Practical Tips for Overcoming Personal and Career Obstacles

Discover practical strategies, essential tools, and valuable resources to navigate and excel through personal and career challenges and obstacles through each season of your life.

Practical Office Orthopedics and Sports Medicine for the Internist: 2023 Video Recordings Package

Musculoskeletal complaints and sport-related injuries are common in primary care, but internists receive little instruction in office-based orthopedics. Most of these conditions do not require surgery and can therefore be managed by the knowledgeable internist.

Practical Office Orthopedics: 2024 Video Recordings Package

Expert clinician-educators will provide participants with the knowledge and tools needed to correctly evaluate, diagnose, and treat most orthopedic complaints seen in the internal medicine office. Faculty will use a case-based approach to familiarize participants with basic joint and tendon anatomy and landmarks and make participants comfortable with performing a concise, targeted office examination. This will be combined with knowledge of the epidemiology of musculoskeletal complaints in primary care to develop an accurate diagnostic approach.

Postoperative Troponin Elevation

The Annals Consult Guys provide guidance about the measurement and interpretation of high-sensitivity cardiac troponin in the setting of noncardiac surgery.

Postoperative Euglycemic Diabetic Ketoacidosis

The Annals Consult Guys provide a viewer consultation of a patient who developed ketoacidosis after a Whipple procedure.

Post-Kidney Transplant: 5 Pearls Segment

End-stage renal disease affects approximately 500,000 people in the United States. The optimal choice of renal replacement therapy is kidney transplant, as it improves quality of life, morbidity, and mortality. Many health care practitioners may, however, feel uncomfortable with post-kidney transplant care.

Physicians with Disabilities: A Conversation with Dr. John Hall

Many Internal Medicine physicians may have limited awareness and understanding of the diverse accommodation needs that physicians and patients with disabilities may require. This gap in knowledge can hinder the creation of inclusive work environments, affect the overall well-being and performance of physicians with disabilities as well as negatively impact the patient-physician relationship.

Physician Suicide Prevention: The Ethics and Role of the Physician Colleague and the Healing Community

Suicide is a major health issue that has a tremendous impact on individuals, families, and communities. The medical community is no exception. This ethics case study is intended to raise awareness of stressors and provide guidance. The 2024 rerelease of this ethics case study provides an additional learning and credit earning opportunity for learners who claimed credit for earlier versions.

Periprocedural Anticoagulation

Management of patients taking anticoagulants around the time of a procedure is a common and complex clinical scenario. Providing evidence-based care requires estimation of risk for thrombosis and bleeding, knowledge of commonly used medications, multidisciplinary communication and collaboration, and patient engagement and education. This review provides a standardized, evidence-based approach to periprocedural management of anticoagulation, based on current evidence and expert clinical guidelines.

Perioperative Medicine: 2025 Video Recordings Package

Highly-rated clinician-educators will review the assessment and management of patients with medical comorbidities undergoing noncardiac surgical procedures and discuss preoperative anesthesia essentials, a selection of validated cardiac risk assessment tools, venous thromboembolism prophylaxis in the most frequently performed surgeries, and antiplatelet agent management in patients with cardiac disease undergoing noncardiac surgery. Interspersed between these presentations will be clinical vignettes that complement the presentations and expand the topics discussed.

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.

How Would You Treat This Patient With Pulmonary Embolism?: Grand Rounds Discussion From Beth Israel Deaconess Medical Center: Annals of Internal Medicine: Vol 175, No 8

Pulmonary embolism can be acutely life-threatening and is associated with long-term consequences such as recurrent venous thromboembolism and chronic thromboembolic pulmonary hypertension. In 2020, the American Society of Hematology published updated guidelines on the management of patients with venous thromboembolism. Here, a hematologist and a cardiology and vascular medicine specialist discuss these guidelines in the context of the care of a patient with pulmonary embolism. They discuss advanced therapies such as catheter-directed thrombolysis in the short-term management of patients with intermediate-risk disease, recurrence risk stratification at presentation, and ideal antithrombotic regimens for patients whose pulmonary embolism was associated with a transient minor risk factor.

Risk for Myocardial Infarction, Stroke, and Pulmonary Embolism Following COVID-19 Vaccines in Adults Younger Than 75 Years in France

Background: The BNT162b2 (Pfizer–BioNTech) vaccine has been shown to be safe with regard to risk for severe cardiovascular events (such as myocardial infarction [MI], pulmonary embolism [PE], and stroke) in persons aged 75 years or older. Less is known about the safety of other COVID-19 vaccines or outcomes in younger populations. Objective: To assess short-term risk for severe cardiovascular events (excluding myocarditis and pericarditis) after COVID-19 vaccination in France's 46.5 million adults younger than 75 years. Design: Self-controlled case series method adapted to event-dependent exposure and high event-related mortality. Setting: France, 27 December 2020 to 20 July 2021. Patients: All adults younger than 75 years hospitalized for PE, acute MI, hemorrhagic stroke, or ischemic stroke (n = 73 325 total events). Measurements: Linkage between the French National Health Data System and COVID-19 vaccine databases enabled identification of hospitalizations for cardiovascular events (MI, PE, or stroke) and receipt of a first or second dose of the Pfizer–BioNTech, mRNA-1273 (Moderna), Ad26.COV2.S (Janssen), or ChAdOx1 nCoV-19 (Oxford–AstraZeneca) vaccine. The relative incidence (RI) of each cardiovascular event was estimated in the 3 weeks after vaccination compared with other periods, with adjustment for temporality (7-day periods). Results: No association was found between the Pfizer–BioNTech or Moderna vaccine and severe cardiovascular events. The first dose of the Oxford–AstraZeneca vaccine was associated with acute MI and PE in the second week after vaccination (RI, 1.29 [95% CI, 1.11 to 1.51] and 1.41 [CI, 1.13 to 1.75], respectively). An association with MI in the second week after a single dose of the Janssen vaccine could not be ruled out (RI, 1.75 [CI, 1.16 to 2.62]). Limitations: It was not possible to ascertain the relative timing of injection and cardiovascular events on the day of vaccination. Outpatient deaths related to cardiovascular events were not included. Conclusion: In persons aged 18 to 74 years, adenoviral-based vaccines may be associated with increased incidence of MI and PE. No association between mRNA-based vaccines and the cardiovascular events studied was observed. Primary Funding Source: None.

Timing of stroke treatment, preventive therapies presented at stroke meeting

Serum urate level may predict flare risk in patients with gout

Put words in our mouth

ACP's identity campaign highlights internal medicine physicians in different settings

Decision support intervention for clinicians helped decrease low-value care

MKSAP Quiz: Evaluation after an ED visit

Insomnia symptoms, short sleep duration in midlife women linked to CVD risk

Promoting second quit attempts right after relapse may improve rates of smoking abstinence

The ins and outs of insulin updates, new guidelines, and more

The ethical nexus of health care: Purpose over profit

Checklist improved care consistency after in-hospital cardiac arrest | ACP Hospitalist

Women in academia report more sexual harassment, negative work climates, survey finds | ACP Hospitalist

Two-step testing for Clostridioides difficile appears safe in multicenter study | ACP Hospitalist

Stigmatizing language about OUD common in hospital records, associated with less follow-up | ACP Hospitalist

Reducing returns to the ED | ACP Hospitalist

Heart failure care at home | ACP Hospitalist

Disparities seen in postdischarge care for Medicaid beneficiaries | ACP Hospitalist

Supervised walking may benefit hospitalized older adults, trial finds | ACP Hospitalist

Intensive treatment may increase adverse events in older adults with elevated blood pressure | ACP Hospitalist

Even the smallest steps can bring big changes | ACP Hospitalist