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.

Post Disruptive Growth

Explore Post-Disruptive Growth (PDG) as a vital leadership concept for navigating evolving work environments through crises and disruptions . Define PDG, identify when it emerges, and learn to cultivate conditions for healthy growth across individuals, teams, and systems. Through applied exercises, gain the insights needed to foster team stability and lead effectively through constant change.

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.

Physicians Not Providers

In this episode of Annals On Call, Dr. Centor discusses why the American College of Physicians believes that physicians should not be called providers with Drs. Robert McLean and Jan Carney.First, listen to the podcast. After listening, ACP members can take the CME/MOC quiz for free.

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.

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.

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.

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.

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

Comparison of Rapid Antigen Tests' Performance Between Delta and Omicron Variants of SARS-CoV-2: A Secondary Analysis From a Serial Home Self-testing Study: Annals of Internal Medicine: Vol 175, No 12

Background: It is important to document the performance of rapid antigen tests (Ag-RDTs) in detecting SARS-CoV-2 variants. Objective: To compare the performance of Ag-RDTs in detecting the Delta (B.1.617.2) and Omicron (B.1.1.529) variants of SARS-CoV-2. Design: Secondary analysis of a prospective cohort study that enrolled participants between 18 October 2021 and 24 January 2022. Participants did Ag-RDTs and collected samples for reverse transcriptase polymerase chain reaction (RT-PCR) testing every 48 hours for 15 days. Setting: The parent study enrolled participants throughout the mainland United States through a digital platform. All participants self-collected anterior nasal swabs for rapid antigen testing and RT-PCR testing. All Ag-RDTs were completed at home, whereas nasal swabs for RT-PCR were shipped to a central laboratory. Participants: Of 7349 participants enrolled in the parent study, 5779 asymptomatic persons who tested negative for SARS-CoV-2 on day 1 of the study were eligible for this substudy. Measurements: Sensitivity of Ag-RDTs on the same day as the first positive (index) RT-PCR result and 48 hours after the first positive RT-PCR result. Results: A total of 207 participants were positive on RT-PCR (58 Delta, 149 Omicron). Differences in sensitivity between variants were not statistically significant (same day: Delta, 15.5% [95% CI, 6.2% to 24.8%] vs. Omicron, 22.1% [CI, 15.5% to 28.8%]; at 48 hours: Delta, 44.8% [CI, 32.0% to 57.6%] vs. Omicron, 49.7% [CI, 41.6% to 57.6%]). Among 109 participants who had RT-PCR–positive results for 48 hours, rapid antigen sensitivity did not differ significantly between Delta- and Omicron-infected participants (48-hour sensitivity: Delta, 81.5% [CI, 66.8% to 96.1%] vs. Omicron, 78.0% [CI, 69.1% to 87.0%]). Only 7.2% of the 69 participants with RT-PCR–positive results for shorter than 48 hours tested positive by Ag-RDT within 1 week; those with Delta infections remained consistently negative on Ag-RDTs. Limitation: A testing frequency of 48 hours does not allow a finer temporal resolution of the analysis of test performance, and the results of Ag-RDTs are based on self-report. Conclusion: The performance of Ag-RDTs in persons infected with the SARS-CoV-2 Omicron variant is not inferior to that in persons with Delta infections. Serial testing improved the sensitivity of Ag-RDTs for both variants. The performance of rapid antigen testing varies on the basis of duration of RT-PCR positivity. Primary Funding Source: National Heart, Lung, and Blood Institute of the National Institutes of Health.

Potential Medicare Part D Savings on Generic Drugs From the Mark Cuban Cost Plus Drug Company

Ethical Considerations in Precision Medicine and Genetic Testing in Internal Medicine Practice: A Position Paper From the American College of Physicians

This American College of Physicians position paper aims to inform ethical decision making for the integration of precision medicine and genetic testing into clinical care. Although the positions are primarily intended for practicing physicians, they may apply to other health care professionals and can also inform how health care systems, professional schools, and residency programs integrate genomics into educational and clinical settings. Addressing the challenges of precision medicine and genetic testing will guide ethical and responsible implementation to improve health outcomes.

Periconception Red Blood Cell Folate and Offspring Congenital Heart Disease: Nested Case–Control and Mendelian Randomization Studies: Annals of Internal Medicine: Vol 175, No 9

Background: Periconception folic acid supplementation has been suggested to protect against congenital heart disease (CHD), but the association between maternal red blood cell (RBC) folate, the gold-standard biomarker of folate exposure, and subsequent offspring CHD risk is lacking. Objective: To quantify the association between periconception maternal RBC folate and offspring CHD risk. Design: Prospective, nested, case–control study and 1-sample Mendelian randomization. (ClinicalTrials.gov: NCT02737644) Setting: 29 maternity institutions in 12 districts of Greater Shanghai, China. Participants: All 197 mothers of offspring with CHD and 788 individually matched mothers of unaffected offspring from the SPCC (Shanghai Preconception Cohort). Measurements: Maternal RBC folate was measured before or at early pregnancy. Odds ratios [ORs] were estimated using conditional logistic regression after adjustment for covariates. Mendelian randomization was done using the methylenetetrahydrofolate reductase (MTHFR) C677T as the genetic instrument. Results: Case patients had lower median maternal RBC folate concentrations than control participants (714 nmol/L [interquartile range, 482 to 1008 nmol/L] vs. 788 nmol/L [557 to 1094 nmol/L]). Maternal RBC folate concentrations were inversely associated with offspring CHD (adjusted OR per 100 nmol/L, 0.93 [95% CI, 0.89 to 0.99]). The adjusted OR for mothers with periconception RBC folate of 906 nmol/L or more (vs. <906 nmol/L) was 0.61 (CI, 0.40 to 0.93). Mendelian randomization showed that each 100-nmol increase in maternal RBC folate concentrations was significantly associated with reduced offspring CHD risk (OR, 0.75 [CI, 0.61 to 0.92]). Limitation: Potential confounding due to unmeasured covariates in the nested case–control study. Conclusion: Higher maternal RBC folate is associated with reduced offspring CHD risk. For primary CHD prevention, higher target RBC folate levels than currently recommended for neural tube defect prevention may be needed and warrant further study. Primary Funding Source: National Key Research and Development Program of China, National Natural Science Foundation of China, China Postdoctoral Science Foundation, and Chinese Academy of Medical Sciences Innovation Fund for Medical Sciences.

Direct-to-Consumer Generic Drugs: A Maverick Approach or Another Exposure of Market Failures?

Put words in our mouth

ACP announces keynote speaker for Internal Medicine Meeting 2023 Opening Ceremony

ACP joins the Coalition for Trust in Health and Science initiative to curb misinformation

Home-based cardiac rehabilitation may reduce mortality, study finds

MKSAP Quiz: Evaluation during annual follow-up visit

Alcohol screening in primary care increased initial treatment but not longer-term engagement

Hydrochlorothiazide no better than placebo for preventing kidney stone recurrence

Put words in our mouth

Antibiotic stewardship improved prescribing for suspected UTI in frail older adults

Register now for ACP's and Annals of Internal Medicine's forum on overweight and obesity

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