Lifestyle Recommendations: Can They Really Improve Public Health?

In this episode of Annals On Call, Dr. Centor discusses why guidelines recommending that clinicians advise patients on lifestyle changes may be a questionable approach to improving public health with Dr. Minna Johansson. First, listen to the podcast. After listening, ACP members can take the CME/MOC quiz for free.

Lack of Control and Physician Burnout

In this episode of Annals On Call, Dr. Centor discusses factors associated with physician burnout with Dr. Christine Sinsky. First, listen to the podcast. After listening, ACP members can take the CME/MOC quiz for free.

Kratom: A Substance Physicians Should Be Aware Of

In this episode of Annals On Call, Dr. Centor discusses kratom and what physicians should know about how patients may be using this substance with Drs. Eileen Barrett and Amanda Collar. First, listen to the podcast. After listening, ACP members can take the CME/MOC quiz for free.

Knee Osteoarthritis

Knee osteoarthritis (OA) typically presents with joint pain that is exacerbated by use and alleviated with rest. There is relatively brief, self-limited morning stiffness and absence of constitutional symptoms. Overweight and obesity are the most important modifiable risk factors. Although pharmacologic and nonpharmacologic interventions are generally effective at alleviating pain and improving physical function, they do not fundamentally reverse the pathologic and radiographic process of knee OA.

Is This Patient a Good Candidate for Bariatric Surgery?

The Annals Consult Guys discuss the current indications for bariatric surgery, various bariatric procedures, and how to evaluate risk for complications.

Is Preoperative Evaluation Required Before Cataract Surgery?

The Annals Consult Guys address the history and the evidence behind the practice of preoperative evaluation of patients undergoing cataract surgery.

Is Adherence to SEP-1 Linked to Mortality Reduction for Patients With Sepsis?

Dr. Centor discusses the evidence that implementation of the SEP-1 Bundle is associated with favorable outcomes for patients with sepsis with Drs. James Ford and Gabriel Wardi. First, listen to the podcast. After listening, ACP members can take the CME/MOC quiz for free.

Irritable Bowel Syndrome

Irritable bowel syndrome (IBS) is a common gastrointestinal disorder, with a prevalence of 4% to 10%. It is a chronic condition characterized by abdominal pain in conjunction with altered bowel habits, abdominal distention, or bloating. IBS can present with 3 different defecation patterns: IBS with constipation, IBS with diarrhea, or mixed IBS. Recent advances in IBS include a positive diagnosis based on symptom-based criteria and a treatment plan based on IBS subtype and bothersome symptoms.

Iron Deficiency Treatment: 5 Pearls Segment

In this episode of Core IM the team tackles understanding the nuances of oral and intravenous approaches, addressing special considerations regarding different formulations, managing patients with chronic inflammatory disorders, and recognizing associated complications and side effects of treatment. Join them for Iron Deficiency Treatment: 5 Pearls Segment!

Iron Deficiency: Grey Matters Segment

Iron deficiency is a common diagnosis and frequent cause of morbidity. However, there is significant variation in how it is diagnosed, with divergent practice patterns and uncertainty among providers. In this episode the team explores the state of current guidelines regarding how to implement iron testing and areas of ongoing clinical uncertainty including iron deficiency in chronic inflammation.

Apixaban Versus Rivaroxaban in Patients With Atrial Fibrillation and Valvular Heart Disease: A Population-Based Study: Annals of Internal Medicine: Vol 175, No 11

Background: Although apixaban and rivaroxaban are commonly used in patients with atrial fibrillation (AF) and valvular heart disease (VHD), there is limited evidence comparing the 2 drugs in these patients. Objective: To emulate a target trial of effectiveness and safety of apixaban and rivaroxaban in patients with AF and VHD. Design: New-user, active comparator, cohort study design. Setting: Commercial health insurance database from 1 January 2013 to 31 December 2020. Patients: New users of apixaban or rivaroxaban who had a diagnosis of AF and VHD before initiation of anticoagulant therapy. Measurements: The primary effectiveness outcome was a composite of ischemic stroke or systemic embolism. The primary safety outcome was a composite of gastrointestinal or intracranial bleeding. Cox proportional hazards regression with a robust variance estimator was used to estimate hazard ratios (HRs) and 95% CIs. Results: When compared with rivaroxaban in a propensity score–matched cohort of 19 894 patients (9947 receiving each drug), apixaban was associated with a lower rate of ischemic stroke or systemic embolism (HR, 0.57 [95% CI, 0.40 to 0.80]) and bleeding (HR, 0.51 [CI, 0.41 to 0.62]). The absolute reduction in the probability of stroke or systemic embolism with apixaban compared with rivaroxaban was 0.0026 within 6 months and 0.011 within 1 year of treatment initiation. The absolute reduction in the probability of bleeding events with apixaban compared with rivaroxaban was 0.012 within 6 months and 0.019 within 1 year of treatment initiation. Limitation: Short follow-up time and inability to ascertain some types of VHD. Conclusion: In this study of patients with AF and VHD, patients receiving apixaban had a lower risk for ischemic stroke or systemic embolism and for bleeding when compared with those receiving rivaroxaban. Primary Funding Source: National Institutes of Health.

Ideation

Grief's Terrain

Comparison of Patients Infected With Delta Versus Omicron COVID-19 Variants Presenting to Paris Emergency Departments: A Retrospective Cohort Study: Annals of Internal Medicine: Vol 175, No 6

Background: At the end of 2021, the B.1.1.529 SARS-CoV-2 variant (Omicron) wave superseded the B.1.617.2 variant (Delta) wave. Objective: To compare baseline characteristics and in-hospital outcomes of patients with SARS-CoV-2 infection with the Delta variant versus the Omicron variant in the emergency department (ED). Design: Retrospective chart reviews. Setting: 13 adult EDs in academic hospitals in the Paris area from 29 November 2021 to 10 January 2022. Patients: Patients with a positive reverse transcriptase polymerase chain reaction (RT-PCR) test result for SARS-CoV-2 and variant identification. Measurements: Main outcome measures were baseline clinical and biological characteristics at ED presentation, intensive care unit (ICU) admission, mechanical ventilation, and in-hospital mortality. Results: A total of 3728 patients had a positive RT-PCR test result for SARS-CoV-2 during the study period; 1716 patients who had a variant determination (818 Delta and 898 Omicron) were included. Median age was 58 years, and 49% were women. Patients infected with the Omicron variant were younger (54 vs. 62 years; difference, 8.0 years [95% CI, 4.6 to 11.4 years]), had a lower rate of obesity (8.0% vs. 12.5%; difference, 4.5 percentage points [CI, 1.5 to 7.5 percentage points]), were more vaccinated (65% vs. 39% for 1 dose and 22% vs. 11% for 3 doses), had a lower rate of dyspnea (26% vs. 50%; difference, 23.6 percentage points [CI, 19.0 to 28.2 percentage points]), and had a higher rate of discharge home from the ED (59% vs. 37%; difference, 21.9 percentage points [−26.5 to −17.1 percentage points]). Compared with Delta, Omicron infection was independently associated with a lower risk for ICU admission (adjusted difference, 11.4 percentage points [CI, 8.4 to 14.4 percentage points]), mechanical ventilation (adjusted difference, 3.6 percentage points [CI, 1.7 to 5.6 percentage points]), and in-hospital mortality (adjusted difference, 4.2 percentage points [CI, 2.0 to 6.5 percentage points]). Limitation: Patients with COVID-19 illness and no SARS-CoV-2 variant determination in the ED were excluded. Conclusion: Compared with the Delta variant, infection with the Omicron variant in patients in the ED had different clinical and biological patterns and was associated with better in-hospital outcomes, including higher survival. Primary Funding Source: None.

Adenoma Detection Rate and Risk for Interval Postcolonoscopy Colorectal Cancer in Fecal Immunochemical Test–Based Screening: A Population-Based Cohort Study: Annals of Internal Medicine: Vol 175, No 10

Background: The adenoma detection rate (ADR) is an essential quality indicator for endoscopists performing colonoscopies for colorectal cancer (CRC) screening as it is associated with postcolonoscopy CRCs (PCCRCs). Currently, data on ADRs of endoscopists performing colonoscopies in fecal immunochemical testing (FIT)-based screening, the most common screening method, are scarce. Also, the association between the ADR and PCCRC has not been demonstrated in this setting. Objective: To evaluate the association between the ADR and PCCRC risk in colonoscopies done after a positive FIT result. Design: Population-based cohort. Setting: Dutch, FIT-based, CRC screening program. Participants: Patients undergoing colonoscopy, done by accredited endoscopists, after a positive FIT result. Measurements: Quality indicator performance and PCCRC incidence for colonoscopies in FIT-positive screenees were assessed. The PCCRCs were classified as interval, a cancer detected before recommended surveillance, or noninterval. The association between ADR and interval PCCRC was evaluated with a multivariable Cox regression model and PCCRC incidence was determined for different ADRs. Results: 362 endoscopists performed 116 360 colonoscopies with a median ADR of 67%. In total, 209 interval PCCRCs were identified. The ADR was associated with interval PCCRC, with an adjusted hazard ratio of 0.95 (95% CI, 0.92 to 0.97) per 1% increase in ADR. For every 1000 patients undergoing colonoscopy, the expected number of interval PCCRC diagnoses after 5 years was approximately 2 for endoscopists with ADRs of 70%, compared with more than 2.5, almost 3.5, and more than 4.5 for endoscopists with ADRs of 65%, 60%, and 55%, respectively. Limitation: The relative short duration of follow-up (median, 52 months) could be considered a limitation. Conclusion: The ADR of endoscopists is inversely associated with the risk for interval PCCRC in FIT-positive colonoscopies. Endoscopists performing colonoscopy in FIT-based screening should aim for markedly higher ADRs compared with primary colonoscopy. Primary Funding Source: None.

Prescribing Nirmatrelvir–Ritonavir: How to Recognize and Manage Drug–Drug Interactions

QUAPAS: An Adaptation of the QUADAS-2 Tool to Assess Prognostic Accuracy Studies

Whereas diagnostic tests help detect the cause of signs and symptoms, prognostic tests assist in evaluating the probable course of the disease and future outcome. Studies to evaluate prognostic tests are longitudinal, which introduces sources of bias different from those for diagnostic accuracy studies. At present, systematic reviews of prognostic tests often use the QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies 2) tool to assess risk of bias and applicability of included studies because no equivalent instrument exists for prognostic accuracy studies. QUAPAS (Quality Assessment of Prognostic Accuracy Studies) is an adaptation of QUADAS-2 for prognostic accuracy studies. Questions likely to identify bias were evaluated in parallel and collated from QUIPS (Quality in Prognosis Studies) and PROBAST (Prediction Model Risk of Bias Assessment Tool) and paired to the corresponding question (or domain) in QUADAS-2. A steering group conducted and reviewed 3 rounds of modifications before arriving at the final set of domains and signaling questions. QUAPAS follows the same steps as QUADAS-2: Specify the review question, tailor the tool, draw a flow diagram, judge risk of bias, and identify applicability concerns. Risk of bias is judged across the following 5 domains: participants, index test, outcome, flow and timing, and analysis. Signaling questions assist the final judgment for each domain. Applicability concerns are assessed for the first 4 domains. The authors used QUAPAS in parallel with QUADAS-2 and QUIPS in a systematic review of prognostic accuracy studies. QUAPAS improved the assessment of the flow and timing domain and flagged a study at risk of bias in the new analysis domain. Judgment of risk of bias in the analysis domain was challenging because of sparse reporting of statistical methods.

Preventing Obesity in Midlife Women: A Recommendation From the Women's Preventive Services Initiative

Description: The Women's Preventive Services Initiative (WPSI), a national coalition of women's health professional organizations and patient advocacy representatives, developed a recommendation for counseling midlife women aged 40 to 60 years with normal or overweight body mass index (BMI; 18.5 to 29.9 kg/m2) to maintain weight or limit weight gain to prevent obesity with the long-term goals of optimizing health, function, and well-being. This recommendation is intended to guide clinical practice and coverage of clinical preventive health services for the Health Resources and Services Administration and other stakeholders. Clinicians providing preventive health care to women in primary care settings are the target audience for this recommendation. Methods: The WPSI developed this recommendation after evaluating results of a systematic review of the effectiveness and harms of interventions to prevent weight gain and obesity in women aged 40 to 60 years without obesity. Seven randomized clinical trials including 51 638 participants and using various counseling and behavioral interventions were included. Trials indicated favorable weight changes with interventions that were statistically significantly different from control groups in 4 of 5 trials of counseling, but not in 2 trials of exercise. Few harms were reported. Recommendation: The WPSI recommends counseling midlife women aged 40 to 60 years with normal or overweight BMI (18.5 to 29.9 kg/m2) to maintain weight or limit weight gain to prevent obesity. Counseling may include individualized discussion of healthy eating and physical activity.

Black, Incarcerated, and Dying: Reflections on Racism and Inequities in Health Care

U.S. Trends in Registration for Medical Cannabis and Reasons for Use From 2016 to 2020: An Observational Study: Annals of Internal Medicine: Vol 175, No 7

Background: Cannabis policy liberalization has increased cannabis availability for medical or recreational purposes. Up-to-date trends in medical cannabis licensure can inform clinical policy and care. Objective: To describe recent trends in medical cannabis licensure in the United States. Design: Ecological study with repeated measures. Setting: State registry data via state reports and data requests on medical cannabis licensure from 2016 to 2020. Participants: Medical cannabis patients (persons with medical cannabis licenses) in the United States. Measurements: Total patient volume, patients per 10 000 of total population, and patient-reported qualifying conditions (that is, symptoms or conditions qualifying patients for licensure)—including whether these symptoms align with current therapeutic evidence of cannabis–cannabinoid efficacy. Results: In 2020, 26 states and Washington, DC reported patient numbers, and 19 states reported patient-reported qualifying conditions. Total enrolled patients increased approximately 4.5-fold from 678 408 in 2016 to 2 974 433 in 2020. Patients per 10 000 total population generally increased from 2016 to 2020, most dramatically in Oklahoma (927.1 patients per 10 000 population). However, enrollment increased in states without recreational legalization (that is, medical-only states), whereas enrollment decreased in 5 of 7 with recreational legalization (that is, recreational states). In 2020, 68.2% of patient-reported qualifying conditions had substantial or conclusive evidence of therapeutic value versus 84.6% in 2016. Chronic pain was the most common patient-reported qualifying condition in 2020 (60.6%), followed by posttraumatic stress disorder (10.6%). Limitation: Missing state data; lack of rationale for discontinuing medical cannabis licensure. Conclusion: Enrollment in medical cannabis programs approximately increased 4.5-fold from 2016 to 2020, although enrollment decreased in recreational states. Use for conditions or symptoms without a strong evidence basis increased from 15.4% (2016) to 31.8% (2020). Thoughtful regulatory and clinical strategies are needed to effectively manage this rapidly changing landscape. Primary Funding Source: National Institute on Drug Abuse of the National Institutes of Health.

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Welcome to I.M. Matters from ACP

Welcome to I.M. Matters from ACP

Urinalysis as a ‘liquid biopsy of the kidney’

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No temperature cutoff accurately identifies patients with bacteremia | ACP Hospitalist

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Few low-risk inpatients with CAP switched from IV to oral therapy | ACP Hospitalist