Blast Injury and Cardiopulmonary Symptoms in U.S. Veterans: Analysis of a National Registry Ann. Intern. Med. (IF 17.135) Pub Date : 2017-09-19 Nisha Jani, Michael J. Falvo, Anays Sotolongo, Omowunmi Y. Osinubi, Chin-lin Tseng, Mazhgan Rowneki, Michael Montopoli, Sybil W. Morley, Vincent Mitchell, Drew A. Helmer
Background: Recent epidemiologic studies have reported an increased risk for respiratory conditions in service members deployed to Iraq or Afghanistan (1) since 2001 and an increasing prevalence of chronic lung disease in this population (2). Reports of dyspnea and exercise intolerance have mostly been attributed to exposure to airborne hazards, such as burn-pit smoke and particulate matter. Exposure to blast waves during military deployment has been recognized as the hallmark injury of the wars in Iraq and Afghanistan, and considerable efforts have been made to understand the associated neurologic sequelae. However, less attention has been paid to the lungs, which may be particularly susceptible to blast waves given tissue-density gradients. The exact relationship between blast lung injury and long-term sequelae is unknown; however, animal models show long-term, persistent elevations in oxidative stress and vascular abnormalities after blast exposure (3), which may contribute to respiratory symptoms. Associations between blast exposure and chronic lung diseases in this cohort have recently been suggested (2).
Death and Cardiac Arrest in U.S. Triathletes Ann. Intern. Med. (IF 17.135) Pub Date : 2017-09-19
What is the problem and what is known about it so far? Triathlon is a competitive sporting event that began in the 1970s. It combines swimming, bicycling, and running and has become popular among adult recreational athletes. Some people have questioned the safety of triathlons, especially as they grow in popularity and attract increasing numbers of recreational athletes who may have underlying, undiagnosed medical conditions or may not train adequately for the swimming part of the event. Why did the researchers do this particular study? To describe death and cardiac arrest among triathlon participants. Who was studied? Participants in U.S. triathlons from 1985 to 2016. How was the study done? The researchers gathered information on deaths and cardiac arrests in U.S. triathlon participants from 1985 to 2016 from various sources, including the U.S. National Registry of Sudden Death in Athletes and USA Triathlon (USAT) records. From these sources, they collected data on the characteristics of participants who died or had a cardiac arrest, the timing of the death or cardiac arrest during the race, and such factors as the air and water temperature during the race. To help estimate the proportion of participants who died or had a cardiac arrest, the researchers collected information about the number of participants who completed triathlons from USAT records of participants who completed races from 2006 to 2016. This information was not available for earlier years. What did the researchers find? A total of 107 sudden deaths, 13 cardiac arrests that responded to resuscitation, and 15 trauma-related deaths occurred in triathlon participants from 1985 to 2016. Of the participants who died, 85% were men and their average age was 47 years. Most sudden deaths and cardiac arrests occurred during the swimming event (90), but also happened during bicycling (7) and running (15). All trauma-related deaths occurred during bicycling. Using the data from 2006 to 2016, the researchers estimated that death or cardiac arrest occurs in about 1.74 of 100000 triathlon participants (2.4 per 100000 men and 0.74 per 100000 women). The risk was 18.6 per 100000 in men older than 60 years. The risk for death or cardiac arrest was similar in long, intermediate, and short triathlons. Autopsy information was available for 61 of the triathletes who died, 27 of whom had evidence of heart system abnormalities. What were the limitations of the study? Identification of deaths and cardiac arrests may be incomplete in the registry data used for this study, so the researchers may have underestimated the number of events. Also, medical history and autopsy information were not available for most of the included deaths. What are the implications of the study? Sudden death, cardiac arrest, and trauma-related death occur during triathlons but are infrequent. Most of the deaths occurred in middle-aged and older men during the swimming part of the race.
Annals Story Slam - Warren and Wilfred Ann. Intern. Med. (IF 17.135) Pub Date : 2017-09-19 Robert Sargeant
Building on the popular Annals feature “On Being a Doctor,” storytellers share stories about the experience of doctoring on video. For more videos from and information on Annals Story Slam, visit www.annals.org/StorySlam.
Annals Story Slam - The Medicine Man Ann. Intern. Med. (IF 17.135) Pub Date : 2017-09-19 Michael Schull
Building on the popular Annals feature “On Being a Doctor,” storytellers share stories about the experience of doctoring on video. For more videos from and information on Annals Story Slam, visit www.annals.org/StorySlam.
Annals Story Slam - Out of the Mouths of Babes Ann. Intern. Med. (IF 17.135) Pub Date : 2017-09-19 Shelly Dev
Building on the popular Annals feature “On Being a Doctor,” storytellers share stories about the experience of doctoring on video. For more videos from and information on Annals Story Slam, visit www.annals.org/StorySlam.
Annals Story Slam - On Raking Sand Ann. Intern. Med. (IF 17.135) Pub Date : 2017-09-19 Arno Kumagai
Annals Story Slam - Making It Up on the Spot Ann. Intern. Med. (IF 17.135) Pub Date : 2017-09-19 Ariel Lefkowitz
Annals Story Slam - Luther Ann. Intern. Med. (IF 17.135) Pub Date : 2017-09-19 Samir C. Grover
Annals Story Slam - Loss Ann. Intern. Med. (IF 17.135) Pub Date : 2017-09-19 Seema Marwaha
Annals Story Slam - Life and Times Ann. Intern. Med. (IF 17.135) Pub Date : 2017-09-19 Mena Gewarges
Annals Story Slam - Karl's Story Ann. Intern. Med. (IF 17.135) Pub Date : 2017-09-19 Natalie Wong
Annals Story Slam - I Remember Ann. Intern. Med. (IF 17.135) Pub Date : 2017-09-19 Bikrampal Sidhu
Annals Story Slam - Good and Bad Times Ann. Intern. Med. (IF 17.135) Pub Date : 2017-09-19 Thomas Bodley
Annals Story Slam - Going Gentle Ann. Intern. Med. (IF 17.135) Pub Date : 2017-09-19 Kevin Venus
Annals Story Slam - Becoming Batman Ann. Intern. Med. (IF 17.135) Pub Date : 2017-09-19 Nilay Shah
Annals Story Slam - A Story of Stories Ann. Intern. Med. (IF 17.135) Pub Date : 2017-09-19 Lisa Richardson
Annals Story Slam - A Good Death Ann. Intern. Med. (IF 17.135) Pub Date : 2017-09-19 Nadine Abdullah
Annals for Hospitalists Inpatient Notes - Gender Equality in Hospital Medicine—Are We There Yet? Ann. Intern. Med. (IF 17.135) Pub Date : 2017-09-19 Jeanne M. Farnan, Vineet M. Arora
Years ago, when hospital medicine emerged as a subspecialty, it seemed to offer several attractive qualities for women, including scheduling flexibility and a competitive salary. Moreover, it offered diversity, for those with interests in medical education, quality improvement, and patient safety. As a brand-new specialty, it held the promise of moving away from gender norms already firmly ensconced in existing subspecialties. But, has this young field fulfilled its promise of equal opportunity and advancement for women? Despite rising salaries in hospital medicine, women receive a lower mean annual compensation than men in similar positions (1). Female hospitalists work more night shifts, are more likely to work in an academic setting, and earn nearly $15 000 per year less than their male peers (1). Even after such factors as hours worked are controlled for, these discrepancies persist. A recent article (which considered age, experience, rank, and productivity) found that female physicians at 24 public U.S. medical schools, across specialties, received significantly lower salaries than their male counterparts (2). Salary equity clearly has not been achieved in the medical field; however, drivers of this disparity are not fully understood. There are a host of hypothetical explanations, including implicit and explicit bias, poor negotiation skills (disproportionately affecting women), lack of transparency around compensation, and unawareness that the disparity exists. However, none adequately justify or explicate the difference, even though one remains (2).
Annals for Hospitalists - 19 September 2017 Ann. Intern. Med. (IF 17.135) Pub Date : 2017-09-19 David H. Wesorick, Vineet Chopra
Inpatient Notes Gender Equality in Hospital Medicine—Are We There Yet? —Jeanne M. Farnan, MD, MHPE, and Vineet M. Arora, MD, MAPP In this issue's Inpatient Notes, the authors reflect on the current state of gender equality in hospital medicine and discuss their hope for the future. Highlights of Recent Articles From Annals of Internal Medicine In the Clinic: Influenza Ann Intern Med. 2017;167:ITC33-ITC48. doi:AITC201709050 This narrative review provides an update on influenza infection in the United States. Key points for hospitalists include: Patients who are hospitalized with suspected or confirmed influenza should be placed in isolation with droplet precautions, and providers should wear N95 masks (or an equivalent) when aerosol-generating procedures are performed. Patients who are hospitalized with suspected influenza should be tested with a molecular influenza assay, such as the reverse transcriptase polymerase chain reaction (RT-PCR) assay. Molecular assays are more sensitive than antigen detection assays. Despite the lack of evidence in hospitalized patients, the Centers for Disease Control and Prevention recommends the use of neuraminidase inhibitors (e.g., oseltamivir and peramivir) in all hospitalized patients suspected of influenza infection. Although these medications are most effective when started early, late initiation (after 48 hours) may still provide some benefit. Bacterial co-infection (e.g., pneumonia with Pneumococcus, Staphylococcus aureus, or group A Streptococcus) should be considered in patients who present with severe disease, do not improve, worsen, or have acute onset of high fever and malaise after a period of initial improvement. Diagnostic Accuracy of Novel and Traditional Rapid Tests for Influenza Infection Compared With Reverse Transcriptase Polymerase Chain Reaction: A Systematic Review and Meta-analysis Ann Intern Med. 2017;167:394-409. Published 5 September 2017. doi:10.7326/M17-0848 This systematic review and meta-analysis examined 162 studies that compared several rapid influenza tests with the more time-intensive reference standard (RT-PCR). Although all of the tests demonstrated excellent specificity (>98%), there were significant differences in sensitivity among them. Sensitivities for influenza A detection were as follows: traditional rapid influenza diagnostic tests, 54.4%; digital immunoassays, 80%; and rapid nucleic acid amplification tests, 92.6%. The numbers were similar for influenza B. Key points for hospitalists include: Nucleic acid amplification tests are the most sensitive of the rapid tests for influenza, followed by digital immunoassays. Rapid influenza diagnostic tests will likely be phased out soon, given their poor sensitivities. Prescription Opioid Use, Misuse, and Use Disorders in U.S. Adults: 2015 National Survey on Drug Use and Health Ann Intern Med. 2017;167:293-301. Published 1 August 2017. doi:10.7326/M17-0865 This article reports the results of a national survey on opioid use based on 51 200 completed surveys. In 2015, an estimated 91.8 million (37.8%) U.S. civilian, noninstitutionalized adults used prescription opioids, 11.5 million (4.7%) misused them, and 1.9 million (0.8%) met criteria for opioid use disorder. These problems are more common among the uninsured, the unemployed, and those with behavioral health problems. Key points for hospitalists include: 63.4% of patients who misused opioids reported that their motivation was to relieve physical pain, prompting the authors to call for the development of better nonopioid strategies for the management of chronic pain. Among patients who misuse prescription opioids, 40.8% obtained medications from friends or relatives, suggesting the need for more restrictive prescribing practices. Excessive prescribing may lead to sharing or diversion of these medications. An editorial discusses how unemployment and a lack of health insurance might exacerbate opioid misuse by limiting access to evidence-based chronic pain management. The Latest Highlights From ACP Journal Club Is short-term use of corticosteroids associated with an increased risk for adverse events? Short-term use of oral corticosteroids was linked to increased risk for sepsis, VTE, and fractures Ann Intern Med. 2017;167:JC20. doi:10.7326/ACPJC-2017-167-4-020 This retrospective cohort study examined rates of sepsis, venous thromboembolism, and bone fracture among 372 452 patients after treatment with short-term courses of systemic steroids. The study compared the rates of these adverse events in the period after steroid treatment to the rates during a 180-day period before steroid treatment in the same patients. The rates of all of 3 complications were significantly elevated during the posttreatment period, including a 5-fold higher rate of sepsis. When used for stroke prophylaxis in atrial fibrillation, do all of the direct oral anticoagulants (DOACs) confer similar gastrointestinal (GI) bleeding risks? In nonvalvular AF, DOAC-related risk for GI bleeding was lower with apixaban than dabigatran or rivaroxaban Ann Intern Med. 2017;167:JC21. doi:10.7326/ACPJC-2017-167-4-021 In this retrospective cohort study, the authors used pharmacy administrative claims data to identify 43 303 patients treated with dabigatran, rivaroxaban, or apixiban for stroke prophylaxis. Following matching by propensity scores, the authors reported that apixaban was associated with lower rates of GI bleeding than the other 2 DOACs. However, because this was not a head-to-head study of these medications, definitive conclusions about their relative safety remain limited. Sign up here to have Annals for Hospitalists delivered to your inbox each month.
Annals for Educators - 19 September 2017 Ann. Intern. Med. (IF 17.135) Pub Date : 2017-09-19 Darren B. Taichman
Clinical Practice Points Continuous Glucose Monitoring Versus Usual Care in Patients With Type 2 Diabetes Receiving Multiple Daily Insulin Injections. A Randomized Trial Continuous glucose monitoring (CGM), which has been shown to be beneficial for adults with type 1 diabetes, has not been well-evaluated in those with type 2 diabetes receiving insulin. This randomized trial compares hemoglobin A1c reduction at 24 weeks using CGM versus usual care in adults with type 2 diabetes receiving multiple daily injections of insulin. Use this study to: Ask whether your learners have cared for patients who used CGM to manage their type 1 diabetes. What have been the challenges? Use the accompanying editorial to help frame your discussion. Invite a diabetes specialist to discuss the use of CGM with your team. In whom should it be considered? Are there contraindications? Is the difference between the changes in hemoglobin A1c values achieved in the trial's 2 groups clinically important? What is the difference between clinically important and statistically important? The authors discuss how many patients achieved a goal of a hemoglobin A1c level less than 7%. Why? What do your learners think is the best way to judge the performance of a diabetes intervention? Should CGM be considered for the management of patients with type 2 diabetes? Teach at the bedside! Is there an outpatient or inpatient who has used CGM with whom your team might discuss the experience? Did CGM improve the patient's glycemic control? At what cost (or benefit) to the patient's quality of life? Safety and Tolerability of Maraviroc-Containing Regimens to Prevent HIV Infection in Women. A Phase 2 Randomized Trial Maraviroc is a candidate drug for HIV preexposure prophylaxis (PrEP), and it has especially favorable properties in women. In this prospective, randomized, multicenter study, the authors compared the safety and tolerability of 4 antiretroviral regimens in U.S. women at risk for HIV infection. Use this study to: Start a teaching session with a multiple-choice question. We've provided one below! Ask your learners whether they have discussed PrEP with their patients and whether they have prescribed it. For whom is PrEP recommended? What other practices should we discuss with our patients to prevent HIV infection? What are the goals of phase 1, 2, 3, and 4 clinical trials? Why is this study a phase 2 trial and not a phase 3 trial? What properties would your learners want to consider when choosing an agent for PrEP in women? See what the authors say in the paper's introduction. On the basis of this trial, what may we conclude about the safety and efficacy of maraviroc? What is needed before this approach to PrEP would be recommended? What end points would your learners suggest be evaluated in future studies? Some have expressed concern that the availability of PrEP might provide some patients with a false sense of security and thus encourage high-risk behaviors. How would your learners propose studying this concern? How would they counsel patients? Screening for Occult Cancer in Patients With Unprovoked Venous Thromboembolism. A Systematic Review and Meta-analysis of Individual Patient Data Using data from 10 prospective studies, this meta-analysis of individual patient data examines the prevalence of occult cancer in patients with unprovoked venous thromboembolism (VTE) and whether prevalence differs in various subgroups. Use this study to: Ask your learners what “Trousseau syndrome” is. What is required to designate a VTE event as “unprovoked”? What needs to be excluded? How is this done? What is the risk for a subsequent cancer diagnosis among patients with unprovoked VTE? Is there a benefit to extensive testing for cancer? What did this systematic review find? Why do your learners think that despite the frequency of cancer among patients with unprovoked VTE, a clear benefit has been established only for age-appropriate screening tests? What is the difference between a screening test and one performed to evaluate a symptom? What should the approach to cancer screening be among patients with unprovoked VTE? Use the accompanying editorial to help frame your discussion. Video Learning Annals Consult Guys - Abdominal Aortic Aneurysm: When to Screen? When to Follow? Howard and Geno (the Consult Guys) tackle the thorny issue of how to screen for an abdominal aortic aneurysm and how to follow it if it is present. Use this feature to: Take a break and watch the video. Use the provided multiple-choice questions before viewing the video to check your learners' knowledge or after viewing it to see whether they were paying attention. And, log on to enter your responses to earn CME and MOC credit for yourself! Our Health Care System The Relationship of Health Insurance and Mortality: Is Lack of Insurance Deadly? An Institute of Medicine (IOM) review in 2002 concluded that lack of insurance increases mortality, but several relevant studies have since appeared. This article summarizes current evidence concerning the relationship between insurance and mortality. Use this paper to: Ask your learners whether they have seen a lack of insurance affect a patient's outcome. Why do your learners think it is difficult to study the relationship between insurance status and mortality? Use Table 2, and see what the authors say in the paper's discussion. In what ways might insurance reduce mortality? Are there ways in which it might increase mortality? The authors provide 2 examples in the discussion. What other benefits to individuals and society might result from health insurance? Do your learners think physicians should be vocal in the national debate over health insurance? Humanism and Professionalism On Being a Doctor: A Great Gift Dr. Molitor describes how he saved a patient, and how she saved him. Use this essay to: Listen to an audio recording of the essay, read by Dr. Michael LaCombe. Ask your learners whether they have felt the way Dr. Molitor described feeling before he entered his patient's room. Have they ever doubted whether what they do matters? Ask your learners to list the things they do for their patients. If they need help or are too modest, read the list provided in the penultimate paragraph of a recent letter to new interns. Now how do they feel? Are there ways to remind ourselves of the ways in which we make a difference to help carry us through the tough times? MKSAP 17 Question A 39-year-old man undergoes consultation about HIV prevention. He has a male sex partner with HIV infection. He reports they use condoms “most of the time.” He asks about other options that can reduce his risk for acquiring HIV from his partner. He is asymptomatic. Medical history is noncontributory, although he has been vaccinated for hepatitis B. He takes no medications. On physical examination, vital signs are normal, as is the remainder of the examination. Results of testing for HIV are negative. Testing for hepatitis B surface antigen yields negative findings, and hepatitis B surface antibody results are positive. Which of the following is the most appropriate management? A. Counsel that consistent condom use provides adequate protection B. Prescribe daily combination tenofovir-emtricitabine C. Prescribe daily combination tenofovir-emtricitabine and raltegravir D. Prescribe daily tenofovir Correct Answer B. Prescribe daily combination tenofovir-emtricitabine Educational Objective Provide preexposure prophylaxis for HIV to a person at ongoing risk. Critique This patient is at risk for HIV infection because of regular sexual activity with an infected person and should be considered for preexposure prophylaxis (PrEP). Daily combination tenofovir-emtricitabine therapy is FDA approved for prevention of HIV infection in persons considered at ongoing risk for infection. Studies have shown efficacy in men who have sex with men, heterosexual couples, and injection drug users. Rates of effectiveness in prevention depend on adherence to the medication, and prophylaxis should always be accompanied by safer-sex counseling. Testing for HIV and other sexually transmitted diseases, pregnancy, and kidney function should be performed before initiation of prophylaxis and every 2 to 3 months during preventive therapy. Reduction in viral load with antiretroviral therapy does reduce transmission of HIV, although transmission may still occur even with undetectable blood levels. Although consistent condom use can reduce the risk for HIV transmission, the addition of PrEP can further reduce rates of acquisition of HIV and should be considered in those at high risk. Such preventive therapy should be taken daily, however, and not episodically only with exposure. Studies on which FDA approval was based used a two-drug combination of tenofovir-emtricitabine alone without additional medication. Therefore, no clear indication exists for exposing the patient to the additional cost and risk of a third drug. The three-drug regimen of combination tenofovir-emtricitabine and raltegravir is the preferred regimen for postexposure prophylaxis. Whereas tenofovir alone has shown some benefit in reducing acquisition of HIV because of concerns about resistance, combination tenofovir-emtricitabine is preferred for PrEP. Key Point Combination tenofovir-emtricitabine should be considered as preexposure prophylaxis to prevent HIV infection in all persons considered at ongoing risk of infection. Bibliography Centers for Disease Control and Prevention (CDC). Interim guidance: preexposure prophylaxis for the prevention of HIV infection in men who have sex with men. MMWR Morb Mortal Wkly Rep. 2011 Jan 28;60(3):65-8. Do you like reading Annals for Educators? Receive it direct to your inbox. Sign up for the Annals for Educators alert today.
Annals Consult Guys - Abdominal Aortic Aneurysm: When to Screen? When to Follow? Ann. Intern. Med. (IF 17.135) Pub Date : 2017-09-19 Geno J. Merli, Howard H. Weitz
Annals Consult Guys brings a new perspective to the art and science of medicine with lively discussion and analysis of real-world cases and situations. They address medically relevant topics—whether they be poignant, thought-provoking, or just plain entertaining. For more videos from and information on Annals Consult Guys, visit go.annals.org/ConsultGuys.
Declaration of Faith Ann. Intern. Med. (IF 17.135) Pub Date : 2017-09-19 Lawrence J. Hergott
Prison Break Ann. Intern. Med. (IF 17.135) Pub Date : 2017-09-19 Jack Coulehan
Correction: Treatment of Low Bone Density or Osteoporosis to Prevent Fractures in Men and Women Ann. Intern. Med. (IF 17.135) Pub Date : 2017-09-19
There were mistakes in a recent guideline (1). The last sentence in the Monitoring of Patients With Osteoporosis section should read, “Overall data from several studies showed that women treated with bisphosphonates, raloxifene, and teriparatide benefited from reduced fractures with treatment even if BMD did not increase.” The third sentence in the Duration of Pharmacologic Therapy section should read, “Post hoc analysis of this study showed that women with femoral neck T scores of −2.5 or worse without baseline prevalent vertebral fracture had reduced fracture risk by continuing alendronate therapy for 10 years versus stopping after 5 years compared with placebo (11.1% to 5.3%).” The last sentence of Recommendation 2 should read, “Post hoc analysis from an RCT suggested that patients treated with alendronate without preexisting fractures and a BMD of −2.5 or less after 5 years of initial therapy may benefit from continued treatment, because these patients experienced a decreased incidence of new clinical vertebral fractures.” This has been corrected in the online version. References Qaseem A Forciea MA McLean RM Denberg TD Clinical Guidelines Committee of the American College of Physicians Treatment of low bone density or osteoporosis to prevent fractures in men and women: a clinical practice guideline update from the American College of Physicians Ann Intern Med 2017 166 818 39 CrossRef PubMed
Correction: Pharmacologic Treatment of Hypertension in Adults Aged 60 Years or Older Ann. Intern. Med. (IF 17.135) Pub Date : 2017-09-19
In a recent letter to the editor (1), an author's affiliation was incorrect. Dr. Cutler is an independent consultant in Washington, DC. This has been corrected in the online version. References Cushman WC Johnson KC Applegate WB Cutler JA Pharmacologic treatment of hypertension in adults aged 60 years or older [Letter] Ann Intern Med 2017 167 290 1 CrossRef PubMed
A Great Gift Ann. Intern. Med. (IF 17.135) Pub Date : 2017-09-19 Jerry A. Molitor
I was halfway through my second year of internal medicine residency. It was winter, and the nights were long and dark. The days somehow felt even longer, darker. Neither was a match for my mood, the darkest of all. I was barely 18 months into my postgraduate training, but I increasingly felt as though nothing I did really mattered. Patients came, left, and returned, often sicker than ever. Medical advances seemed to make very little real difference in the lives of my patients. One of these dark evenings promised early on to be a hard one. These were the early days of capping the number of intern admissions, and both of my interns had just reached their limit. As their senior resident, I would continue to take the rest of the admissions. In rapid succession came three telephone calls from the ER.
The Slippery Slope of Legalization of Physician-Assisted Suicide Ann. Intern. Med. (IF 17.135) Pub Date : 2017-09-19 William G. Kussmaul
The American College of Physicians (ACP) position paper on the legalization of physician-assisted suicide reaffirms the ACP's opposition to this practice, even though it is now legal in several countries and U.S. jurisdictions (1). The ACP's position deserves credit for its clarity and courage. Among other achievements, the ACP paper identifies “euthanasia” and “medical assistance in dying” as euphemisms. These terms do what euphemisms are supposed to do: make a distasteful subject palatable, or at least discussable. The social process of change in ethical and moral standards makes bold use of such euphemisms. At one time, “mercy killing” and physician-assisted suicide were both illegal and unthinkable. However, times are changing, and the changes have followed a recognizable pattern (2). First, the unthinkable becomes discussable although highly controversial. After a while, it is seen as acceptable under certain circumstances. As it becomes more familiar, it seems increasingly sensible and reasonable. Finally, it is established as a legal right. In this way, what was once unthinkable can eventually become policy, or even a duty (3).
Sudden Death During Triathlons: The Heart of the Swim Ann. Intern. Med. (IF 17.135) Pub Date : 2017-09-19 Reginald T. Ho, Karen Glanz
The first recorded episode of sudden death in an athlete occurred in 490 BCE after the Battle of Marathon, when the Greek soldier Pheidippides ran 26 miles to Athens to proclaim Greece's victory over the powerful Persian army, collapsed, and died. Little attention, however, was paid to athletes dying suddenly until 1976, when 2 collegiate basketball players from the University of Maryland died unexpectedly within 2 months of each other (1). Since then, the emotional and highly publicized deaths of several other athletes, most notably Hank Gathers and Reggie Lewis, have captured the nation's attention and kept this issue in the public spotlight.
Physician-Assisted Suicide: Finding a Path Forward in a Changing Legal Environment Ann. Intern. Med. (IF 17.135) Pub Date : 2017-09-19 Timothy E. Quill, Robert M. Arnold, Stuart J. Youngner
Imagine yourself with a disease that has recently become terminal. What kinds of treatments and options would be most important to you? Almost everyone would want to be sure their physicians had considered, if not tried, all potentially effective disease-directed therapy and best possible palliative treatments to maximize their quantity and quality of life. Many patients would want to consider a timely transition to hospice care if no acceptable disease-directed therapies existed, hoping to live as fully as possible for their remaining time, and then to die peacefully. On these points we are completely in sync with the American College of Physicians (ACP) position paper (1).
Firearm Surrender Laws: Prompting Promise for Women's Health Ann. Intern. Med. (IF 17.135) Pub Date : 2017-09-19 Joslyn Fisher, Amy Bonomi
Homicide is a leading cause of death in women of childbearing age (1). Further, more than half of female homicides with a known perpetrator are committed by a current or former intimate partner (2). Firearm access in the home exacerbates the risk for homicide by an intimate partner (3). Although federal legislation, such as the Violence Against Women Act, restricts domestic abusers' access to firearms, state and local implementation of these regulations is highly variable. In this issue, Díez and colleagues report a timely study that informs a simmering national debate about firearm-related policy (4). The researchers used data from the Federal Bureau of Investigation's Uniform Crime Reports to investigate the effect of “relinquishment” laws on intimate partner homicide rates across all 50 states from 1991 to 2015. Relinquishment laws are those that prohibit firearm possession by domestic abusers who are subject to a restraining order and require abusers to surrender their firearms.
Oregon's Death With Dignity Act: 20 Years of Experience to Inform the Debate Ann. Intern. Med. (IF 17.135) Pub Date : 2017-09-19 Katrina Hedberg, Craig New
Twenty years ago, Oregon voters approved the Death With Dignity Act, making Oregon the first state in the United States to allow physicians to prescribe medications to be self-administered by terminally ill patients to hasten their death. This report summarizes the experience in Oregon, including the numbers and types of participating patients and providers. These data should inform the ongoing policy debate as additional jurisdictions consider such legislation.
Your Money or Your Patient's Life? Ransomware and Electronic Health Records Ann. Intern. Med. (IF 17.135) Pub Date : 2017-09-19 I. Glenn Cohen, Sharona Hoffman, Eli Y. Adashi
The mugger's demand “Your money or your life” is a familiar one. However, in an era of vast hospital computer networks and electronic health records, a novel risk to worry about is, “Your money or your patient's life.” This threat, known as “ransomware,” is an increasingly common experience for computer users around the world. The relevance of this hazard to health care became widely apparent on 12 May 2017 after a global attack effected by ransomware named WannaCry (1). Among those most severely affected were hospitals, pharmacies, and clinics of the British National Health Service (2). On these shores, President Trump issued an executive order requiring all government agencies to provide a risk management report to the Department of Homeland Security and the Office of Management and Budget within 90 days (3).
Reimagining Halfway Technologies With Behavioral Science Ann. Intern. Med. (IF 17.135) Pub Date : 2017-09-19 David A. Asch, Kevin G. Volpp
In 1971 (1), Lewis Thomas outlined 3 levels of health care technology. The first he called “nontechnology”: care that attends to ill patients but does little to alter the course of disease. Second were “halfway technologies”: those that do not eliminate diseases but at least postpone their effects. In this large group he put everything from solid organ transplantation to cardiac care units—what today we might call chronic disease management. Third was technology so transformative we often take it for granted, such as childhood vaccines to prevent diphtheria and antimicrobials to treat syphilis. He urged further investment in the basic sciences that support this third level of technology, arguing that the first 2 contributed greatly to the $60 billion spent at the time on U.S. health care and the third was “the only way to get the full mileage that biology owes to the science of medicine, even though it seems … like asking for the moon.”
Ethics and the Legalization of Physician-Assisted Suicide: An American College of Physicians Position Paper Ann. Intern. Med. (IF 17.135) Pub Date : 2017-09-19 Lois Snyder Sulmasy, Paul S. Mueller
Calls to legalize physician-assisted suicide have increased and public interest in the subject has grown in recent years despite ethical prohibitions. Many people have concerns about how they will die and the emphasis by medicine and society on intervention and cure has sometimes come at the expense of good end-of-life care. Some have advocated strongly, on the basis of autonomy, that physician-assisted suicide should be a legal option at the end of life. As a proponent of patient-centered care, the American College of Physicians (ACP) is attentive to all voices, including those who speak of the desire to control when and how life will end. However, the ACP believes that the ethical arguments against legalizing physician-assisted suicide remain the most compelling. On the basis of substantive ethics, clinical practice, policy, and other concerns articulated in this position paper, the ACP does not support legalization of physician-assisted suicide. It is problematic given the nature of the patient–physician relationship, affects trust in the relationship and in the profession, and fundamentally alters the medical profession's role in society. Furthermore, the principles at stake in this debate also underlie medicine's responsibilities regarding other issues and the physician's duties to provide care based on clinical judgment, evidence, and ethics. Society's focus at the end of life should be on efforts to address suffering and the needs of patients and families, including improving access to effective hospice and palliative care. The ACP remains committed to improving care for patients throughout and at the end of life.
State Intimate Partner Violence–Related Firearm Laws and Intimate Partner Homicide Rates in the United States, 1991 to 2015 Ann. Intern. Med. (IF 17.135) Pub Date : 2017-09-19 Carolina Díez, Rachel P. Kurland, Emily F. Rothman, Megan Bair-Merritt, Eric Fleegler, Ziming Xuan, Sandro Galea, Craig S. Ross, Bindu Kalesan, Kristin A. Goss, Michael Siegel
Background: To prevent intimate partner homicide (IPH), some states have adopted laws restricting firearm possession by intimate partner violence (IPV) offenders. “Possession” laws prohibit the possession of firearms by these offenders. “Relinquishment” laws prohibit firearm possession and also explicitly require offenders to surrender their firearms. Few studies have assessed the effect of these policies. Objective: To study the association between state IPV-related firearm laws and IPH rates over a 25-year period (1991 to 2015). Design: Panel study. Setting: United States, 1991 to 2015. Participants: Homicides committed by intimate partners, as identified in the Federal Bureau of Investigation's Uniform Crime Reports, Supplementary Homicide Reports. Measurements: IPV-related firearm laws (predictor) and annual, state-specific, total, and firearm-related IPH rates (outcome). Results: State laws that prohibit persons subject to IPV-related restraining orders from possessing firearms and also require them to relinquish firearms in their possession were associated with 9.7% lower total IPH rates (95% CI, 3.4% to 15.5% reduction) and 14.0% lower firearm-related IPH rates (CI, 5.1% to 22.0% reduction) than in states without these laws. Laws that did not explicitly require relinquishment of firearms were associated with a non–statistically significant 6.6% reduction in IPH rates. Limitations: The model did not control for variation in implementation of the laws. Causal interpretation is limited by the observational and ecological nature of the analysis. Conclusion: Our findings suggest that state laws restricting firearm possession by persons deemed to be at risk for perpetrating intimate partner abuse may save lives. Laws requiring at-risk persons to surrender firearms already in their possession were associated with lower IPH rates. Primary Funding Source: Robert Wood Johnson Foundation.
Death and Cardiac Arrest in U.S. Triathlon Participants, 1985 to 2016: A Case Series Ann. Intern. Med. (IF 17.135) Pub Date : 2017-09-19 Kevin M. Harris, Lawrence L. Creswell, Tammy S. Haas, Taylor Thomas, Monica Tung, Erin Isaacson, Ross F. Garberich, Barry J. Maron
Background: Reports of race-related triathlon fatalities have raised questions regarding athlete safety. Objective: To describe death and cardiac arrest among triathlon participants. Design: Case series. Setting: United States. Participants: Participants in U.S. triathlon races from 1985 to 2016. Measurements: Data on deaths and cardiac arrests were assembled from such sources as the U.S. National Registry of Sudden Death in Athletes (which uses news media, Internet searches, LexisNexis archival databases, and news clipping services) and USA Triathlon (USAT) records. Incidence of death or cardiac arrest in USAT-sanctioned races from 2006 to 2016 was calculated. Results: A total of 135 sudden deaths, resuscitated cardiac arrests, and trauma-related deaths were compiled; mean age of victims was 46.7 ± 12.4 years, and 85% were male. Most sudden deaths and cardiac arrests occurred in the swim segment (n = 90); the others occurred during bicycling (n = 7), running (n = 15), and postrace recovery (n = 8). Fifteen trauma-related deaths occurred during the bike segment. Incidence of death or cardiac arrest among USAT participants (n = 4 776 443) was 1.74 per 100 000 (2.40 in men and 0.74 in women per 100 000; P < 0.001). In men, risk increased substantially with age and was much greater for those aged 60 years and older (18.6 per 100 000 participants). Death or cardiac arrest risk was similar for short, intermediate, and long races (1.61 vs. 1.41 vs. 1.92 per 100 000 participants). At autopsy, 27 of 61 decedents (44%) had clinically relevant cardiovascular abnormalities, most frequently atherosclerotic coronary disease or cardiomyopathy. Limitations: Case identification may be incomplete and may underestimate events, particularly in the early study period. In addition, prerace medical history is unknown in most cases. Conclusion: Deaths and cardiac arrests during the triathlon are not rare; most have occurred in middle-aged and older men. Most sudden deaths in triathletes happened during the swim segment, and clinically silent cardiovascular disease was present in an unexpected proportion of decedents. Primary Funding Source: Minneapolis Heart Institute Foundation.
Distribution of Prescription Opioid Use Among Privately Insured Adults Without Cancer: United States, 2001–2013 Ann. Intern. Med. (IF 17.135) Pub Date : 2017-09-12 Eric C. Sun, Anupam B. Jena
Background: Deaths from prescription opioids have sharply increased in the United States. In response, the Centers for Disease Control and Prevention recently issued recommendations for opioid prescribing for chronic pain (1). In light of this and other public health efforts, an integral piece of epidemiologic information about opioid misuse remains unknown: the distribution of use across the population. This fact has important policy implications. Concentration of opioid use among a few patients would argue for focused efforts aimed at reducing use among these persons. Conversely, even distribution would argue for broader, population-wide policies.
Duration of Sedentary Episodes Is Associated With Risk for Death Ann. Intern. Med. (IF 17.135) Pub Date : 2017-09-12
What is the problem and what is known about it so far? Spending more of our waking hours sedentary (for example, sitting and watching television) is associated with poorer markers of health and higher risk for death than spending more time engaged in physical activity (such as walking or playing sports). However, studies showing this increased risk for death have mostly relied on study participants' memories of how much time they spent sitting rather than on direct measures of that time. In addition, whether it matters if the total sedentary time is accumulated in shorter or longer bouts (that is, sitting for hours at a time without moving) is not known.Why did the researchers do this particular study? To assess the association of total sedentary time and longer and shorter bouts of sedentary time with mortality using an objective measurement tool.Who was studied? 7985 black and white adults aged 45 years or older.How was the study done? The study participants were asked to wear devices that measure physical activity (accelerometers) for 7 days. The researchers also collected information on the participants' health-related characteristics, such as whether they smoked and had certain diseases like high blood pressure. They then followed the participants for years to see whether the total amount and patterns of sedentary time differed between those who did and those who did not die.What did the researchers find? Participants who spent more of their waking hours sedentary had an increased risk for death during the years of follow-up. In addition, longer bouts of sedentary time were associated with a higher risk for death than were shorter bouts of sedentary time. Shorter bouts of sedentary time (less than 30 minutes) were associated with less of an increase in risk than were longer bouts.What were the limitations of the study? The 7-day activity measurements and other health-related variables were collected early in the study and may have changed over the years of follow-up. Also, this study cannot prove that changing one's sedentary time or its pattern will reduce the risk for death.What are the implications of the study? The results suggest that spending less of our waking time being sedentary would be beneficial, and although no duration of sedentary time is good for you, shorter bouts seem to be associated with less risk.
We Didn't Get Cold Feet Ann. Intern. Med. (IF 17.135) Pub Date : 2017-09-12 Sarah G. Candler
We didn't get cold feet—just very, very wet. That's what I e-mailed my wedding guests 5 days before our big day. My fiancé and I had been glued to our TV in Houston all weekend, watching Harvey make landfall and devastate our friends' and neighbors' lives. We cautiously opened our front door with both relief and guilt. After 24 hours of sitting on our couch, we were exhausted from waiting for waters that never came.Throughout the week, our street remained dry enough for me to get safely to the VA hospital where I work as a primary care doctor. Our clinic was scheduled to be closed over the weekend, but I spent two nights on the plastic recliners in our treatment room in case I was needed the next day and couldn't get back in. I helped to staff one of our inpatient teaching services when a colleague at home was flooded in. Our team saw walk-in patients who had braved the storm for cuts, medications, or a tetanus shot (yes, a man did that!). By Tuesday, more than half of our staff was in the office and ready for whatever business came our way. We had scheduled appointments that were canceled, so we waited.As a primary care doctor, I wait a lot. Most of the benefits of my work won't be visible for months, years, or even decades. It's not the medical heroism of prime-time TV. Primary care takes patience. There are a few emergencies, however. This week, I stopped waiting for patients and went looking for them instead. I spent 10 hours at my desk Wednesday making phone calls. I started with kidney failure, heart failure, and diabetes—the patients who could die without their treatments. Only a few answered, so I left messages: “This is your doctor. If you can safely get to us, your VA is open.”Saturday I manned a mobile medical unit serving veterans in the community. I provided reassurance and medication refills. While the rest of the community was scrambling and displaced, the primary care providers were back at work, checking blood pressure and asking about sugars. I realized that what had initially seemed anticlimactic was exactly what my patients needed: support and reassurance from someone who knows that healing takes time.The decision to postpone the wedding was an easy one. Family and friends reported that airlines had already cancelled flights in anticipation of a backlog from the previous week's airport closures. Our vendors were drying out their own homes or those of their friends and families. Most important, we were exhausted. I called my parents to explain what was happening on the ground. The news showed the physical destruction, but the heartache and emotional toll, more difficult to capture on film, was pervasive. Even if everyone could get here and the vendors were all open, now was not a time to celebrate. Now we work. Hard. We do what we can. And then we wait.
Tracking Our Physical Inactivity and Progression to Death: Is This Evolutionary Stagnation? Ann. Intern. Med. (IF 17.135) Pub Date : 2017-09-12 David A. Alter
Progression is rarely linear. Once highly mobile hunters and gatherers, we have evolved into a technologically advanced but kinetically stagnant species. Sedentary societies define today's cultural norms (1). The adverse health outcomes associated with sedentary behavior have led many to conclude that sedentary behavior is a novel risk factor whose population-attributable risk may even surpass that of smoking (2). Others have interpreted such associations more cautiously, given inconsistencies in evidence across studies, measurement biases, residual confounding, ambiguity in explanatory intercausal pathway mechanisms, and the absence of clinical trials that are adequately powered to detect differences in mortality from sedentary interventions (3).
Diagnostic Reasoning: An Endangered Competency in Internal Medicine Training Ann. Intern. Med. (IF 17.135) Pub Date : 2017-09-12 Arabella L. Simpkin, Jatin M. Vyas, Katrina A. Armstrong
Diagnosis is one of the most important tasks performed by internal medicine physicians, and diagnostic reasoning is perhaps the most critical of an internist's skills. The foundation of the diagnostic process is the patient's medical history and the physical examination, which lead to an initial differential diagnosis that is adjudicated through an ever-increasing array of diagnostic tests and data points as well as the patient's course over time. Historically, diagnostic reasoning and expertise have been highly valued in residency training, figuring prominently in curricula, conferences, and teaching rounds. However, despite growing recognition of the importance of diagnostic error with regard to patient safety and the need to “enhance healthcare professional education and training in the diagnostic process” (1), several signs indicate that the focus on diagnostic reasoning in internal medicine training may be threatened (2). Indeed, only 2 of the 22 Internal Medicine Milestones of the Accreditation Council for Graduate Medical Education and American Board of Internal Medicine—milestones 1 and 7—explicitly include diagnostic skills (3). Although this disconnect between the importance of diagnostic reasoning skills and the current approach to medical education has not gone unnoticed, responses largely have focused on adding clinical reasoning courses to medical school curricula and incorporating clinical reasoning into certification assessments (1, 4).
Treatment of Type 1 Diabetes: Synopsis of the 2017 American Diabetes Association Standards of Medical Care in Diabetes Ann. Intern. Med. (IF 17.135) Pub Date : 2017-09-12 James J. Chamberlain, Rita Rastogi Kalyani, Sandra Leal, Andrew S. Rhinehart, Jay H. Shubrook, Neil Skolnik, William H. Herman
Description:The American Diabetes Association (ADA) annually updates Standards of Medical Care in Diabetes to provide clinicians, patients, researchers, payers, and other interested parties with evidence-based recommendations for the diagnosis and management of patients with diabetes.Methods:For the 2017 Standards of Care, the ADA Professional Practice Committee did MEDLINE searches from 1 January 2016 to November 2016 to add, clarify, or revise recommendations on the basis of new evidence. The committee rated the recommendations as A, B, or C, depending on the quality of evidence, or E for expert consensus or clinical experience. The Standards of Care were reviewed and approved by the Executive Committee of the ADA Board of Directors, which includes health care professionals, scientists, and laypersons. Feedback from the larger clinical community informed revisions.Recommendation:This synopsis focuses on recommendations from the 2017 Standards of Care about monitoring and pharmacologic approaches to glycemic management for type 1 diabetes.
Patterns of Sedentary Behavior and Mortality in U.S. Middle-Aged and Older Adults: A National Cohort Study Ann. Intern. Med. (IF 17.135) Pub Date : 2017-09-12 Keith M. Diaz, Virginia J. Howard, Brent Hutto, Natalie Colabianchi, John E. Vena, Monika M. Safford, Steven N. Blair, Steven P. Hooker
Background:Excessive sedentary time is ubiquitous in Western societies. Previous studies have relied on self-reporting to evaluate the total volume of sedentary time as a prognostic risk factor for mortality and have not examined whether the manner in which sedentary time is accrued (in short or long bouts) carries prognostic relevance.Objective:To examine the association between objectively measured sedentary behavior (its total volume and accrual in prolonged, uninterrupted bouts) and all-cause mortality.Design:Prospective cohort study.Setting:Contiguous United States.Participants:7985 black and white adults aged 45 years or older.Measurements:Sedentary time was measured using a hip-mounted accelerometer. Prolonged, uninterrupted sedentariness was expressed as mean sedentary bout length. Hazard ratios (HRs) were calculated comparing quartiles 2 through 4 to quartile 1 for each exposure (quartile cut points: 689.7, 746.5, and 799.4 min/d for total sedentary time; 7.7, 9.6, and 12.4 min/bout for sedentary bout duration) in models that included moderate to vigorous physical activity.Results:Over a median follow-up of 4.0 years, 340 participants died. In multivariable-adjusted models, greater total sedentary time (HR, 1.22 [95% CI, 0.74 to 2.02]; HR, 1.61 [CI, 0.99 to 2.63]; and HR, 2.63 [CI, 1.60 to 4.30]; P for trend < 0.001) and longer sedentary bout duration (HR, 1.03 [CI, 0.67 to 1.60]; HR, 1.22 [CI, 0.80 to 1.85]; and HR, 1.96 [CI, 1.31 to 2.93]; P for trend < 0.001) were both associated with a higher risk for all-cause mortality. Evaluation of their joint association showed that participants classified as high for both sedentary characteristics (high sedentary time [≥12.5 h/d] and high bout duration [≥10 min/bout]) had the greatest risk for death.Limitation:Participants may not be representative of the general U.S. population.Conclusion:Both the total volume of sedentary time and its accrual in prolonged, uninterrupted bouts are associated with all-cause mortality, suggestive that physical activity guidelines should target reducing and interrupting sedentary time to reduce risk for death.Primary Funding Source:National Institutes of Health.
Survival After Fulminant Myocarditis Induced by Immune-Checkpoint Inhibitors Ann. Intern. Med. (IF 17.135) Pub Date : 2017-09-05 Dimitri Arangalage, Julie Delyon, Mathilde Lermuzeaux, Kenneth Ekpe, Stéphane Ederhy, Cécile Pages, Céleste Lebbé
Background: Some patients with metastatic melanoma live longer when they are treated with combinations of immune-checkpoint inhibitors (1, 2). However, up to 55% of these patients experience high-grade, immune-related adverse events (3–5). In phase 3 trials of these drugs, immune-related adverse events involving the heart affected only 0.19% of patients; fulminant myocarditis was the most serious of these (5). Objective: To report what we believe to be the first patient to survive fulminant myocarditis induced by immune-checkpoint inhibitors.
Different Effects of Screening on Prostate Cancer Death in Two Trials Ann. Intern. Med. (IF 17.135) Pub Date : 2017-09-05
What is the problem and what is known about it so far? Prostate cancer occurs frequently, and the screening test does a good job of identifying men with the disease. Some cancer cases respond well to treatment, but others do not need treatment because the cancer does not respond or because it grows very slowly. It is difficult to separate cancer that responds from other cancer, so it is difficult to know when to treat and when not to treat. In this situation, screening involves tradeoffs. If screening is not done, more men will fail to get treatment that might prevent premature death because their cancer will go undetected until after it has spread. If screening is done, more men will get treatment that cannot help them, and some of them will have lower quality of life due to the treatment. Why did the researchers do this particular study? Two clinical trials—one in Europe and the other in the United States—provide the best information about whether screening lowers the risk for death due to prostate cancer. The European study found that men who were invited to be screened had fewer prostate cancer deaths than men who were not invited, but the American study found similar numbers of prostate cancer deaths in the 2 groups. The researchers of the current study wanted to figure out whether the results of the 2 trials were as different as they seemed. Who was studied? Both trials studied men aged 55 years or older, and both randomly invited some men to be screened but not others. How was the study done? In the 2 original studies, some men who were invited to be screened did not get screened, and some men who were not invited were screened anyway. These studies used traditional methods to compare the risk for death due to prostate cancer in men invited to have screening with the risk for death in men who were not invited to have screening. In contrast, the current study used a different approach to examine how the actual amount of screening in each group—regardless of whether men were invited to have screening—affected the risk for death due to prostate cancer. What did the researchers find? The 2 trials had remarkably similar results when the amount of screening actually received in each group was accounted for. Screening lowered the risk for prostate cancer death by 25% to 32% in men who were invited to have screening in the 2 trials compared with those who were not screened. What were the limitations of the study? The researchers used a simplified summary measure of how much screening was actually received in each trial group. What are the implications of the study? The European and American trials agree that screening lowers the risk for death due to prostate cancer compared with no screening.
Annals Graphic Medicine - Dear Doctor I Ann. Intern. Med. (IF 17.135) Pub Date : 2017-09-05 K.C. Councilor
Influenza Ann. Intern. Med. (IF 17.135) Pub Date : 2017-09-05 Timothy M. Uyeki
Influenza is an acute viral respiratory disease that affects persons of all ages and is associated with millions of medical visits, hundreds of thousands of hospitalizations, and thousands of deaths during annual winter epidemics of variable severity in the United States. Elderly persons have the highest influenza-associated hospitalization and mortality rates. The primary method of prevention is annual vaccination. Early antiviral treatment has the greatest clinical benefit; otherwise, management includes adherence to recommended infection prevention and control measures as well as supportive care of complications.
Annals for Educators - 5 September 2017 Ann. Intern. Med. (IF 17.135) Pub Date : 2017-09-05 Darren B. Taichman
Clinical Practice Points The Effects of Cannabis Among Adults With Chronic Pain and an Overview of General Harms. A Systematic Review Benefits and Harms of Plant-Based Cannabis for Posttraumatic Stress Disorder. A Systematic Review These systematic reviews examine available evidence about the benefits and harms of plant-based cannabis preparations for treating chronic pain and posttraumatic stress disorder in adults. Use these reviews to: Start a teaching session with a multiple-choice question. We've provided one below! Ask your learners whether and for what purposes cannabis use is legal in your state. What are the laws? What did these systematic reviews find with regard to the benefits and risks of use? Why do your learners think the evidence base is so weak in this area? Do your learners ask their patients about cannabis use? Should they? Have their patients asked them about it? If so, under what circumstances? How should your learners advise their patients? Do your learners agree with the often-heard reasoning among patients seeking help for a chronic and perhaps poorly treated condition that using cannabis “couldn't hurt”? Why or why not? What more do we need to know? Use the accompanying editorial to help frame your discussion. Prescription Opioid Use, Misuse, and Use Disorders in U.S. Adults: 2015 National Survey on Drug Use and Health Despite the continuing epidemic of opioid misuse, data about the prevalence and correlates of misuse are scarce. This study used data from the National Survey on Drug Use and Health to estimate the prevalence of prescription opioid use, misuse, and use disorders among civilian, noninstitutionalized U.S. adults. Use this study to: Ask your learners to guess what percentage of U.S. adults used opioids in 2015. What percentage do they think misused them or had a use disorder? How would your learners define misuse and use disorder? Share the results of this national survey. Do the numbers surprise your learners? Do they think that a third of their patients have used opioids in the past year? Look at the reasons respondents gave for using opioids. Do your learners think about these reasons in their practice? Should they? Would asking patients about them be useful? Teach at the bedside! Ask each of your team's patients whether they have used opioids for any reason in the past year. Where did they get them? Did you learn anything that might be helpful in the care of your patients, either during their hospitalization or in long-term follow-up? The authors note that certain groups reported use more frequently. Do these groups surprise your learners? Where do the solutions lie? Use the accompanying editorial to help frame your discussion. In the Clinic In the Clinic: Influenza Influenza affects persons of all ages and is associated with millions of medical visits, hundreds of thousands of hospitalizations, and thousands of deaths during annual winter epidemics of variable severity in the United States. Are your learners prepared? Use this paper to: Ask who should receive influenza vaccination. What vaccines are available, and how effective are they? Which patients with acute febrile illness should and should not be vaccinated? What about patients with a reported egg allergy? Pregnant women? How should your learners reply to a patient who declines vaccination and says, “The last time I got the flu shot, I got the flu”? In whom should chemoprophylaxis with a neuraminidase inhibitor be considered? When should these agents be considered for treatment of influenza? How should these drugs be prescribed? What are the potential adverse effects? Use the information in Table 3. When and how should a diagnosis of influenza be confirmed? What complications of influenza should your learners be mindful of? Which patients should be hospitalized? Use the multiple-choice questions to introduce topics during a teaching session. Be sure to log on and enter your responses to earn CME and MOC credit for yourself! Download the teaching slides to help prepare a teaching session. Humanism and Professionalism Annals Graphic Medicine - Dear Doctor I The artist depicts a patient's surprise at and appreciation of a physician's blush during an initial medical encounter. Use this work to: Have your learners read the graphic narrative. What is their reaction? What about the physician's reaction made the patient feel at ease? What might we learn about situations in which we feel a bit uncomfortable and about how our reactions influence the experience of our patients? Is it always necessary for a physician to seem imperturbable? Our Profession: Maintenance of Certification Effect of Access to an Electronic Medical Resource on Performance Characteristics of a Certification Examination. A Randomized Controlled Trial Closed-book medical certification examinations have been criticized for not mimicking real-life practice, in which physicians frequently look up information to inform care. This randomized trial assessed whether allowing examinees to use an online medical information resource altered the test's ability to differentiate those who perform adequately from those who do not. Use this study to: Ask your learners if they know what they need to do in order to become and remain certified by the American Board of Internal Medicine. Do your learners think high-stakes examinations should allow the use of external sources, as was tested in this study? Why do your learners think maintenance of certification is controversial? What do they think should be required of physicians? Use the accompanying editorial to help frame your discussion. Teaching Scholarship Opportunity for Chief Residents Herbert S. Waxman Clinical Skills Center Teaching Scholarship Chief residents who are members of ACP are eligible to apply for a Herbert S. Waxman Clinical Skills Center Teaching Scholarship. Waxman Scholars assist in teaching popular workshops under the guidance and mentorship of expert faculty at ACP's annual Internal Medicine Meeting. Workshops provide hands-on, small-group learning opportunities for clinical and procedural skills (e.g., central line placement, paracentesis, thoracentesis, and lumbar puncture). The scholarship includes the cost of meeting registration, travel, and accommodations for the ACP Internal Medicine Meeting 2018, to be held April 19–21 in New Orleans, Louisiana. This is an opportunity to build your CV and gain valuable experience teaching a workshop. The submission deadline for applications is September 29, 2017. Visit this page to complete your application. MKSAP 17 Question A 35-year-old man is evaluated for a 2-year history of nausea and vomiting. He describes the nausea as nearly constant. Vomiting, occasionally accompanied by diarrhea, occurs for 2 to 4 days once or twice a month before resolving spontaneously. The patient reports no problems with eating in between episodes of vomiting and no abdominal pain. He also has chronic pain syndrome related to injuries from a motor vehicle accident 3 years ago. He uses medical marijuana to control the pain. Over the last 2 years, he has increased marijuana use to address his nausea and stimulate his appetite. The vomiting is severe enough to interrupt marijuana use; he notes that the vomiting subsides when he stops marijuana use or takes hot showers. In addition to marijuana 4 to 5 times daily, he takes ondansetron as needed. On physical examination, vital signs and other findings are normal. Upper endoscopy is normal. Duodenal biopsies are negative for celiac disease. A gastric emptying study reveals 5% retention of food at 4 hours. According to the Rome IV criteria, which of the following is the most likely diagnosis? A. Cannabinoid hyperemesis syndrome B. Cyclic vomiting syndrome C. Gastroparesis D. Narcotic bowel syndrome Correct Answer A. Cannabinoid hyperemesis syndrome Educational Objective Diagnose cannabinoid hyperemesis syndrome. Critique Cannabinoid hyperemesis syndrome is the most likely diagnosis in this patient. Cannabinoid hyperemesis syndrome is a new diagnosis in the Rome IV category of functional gastroduodenal disorders. It is defined by the presence of the following three clinical criteria: (1) episodic vomiting resembling cyclic vomiting syndrome in terms of onset, duration, and frequency; (2) presentation after prolonged, excessive cannabis use; (3) relief of vomiting episodes with sustained cessation of cannabis use. This young man's recurrent episodes of vomiting are typical of cyclic vomiting syndrome, with acute onset and short duration of vomiting. Although the characteristics of his vomiting fit a diagnosis of cyclic vomiting syndrome, his history reveals longstanding, excessive cannabis use and relief of vomiting with cessation of cannabis use. Therefore, the most likely diagnosis is cannabinoid hyperemesis syndrome. An effort should be made to discontinue marijuana use, but this recommendation is frequently met with resistance by patients. Tricyclic antidepressants are used in the treatment of cyclic vomiting syndrome, and similarly, a trial of a tricyclic antidepressant can be considered in patients with cannabinoid hyperemesis syndrome who are unwilling to discontinue marijuana use. This patient's gastric emptying study shows retention of 5% of gastric contents at 4 hours, which is normal. Retention of 10% or more is required to make a diagnosis of gastroparesis. Because the patient is not taking an opioid analgesic and does not report abdominal pain, the diagnosis of narcotic bowel syndrome can be excluded. Key Point Cannabinoid hyperemesis syndrome is defined by the presence of three clinical criteria: (1) episodic vomiting resembling cyclic vomiting syndrome in terms of onset, duration, and frequency; (2) presentation after prolonged, excessive cannabis use; (3) relief of vomiting episodes with sustained cessation of cannabis use. Bibliography Stanghellini V, Chan FK, Hasler WL, Malagelada JR, Suzuki H, Tack J, et al. Gastroduodenal Disorders. Gastroenterology. 2016;150:1380-92. doi:10.1053/j.gastro.2016.02.011 Do you like reading Annals for Educators? Receive it direct to your inbox. Sign up for the Annals for Educators alert today.
connecting flight to Rochester, MN Ann. Intern. Med. (IF 17.135) Pub Date : 2017-09-05 D.A. Frater
Let me stop when it is done Ann. Intern. Med. (IF 17.135) Pub Date : 2017-09-05 D.A. Frater
Shared Humanity Ann. Intern. Med. (IF 17.135) Pub Date : 2017-09-05 George Goshua
He is wearing his long overalls and a beige, straw rancher hat. A long beard descends to a point just above his navel. Robert drove in from a small rural town. At first glance, he seems thin and in good shape. I look further. Perhaps a bit too thin. I meet this man at the end of my first year of medical school. With an interest in surgery, I spend my time seeing patients in the hospital's ear, nose, and throat surgery clinic. The man speaks in a thick country accent. He takes off his hat and lifts his beard. Hidden beneath it lies a contour-breaking lump. An affirming exchange of nods between him and me. I feel it. Incorporate its nonmobile nature into my mind.
Prostate Cancer Screening: Time to Question How to Optimize the Ratio of Benefits and Harms Ann. Intern. Med. (IF 17.135) Pub Date : 2017-09-05 Andrew J. Vickers
Screening for prostate cancer with prostate-specific antigen (PSA) testing has been widespread in the United States since the late 1980s. Remarkably, it was not until 2009 that good evidence was published on the effectiveness of PSA screening, when the results of the PLCO (Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial) and the ERSPC (European Randomized Study of Screening for Prostate Cancer) appeared together in the New England Journal of Medicine (1, 2). Their findings seemed contradictory: The PLCO found low rates of prostate cancer death that did not differ significantly between groups (1), whereas the ERSPC suggested that screening reduced prostate cancer mortality by 20% (2).
Contemporary Influenza Diagnostics: Renewed Focus on Testing Patients Ann. Intern. Med. (IF 17.135) Pub Date : 2017-09-05 Michael G. Ison
Antiviral therapy for influenza has been studied in many settings and has consistently reduced illness, mortality, and complications when started early (1–4). Despite this clear benefit, suboptimal use of antiviral and antibacterial therapy for patients with confirmed influenza exists in both ambulatory and hospitalized settings (5, 6). In recent studies of ambulatory adults, antiviral and antibacterial therapies were prescribed to 15% and 30%, respectively, of outpatients with influenza (7). In recent studies of hospitalized adults, prescription of antiviral agents for influenza was low in the prepandemic period (51% to 57%, with early therapy prescribed in 47% to 55%) and increased to 89% in 2014 and 2015 (5, 8). Initiation of antiviral therapy on the day of admission has increased from 38% during the first wave of the pandemic to 56% after the pandemic (5, 8). In comparison, 73% to 79% of patients received antibacterial therapy, 93% to 95% in the first 1 to 2 days after admission, reflecting clinicians' greater reluctance to prescribe antivirals than antibacterials (6).
Proposed U.S. Funding Cuts Threaten Progress on Antimicrobial Resistance Ann. Intern. Med. (IF 17.135) Pub Date : 2017-09-05 Helen W. Boucher, Barbara E. Murray, William G. Powderly
Antimicrobial resistance (AMR) is an escalating public health crisis that kills patients, threatens national security, and reduces the safety of medical procedures essential to save and enhance lives. Many types of complex medical care can be complicated by serious infections and rely on the availability of safe, effective antimicrobial drugs. In the past 2 years, national and global leaders have united against this threat, making tangible progress. However, budget cuts of a historic magnitude proposed by the Trump administration now threaten to undo this progress, placing patients in grave danger. The Centers for Disease Control and Prevention (CDC) estimates that at least 2 million persons in the United States acquire antibiotic-resistant infections each year, resulting in at least 23 000 deaths. Antibiotic resistance is estimated to cost our health system more than $20 billion annually (1). Approximately 700 000 deaths are attributable to AMR each year globally. By 2050, a total of 350 million cumulative deaths will likely be attributable to AMR if current trends continue (2), and multidrug-resistant tuberculosis will account for most of these deaths (3).
Diagnostic Accuracy of Novel and Traditional Rapid Tests for Influenza Infection Compared With Reverse Transcriptase Polymerase Chain Reaction: A Systematic Review and Meta-analysis Ann. Intern. Med. (IF 17.135) Pub Date : 2017-09-05 Joanna Merckx, Rehab Wali, Ian Schiller, Chelsea Caya, Genevieve C. Gore, Caroline Chartrand, Nandini Dendukuri, Jesse Papenburg
Background: Rapid and accurate influenza diagnostics can improve patient care. Purpose: To summarize and compare accuracy of traditional rapid influenza diagnostic tests (RIDTs), digital immunoassays (DIAs), and rapid nucleic acid amplification tests (NAATs) in children and adults with suspected influenza. Data Sources: 6 databases from their inception through May 2017. Study Selection: Studies in English, French, or Spanish comparing commercialized rapid tests (that is, providing results in <30 minutes) with reverse transcriptase polymerase chain reaction reference standard for influenza diagnosis. Data Extraction: Data were extracted using a standardized form; quality was assessed using QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies 2) criteria. Data Synthesis: 162 studies were included (130 of RIDTs, 19 of DIAs, and 13 of NAATs). Pooled sensitivities for detecting influenza A from Bayesian bivariate random-effects models were 54.4% (95% credible interval [CrI], 48.9% to 59.8%) for RIDTs, 80.0% (CrI, 73.4% to 85.6%) for DIAs, and 91.6% (CrI, 84.9% to 95.9%) for NAATs. Those for detecting influenza B were 53.2% (CrI, 41.7% to 64.4%) for RIDTs, 76.8% (CrI, 65.4% to 85.4%) for DIAs, and 95.4% (CrI, 87.3% to 98.7%) for NAATs. Pooled specificities were uniformly high (>98%). Forty-six influenza A and 24 influenza B studies presented pediatric-specific data; 35 influenza A and 16 influenza B studies presented adult-specific data. Pooled sensitivities were higher in children by 12.1 to 31.8 percentage points, except for influenza A by rapid NAATs (2.7 percentage points). Pooled sensitivities favored industry-sponsored studies by 6.2 to 34.0 percentage points. Incomplete reporting frequently led to unclear risk of bias. Limitations: Underreporting of clinical variables limited exploration of heterogeneity. Few NAAT studies reported adult-specific data, and none evaluated point-of-care testing. Many studies had unclear risk of bias. Conclusion: Novel DIAs and rapid NAATs had markedly higher sensitivities for influenza A and B in both children and adults than did traditional RIDTs, with equally high specificities. Primary Funding Source: Québec Health Research Fund and BD Diagnostic Systems.
Reconciling the Effects of Screening on Prostate Cancer Mortality in the ERSPC and PLCO Trials Ann. Intern. Med. (IF 17.135) Pub Date : 2017-09-05 Alex Tsodikov, Roman Gulati, Eveline A.M. Heijnsdijk, Paul F. Pinsky, Sue M. Moss, Sheng Qiu, Tiago M. de Carvalho, Jonas Hugosson, Christine D. Berg, Anssi Auvinen, Gerald L. Andriole, Monique J. Roobol, E. David Crawford, Vera Nelen, Maciej Kwiatkowski, Marco Zappa, Marcos Luján, Arnauld Villers, Eric J. Feuer, Harry J. de Koning, Angela B. Mariotto, Ruth Etzioni
Background: The ERSPC (European Randomized Study of Screening for Prostate Cancer) found that screening reduced prostate cancer mortality, but the PLCO (Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial) found no reduction. Objective: To evaluate whether effects of screening on prostate cancer mortality relative to no screening differed between the ERSPC and PLCO. Design: Cox regression of prostate cancer death in each trial group, adjusted for age and trial. Extended analyses accounted for increased incidence due to screening and diagnostic work-up in each group via mean lead times (MLTs), which were estimated empirically and using analytic or microsimulation models. Setting: Randomized controlled trials in Europe and the United States. Participants: Men aged 55 to 69 (ERSPC) or 55 to 74 (PLCO) years at randomization. Intervention: Prostate cancer screening. Measurements: Prostate cancer incidence and survival from randomization; prostate cancer incidence in the United States before screening began. Results: Estimated MLTs were similar in the ERSPC and PLCO intervention groups but were longer in the PLCO control group than the ERSPC control group. Extended analyses found no evidence that effects of screening differed between trials (P = 0.37 to 0.47 [range across MLT estimation approaches]) but strong evidence that benefit increased with MLT (P = 0.0027 to 0.0032). Screening was estimated to confer a 7% to 9% reduction in the risk for prostate cancer death per year of MLT. This translated into estimates of 25% to 31% and 27% to 32% lower risk for prostate cancer death with screening as performed in the ERSPC and PLCO intervention groups, respectively, compared with no screening. Limitation: The MLT is a simple metric of screening and diagnostic work-up. Conclusion: After differences in implementation and settings are accounted for, the ERSPC and PLCO provide compatible evidence that screening reduces prostate cancer mortality. Primary Funding Source: National Cancer Institute.
Effects of Intensive Systolic Blood Pressure Control on Kidney and Cardiovascular Outcomes in Persons Without Kidney Disease: A Secondary Analysis of a Randomized Trial Ann. Intern. Med. (IF 17.135) Pub Date : 2017-09-05 Srinivasan Beddhu, Michael V. Rocco, Robert Toto, Timothy E. Craven, Tom Greene, Udayan Bhatt, Alfred K. Cheung, Debbie Cohen, Barry I. Freedman, Amret T. Hawfield, Anthony A. Killeen, Paul L. Kimmel, James Lash, Vasilios Papademetriou, Mahboob Rahman, Anjay Rastogi, Karen Servilla, Raymond R. Townsend, Barry Wall, Paul K. Whelton
Background: The public health significance of the reported higher incidence of chronic kidney disease (CKD) with intensive systolic blood pressure (SBP) lowering is unclear. Objective: To examine the effects of intensive SBP lowering on kidney and cardiovascular outcomes and contrast its apparent beneficial and adverse effects. Design: Subgroup analyses of SPRINT (Systolic Blood Pressure Intervention Trial). (ClinicalTrials.gov: NCT01206062) Setting: Adults with high blood pressure and elevated cardiovascular risk. Participants: 6662 participants with a baseline estimated glomerular filtration rate (eGFR) of at least 60 mL/min/1.73 m2. Intervention: Random assignment to an intensive or standard SBP goal (120 or 140 mm Hg, respectively). Measurements: Differences in mean eGFR during follow-up (estimated with a linear mixed-effects model), prespecified incident CKD (defined as a >30% decrease in eGFR to a value <60 mL/min/1.73 m2), and a composite of all-cause death or cardiovascular event, with surveillance every 3 months. Results: The difference in adjusted mean eGFR between the intensive and standard groups was −3.32 mL/min/1.73 m2 (95% CI, −3.90 to −2.74 mL/min/1.73 m2) at 6 months, was −4.50 mL/min/1.73 m2 (CI, −5.16 to −3.85 mL/min/1.73 m2) at 18 months, and remained relatively stable thereafter. An incident CKD event occurred in 3.7% of participants in the intensive group and 1.0% in the standard group at 3-year follow-up, with a hazard ratio of 3.54 (CI, 2.50 to 5.02). The corresponding percentages for the composite of death or cardiovascular event were 4.9% and 7.1% at 3-year follow-up, with a hazard ratio of 0.71 (CI, 0.59 to 0.86). Limitation: Long-term data were lacking. Conclusion: Intensive SBP lowering increased risk for incident CKD events, but this was outweighed by cardiovascular and all-cause mortality benefits. Primary Funding Source: National Institutes of Health.
A Misleading Pattern of Serologic Findings During Hepatitis B Virus Infection Ann. Intern. Med. (IF 17.135) Pub Date : 2017-08-29 Gil Ben-Yakov, Kapuria Devika, Ohad Etzion, Christopher Koh, Theo Heller
Background: The most widely recognized feature of hepatitis B virus (HBV) infection is a positive result on blood testing for hepatitis B surface antigen (HBsAg). In patients with acute infection that resolves, HBsAg usually becomes undetectable within a few months and IgG antibody to hepatitis B core antigen becomes detectable at approximately the same time; only later does antibody to HBsAg appear. When HBV infection is chronic, HBsAg is produced continuously in large amounts, hepatitis B core antibody is present, and HBsAg antibody is absent (1). Approximately 1.6% of persons with chronic HBV infection have spontaneous loss of HBsAg each year (2), which usually indicates clearance of the virus.
Population Health Science and the Challenges of Prediction Ann. Intern. Med. (IF 17.135) Pub Date : 2017-08-29 Sandro Galea, Katherine M. Keyes
Peering into the future to accurately predict health outcomes is challenging and imprecise. Yet, this has not stopped the development of a broad array of models to predict future disease. The widespread availability of regression modeling approaches has made it seem easy to develop prediction models. A substantial body of literature documents the development, calibration, and validation of risk prediction models using large data sets. Typically, these models use individual patient risk factors to estimate the probability of a future health outcome. Patient-friendly Web sites provide tools that enable patients to calculate their own risk for such conditions as cardiovascular disease or cancer, in theory to motivate them to improve their risk profiles. However, the prediction modeling enterprise faces substantial challenges that seldom attract as much attention as they should.
Raising the Bar in Attribution Ann. Intern. Med. (IF 17.135) Pub Date : 2017-08-29 Ateev Mehrotra, Helen Burstin, Carol Raphael
The U.S. Department of Health and Human Services has set an ambitious goal of tying more than 90% of Medicare payments to quality by 2018 and shifting more than half of payments to alternative payment models, such as accountable care organizations (ACOs) and bundled payments (1). The hope is that this move from fee-for-service will improve coordination and integration of care. Unfortunately, in this rapid shift to new payment models, the issue of attribution has received insufficient attention. Patients receive care from a broad array of providers, including hospitals, physicians, and nurses (2). Attribution models are sets of rules used to determine which provider (or group of providers) is responsible for a patient's care from a quality, cost, or payment perspective. The models vary widely and may be complex. For example, under the Medicare Shared Savings Program, a patient is assigned to an ACO if the largest portion of primary care services was furnished by primary care practitioners at the participating ACO. If a patient did not receive care from a primary care practitioner in an ACO, the patient may be attributed to the ACO if the greatest portion of selected services was furnished by specialists at the ACO (1).
Some contents have been Reproduced by permission of The Royal Society of Chemistry.
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