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.

Systems Approaches to Achieving Quick Wins

Identify practical quick wins that promote clinician well‑being. Explore how individual actions can create meaningful impact, including ways to secure leadership buy‑in for well‑being efforts, and consider how these approaches can be applied within one’s own workplace to support engagement and positive change.

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.

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.

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.

Effectiveness of a Fourth Dose of COVID-19 mRNA Vaccine Against Omicron Variant Among Elderly People in Singapore

The Dodo

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)

Cost-Effectiveness of First- and Second-Step Treatment Strategies for Major Depressive Disorder: A Rapid Review: Annals of Internal Medicine: Vol 176, No 2

Background: Major depressive disorder (MDD) is the most prevalent, disabling form of depression, with a high economic effect. Purpose: To assess evidence on cost-effectiveness of pharmacologic and nonpharmacologic interventions as first- and second-step treatments in patients with MDD. Data Sources: Multiple electronic databases limited to English language were searched (1 January 2015 to 29 November 2022). Study Selection: Two investigators independently screened the literature. Seven economic modeling studies fulfilled the eligibility criteria. Data Extraction: Data abstraction by a single investigator was confirmed by a second; 2 investigators independently rated risk of bias. One investigator determined certainty of evidence, and another checked for plausibility. Data Synthesis: Seven modeling studies met the eligibility criteria. In a U.S. setting over a 5-year time horizon, cognitive behavioral therapy (CBT) was cost-effective compared with second-generation antidepressants (SGAs) as a first-step treatment from the societal and health care sector perspectives. However, the certainty of evidence is low, and the findings should be interpreted cautiously. For second-step treatment, only switch strategies between SGAs were assessed. The evidence is insufficient to draw any conclusions. Limitations: Methodologically heterogeneous studies, which compared only CBT and some SGAs, were included. No evidence on other psychotherapies or complementary and alternative treatments as first-step treatment or augmentation strategies as second-step treatment was available. Conclusion: Although CBT may be cost-effective compared with SGAs as a first-step treatment at a 5-year time horizon from the societal and health care sector perspectives, the certainty of evidence is low, and the findings need to be interpreted cautiously. For other comparisons, the evidence was entirely missing or insufficient to draw conclusions. Primary Funding Source: American College of Physicians.

Participant Recruitment From Low- and Middle-Income Countries for Pivotal Trials of Drugs Approved by the U.S. Food and Drug Administration: A Cross-Sectional Analysis: Annals of Internal Medicine: Vol 175, No 12

Background: Many participants in clinical trials supporting U.S. Food and Drug Administration (FDA) drug approvals are recruited from outside the United States, including from low- and middle-income countries (LMICs). Where participants are recruited for pivotal trials has implications for ethical research conduct and generalizability. Objective: To describe LMIC recruitment for pivotal trials of newly approved drugs for cancer, neurologic disease, and cardiovascular disease. Design: Cross-sectional analysis. Setting: Pivotal trials of new cancer, cardiovascular, and neurologic drugs approved from 2012 to 2019 matched to ClinicalTrials.gov, FDA records, and publications. Measurements: Host countries and available per country enrollments were extracted. The primary end point was the proportion of pivotal trials enrolling participants in LMICs. The secondary end point was the proportion of pivotal trial participants contributed by LMICs for each indication area. Results: Data were obtained from 66 new drugs and 144 pivotal clinical trials. All cardiovascular approvals (12 drugs, 29 trials) and neurologic approvals (26 drugs, 54 trials) were analyzed, as well as a random sample of cancer approvals (28 of 85 drugs [33%]) matched to their pivotal trials (61 of 210 trials [29%]). Among the trials, 56% in cancer, 79% in cardiovascular disease, and 56% in neurology recruited from an LMIC. For multicountry trials, country-level enrollment figures were not available for 71 trials (55%). For those reporting per country enrollment, the percentage of participants recruited from LMICs was 8% for cancer trials, 36% for cardiovascular trials, and 17% for neurology trials. Limitations: The study was limited to FDA-approved drugs in 3 areas, including a sample of cancer drugs. Pivotal trials of nonapproved drugs or drugs for other indications were not captured. Conclusion: Most pivotal trials for FDA-approved drugs recruit from LMICs. Publications and FDA documents generally do not provide country-level data on recruitment. Primary Funding Source: None.

Effectiveness of mRNA COVID-19 Vaccine Boosters Against Infection, Hospitalization, and Death: A Target Trial Emulation in the Omicron (B.1.1.529) Variant Era

Background: The effectiveness of a third mRNA COVID-19 vaccine dose (booster dose) against the Omicron (B.1.1.529) variant is uncertain, especially in older, high-risk populations. Objective: To determine mRNA booster vaccine effectiveness (VE) against SARS-CoV-2 infection, hospitalization, and death in the Omicron era by booster type, primary vaccine type, time since primary vaccination, age, and comorbidity burden. Design: Retrospective matched cohort study designed to emulate a target trial of booster vaccination versus no booster, conducted from 1 December 2021 to 31 March 2022. Setting: U.S. Department of Veterans Affairs health care system. Participants: Persons who had received 2 mRNA COVID-19 vaccine doses at least 5 months earlier. Intervention: Booster monovalent mRNA vaccination (Pfizer–BioNTech's BNT162b2 or Moderna's mRNA-1273) versus no booster. Measurements: Booster VE. Results: Each group included 490 838 well-matched persons, who were predominantly male (88%), had a mean age of 63.0 years (SD, 14.0), and were followed for up to 121 days (mean, 79.8 days). Booster VE more than 10 days after a booster dose was 42.3% (95% CI, 40.6% to 43.9%) against SARS-CoV-2 infection, 53.3% (CI, 48.1% to 58.0%) against SARS-CoV-2–related hospitalization, and 79.1% (CI, 71.2% to 84.9%) against SARS-CoV-2–related death. Booster VE was similar for different booster types (BNT162b2 or mRNA-1273), age groups, and primary vaccination regimens but was significantly higher with longer time since primary vaccination and higher comorbidity burden. Limitation: Predominantly male population. Conclusion: Booster mRNA vaccination was highly effective in preventing death and moderately effective in preventing infection and hospitalization for up to 4 months after administration in the Omicron era. Increased uptake of booster vaccination, which is currently suboptimal, should be pursued to limit the morbidity and mortality of SARS-CoV-2 infection, especially in persons with high comorbidity burden. Primary Funding Source: U.S. Department of Veterans Affairs.

Nonpharmacologic and Pharmacologic Treatments of Adult Patients With Major Depressive Disorder: A Systematic Review and Network Meta-analysis for a Clinical Guideline by the American College of Physicians

An update is available for this article. Background: Primary care patients and clinicians may prefer alternative options to second-generation antidepressants for major depressive disorder (MDD). Purpose: To compare the benefits and harms of nonpharmacologic treatments with second-generation antidepressants as first-step interventions for acute MDD, and to compare second-step treatment strategies for patients who did not achieve remission after an initial attempt with antidepressants. Data Sources: English-language studies from several electronic databases from 1 January 1990 to 8 August 2022, trial registries, gray literature databases, and reference lists to identify unpublished research. Study Selection: 2 investigators independently selected randomized trials of at least 6 weeks' duration. Data Extraction: Reviewers abstracted data about study design and conduct, participants, interventions, and outcomes. They dually rated the risk of bias of studies and the certainty of evidence for outcomes of interest. Data Synthesis: 65 randomized trials met the inclusion criteria; eligible data from nonrandomized studies were not found. Meta-analyses and network meta-analyses indicated similar benefits of most nonpharmacologic treatments and antidepressants as first-step treatments. Antidepressants had higher risks for discontinuation because of adverse events than most other treatments. For second-step therapies, different switching and augmentation strategies provided similar symptomatic relief. The certainty of evidence for most comparisons is low; findings should be interpreted cautiously. Limitations: Many studies had methodological limitations or dosing inequalities; publication bias might have affected some comparisons. In some cases, conclusions could not be drawn because of insufficient evidence. Conclusion: Although benefits seem to be similar among first- and second-step MDD treatments, the certainty of evidence is low for most comparisons. Clinicians and patients should focus on options with the most reliable evidence and take adverse event profiles and patient preferences into consideration. Primary Funding Source: American College of Physicians. (PROSPERO: CRD42020204703)

Colchicine linked to lower incidence of total knee, hip replacements in patients with chronic coronary artery disease

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ACP, Annals of Internal Medicine host forum on the end of the COVID-19 Public Health Emergency

New ethics case study examines implications of resuscitation approaches

Childhood cancer survivors at higher long-term risk for major surgery

MKSAP Quiz: Evaluation for risk of rheumatoid arthritis

Nonsugar sweeteners should not be used for weight loss, WHO guideline states

Amiodarone increases bleeding compared with flecainide or sotalol in patients on anticoagulant therapy

Put words in our mouth

ACP observes Mental Health Awareness Month

Problems with grateful patient programs | ACP Hospitalist

Chinese medicine reduced cardiac events after STEMI, trial finds | ACP Hospitalist

Catheter-directed thrombolysis reduced mortality versus anticoagulation alone in PE | ACP Hospitalist

Carminative | ACP Hospitalist

Adding vancomycin to cefazolin didn't reduce infections among arthroplasty patients | ACP Hospitalist

User-friendly EHRs also more safety-friendly | ACP Hospitalist

Updated AABB guidelines offer hemoglobin thresholds for transfusion | ACP Hospitalist

Readmission rates held steady during pandemic, AHRQ brief finds | ACP Hospitalist

Nudging physicians not to test | ACP Hospitalist

Costs for pneumonia hospitalization vary by comorbidity, care practices | ACP Hospitalist