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.

Reinterpreted Genetic Tests

In this episode of Annals On Call, Dr. Centor discusses the obligation of physicians to follow up with patients no longer in their care when genetic test interpretation changes with Dr. Paul Appelbaum. First, listen to the podcast. After listening, ACP members can take the CME/MOC quiz for free.

Recurrent Atrial Fibrillation: The “Why?” and “When?” of “What to Do?"

The Annals Consult Guys discuss the care of a patient with 2 symptomatic episodes of atrial fibrillation who is currently in sinus rhythm.

Real-World Complications of Lung Cancer Screening

In this episode of Annals On Call, Dr. Centor discusses the real-world complications of lung cancer screening with Drs. Katharine A. Rendle and Anil Vachani. First, listen to the podcast. After listening, ACP members can take the CME/MOC quiz for free.

Raising Money from Patients? What’s a Physician to Do?

Physicians often are not trained about or aware of the ethical implications of raising money from patients. This gap can lead to a number of ethical concerns. In this case study, the authors examine the implications for the patient-physician relationship and physician professionalism, patient confidentiality, implications for community-institution relationships, and the importance of physician leadership.

Radiation Oncology Side Effects: 5 Pearls Segment

Though therapeutic radiation is a common intervention among cancer patients, with up to 50% of all cancer patients receiving some form of radiation therapy, understanding of radiation therapy among generalists remains an unmet need. Medical school curricula commonly include the basic underlying mechanisms of chemotherapy, but the physiology and role of radiation therapy is often unaddressed (or remains a limited/optional module).

R2D2

Clinicians are often expected to utilize clinical decision support systems. However, they receive little to no training in the actual use of such systems.

QI Curriculum Step 4: Implement and Sustain Change

In Step 4 of ACP’s four-part Quality Improvement (QI) curriculum, you will focus on how to consider what changes to try, study the results of trials of those changes, and identify improvements to adopt and sustain. Developed by physicians for physicians and their clinical teams, this online training series guides you through each stage of the QI journey.

QI Curriculum Step 3: Plan for Change and Identify Solutions

In Step 3 of ACP’s four-part Quality Improvement (QI) curriculum, you will determine the major causes contributing to the issues at hand and identify solutions to address these causes. Developed by physicians for physicians and their clinical teams, this online training series guides you through each stage of the QI journey.

QI Curriculum Step 2: Identify How to Measure Change

In Step 2 of ACP’s four-part Quality Improvement (QI) curriculum, you will learn strategies for selecting metrics and for measuring change at each stage of the QI process. Developed by physicians for physicians and their clinical teams, this online training series guides you through each stage of the QI journey.

Care of Patients With New, Continuing, or Recurring Symptoms After Acute SARS-CoV-2 Infection

Lightning: Another Climate Change Threat

Long-Term Health Consequences After Ovarian Removal at Benign Hysterectomy: A Nationwide Cohort Study: Annals of Internal Medicine: Vol 176, No 5

Background: More evidence is needed to substantiate current recommendations about removing ovaries during hysterectomy for benign conditions. Objective: To compare long-term outcomes in women with and without bilateral salpingo-oophorectomy (BSO) during hysterectomy for benign conditions. Design: Emulated target trial using data from a population-based cohort. Setting: Women in Denmark aged 20 years or older during 1977 to 2017. Participants: 142 985 women with hysterectomy for a benign condition, 22 974 with BSO and 120 011 without. Intervention: Benign hysterectomy with or without BSO. Measurements: The primary outcomes were overall hospitalization for cardiovascular disease (CVD), overall cancer incidence, and all-cause mortality through December 2018. Results: Compared with women without BSO, women with BSO who were younger than 45 years at surgery had a higher 10-year cumulative risk for hospitalization for CVD (risk difference [RD], 1.19 percentage points [95% CI, 0.09 to 2.43 percentage points]). Women with BSO had a higher 10-year cumulative risk for cancer for ages 45 to 54 years (RD, 0.73 percentage point [CI, 0.05 to 1.38 percentage points]), 55 to 64 years (RD, 1.92 percentage points [CI, 0.69 to 3.25 percentage points]), and 65 years or older (RD, 2.54 percentage points [CI, 0.91 to 4.25 percentage points]). Women with BSO had higher 10-year mortality in all age groups, although the differences were statistically significant only for ages 45 to 54 years (RD, 0.79 percentage point [CI, 0.27 to 1.30 percentage points]). The mortality at 20 years was inconsistent with that at 10 years in women aged 65 years or older. Limitation: Age was a proxy for menopausal status. Conclusion: The authors find that these results support current recommendations for conserving ovaries in premenopausal women without a high risk for ovarian cancer and suggest a cautious approach in postmenopausal women. Primary Funding Source: The Danish Cancer Society's Scientific Committee and the Mermaid Project.

Prevalence and Characteristics of Adrenal Tumors in an Unselected Screening Population: A Cross-Sectional Study: Annals of Internal Medicine: Vol 175, No 10

Background: With the widespread use of advanced imaging technology, adrenal tumors are increasingly being identified. Objective: To investigate the prevalence and characteristics of adrenal tumors in an unselected screening population in China. Design: Cross-sectional study. (ClinicalTrials.gov: NCT04682938) Setting: A health examination center in China. Patients: Adults having an annual checkup were invited to be screened for adrenal tumors by adrenal computed tomography. Measurements: The participants with adrenal tumors had further evaluation for malignancy risk and adrenal function. Results: A total of 25 356 participants were screened, 351 of whom were found to have adrenal tumors, for a prevalence of 1.4%. The prevalence increased with age, from 0.2% in participants aged 18 to 25 years to 3.2% in those older than 65 years. Among 351 participants with adrenal tumors, 337 were diagnosed with an adrenocortical adenoma, 14 with another benign nodule, and none with a malignant mass. In 212 participants with an adenoma who completed endocrine testing, 69.3% were diagnosed with a nonfunctioning adenoma, 18.9% with cortisol autonomy, 11.8% with primary aldosteronism, and none with pheochromocytoma. Proportions of nonfunctioning adenomas were similarly high in various age groups (72.2%, 67.8%, and 72.2% in those aged <46, 46 to 65, and ≥66 years, respectively). Limitation: Only 212 of 337 participants with an adrenocortical adenoma had endocrine testing. Conclusion: The prevalence of adrenal tumors in the general adult screening population is 1.4%, and most of these tumors are nonfunctioning regardless of patient age. Cortisol and aldosterone secretion are the main causes of functional adenomas. Primary Funding Source: National Key Research and Development Program of China and National Natural Science Foundation of China.

The Management of Major Depressive Disorder: Synopsis of the 2022 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guideline

Description: In February 2022, the U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense (DoD) approved a joint clinical practice guideline (CPG) for the management of major depressive disorder (MDD). This synopsis summarizes key recommendations. Methods: Senior leaders within the VA and the DoD assembled a team to update the 2016 CPG for the management of MDD that included clinical stakeholders and conformed to the National Academy of Medicine's tenets for trustworthy CPGs. The guideline panel developed key questions, systematically searched and evaluated the literature, created two 1-page algorithms, and distilled 36 recommendations for care using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. Select recommendations that were identified by the authors to represent key changes from the prior CPG are presented in this synopsis. Recommendations: The scope of the CPG is diverse; however, this synopsis focuses on key recommendations that the authors identified as important new evidence and changes to prior recommendations on pharmacologic management, pharmacogenomics, psychotherapy, complementary and alternative therapies, and the use of telemedicine.

From Individualized Interactions to Standardized Schedules: A History of Time Organization in U.S. Outpatient Medicine

Many outpatient physicians and patients feel that current scheduling systems do not afford enough time for direct patient–physician interaction, leaving patients feeling unheard and physicians feeling demoralized. This dissatisfaction degrades patients' trust in the health care system and contributes to workforce moral injury and burnout. In the hopes of understanding the roots of this time stress and helping to guide future decisions about how to organize physicians' time, this article describes changes in the organization of U.S. outpatient physicians' time, starting from care at home in the late 19th century. It discusses the origins of the appointment system, which was invented to be highly personalized, with assistants adjusting appointment durations to accommodate clinical activities, specific patient needs, and individual physician proclivities. The article then describes how centralization of appointment scheduling became more common as U.S. medicine became increasingly consolidated into larger and larger groups and health systems. This distanced schedulers from the people and care they were organizing and necessitated standardized appointment durations, which did not accommodate individual patient and physician needs. With the rise of managerialism, schedulers became increasingly accountable to administrators rather than patients and physicians. Whereas early appointment systems depended on personal connection between schedulers and the physicians and patients they supported, today's schedulers have few such interactions. The widespread shift to centralized scheduling and standardized time slots has contributed to misalignment among time allocation, patient care, and health care workforce well-being and is likely exacerbating ongoing tensions among patients, physicians, and administrators.

I Remember Marjorie

Perioperative Safety and Early Patient and Device Outcomes Among Subcutaneous Versus Transvenous Implantable Cardioverter Defibrillator Implantations: A Randomized, Multicenter Trial: Annals of Internal Medicine: Vol 175, No 12

Background: Implantable cardioverter defibrillators (ICDs) improve survival in patients at risk for cardiac arrest, but are associated with intravascular lead-related complications. The subcutaneous ICD (S-ICD), with no intravascular components, was developed to minimize lead-related complications. Objective: To assess key ICD performance measures related to delivery of ICD therapy, including inappropriate ICD shocks (delivered in absence of life-threatening arrhythmia) and failed ICD shocks (which did not terminate ventricular arrhythmia). Design: Randomized, multicenter trial. (ClinicalTrials.gov: NCT02881255) Setting: The ATLAS trial. Patients: 544 eligible patients (141 female) with a primary or secondary prevention indication for an ICD who were younger than age 60 years, had a cardiogenetic phenotype, or had prespecified risk factors for lead complications were electrocardiographically screened and 503 randomly assigned to S-ICD (251 patients) or transvenous ICD (TV-ICD) (252 patients). Mean follow-up was 2.5 years (SD, 1.1). Mean age was 49.0 years (SD, 11.5). Measurements: The primary outcome was perioperative major lead-related complications. Results: There was a statistically significant reduction in perioperative, lead-related complications, which occurred in 1 patient (0.4%) with an S-ICD and in 12 patients (4.8%) with TV-ICD (−4.4%; 95% CI, −6.9 to −1.9; P = 0.001). There was a trend for more inappropriate shocks with the S-ICD (hazard ratio [HR], 2.37; 95% CI, 0.98 to 5.77), but no increase in failed appropriate ICD shocks (HR, 0.61 (0.15 to 2.57). Patients in the S-ICD group had more ICD site pain, measured on a 10-point numeric rating scale, on the day of implant (4.2 ± 2.8 vs. 2.9 ± 2.2; P < 0.001) and 1 month later (1.3 ± 1.8 vs. 0.9 ± 1.5; P = 0.035). Limitation: At present, the ATLAS trial is underpowered to detect differences in clinical shock outcomes; however, extended follow-up is ongoing. Conclusion: The S-ICD reduces perioperative, lead-related complications without significantly compromising the effectiveness of ICD shocks, but with more early postoperative pain and a trend for more inappropriate shocks. Primary Funding Source: Boston Scientific.

Effectiveness of an Intervention to Improve Decision Making for Older Patients With Advanced Chronic Kidney Disease: A Randomized Controlled Trial: Annals of Internal Medicine: Vol 176, No 1

Background: Older patients with advanced chronic kidney disease (CKD) face difficult decisions about managing kidney failure, frequently experiencing decisional conflict, regret, and treatment misaligned with preferences. Objective: To assess whether a decision aid about kidney replacement therapy improved decisional quality compared with usual care. Design: Multicenter, randomized, controlled trial. (ClinicalTrials.gov: NCT03522740) Setting: 8 outpatient nephrology clinics associated with 4 U.S. centers. Participants: English-fluent patients, 70 years and older with nondialysis CKD stages 4 to 5 recruited from 2018 to 2020. Intervention: DART (Decision-Aid for Renal Therapy) is an interactive, web-based decision aid for older adults with CKD. Both groups received written education about treatments. Measurements: Change in the decisional conflict scale (DCS) score from baseline to 3, 6, 12, and 18 months. Secondary outcomes included change in prognostic and treatment knowledge and change in uncertainty. Results: Among 400 participants, 363 were randomly assigned: 180 to usual care, 183 to DART. Decisional quality improved with DART with mean DCS declining compared with control (mean difference, −8.5 [95% CI, −12.0 to −5.0]; P < 0.001), with similar findings at 6 months, attenuating thereafter. At 3 months, knowledge improved with DART versus usual care (mean difference, 7.2 [CI, 3.7 to 10.7]; P < 0.001); similar findings at 6 months were modestly attenuated at 18 months (mean difference, 5.9 [CI, 1.4 to 10.3]; P = 0.010). Treatment preferences changed from 58% “unsure” at baseline to 28%, 20%, 23%, and 14% at 3, 6, 12, and 18 months, respectively, with DART, versus 51% to 38%, 35%, 32%, and 18% with usual care. Limitation: Latinx patients were underrepresented. Conclusion: DART improved decision quality and clarified treatment preferences among older adults with advanced CKD for 6 months after the DART intervention. Primary Funding Source: Patient-Centered Outcomes Research Institute (PCORI).

Assessing Heterogeneity of Treatment Effect in Real-World Data

Increasing availability of real-world data (RWD) generated from patient care enables the generation of evidence to inform clinical decisions for subpopulations of patients and perhaps even individuals. There is growing opportunity to identify important heterogeneity of treatment effects (HTE) in these subgroups. Thus, HTE is relevant to all with interest in patients' responses to interventions, including regulators who must make decisions about products when signals of harms arise postapproval and payers who make coverage decisions based on expected net benefit to their beneficiaries. Prior work discussed HTE in randomized studies. Here, we address methodological considerations when investigating HTE in observational studies. We propose 4 primary goals of HTE analyses and the corresponding approaches in the context of RWD: to confirm subgroup effects, to describe the magnitude of HTE, to discover clinically important subgroups, and to predict individual effects. We discuss other possible goals including exploring prognostic score– and propensity score–based treatment effects, and testing the transportability of trial results to populations different from trial participants. Finally, we outline methodological needs for enhancing real-world HTE analysis.

Intervention successful in decreasing routine vitamin D testing

Multiple agents effective for excessive daytime sleepiness but may be discontinued due to side effects, review finds

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Register now for ACP's live, virtual POCUS Mentorship Program

This Earth Day, learn about ACP's efforts to protect the planet

Large review compares benefits, harms of drugs to treat type 2 diabetes

MKSAP Quiz: Increased frequency of long-term headaches

Studies look at effectiveness of bivalent booster, fluvoxamine plus inhaled budesonide for COVID-19

Patients may respond differently to different hypertension drug classes

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Most buprenorphine prescriptions not continued during hospitalization, VA study finds | ACP Hospitalist

Drug shortages drag on | ACP Hospitalist

1 in 3 adults with new-onset a fib during hospitalization have recurrence within a year | ACP Hospitalist

Walk this way | ACP Hospitalist

Use of preoperative cardiac testing varies problematically, can be changed, review finds | ACP Hospitalist

Hospital pricing often unclear despite transparency requirements | ACP Hospitalist

Could you repeat that? | ACP Hospitalist

AHA updates guidance for treating life-threatening poisonings | ACP Hospitalist

ACP addresses ethics of physician fundraising from ‘grateful patients' | ACP Hospitalist

Passive EHR tool reduces potentially inappropriate medications in older adults | ACP Hospitalist