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 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.

Iron Deficiency Anemia

Iron deficiency anemia (IDA) is caused by iron deficiency, a common yet underrecognized clinical entity. Populations at greatest risk include children, menstruating and pregnant persons, and people of low socioeconomic status. Timely diagnosis and management of iron deficiency are key to preventing IDA and require thorough assessment of the underlying cause and appropriate iron repletion through either oral or parenteral therapy.

Invasive Fungal Diseases: 5 Pearls Segment

Invasive fungal diseases are increasingly common but often under-recognized due to outdated risk frameworks, misinterpretation of diagnostic tests, and unfamiliarity with antifungal therapies. Many clinicians struggle to appropriately identify at-risk patients, interpret fungal markers like Beta-D-Glucan and galactomannan, and initiate timely antifungal treatment. This podcast addresses these gaps by providing practical strategies for risk assessment, diagnostic testing, and evidence-based management of fungal infections.

Intimate Partner Violence: Educating and Connecting

When, where, and how you ask about intimate partner violence matter. In this interactive course, the second in a two-part series, you will learn universal education approaches that both promote prevention and improve health and safety outcomes. Audio Version Now Available Modules and CME/MOC credit are free to ACP Members. Nonmembers may purchase access to claim CME/MOC credit for each module for $25. Copyright 2022 American College of Physicians. All Rights Reserved.

Intimate Partner Violence: Dynamics and Effects

Gain the strategies you need to effectively care for your patients affected by intimate partner violence (IPV) and exploitation. This interactive online activity explores the dynamics and effects of IPV and offers evidence-backed approaches for effective prevention and response. See part two of this series for more practical tips and universal education approaches to prevent IPV and improve health outcomes.

Diversity in Internal Medicine Residency Programs: Time to Redesign the Gatekeepers and the Gate

The Epidemiology of Thrombosis With Thrombocytopenia Syndrome: Analogies With Heparin-Induced Thrombocytopenia

Accuracy and Efficiency of Machine Learning–Assisted Risk-of-Bias Assessments in “Real-World” Systematic Reviews: A Noninferiority Randomized Controlled Trial: Annals of Internal Medicine: Vol 175, No 7

Background: Automation is a proposed solution for the increasing difficulty of maintaining up-to-date, high-quality health evidence. Evidence assessing the effectiveness of semiautomated data synthesis, such as risk-of-bias (RoB) assessments, is lacking. Objective: To determine whether RobotReviewer-assisted RoB assessments are noninferior in accuracy and efficiency to assessments conducted with human effort only. Design: Two-group, parallel, noninferiority, randomized trial. (Monash Research Office Project 11256) Setting: Health-focused systematic reviews using Covidence. Participants: Systematic reviewers, who had not previously used RobotReviewer, completing Cochrane RoB assessments between February 2018 and May 2020. Intervention: In the intervention group, reviewers received an RoB form prepopulated by RobotReviewer; in the comparison group, reviewers received a blank form. Studies were assigned in a 1:1 ratio via simple randomization to receive RobotReviewer assistance for either Reviewer 1 or Reviewer 2. Participants were blinded to study allocation before starting work on each RoB form. Measurements: Co-primary outcomes were the accuracy of individual reviewer RoB assessments and the person-time required to complete individual assessments. Domain-level RoB accuracy was a secondary outcome. Results: Of the 15 recruited review teams, 7 completed the trial (145 included studies). Integration of RobotReviewer resulted in noninferior overall RoB assessment accuracy (risk difference, −0.014 [95% CI, −0.093 to 0.065]; intervention group: 88.8% accurate assessments; control group: 90.2% accurate assessments). Data were inconclusive for the person-time outcome (RobotReviewer saved 1.40 minutes [CI, −5.20 to 2.41 minutes]). Limitation: Variability in user behavior and a limited number of assessable reviews led to an imprecise estimate of the time outcome. Conclusion: In health-related systematic reviews, RoB assessments conducted with RobotReviewer assistance are noninferior in accuracy to those conducted without RobotReviewer assistance. Primary Funding Source: University College London and Monash University.

Effect of Social Needs Case Management on Hospital Use Among Adult Medicaid Beneficiaries: A Randomized Study: Annals of Internal Medicine: Vol 175, No 8

Background: Case management programs assisting patients with social needs may improve health and avoid unnecessary health care use, but little is known about their effectiveness. Objective: This large-scale study assessed the population-level impact of a case management program designed to address patients' social needs. Design: Single-site randomized encouragement design with administrative enrollment from an eligible population and intention-to-treat analysis. Study participants were enrolled between August 2017 and December 2018 and followed for 1 year. (ClinicalTrials.gov: NCT04000074) Setting: Contra Costa County, an economically and culturally diverse community in the San Francisco Bay Area. Participants: 57 972 randomized enrollments of adult Medicaid patients at elevated risk for health care use (top 15%) to the intervention or control group. Intervention: Enrollees were offered 12 months of social needs case management, which provided more intensive services to patients with higher demonstrated needs. Measurements: Medical use was measured via emergency department (ED) visits and inpatient admissions, some of which were classified as avoidable. Results: Participants in the intervention group visited the ED at ratios of 0.96 (95% CI, 0.91 to 1.00) for all visits and 0.97 (CI, 0.92 to 1.03) for avoidable visits relative to the control group. The intervention group was hospitalized at ratios of 0.89 (CI, 0.81 to 0.98) for all admissions and 0.72 (CI, 0.55 to 0.88) for avoidable admissions. Limitations: Only 40% of the intervention group engaged with the program. The program was in continual development during the trial period. Conclusion: Although social needs case management programs may reduce health care use, these savings may not cover full program costs. More work is needed to identify ways to increase patient uptake and define characteristics of successful programs. Primary Funding Source: Contra Costa Health Services via the Medicaid waiver program.

Determining the Most Appropriate Use of Available Regimens for HIV Preexposure Prophylaxis

Tea Consumption and All-Cause and Cause-Specific Mortality in the UK Biobank: A Prospective Cohort Study: Annals of Internal Medicine: Vol 175, No 9

Background: Tea is frequently consumed worldwide, but the association of tea drinking with mortality risk remains inconclusive in populations where black tea is the main type consumed. Objective: To evaluate the associations of tea consumption with all-cause and cause-specific mortality and potential effect modification by genetic variation in caffeine metabolism. Design: Prospective cohort study. Setting: The UK Biobank. Participants: 498 043 men and women aged 40 to 69 years who completed the baseline touchscreen questionnaire from 2006 to 2010. Measurements: Self-reported tea intake and mortality from all causes and leading causes of death, including cancer, all cardiovascular disease (CVD), ischemic heart disease, stroke, and respiratory disease. Results: During a median follow-up of 11.2 years, higher tea intake was modestly associated with lower all-cause mortality risk among those who drank 2 or more cups per day. Relative to no tea drinking, the hazard ratios (95% CIs) for participants drinking 1 or fewer, 2 to 3, 4 to 5, 6 to 7, 8 to 9, and 10 or more cups per day were 0.95 (95% CI, 0.91 to 1.00), 0.87 (CI, 0.84 to 0.91), 0.88 (CI, 0.84 to 0.91), 0.88 (CI, 0.84 to 0.92), 0.91 (CI, 0.86 to 0.97), and 0.89 (CI, 0.84 to 0.95), respectively. The association was most consistent for those who drank tea without added sugar or added milk to their tea. Inverse associations were seen for mortality from all CVD, ischemic heart disease, and stroke. Findings were similar regardless of whether participants also drank coffee or not or of genetic score for caffeine metabolism. Limitation: Potentially important aspects of tea intake (for example, portion size and tea strength) were not assessed. Conclusion: Higher tea intake was associated with lower mortality risk among those drinking 2 or more cups per day, regardless of genetic variation in caffeine metabolism. These findings suggest that tea, even at higher levels of intake, can be part of a healthy diet. Primary Funding Source: National Cancer Institute Intramural Research Program.

How Would You Treat This Patient With Acute and Chronic Pain From Sickle Cell Disease?: Grand Rounds Discussion From Beth Israel Deaconess Medical Center: Annals of Internal Medicine: Vol 175, No 4

Sickle cell disease is prevalent in large numbers of patients in the United States and has a significant global impact. Its complications span numerous organs and lead to reduced life expectancy. Acute and chronic sickle cell pain is a common cause of patient suffering. The American Society of Hematology published updated guidelines on management of acute and chronic pain from sickle cell disease in 2019. Several of the recommendations are conditional and leave specific decisions to the treating physician. These include conditional recommendations about the use of ketamine for acute pain and the initiation and discontinuation of long-term opioid therapy for chronic pain. Here, 2 hematologists discuss these guidelines and make contrasting recommendations for the management of acute and chronic pain for a patient with sickle cell disease.

Recommended Adult Immunization Schedule, United States, 2022*

Addressing Inequities in SARS-CoV-2 Vaccine Uptake: The Boston Medical Center Health System Experience

Academic medical centers could play an important role in increasing access to and uptake of SARS-CoV-2 vaccines, especially in Black and Latino communities that have been disproportionately affected by the pandemic. This article describes the vaccination program developed by the Boston Medical Center (BMC) health system (New England's largest safety-net health system), its affiliated community health centers (CHCs), and community partners. The program was based on a conceptual framework for community interventions and aimed to increase equitable access to vaccination in the hardest-hit communities through community-based sites in churches and community centers, mobile vaccination events, and vaccination on the BMC campus. Key strategies included a communication campaign featuring trusted messengers, a focus on health equity, established partnerships with community leaders and CHCs, and strong collaboration with local health departments and the Commonwealth of Massachusetts to ensure equitable allocation of the vaccine supply. Process factors involved the use of robust analytics relying on the Centers for Disease Control and Prevention's Social Vulnerability Index (SVI). The vaccination program administered 109 938 first doses, with 94 703 (86%) given at community sites and 2466 (2%) given at mobile sites. Mobile vaccination events were key in reaching younger people living in locations with the highest SVIs. Challenges included the need for a robust operational infrastructure and mistrust of the health system given the long history of economic disinvestment in the surrounding community. The BMC model could serve as a blueprint for other medical centers interested in implementing programs aimed at increasing vaccine uptake during a pandemic and in developing an infrastructure to address other health-related disparities.

Implementation of a SARS-CoV-2 Genotyping Panel for Prompt Omicron Variant Identification: A Pragmatic Tool for Clinical Laboratories

MKSAP Quiz: 2-week history of fatigue, poor appetite, arthralgia, and rash

Long-term low-dose hydroxychloroquine use associated with low risk for retinopathy

ACG updates, reaffirms guidelines on evaluation, management of patients with celiac disease

Put words in our mouth

Governor-elect Designee election results announced

New Career & Professional Development Center offered at Internal Medicine Meeting 2023

Relationships between primary care physicians, specialists may affect patient satisfaction

MKSAP Quiz: 1-week history of burning pain, rash

About 6% of older adults received a new sedative prescription after critical illness

KDIGO guideline summary provides key points for treating diabetes, chronic kidney disease

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

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

Adding up adverse events | ACP Hospitalist