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Displaying 981 - 990 of 7607 in ACP Online
Inpatient Management of Patients With Cirrhosis
Cirrhosis affects millions of U.S. adults and costs the U.S. health care system upward of $6 billion annually. Cirrhosis is underrecognized, and the only cure is transplantation. Complications, including bleeding, infection, ascites, and renal injury, contribute to high rates of hospitalization, readmission, and mortality in this population. Evidence-based practices and guidelines offer quality recommendations for clinicians, but many of these guidelines have changed recently. This article provides an update on the current guidelines for the inpatient management of cirrhosis.
Improving Research Reports: Avoiding P Values
In this episode of Annals On Call, Dr. Centor discusses how to go beyond statistical significance testing when interpreting study findings with Dr. David Savitz. First, listen to the podcast. After listening, ACP members can take the CME/MOC quiz for free.
Immune-Related Adverse Events of Immune Checkpoint Inhibitors
Immune-related adverse events (irAEs) are toxicities that arise after the administration of monoclonal antibodies targeting immune checkpoints (immune checkpoint inhibitors [ICIs]) in patients with cancer. They can occur at any time after initiation of ICI treatment, with a broad clinical phenotype that can be organ-specific or systemic. Although most irAEs manifest as mild to moderate signs and symptoms, severe forms of irAEs can lead to irreversible organ failure and have acute life-threatening presentations. Treatment should be tailored to the specific organ involved and the severity.
Immune Checkpoint Inhibitor Adverse Events 2.0: 5 Pearls Segment
Although internal medicine providers are familiar with checkpoint inhibitors and their immune-related adverse events (IRAE), there is a gap in the knowledge of specific characteristics of these drugs. They are clinically relevant because their adverse events can present similar to other medical conditions and a high degree of suspicion is needed to identify IRAEs.
ILD and High-Risk Medication Prescribing: Gray Matters Segment
Many clinicians lack familiarity with the diagnostic nuances and management strategies for interstitial lung disease (ILD), particularly in distinguishing subtypes (e.g., UIP vs. NSIP) and selecting appropriate treatment options, such as antifibrotics for fibrosing ILDs and avoiding immunosuppressants in idiopathic pulmonary fibrosis (IPF). Additionally, gaps exist in recognizing the role of multidisciplinary care and addressing social determinants of health to improve outcomes.
Hyponatremia Correction: How Fast Is Too Fast?
In this episode of Annals On Call, Dr. Centor discusses hyponatremia correction rates with Dr. Dustin Mark.First, listen to the podcast. After listening, ACP members can take the CME/MOC quiz for free.
Hyponatremia
Hyponatremia is the most common electrolyte disorder in hospitalized patients. Hospital-associated hyponatremia includes community-acquired (e.g., hyponatremia on admission) and hospital-acquired hyponatremia. Acute-onset hyponatremia requires rapid treatment with hypertonic saline to decrease cerebral edema. In cases of chronic hyponatremia (>48 hours), the brain has time to normalize cell volume by losing solutes. However, even mild chronic cases can have adverse outcomes, such as decreased cognition, osteoporosis, increased risk for falls, and fractures.
Hypomagnesemia and Hypophosphatemia: 5 Pearls Segment
Hypomagnesemia and hypophosphatemia, often overlooked, are prevalent electrolyte disorders, affecting around 5-10% of hospitalized patients. Magnesium acts as a vital cofactor for multiple enzymes and helps regulate calcium and potassium levels, while phosphate is integral to various metabolic and signaling cellular processes. Depletion of these elements correlates with multiple symptoms and adverse outcomes. The rapid identification, diagnosis, and management from internists are crucial for optimal results across different medical settings.
Hypokalemia & Potassium Repletion: 5 Pearls Segment
Hypokalemia is one of the most frequent and significant electrolyte disorders. As the main ion that determines the electrochemical gradient of cells, potassium plays a central role in almost all cellular processes.
Signs of Human Trafficking and Response: A Physician's Guide | ACP
Human trafficking is a widespread issue so physicians need to know signs of human trafficking and treatment. Learn about recognizing and responding to survivors with this course.
Displaying 981 - 990 of 6853 in Annals of Internal Medicine
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Early Rhythm Control Therapy for Atrial Fibrillation in Low-Risk Patients: A Nationwide Propensity Score–Weighted Study: Annals of Internal Medicine: Vol 175, No 10
Background: Rhythm control is associated with lower risk for adverse cardiovascular outcomes compared with usual care among patients recently diagnosed with atrial fibrillation (AF) with a CHA2DS2-VASc score of approximately 2 or greater in EAST-AFNET 4 (Early Treatment of Atrial Fibrillation for Stroke Prevention Trial). Objective: To investigate whether the results can be generalized to patients with low stroke risk. Design: Population-based cohort study. Setting: Nationwide claims database of the Korean National Health Insurance Service. Participants: 54 216 patients with AF having early rhythm control (antiarrhythmic drugs or ablation) or rate control therapy that was initiated within 1 year of the AF diagnosis. Measurements: The effect of early rhythm control on the primary composite outcome of cardiovascular death, ischemic stroke, hospitalization for heart failure, or myocardial infarction was compared between eligible and ineligible patients for EAST-AFNET 4 (CHA2DS2-VASc score, approximately 0 to 1) using propensity overlap weighting. Results: In total, 37 557 study participants (69.3%) were eligible for the trial (median age, 70 years; median CHA2DS2-VASc score, 4), among whom early rhythm control was associated with lower risk for the primary composite outcome than rate control (hazard ratio, 0.86 [95% CI, 0.81 to 0.92]). Among the 16 659 low-risk patients (30.7%) who did not meet the inclusion criteria (median age, 54 years; median CHA2DS2-VASc score, 1), early rhythm control was consistently associated with lower risk for the primary outcome (hazard ratio, 0.81 [CI, 0.66 to 0.98]). No significant differences in safety outcomes were found between the rhythm and rate control strategies regardless of trial eligibility. Limitation: Residual confounding. Conclusion: In routine clinical practice, the beneficial association between early rhythm control and cardiovascular complications was consistent among low-risk patients regardless of trial eligibility. Primary Funding Source: The Ministry of Health and Welfare and the Ministry of Food and Drug Safety, Republic of Korea.
Major Update 2: Remdesivir for Adults With COVID-19: A Living Systematic Review and Meta-analysis for the American College of Physicians Practice Points
Background: Remdesivir is approved for the treatment of adults hospitalized with COVID-19. Purpose: To update a living review of remdesivir for adults with COVID-19. Data Sources: Several electronic U.S. Food and Drug Administration, company, and journal websites from 1 January 2020 through 19 October 2021. Study Selection: English-language, randomized controlled trials (RCTs) of remdesivir for COVID-19. Data Extraction: One reviewer abstracted, and a second reviewer verified data. The Cochrane Risk of Bias Tool and GRADE (Grading of Recommendations Assessment, Development and Evaluation) method were used. Data Synthesis: Since the last update (search date 9 August 2021), 1 new RCT and 1 new subtrial comparing a 10-day course of remdesivir with control (placebo or standard care) were identified. This review summarizes and updates the evidence on the cumulative 5 RCTs and 2 subtrials for this comparison. Our updated results confirm a 10-day course of remdesivir, compared with control, probably results in little to no mortality reduction (5 RCTs). Updated results also confirm that remdesivir probably results in a moderate increase in the proportion of patients recovered by day 29 (4 RCTs) and may reduce time to clinical improvement (2 RCTs) and hospital length of stay (4 RCTs). New RCTs, by increasing the strength of evidence, lead to an updated conclusion that remdesivir probably results in a small reduction in the proportion of patients receiving ventilation or extracorporeal membrane oxygenation at specific follow-up times (4 RCTs). New RCTs also alter the conclusions for harms—remdesivir, compared with control, may lead to a small reduction in serious adverse events but may lead to a small increase in any adverse event. Limitation: The RCTs differed in definitions of COVID-19 severity and outcomes reported. Conclusion: In hospitalized adults with COVID-19, the findings confirm that remdesivir probably results in little to no difference in mortality and increases the proportion of patients recovered. Remdesivir may reduce time to clinical improvement and may lead to small reductions in serious adverse events but may result in a small increase in any adverse event. Primary Funding Source: U.S. Department of Veterans Affairs.
Efficacy and Safety of Dapagliflozin According to Frailty in Heart Failure With Reduced Ejection Fraction: A Post Hoc Analysis of the DAPA-HF Trial: Annals of Internal Medicine: Vol 175, No 6
Background: Frailty may modify the risk−benefit profile of certain treatments, and frail patients may have reduced tolerance to treatments. Objective: To investigate the efficacy of dapagliflozin according to frailty status, using the Rockwood cumulative deficit approach, in DAPA-HF (Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure). Design: Post hoc analysis of a phase 3 randomized clinical trial. (ClinicalTrials.gov: NCT03036124) Setting: 410 sites in 20 countries. Patients: Patients with symptomatic heart failure (HF) with a left ventricular ejection fraction of 40% or less and elevated natriuretic peptide. Intervention: Addition of once-daily 10 mg of dapagliflozin or placebo to guideline-recommended therapy. Measurements: The primary outcome was worsening HF or cardiovascular death. Results: Of the 4744 patients randomly assigned in DAPA-HF, a frailty index (FI) was calculable in 4742. In total, 2392 patients (50.4%) were in FI class 1 (FI ≤0.210; not frail), 1606 (33.9%) in FI class 2 (FI 0.211 to 0.310; more frail), and 744 (15.7%) in FI class 3 (FI ≥0.311; most frail). The median follow-up time was 18.2 months. Dapagliflozin reduced the risk for worsening HF or cardiovascular death, regardless of FI class. The differences in event rate per 100 person-years for dapagliflozin versus placebo from lowest to highest FI class were −3.5 (95% CI, −5.7 to −1.2), −3.6 (CI, −6.6 to −0.5), and −7.9 (CI, −13.9 to −1.9). Consistent benefits were observed for other clinical events and health status, but the absolute reductions were generally larger in the most frail patients. Study drug discontinuation and serious adverse events were not more frequent with dapagliflozin than placebo, regardless of FI class. Limitation: Enrollment criteria precluded the inclusion of very high-risk patients. Conclusion: Dapagliflozin improved all outcomes examined, regardless of frailty status. However, the absolute reductions were larger in more frail patients. Primary Funding Source: AstraZeneca.
The Underuse of Medicare's Prevention and Coordination Codes in Primary Care: A Cross-Sectional and Modeling Study: Annals of Internal Medicine: Vol 175, No 8
Background: Efforts to better support primary care include the addition of primary care–focused billing codes to the Medicare Physician Fee Schedule (MPFS). Objective: To examine potential and actual use by primary care physicians (PCPs) of the prevention and coordination codes that have been added to the MPFS. Design: Cross-sectional and modeling study. Setting: Nationally representative claims and survey data. Participants: Medicare patients. Measurements: Frequency of use and estimated Medicare revenue involving 34 billing codes representing prevention and coordination services for which PCPs could but do not necessarily bill. Results: Eligibility among Medicare patients for each service ranged from 8.8% to 100%. Among eligible patients, the median use of billing codes was 2.3%, even though PCPs provided code-appropriate services to more patients, for example, to 5.0% to 60.6% of patients eligible for prevention services. If a PCP provided and billed all prevention and coordination services to half of all eligible patients, the PCP could add to the practice's annual revenue $124 435 (interquartile range [IQR], $30 654 to $226 813) for prevention services and $86 082 (IQR, $18 011 to $154 152) for coordination services. Limitation: Service provision based on survey questions may not reflect all billing requirements; revenues do not incorporate the compliance, billing, and opportunity costs that may be incurred when using these codes. Conclusion: Primary care physicians forego considerable amounts of revenue because they infrequently use billing codes for prevention and coordination services despite having eligible patients and providing code-appropriate services to some of those patients. Therefore, creating additional billing codes for distinct activities in the MPFS may not be an effective strategy for supporting primary care. Primary Funding Source: National Institute on Aging.