Pediatric-to-Adult Transitions of Care, Part 2: Intellectual and Developmental Disabilities

The DEI Shift team picks up where they left off in Part 1 (Season 4, Episode 3) by applying the pediatric-to-adult transitions strategies learned in that episode to a specific patient population: those with Intellectual and Developmental Disabilities (IDD), like Autism Spectrum Disorder (ASD).

Parenting in Medicine, Part 2 – A Conversation with Dr. Charlie Goldberg

Physicians often postpone starting families compared to the general population. However, in recent years, an increasing number of physicians have chosen to have children during their training. This episode explores the unique challenges physician-parents face—such as extended training periods and delays in career advancement—and offers practical advice on navigating these obstacles.

Parenting in Medicine, Part 1 – A Conversation with Dr. Brindha Bhavan

Due to a variety of factors, physicians have higher rates of infertility compared to the general population. This episode aims to shed light on why this disparity is present and discuss the logistical, financial, and biological considerations for various fertility preservation procedures.

Palliative Care: A Family Perspective

In this episode of Annals On Call, Dr. Centor discusses a family perspective on palliative care with Ms. Monica Wright, the author of an On Being a Patient essay.First, listen to the podcast. After listening, ACP members can take the CME/MOC quiz for free.

Pain Management Near the End-of-Life: What Would Mom Want?

All physicians have a duty to develop core competencies of primary palliative care: symptom management; patient/family education about this; and communication skills necessary to ensure shared, informed decision-making tailored to the needs and values of the patient. In this case study, Pain Management Near the End-of-Life: What Would Mom Want? authors Drs. Eduardo Bruera, Kari Esbensen, and Lois Snyder Sulmasy, JD present a case history and offer commentary on end-of-life care.

Osteoporosis

Osteoporosis is a common systemic skeletal disorder resulting in bone fragility and increased fracture risk. Evidence-based screening strategies improve identification of patients who are most likely to benefit from drug treatment to prevent fracture. In addition, careful consideration of when pharmacotherapy should be started, choice of medication, and duration of treatment maximizes the benefits of fracture prevention while minimizing potential harms of long-term drug exposure.

Obesity Management 3: Metabolic and Bariatric Surgery

Better care for patients who are considering metabolic and bariatric surgery (MBS) or who have completed surgery. Optimize medical care for patients undergoing the most common MBS: sleeve gastrectomy and the Roux-en-Y gastric bypass. Learn to evaluate surgery as an appropriate therapy option, and discuss short-term and long-term management considerations with patients. After completing this activity, learners will be able to:

Obesity Management 2: Pharmacotherapy

Safely pursue pharmacotherapy for obesity by supporting evidence-based prescription of medications for people with obesity, avoiding medication-induced weight gain and initiating medication-facilitated weight loss as part of a complete treatment plan. After completing this activity, learners will be able to:

Obesity Management 1: Lifestyle Modification

Assist patients with obesity in establishing lifestyle modification goals, monitoring diet, engaging in physical activity, and achieving desired weight loss. After completing this activity, learners will be able to:

Obesity

Obesity is a common condition and a major cause of morbidity and mortality. Fortunately, weight loss treatment can reduce obesity-related complications. This review summarizes the evidence-based strategies physicians can employ to identify, prevent, and treat obesity, including best practices to diagnose and counsel patients, to assess and address the burden of weight-related disease including weight stigma, to address secondary causes of weight gain, and to help patients set individualized and realistic weight loss goals and an effective treatment plan.

Evolving Real-World Effectiveness of Monoclonal Antibodies for Treatment of COVID-19: A Cohort Study: Annals of Internal Medicine: Vol 176, No 4

Background: Treatment guidelines and U.S. Food and Drug Administration emergency use authorizations (EUAs) of monoclonal antibodies (mAbs) for treatment of high-risk outpatients with mild to moderate COVID-19 changed frequently as different SARS-CoV-2 variants emerged. Objective: To evaluate whether early outpatient treatment with mAbs, overall and by mAb product, presumed SARS-CoV-2 variant, and immunocompromised status, is associated with reduced risk for hospitalization or death at 28 days. Design: Hypothetical pragmatic randomized trial from observational data comparing mAb-treated patients with a propensity score–matched, nontreated control group. Setting: Large U.S. health care system. Participants: High-risk outpatients eligible for mAb treatment under any EUA with a positive SARS-CoV-2 test result from 8 December 2020 to 31 August 2022. Intervention: Single-dose intravenous mAb treatment with bamlanivimab, bamlanivimab–etesevimab, sotrovimab, bebtelovimab, or intravenous or subcutaneous casirivimab–imdevimab administered within 2 days of a positive SARS-CoV-2 test result. Measurements: The primary outcome was hospitalization or death at 28 days among treated patients versus a nontreated control group (no treatment or treatment ≥3 days after SARS-CoV-2 test date). Results: The risk for hospitalization or death at 28 days was 4.6% in 2571 treated patients and 7.6% in 5135 nontreated control patients (risk ratio [RR], 0.61 [95% CI, 0.50 to 0.74]). In sensitivity analyses, the corresponding RRs for 1- and 3-day treatment grace periods were 0.59 and 0.49, respectively. In subgroup analyses, those receiving mAbs when the Alpha and Delta variants were presumed to be predominant had estimated RRs of 0.55 and 0.53, respectively, compared with 0.71 for the Omicron variant period. Relative risk estimates for individual mAb products all suggested lower risk for hospitalization or death. Among immunocompromised patients, the RR was 0.45 (CI, 0.28 to 0.71). Limitations: Observational study design, SARS-CoV-2 variant presumed by date rather than genotyping, no data on symptom severity, and partial data on vaccination status. Conclusion: Early mAb treatment among outpatients with COVID-19 is associated with lower risk for hospitalization or death for various mAb products and SARS-CoV-2 variants. Primary Funding Source: None.

Late in the Afternoon

Anticoagulant Therapy for Cancer-Associated Thrombosis: A Cost-Effectiveness Analysis: Annals of Internal Medicine: Vol 176, No 1

Background: Direct oral anticoagulants (DOACs) offer an alternative to low-molecular-weight heparin (LMWH) and warfarin for treating cancer-associated thrombosis (CAT). Objective: To determine the cost and effectiveness of DOACs versus LMWH. Design: Cohort-state transition decision analytic model. Data Sources: Network meta-analysis comparing DOACs versus LMWH. Target Population: Adult patients with cancer at the time they develop thrombosis. Time Horizon: Lifetime. Perspective: Health care sector. Intervention: Strategies of 1) enoxaparin, 2) apixaban, 3) edoxaban, and 4) rivaroxaban for treatment of CAT. Outcome Measures: Incremental cost-effectiveness ratio (ICER) in 2022 U.S. dollars per quality-adjusted life-year (QALY) gained. Results of Base-Case Analysis: In the base-case scenario, using drug prices from the U.S. Department of Veterans Affairs Federal Supply Schedule, apixaban dominated enoxaparin and edoxaban by being less costly and more effective. Rivaroxaban was slightly more effective than apixaban, with an ICER of $493 246. In a scenario analysis using “real-world” drug prices from GoodRx, rivaroxaban was cost-effective with an ICER of $50 053 per QALY. Results of Sensitivity Analysis: Results were highly sensitive to monthly drug costs. Probabilistic sensitivity analyses showed that at a willingness-to-pay threshold of $50 000 per QALY, apixaban was preferred in 80% of simulations. However, sensitivity analyses also demonstrated that apixaban only remained cost-effective if monthly medication costs were below $530. Above this, rivaroxaban became cost-effective. Limitations: An assumption was made that patients would continue anticoagulation indefinitely unless they suffered a major bleed. Nonmedical costs such as patient and caregiver loss of productivity were not accounted for, and long-term thrombotic complications were not explicitly modeled. Conclusion: The 3 DOACs are more effective and more cost-effective than LMWH. The most cost-effective DOAC depends on the relative cost of each of these agents. These are important considerations for treating physicians and health policymakers. Primary Funding Source: None.

Health Care and Climate Change: Challenges and Pathways to Sustainable Health Care

Diabetes Screening: Different Thresholds for Different Racial/Ethnic Groups

Alcestis

Evaluation of Harms Reporting in U.S. Cancer Screening Guidelines

Background: Cancer screening should be recommended only when the balance between benefits and harms is favorable. This review evaluated how U.S. cancer screening guidelines reported harms, within and across organ-specific processes to screen for cancer. Objective: To describe current reporting practices and identify opportunities for improvement. Design: Review of guidelines. Setting: United States. Patients: Patients eligible for screening for breast, cervical, colorectal, lung, or prostate cancer according to U.S. guidelines. Measurements: Information was abstracted on reporting of patient-level harms associated with screening, diagnostic follow-up, and treatment. The authors classified harms reporting as not mentioned, conceptual, qualitative, or quantitative and noted whether literature was cited when harms were described. Frequency of harms reporting was summarized by organ type. Results: Harms reporting was inconsistent across organ types and at each step of the cancer screening process. Guidelines did not report all harms for any specific organ type or for any category of harm across organ types. The most complete harms reporting was for prostate cancer screening guidelines and the least complete for colorectal cancer screening guidelines. Conceptualization of harms and use of quantitative evidence also differed by organ type. Limitations: This review considers only patient-level harms. The authors did not verify accuracy of harms information presented in the guidelines. Conclusion: The review identified opportunities for improving conceptualization, assessment, and reporting of screening process–related harms in guidelines. Future work should consider nuances associated with each organ-specific process to screen for cancer, including which harms are most salient and where evidence gaps exist, and explicitly explore how to optimally weigh available evidence in determining net screening benefit. Improved harms reporting could aid informed decision making, ultimately improving cancer screening delivery. Primary Funding Source: National Cancer Institute.

Clinical Practice Guidelines From the Association for the Advancement of Blood and Biotherapies (AABB): COVID-19 Convalescent Plasma

Description: Coronavirus disease 2019 convalescent plasma (CCP) has emerged as a potential treatment of COVID-19. However, meta-analysis data and recommendations are limited. The Association for the Advancement of Blood and Biotherapies (AABB) developed clinical practice guidelines for the appropriate use of CCP. Methods: These guidelines are based on 2 living systematic reviews of randomized controlled trials (RCTs) evaluating CCP from 1 January 2019 to 26 January 2022. There were 33 RCTs assessing 21 916 participants. The results were summarized using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) method. An expert panel reviewed the data using the GRADE framework to formulate recommendations. Recommendation 1 (Outpatient): The AABB suggests CCP transfusion in addition to the usual standard of care for outpatients with COVID-19 who are at high risk for disease progression (weak recommendation, moderate-certainty evidence). Recommendation 2 (Inpatient): The AABB recommends against CCP transfusion for unselected hospitalized persons with moderate or severe disease (strong recommendation, high-certainty evidence). This recommendation does not apply to immunosuppressed patients or those who lack antibodies against SARS-CoV-2. Recommendation 3 (Inpatient): The AABB suggests CCP transfusion in addition to the usual standard of care for hospitalized patients with COVID-19 who do not have SARS-CoV-2 antibodies detected at admission (weak recommendation, low-certainty evidence). Recommendation 4 (Inpatient): The AABB suggests CCP transfusion in addition to the usual standard of care for hospitalized patients with COVID-19 and preexisting immunosuppression (weak recommendation, low-certainty evidence). Recommendation 5 (Prophylaxis): The AABB suggests against prophylactic CCP transfusion for uninfected persons with close contact exposure to a person with COVID-19 (weak recommendation, low-certainty evidence). Good Clinical Practice Statement: CCP is most effective when transfused with high neutralizing titers to infected patients early after symptom onset.

Belt and Suspenders: Vaccines and Tixagevimab/Cilgavimab for Prevention of COVID-19 in Immunocompromised Patients

Adenoma Detection Rate and Colorectal Cancer Risk in Fecal Immunochemical Test Screening Programs: An Observational Cohort Study: Annals of Internal Medicine: Vol 176, No 3

Background: Colorectal cancer (CRC) screening programs based on fecal immunochemical tests (FITs) represent the standard of care for population-based interventions. Their benefit depends on the identification of neoplasia at colonoscopy after FIT positivity. Colonoscopy quality measured by adenoma detection rate (ADR) may affect screening program effectiveness. Objective: To examine the association between ADR and postcolonoscopy CRC (PCCRC) risk in a FIT-based screening program. Design: Retrospective population-based cohort study. Setting: Fecal immunochemical test–based CRC screening program between 2003 and 2021 in northeastern Italy. Patients: All patients with a positive FIT result who had a colonoscopy were included. Measurements: The regional cancer registry supplied information on any PCCRC diagnosed between 6 months and 10 years after colonoscopy. Endoscopists' ADR was categorized into 5 groups (20% to 39.9%, 40% to 44.9%, 45% to 49.9%, 50% to 54.9%, and 55% to 70%). To examine the association of ADR with PCCRC incidence risk, Cox regression models were fitted to estimate hazard ratios (HRs) and 95% CIs. Results: Of the 110 109 initial colonoscopies, 49 626 colonoscopies done by 113 endoscopists between 2012 and 2017 were included. After 328 778 person-years follow-up, 277 cases of PCCRC were diagnosed. Mean ADR was 48.3% (range, 23% and 70%). Incidence rates of PCCRC from lowest to highest ADR group were 13.13, 10.61, 7.60, 6.01, and 5.78 per 10 000 person-years. There was a significant inverse association between ADR and PCCRC incidence risk, with a 2.35-fold risk increase (95% CI, 1.63 to 3.38) in the lowest group compared with the highest. The adjusted HR for PCCRC associated with 1% increase in ADR was 0.96 (CI, 0.95 to 0.98). Limitation: Adenoma detection rate is partly determined by FIT positivity cutoff; exact values may vary in different settings. Conclusion: In a FIT-based screening program, ADR is inversely associated with PCCRC incidence risk, mandating appropriate colonoscopy quality monitoring in this setting. Increasing endoscopists' ADR may significantly reduce PCCRC risk. Primary Funding Source: None.

Only half of patients with mood problems after stroke receive mental health care

MKSAP Quiz: Evaluation for fatigue, headache

Temporary weight management programs may have long-term cardiometabolic benefits

Nocturnal hypoglycemia underdiagnosed in older patients on insulin for type 2 diabetes

Why to open your Open Payments record

Uncover trauma to treat patients efficiently

Thriving at the annual meeting in your early-career years

Over-the-counter test for flu, COVID-19 authorized

MKSAP Quiz: Inpatient with fever, dry cough, shortness of breath

Another pitfall for spontaneous bacterial peritonitis

Iron/EPO combination beats other options for reducing transfusions | ACP Hospitalist

Catching postop problems | ACP Hospitalist

Buprenorphine, cannabis, and other periop challenges | ACP Hospitalist

Transition service reduced readmissions in young adults with chronic childhood-onset disease | ACP Hospitalist

Surgical devices, ventilators, dialysis machines recalled | ACP Hospitalist

Off-label dosing of DOACs at discharge common in afib patients | ACP Hospitalist

No significant difference in outcomes with liberal, restrictive transfusion in acute MI | ACP Hospitalist

Hospital medicine programs strategize responses to growth in clinical workload | ACP Hospitalist

Finding a better way to handle inpatient substance use | ACP Hospitalist

Overnight boarding in the ED linked with worse outcomes among older patients | ACP Hospitalist