uncontrolled hyperglycemia, hypercholesterolemia, and hypertension are common in persons with diabetes. Objective: To compare the effectiveness of team-based care with and without a clinical decision support system (CDSS) in controlling glycemia, lipids, and blood pressure (BP) among patients with type 2 diabetes. Design: Cluster randomized trial. (ClinicalTrials.gov: NCT02835287) Setting: 38 community health centers in Xiamen, China. Patients: 11 132 persons aged 50 years or older with uncontrolled diabetes and comorbid conditions, 5475 receiving team-based care with a CDSS and 5657 receiving team-based care alone. Intervention: Team-based care was delivered by primary care physicians, health coaches, and diabetes specialists in all centers. In addition, a computerized CDSS, which generated individualized treatment recommendations based on clinical guidelines, was implemented in 19 centers delivering team-based care with a CDSS. Measurements: Coprimary outcomes were mean reductions in hemoglobin A1c (HbA1c) level, low-density lipoprotein cholesterol (LDL-C) level, and systolic BP over 18 months and the proportion of participants with all 3 risk factors controlled at 18 months. Results: During the 18-month intervention, HbA1c levels, LDL-C levels, and systolic BP significantly decreased by −0.9 percentage point (95% CI, −0.9 to −0.8 percentage point), −0.49 mmol/L (CI, −0.53 to −0.45 mmol/L) (−19.0 mg/dL [CI, −20.4 to −17.5 mg/dL]), and −9.1 mm Hg (CI, −9.9 to −8.3 mm Hg), respectively, in team-based care with a CDSS and by −0.6 percentage point (CI, −0.7 to −0.5 percentage point), −0.32 mmol/L (CI, −0.35 to −0.29 mmol/L) (−12.5 mg/dL [CI, −13.6 to −11.3 mg/dL]), and −7.5 mm Hg (CI, −8.4 to −6.6 mm Hg), respectively, in team-based care alone. Net differences were −0.2 percentage point (CI, −0.3 to −0.1 percentage point) for HbA1c level, −0.17 mmol/L (CI, −0.21 to −0.12 mmol/L) (−6.5 mg/dL [CI, −8.3 to −4.6 mg/dL]) for LDL-C level, and −1.5 mm Hg (CI, −2.8 to −0.3 mm Hg) for systolic BP. The proportion of patients with controlled HbA1c, LDL-C, and systolic BP was 16.9% (CI, 15.7% to 18.2%) in team-based care with a CDSS and 13.0% (CI, 11.7% to 14.3%) in team-based care alone. Limitation: There was no usual care control, and clinical outcome assessors were unblinded; the analysis did not account for multiple comparisons. Conclusion: Compared with team-based care alone, team-based care with a CDSS significantly reduced cardiovascular risk factors in patients with diabetes, but the effect was modest. Primary Funding Source: Xiamen Municipal Health Commission.
Values and Preferences of Patients With Depressive Disorders Regarding Pharmacologic and Nonpharmacologic Treatments: A Rapid Review: Annals of Internal Medicine: Vol 176, No 2
Background: Developers of clinical practice guidelines need to take patient values and preferences into consideration when weighing benefits and harms of treatment options for depressive disorder. Purpose: To assess patient values and preferences regarding pharmacologic and nonpharmacologic treatments of depressive disorder. Data Sources: MEDLINE (Ovid) and PsycINFO (EBSCO) were searched for eligible studies published from 1 January 2014 to 30 November 2022. Study Selection: Pairs of reviewers independently screened 30% of search results. The remaining 70% of the abstracts were screened by single reviewers; excluded abstracts were checked by a second reviewer. Pairs of reviewers independently screened full texts. Data Extraction: One reviewer extracted data and assessed the certainty of evidence, and a second reviewer checked for completeness and accuracy. Two reviewers independently assessed risk of bias. Data Synthesis: The review included 11 studies: 4 randomized controlled trials, 5 cross-sectional studies, and 2 qualitative studies. In 1 randomized controlled trial, participants reported at the start of therapy that they expected supportive-expressive psychotherapy and antidepressants to yield similar improvements. A cross-sectional study reported that non-Hispanic White participants and men generally preferred antidepressants over talk therapy, whereas Hispanic and non-Hispanic Black participants and women generally did not have a preference. Another cross-sectional study reported that the most important nonserious adverse events for patients treated with antidepressants were insomnia, anxiety, fatigue, weight gain, agitation, and sexual dysfunction. For other comparisons and outcomes, no conclusions could be drawn because of the insufficient certainty of evidence. Limitations: The main limitation of this review is the low or insufficient certainty of evidence for most outcomes. No evidence was available on second-step depression treatment or differences in values and preferences based on gender, race/ethnicity, age, and depression severity. Conclusion: Low-certainty evidence suggests that there may be some differences in preferences for talk therapy or pharmacologic treatment of depressive disorders based on gender or race/ethnicity. In addition, low-certainty evidence suggests that insomnia, anxiety, fatigue, weight gain, agitation, and sexual dysfunction may be the most important nonserious adverse events for patients treated with antidepressants. Evidence is lacking or insufficient to draw any further conclusions about patients' weighing or valuation of the benefits and harms of depression treatments. Primary Funding Source: American College of Physicians. (PROSPERO: CRD42020212442)