Perioperative Medicine: 2024 Video Recordings Package

Expert clinician-educators will initially discuss preoperative anesthesia essentials, 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. The second phase of the course will be directed at the postoperative issues that face the medical consultants.

Perioperative Medicine: 2023 Video Recordings Package

This Pre-Course, recorded in conjunction with the Internal Medicine Meeting 2023, reviews the assessment and management of patients with medical comorbidities undergoing noncardiac surgical procedures. Expert faculty discuss postoperative nausea and vomiting, preoperative blood pressure control, postoperative headache, and fasting time prior to surgery. Venous thromboembolism (VTE) prophylaxis in the postoperative period for patients with renal impairment, hereditary or acquired coagulation disorders, history recurrent VTE, and the best VTE prophylaxis for surgery are reviewed.

Peer Coaching to Support Individuals and Organizations (Supporting a Colleague in Need)

Identify core coaching skills and ways to leverage them to support a colleague(s) in need. No MOC points available for this activity

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.

Pacemakers & ICDs: 5 Pearls Segment

Pacemakers and implantable cardioverter defibrillators (ICDs) are lifesaving implantable cardiac devices, which are utilized to manage abnormal electrical rhythms and certain forms of heart failure; however, many clinicians struggle to identify the main indications for pacemakers or ICDs. Furthermore, healthcare professionals often encounter clinical scenarios that require a basic understanding of these devices, such as bloodstream infections, device interrogations, or end-of-life decision making considerations in patients with pacemakers or ICDs.

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.

How Do Implicit Bias and Stereotype Threat Affect Mental Health Care for a Student of Color?

Nonoperative Management of Mild Primary Hyperparathyroidism: A Reasonable, Evidence-Based Option

Would You Recommend a Statin to This Patient for Primary Prevention of Cardiovascular Disease?: Grand Rounds Discussion From Beth Israel Deaconess Medical Center: Annals of Internal Medicine: Vol 175, No 6

Cardiovascular disease (CVD) is the leading cause of death in the United States. Hypercholesterolemia is a principal modifiable risk factor for the primary prevention of CVD. In addition to lifestyle modification, statins are an important tool to reduce risk for CVD in selected patients. A useful strategy to identify candidates for statins is to estimate the 10-year risk for CVD through the use of a validated risk calculator. Commonly used calculators include the Framingham risk score and the pooled cohort equation. Multiple randomized controlled trials have shown that statins reduce the risk for CVD in patients without known CVD. Two recent guidelines have proposed an approach to the use of statins in primary prevention of CVD. The American College of Cardiology/American Heart Association and the U.S. Department of Veterans Affairs guidelines form the basis for this discussion. The guidelines differ on the use of advanced testing to modify the 10-year CVD risk estimate and on the need for low-density lipoprotein cholesterol targets to establish the efficacy of statins. Advanced testing with coronary artery calcium measurement may be helpful for patients who are potentially eligible for statin therapy but who are uncertain if they wish to take a statin. In this paper, 2 experts, a preventive cardiologist and a general internist, discuss their approach to the use of statins for primary prevention of CVD and how they would apply the guidelines to an individual patient.

Firearm Injury in the United States: Time to Confront It as the Epidemic It Has Become

Population Genomic Screening for Three Common Hereditary Conditions: A Cost-Effectiveness Analysis: Annals of Internal Medicine: Vol 176, No 5

Background: The cost-effectiveness of screening the U.S. population for Centers for Disease Control and Prevention (CDC) Tier 1 genomic conditions is unknown. Objective: To estimate the cost-effectiveness of simultaneous genomic screening for Lynch syndrome (LS), hereditary breast and ovarian cancer syndrome (HBOC), and familial hypercholesterolemia (FH). Design: Decision analytic Markov model. Data Sources: Published literature. Target Population: Separate age-based cohorts (ages 20 to 60 years at time of screening) of racially and ethnically representative U.S. adults. Time Horizon: Lifetime. Perspective: U.S. health care payer. Intervention: Population genomic screening using clinical sequencing with a restricted panel of high-evidence genes, cascade testing of first-degree relatives, and recommended preventive interventions for identified probands. Outcome Measures: Incident breast, ovarian, and colorectal cancer cases; incident cardiovascular events; quality-adjusted survival; and costs. Results of Base-Case Analysis: Screening 100 000 unselected 30-year-olds resulted in 101 (95% uncertainty interval [UI], 77 to 127) fewer overall cancer cases and 15 (95% UI, 4 to 28) fewer cardiovascular events and an increase of 495 quality-adjusted life-years (QALYs) (95% UI, 401 to 757) at an incremental cost of $33.9 million (95% UI, $27.0 million to $41.1 million). The incremental cost-effectiveness ratio was $68 600 per QALY gained (95% UI, $41 800 to $88 900). Results of Sensitivity Analysis: Screening 30-, 40-, and 50-year-old cohorts was cost-effective in 99%, 88%, and 19% of probabilistic simulations, respectively, at a $100 000-per-QALY threshold. The test costs at which screening 30-, 40-, and 50-year-olds reached the $100 000-per-QALY threshold were $413, $290, and $166, respectively. Variant prevalence and adherence to preventive interventions were also highly influential parameters. Limitations: Population averages for model inputs, which were derived predominantly from European populations, vary across ancestries and health care environments. Conclusion: Population genomic screening with a restricted panel of high-evidence genes associated with 3 CDC Tier 1 conditions is likely to be cost-effective in U.S. adults younger than 40 years if the testing cost is relatively low and probands have access to preventive interventions. Primary Funding Source: National Human Genome Research Institute.

Assessing Performance and Clinical Usefulness in Prediction Models With Survival Outcomes: Practical Guidance for Cox Proportional Hazards Models

Risk prediction models need thorough validation to assess their performance. Validation of models for survival outcomes poses challenges due to the censoring of observations and the varying time horizon at which predictions can be made. This article describes measures to evaluate predictions and the potential improvement in decision making from survival models based on Cox proportional hazards regression. As a motivating case study, the authors consider the prediction of the composite outcome of recurrence or death (the “event”) in patients with breast cancer after surgery. They developed a simple Cox regression model with 3 predictors, as in the Nottingham Prognostic Index, in 2982 women (1275 events over 5 years of follow-up) and externally validated this model in 686 women (285 events over 5 years). Improvement in performance was assessed after the addition of progesterone receptor as a prognostic biomarker. The model predictions can be evaluated across the full range of observed follow-up times or for the event occurring by the end of a fixed time horizon of interest. The authors first discuss recommended statistical measures that evaluate model performance in terms of discrimination, calibration, or overall performance. Further, they evaluate the potential clinical utility of the model to support clinical decision making according to a net benefit measure. They provide SAS and R code to illustrate internal and external validation. The authors recommend the proposed set of performance measures for transparent reporting of the validity of predictions from survival models.

15-Year Benefits of Sigmoidoscopy Screening on Colorectal Cancer Incidence and Mortality: A Pooled Analysis of Randomized Trials: Annals of Internal Medicine: Vol 175, No 11

Background: The effectiveness of screening for colorectal cancer (CRC) by sex and age in randomized trials is uncertain. Objective: To evaluate the 15-year effect of sigmoidoscopy screening on CRC incidence and mortality. Design: Pooled analysis of 4 large-scale randomized trials of sigmoidoscopy screening. Setting: Norway, the United States, the United Kingdom, and Italy. Participants: Women and men aged 55 to 64 years at enrollment. Intervention: Sigmoidoscopy screening. Measurements: Primary end points were cumulative incidence rate ratio (IRR) and mortality rate ratio (MRR) and rate differences after 15 years of follow-up comparing screening versus usual care in intention-to-treat analyses. Stratified analyses were done by sex, cancer site, and age at screening. Results: Analyses comprised 274 952 persons (50.7% women), 137 493 in the screening and 137 459 in the usual care group. Screening attendance was 58% to 84%. After 15 years, the rate difference for CRC incidence was 0.51 cases (95% CI, 0.40 to 0.63 cases) per 100 persons and the IRR was 0.79 (CI, 0.75 to 0.83). The rate difference for CRC mortality was 0.13 deaths (CI, 0.07 to 0.19 deaths) per 100 persons, and the MRR was 0.80 (CI, 0.72 to 0.88). Women had less benefit from screening than men for CRC incidence (IRR for women, 0.84 [CI, 0.77 to 0.91]; IRR for men, 0.75 [CI, 0.70 to 0.81]; P = 0.032 for difference) and mortality (MRR for women, 0.91 [CI, 0.77 to 1.17]; MRR for men, 0.73 [CI, 0.64 to 0.83]; P = 0.025 for difference). There was no statistically significant difference in screening effect between persons aged 55 to 59 years and those aged 60 to 64 years. Limitation: Data from the U.K. trial were less granular because of privacy regulations. Conclusion: This pooled analysis of all large randomized trials of sigmoidoscopy screening demonstrates a significant and sustained effect of sigmoidoscopy on CRC incidence and mortality for 15 years. Primary Funding Source: Health Fund of South-East Norway.

Benefits and Risks Associated With Continuation of Anti–Tumor Necrosis Factor After 24 Weeks of Pregnancy in Women With Inflammatory Bowel Disease: A Nationwide Emulation Trial: Annals of Internal Medicine: Vol 175, No 10

Background: Continuation of biologics for inflammatory disorders during pregnancy is still a difficult decision. Many women with inflammatory bowel diseases (IBDs) stop anti–tumor necrosis factor (anti-TNF) treatment after 24 weeks. Objective: To evaluate the benefits and risks of anti-TNF continuation after 24 weeks of pregnancy for mothers with IBD and their offspring. Design: Target trial emulation between 2010 and 2020. Setting: Nationwide population-based study using the Système National des Données de Santé. Patients: All pregnancies with birth exposed to anti-TNF between conception and 24 weeks of pregnancy in women with IBD. Intervention: Continuation of anti-TNF after 24 weeks of pregnancy. Measurements: Occurrence of maternal IBD relapse up to 6 months after pregnancy, adverse pregnancy outcomes, and serious infections in the offspring during the first 5 years of life was compared according to anti-TNF continuation after 24 weeks of pregnancy using inverse probability–weighted marginal models. Results: A total of 5293 pregnancies were included; among them, anti-TNF treatment was discontinued before 24 weeks for 2890 and continued beyond 24 weeks for 2403. Continuation of anti-TNF was associated with decreased frequencies of maternal IBD relapse (35.8% vs. 39.0%; adjusted risk ratio [aRR], 0.93 [95% CI, 0.86 to 0.99]) and prematurity (7.6% vs. 8.9%; aRR, 0.82 [CI, 0.68 to 0.99]). No difference according to anti-TNF continuation was found regarding stillbirths (0.4% vs. 0.2%; aRR, 2.16 [CI, 0.64 to 7.81]), small weight for gestational age births (13.1% vs. 12.9%; aRR, 1.01 [CI, 0.88 to 1.17]), and serious infections in the offspring (54.2 vs. 50.2 per 1000 person-years; adjusted hazard ratio, 1.08 [CI, 0.94 to 1.25]). Limitation: Algorithms rather than clinical data were used to identify patients with IBD, pregnancies, and serious infections. Conclusion: Continuation of anti-TNF after 24 weeks of pregnancy appears beneficial regarding IBD activity and prematurity, while not affecting neonatal outcomes and serious infections in the offspring. Primary Funding Source: None.

Evaluating the Performance of Centers for Disease Control and Prevention COVID-19 Community Levels as Leading Indicators of COVID-19 Mortality

Background: Centers for Disease Control and Prevention (CDC) defines low, medium, and high “COVID-19 community levels” to guide interventions, but associated mortality rates have not been reported. Objective: To evaluate the diagnostic performance of CDC COVID-19 community level metrics as predictors of elevated community mortality risk. Design: Time series analysis over the period of 30 May 2021 through 4 June 2022. Setting: U.S. states and counties. Participants: U.S. population. Measurements: CDC “COVID-19 community level” metrics based on hospital admissions, bed occupancy, and reported cases; reported COVID-19 deaths; and sensitivity, specificity, and predictive values for CDC and alternative metrics. Results: Mean and median weekly mortality rates per 100 000 population after onset of high COVID-19 community level 3 weeks prior were, respectively, 2.6 and 2.4 (interquartile range [IQR], 1.7 to 3.1) across 90 high episodes in states and 4.3 and 2.1 (IQR, 0 to 5.4) across 7987 high episodes in counties. In 85 of 90 (94%) episodes in states and 4801 of 7987 (60%) episodes in counties, lagged weekly mortality after onset exceeded 0.9 per 100 000 population, and in 57 of 90 (63%) episodes in states and 4018 of 7987 (50%) episodes in counties, lagged weekly mortality after onset exceeded 2.1 per 100 000, which is equivalent to approximately 1000 daily deaths in the national population. Alternative metrics based on lower hospital admissions or case thresholds were associated with lower mortality and had higher sensitivity and negative predictive value for elevated mortality, but the CDC metrics had higher specificity and positive predictive value. Ratios between cases, hospitalizations, and deaths have varied substantially over time. Limitations: Aggregate mortality does not account for nonfatal outcomes or disparities. Continuing evolution of viral variants, immunity, clinical interventions, and public health mitigation strategies complicate prediction for future waves. Conclusion: Designing metrics for public health decision making involves tradeoffs between identifying early signals for action and avoiding undue restrictions when risks are modest. Explicit frameworks for evaluating surveillance metrics can improve transparency and decision support. Primary Funding Source: Council of State and Territorial Epidemiologists.

Paternal Preconception Diabetes Drugs and Birth Defects in Offspring: A Call for More Conclusive Study

Take a team approach to coronary disease

Shifts in insulin use

Salt tablets no salve for hyponatremia

Q&A: Conquering the ABCs of coding and documentation

Points on providing gender-affirming care

OUD risk tests, gene therapies for sickle cell approved

MKSAP Quiz: Brief episodes of wrist pain, swelling, redness

Presidential kudos

Latest updates on ACP's priorities, initiatives

Health policy 'valentines' from ACP

Chief resident-led medical procedure service appears safe, successful | ACP Hospitalist

Adding up adverse events | ACP Hospitalist

90% of patients with Cryptococcus infections were HIV-negative, study finds | ACP Hospitalist

Treating addiction behind bars | ACP Hospitalist

Rapid uptitration of oral therapies after hospitalization was safe, effective across LVEF categories | ACP Hospitalist

MD and DO hospitalists provide care of similar cost and quality | ACP Hospitalist

Hypercalcemia from calcium sulfate antibiotic beads | ACP Hospitalist

Automated alert increased documented goals-of-care conversations | ACP Hospitalist

AHA/ASA update recommendations on aneurysmal subarachnoid hemorrhage | ACP Hospitalist

Use of CT pulmonary angiography for suspected PE rose from 2015 to 2019 | ACP Hospitalist