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Displaying 991 - 1000 of 7510 in ACP Online
How Would You Manage This Patient With Idiopathic Acute Pancreatitis? Grand Rounds Discussion From Beth Israel Deaconess Medical Center
Acute pancreatitis is among the most frequent gastroenterologic reasons for hospitalization in the United States. This condition is associated with significant morbidity, including recurrent acute pancreatitis and chronic pancreatitis. Although most patient cases are due to biliary disease and ethanol, approximately 18% are idiopathic. Diagnostic and management options for idiopathic acute pancreatitis include genetic testing for a number of associated mutations and cholecystectomy to treat subclinical or undetected biliary disease.
How Would You Manage This Patient With Heart Failure With Preserved Ejection Fraction? Grand Rounds Discussion From Beth Israel Deaconess Medical Center
The proportion of patients with new-onset heart failure who have preserved rather than reduced left ventricular ejection fraction (HFpEF and HFrEF) has been increasing over recent decades. In fact, HFpEF now outweighs HFrEF as the predominant heart failure subtype and likely remains underdiagnosed in the community. This is due in part to an aging population and a rise in other risk factors for HFpEF, including obesity and associated cardiometabolic disease.
How Would You Manage This Patient With Gastroesophageal Reflux Symptoms? Grand Rounds Discussion From Beth Israel Deaconess Medical Center
Gastroesophageal reflux disease (GERD) is a common medical condition presenting with heartburn, regurgitation, cough, hoarseness, and/or wheezing. Patients with classic GERD symptoms often do not require diagnostic studies before empirical treatment is initiated. However, if atypical features are present, including alarm symptoms for malignancy, or if symptoms do not respond to conventional treatment, upper endoscopy may be necessary. The optimal management of GERD, which is the subject of debate, depends on the frequency and severity of symptoms.
How Would You Manage This Patient With Decreased Bone Density? Grand Rounds Discussion From Beth Israel Deaconess Medical Center
Osteoporosis is a skeletal condition characterized by low bone mass and fragility resulting in an increased risk for fracture. It affects all bones, but fractures most often occur in the hip and spine. Osteoporosis is common in postmenopausal women, with estrogen deficiency thought to be a major contributing factor. Screening for osteoporosis with bone densitometry is recommended in all women 65 years of age or older and in postmenopausal women younger than 65 who are at increased risk.
How Would You Manage This Patient With Clostridioides difficile Infection? Grand Rounds Discussion From Beth Israel Deaconess Medical Center
The Infectious Diseases Society of America/Society for Healthcare Epidemiology of America and the American College of Gastroenterology recently released updated guidelines on management of patients with Clostridioides difficile infection. Although these 2 guidelines generally agree, there are a few important differences in their advice to clinicians.
How Would You Manage This Patient With Benign Prostatic Hyperplasia? Grand Rounds Discussion From Beth Israel Deaconess Medical Center
Lower urinary tract symptoms due to benign prostatic hyperplasia (BPH) are common in older patients assigned male sex at birth, regardless of gender identity, and treatment of these symptoms is therefore common in primary care practice. In 2021, the American Urological Association published guidelines for management of BPH.
How Would You Manage This Diabetic Patient With a Foot Infection? Grand Rounds Discussion From Beth Israel Deaconess Medical Center
Foot infections are the most common cause of hospitalization in patients with diabetes. They may be superficial, involving only the skin, or deep, involving the soft tissues or bone. Superficial infections are generally caused by aerobic gram-positive cocci, whereas deep infections, including osteomyelitis, tend to be polymicrobial in origin. Clinical manifestations of skin and soft tissue infections include local evidence of inflammation, but peripheral neuropathy and peripheral artery disease may mask these findings.
How Would You Manage HIV Pre-exposure Prophylaxis in This Patient With Medical Comorbidities?: Grand Rounds Discussion From Beth Israel Deaconess Medical Center
Despite advances in treatment, HIV infection remains an important cause of morbidity and mortality, with more than 30 000 new cases diagnosed in the United States each year. There are several interventions traditionally used to prevent HIV transmission, but these vary in effectiveness and there are challenges to their implementation.
How to Build Your Support Network
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How to Apply Compassion
Learn the benefits of applied compassion practice to clinicians and systems, how to adapt and teach it, and real-world ways to clinically apply compassion.
Displaying 991 - 1000 of 6745 in Annals of Internal Medicine
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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.
Race, Genotype, and Azathioprine Discontinuation: A Cohort Study: Annals of Internal Medicine: Vol 175, No 8
Background: Thiopurines are an important class of immunosuppressants despite their risk for hematopoietic toxicity and narrow therapeutic indices. Benign neutropenia related to an ACKR1 variant (rs2814778-CC) is common among persons of African ancestries. Objective: To test whether rs2814778-CC was associated with azathioprine discontinuation attributed to hematopoietic toxicity and lower thiopurine dosing. Design: Retrospective cohort study. Setting: Two tertiary care centers. Patients: Thiopurine users with White or Black race. Measurements: Azathioprine discontinuation attributed to hematopoietic toxicity. Secondary outcomes included weight-adjusted final dose, leukocyte count, and change in leukocyte count. Results: The rate of azathioprine discontinuation attributed to hematopoietic toxicity was 3.92 per 100 person-years among patients with the CC genotype (n = 101) and 1.34 per 100 person-years among those with the TT or TC genotype (n = 1365) (hazard ratio [HR] from competing-risk model, 2.92 [95% CI, 1.57 to 5.41]). The risk remained significant after adjustment for race (HR, 2.61 [CI, 1.01 to 6.71]). The risk associated with race alone (HR, 2.13 [CI, 1.21 to 3.75]) was abrogated by adjustment for genotype (HR, 1.13 [CI, 0.48 to 2.69]). Lower last leukocyte count and lower dosing were significant among patients with the CC genotype. Lower dosing was validated in an external cohort of 94 children of African ancestries prescribed the thiopurine 6-mercaptopurine (6-MP) for acute lymphoblastic leukemia. The CC genotype was independently associated with lower 6-MP dose intensity relative to the target daily dose of 75 mg/m2 (median, 0.83 [IQR, 0.70 to 0.94] for the CC genotype vs. 0.94 [IQR, 0.72 to 1.13] for the TT or TC genotype; P = 0.013). Limitations: Unmeasured confounding; data limited to tertiary centers. Conclusion: Patients with the CC genotype had higher risk for azathioprine discontinuation attributed to hematopoietic toxicity and lower thiopurine doses. Genotype was associated with those risks, even after adjustment for race. Primary Funding Source: National Institutes of Health.