Functional Impairment and Decline in Middle Age Ann. Intern. Med. (IF 17.135) Pub Date : 2017-11-14
What is the problem and what is known about it so far? To live independently, people must be able to do basic activities of daily living (ADLs), such as taking a bath, putting on clothes, or getting out of a chair or bed, without help from another person. The inability to perform ADLs, also known as “functional impairment,” is common in older adults. Studies suggest that functional impairment is also common in middle-aged adults. It is not clear how many middle-aged adults have functional limitations. For those who have problems with ADLs, it is also unclear how long these problems last.Why did the researchers do this particular study? To determine the proportion of middle-aged adults in whom a new functional limitation developed and whether the problem got better, got worse, or stayed the same.Who was studied? 6874 middle-aged adults who were living in the community. These adults did not have problems performing ADLs when they entered the study.How was the study done? The study participants were interviewed by telephone at baseline and every 2 years. At each interview, they were asked whether they had any problems doing basic ADLs, and they answered questions about their general health, medical conditions, and health behaviors. The researchers examined how many participants had a new functional impairment during follow-up. For participants in whom impairment developed, the researchers described those whose impairment got better, those whose impairment got worse, and those whose impairment stayed the same.What did the researchers find? Difficulty with at least 1 ADL developed in about 1 in 4 participants between the ages of 50 and 64 years. Two years after functional impairment developed, 50% of participants continued to have limitations and 37% recovered. In 9%, the impairment worsened, and 4% died. During 10 years of follow-up, 28% of participants recovered from their initial episode and remained independent, whereas about 20% had further episodes, with worsening functional impairment, and 19% died.What were the limitations of the study? The information provided by the participants on their activity limitations was not verified objectively.What are the implications of the study? Functional impairment, or difficulty doing basic ADLs, is common during middle age. Of the middle-aged adults in whom a functional limitation developed, some had further impairment or died during follow-up. These findings suggest that functional impairment may not be a short-term problem during middle age.
Diagnostic Accuracy of Screening Tests and Treatment for Post–Acute Coronary Syndrome Depression: A Systematic Review Ann. Intern. Med. (IF 17.135) Pub Date : 2017-11-14 Jason A. Nieuwsma, John W. Williams, Natasha Namdari, Jeffrey B. Washam, Giselle Raitz, James A. Blumenthal, Wei Jiang, Roshini Yapa, Amanda J. McBroom, Kathryn Lallinger, Robyn Schmidt, Andrzej S. Kosinski, Gillian D. Sanders
Background:Patients who have had an acute coronary syndrome (ACS) event have an increased risk for depression.Purpose:To evaluate the diagnostic accuracy of depression screening instruments and to compare safety and effectiveness of depression treatments in adults within 3 months of an ACS event.Data Sources:MEDLINE, EMBASE, PsycINFO, CINAHL, and Cochrane Database of Systematic Reviews from January 2003 to August 2017, and a manual search of citations from key primary and review articles.Study Selection:English-language studies of post-ACS patients that evaluated the diagnostic accuracy of depression screening tools or compared the safety and effectiveness of a broad range of pharmacologic and nonpharmacologic depression treatments.Data Extraction:2 investigators independently screened each article for inclusion; abstracted the data; and rated the quality, applicability, and strength of evidence.Data Synthesis:Evidence from 6 of the 10 included studies showed that a range of depression screening instruments produces acceptable levels of diagnostic sensitivity, specificity, and negative predictive values (70% to 100%) but low positive predictive values (below 50%). The Beck Depression Inventory-II was the most studied tool. A large study found that a combination of cognitive behavioral therapy (CBT) and antidepressant medication improved depression symptoms, mental health–related function, and overall life satisfaction more than usual care.Limitation:Few studies, no evaluation of the influence of screening on clinical outcomes, and no studies addressing several clinical interventions of interest.Conclusion:Depression screening instruments produce diagnostic accuracy metrics that are similar in post-ACS patients and other clinical populations. Depression interventions have an uncertain effect on cardiovascular outcomes, but CBT combined with antidepressant medication produces modest improvement in psychosocial outcomes.Primary Funding Source:Agency for Healthcare Research and Quality (PROSPERO: CRD42016047032).
Annals Graphic Medicine - The “Problem” List Ann. Intern. Med. (IF 17.135) Pub Date : 2017-11-07 Kyle Burch
Annals Story Slam - Wonder Woman Is a Cartoon Character Ann. Intern. Med. (IF 17.135) Pub Date : 2017-11-07 Ana Maria Lopez
Building on the popular Annals feature “On Being a Doctor,” storytellers share stories about the experience of doctoring on video. Here, Dr. Lopez relays her story of balancing doctoring and parenting.For more videos from and information on Annals Story Slam, visit www.annals.org/StorySlam.
Annals Story Slam - What I Learned From Madame Secretary, Notorious RBG, and Nana Ann. Intern. Med. (IF 17.135) Pub Date : 2017-11-07 Darilyn V. Moyer
Building on the popular Annals feature “On Being a Doctor,” storytellers share stories about the experience of doctoring on video. Here, Dr. Moyer relays her story of balancing doctoring and parenting.For more videos from and information on Annals Story Slam, visit www.annals.org/StorySlam.
Annals Story Slam - Pay Your Nanny Well Ann. Intern. Med. (IF 17.135) Pub Date : 2017-11-07 Heather E. Gantzer
Building on the popular Annals feature “On Being a Doctor,” storytellers share stories about the experience of doctoring on video. Here, Dr. Gantzer relays her story of balancing doctoring and parenting.For more videos from and information on Annals Story Slam, visit www.annals.org/StorySlam.
Annals Story Slam - How Wonder Woman Became My Alter Ego Ann. Intern. Med. (IF 17.135) Pub Date : 2017-11-07 Susan Thompson Hingle
Building on the popular Annals feature “On Being a Doctor,” storytellers share stories about the experience of doctoring on video. Here, Dr. Hingle relays her story of balancing doctoring and parenting.For more videos from and information on Annals Story Slam, visit www.annals.org/StorySlam.
Annals Story Slam - Dr. Mom Gets Sick Ann. Intern. Med. (IF 17.135) Pub Date : 2017-11-07 Jacqueline W. Fincher
Building on the popular Annals feature “On Being a Doctor,” storytellers share stories about the experience of doctoring on video. Here, Dr. Fincher relays her story of balancing doctoring and parenting.For more videos from and information on Annals Story Slam, visit www.annals.org/StorySlam.
Annals Story Slam - Becoming Dr. Mom Ann. Intern. Med. (IF 17.135) Pub Date : 2017-11-07 Rebecca Masters
Building on the popular Annals feature “On Being a Doctor,” storytellers share stories about the experience of doctoring on video. Here, Dr. Masters relays her story of balancing doctoring and parenting.For more videos from and information on Annals Story Slam, visit www.annals.org/StorySlam.
Annals Story Slam - A Missed Opportunity Ann. Intern. Med. (IF 17.135) Pub Date : 2017-11-07 Carrie A. Horwitch
Building on the popular Annals feature “On Being a Doctor,” storytellers share stories about the experience of doctoring on video. Here, Dr. Horwitch relays her story of balancing doctoring and parenting.For more videos from and information on Annals Story Slam, visit www.annals.org/StorySlam.
Annals for Educators - 7 November 2017 Ann. Intern. Med. (IF 17.135) Pub Date : 2017-11-07 Darren B. Taichman
Clinical Practice Points Discontinuing Inappropriate Medication Use in Nursing Home Residents. A Cluster Randomized Controlled Trial Inappropriate prescribing of medications is a common problem associated with increased risk for adverse outcomes in older adults. This randomized controlled trial examined the effect of a multidisciplinary medication review performed by physicians and pharmacists on the discontinuation of inappropriate medication use and clinical outcomes among nursing home residents.Use this paper to:Start a teaching session with a multiple-choice question. We've provided one below!Teach at the bedside! Review with your team the admitting medication list of several nursing home residents on your service. Are the lists long? Are all of the drugs necessary? Do any present potential problems?Ask your learners how they would define polypharmacy. In what ways might it lead to adverse events? The authors address these issues in the introduction to their study. Need the list be long for it to include inappropriate drugs?Review the intervention used in this cluster randomized controlled trial (Table 1). Who was involved? How were medications assessed?How well do your learners think they can assess the appropriateness of each medication for all of their patients? Ask them to do so for each of the patients on their service (or each of the outpatients they see) before your next meeting. Did they identify any potentially inappropriate drugs?Ask whether your learners ever leave patients on drugs they do not think or are not sure are needed. Are they hesitant to discontinue drugs they did not prescribe? How should they approach this issue? To whom should they talk?Who reviews a patient's discharge medication list at your hospital? Look at the Annals Graphic Medicine piece described below. How do patients end up using long lists of medicines they no longer need?Ask what a cluster randomized trial is. How does it differ from more traditional clinical trials? What is the unit of randomization in each? How does this difference influence what may be learned?This study did not find a difference in the secondary outcomes that were assessed. The authors note that the trial was not powered to assess them. What does it mean if a study is “underpowered”? Look at the 95% confidence intervals around the point estimates for the secondary outcomes (Table 4). How should they be interpreted?Why might the study have found only modest effects? Use the accompanying editorial to help frame your discussion. The Spectrum of Subclinical Primary Aldosteronism and Incident Hypertension. A Cohort Study Primary aldosteronism is the most common and modifiable form of secondary hypertension and is usually considered when the classic phenotype of severe hypertension or hypokalemia is encountered. This study assessed whether a spectrum of subclinical primary aldosteronism that increases risk for hypertension exists among normotensive persons.Use this study to:Ask your learners which patients require an evaluation for secondary causes of hypertension. What should the evaluation include? Use In the Clinic: Hypertension to quickly find answers. What are the presenting signs and symptoms of primary aldosteronism? How is it currently diagnosed? Use the information in DynaMed Plus: Primary Aldosteronism (a benefit of your ACP membership). Review with your learners the regulation of renin and aldosterone. How is urinary sodium affected by renin and aldosterone concentrations? Invite a nephrologist to join your discussion.Review the key results of this study. The authors suggest that a state of clinically relevant renin-independent aldosteronism might be common and could affect the risk for subsequent cardiovascular disease. Do your learners think that we should test normotensive patients for this? What additional studies would they want before adopting such a practice? Use the accompanying editorial to help inform your discussion. Synopsis of the 2017 U.S. Department of Veterans Affairs/U.S. Department of Defense Clinical Practice Guideline: Management of Type 2 Diabetes Mellitus This synopsis summarizes key features of the 2017 joint clinical practice guideline from the U.S. Department of Veterans Affairs and the U.S. Department of Defense for the management of type 2 diabetes mellitus.Use this guideline synopsis to:Go down the list of recommendations in Table 1 with your team. Check off items your learners believe they should address with each of their diabetic patients. How would they assess whether they are doing these things? Can your EHR help? Should they review the charts of several of their own patients?Does your practice have a telehealth system available to improve the care of patients with diabetes? What members of the health care team are available to assist in providing diabetes care?The authors discuss the importance of individualizing glycemic goals according to patients' risks, life expectancy, personal goals, and other variables. How should each of these be considered when determining glycemic goals? Do your learners know how to discuss them with patients when choosing a goal, and what questions to ask?The authors discuss how their guideline differs from others. Why do glycemic targets differ in this manner? Use the accompanying editorial to help frame your discussion. Does your institution have protocols for inpatient glycemic control among diabetic patients? What do the authors recommend? Why don't they recommend as tight control for patients outside the ICU compared with those in the ICU? The authors recommend a “basal–bolus-plus-correction” approach to care outside the ICU but note that many inpatients are managed only with “correction” doses of insulin on a sliding-scale basis. What is the difference? What is done at your center, and why?In the Clinic In the Clinic: Acute Kidney Injury Acute kidney injury (AKI) occurs in approximately 20% of hospitalized patients, with major complications that include volume overload, electrolyte disorders, uremic complications, and drug toxicity. Are your learners prepared to prevent and manage AKI?Use this feature to:Ask your learners to list risk factors for AKI. Compare their list with the one provided in the Box.What measures are effective at preventing AKI, and in which patients should they be used?What are the major causes of AKI? Review Figure 2 with your learners. What features help distinguish between decreased kidney perfusion and acute tubular necrosis? List drugs that may cause AKI, and how. Use the information in the boxes for quick lists to help teach.Teach at the bedside (or microscope)! How do urinary tract findings help differentiate among the potential causes? Do your learners know how to assess urinary sediment? Take fresh samples of urine from patients on your service with AKI to the laboratory and review the sediment. Invite a nephrologist to help.Use the multiple-choice questions to introduce new topics for discussion in a teaching session. Download the teaching slides. Log in to answer the multiple-choice questions and claim CME/MOC credit for yourself!Comics and Medicine Annals Graphic Medicine - The “Problem” List Laugh (or cry?) as what starts as a simple issue evolves into a complex medical problem list.Use this feature to:Show the cartoon to your learners. Do they think there is truth to what the author depicts?What drives our medical system's desire to label everything? What practices can help to prevent needless labeling and inappropriate treatment of patients?How might this cartoon relate to the use of inappropriate medications addressed in the first study noted above?Humanism and Professionalism On Being a Patient: The Worst of Days Dr. Grinberg's horrible loss brings back the memories of a patient who was labeled as “crazy.”Use this essay to:Listen to an audio recording, read by Dr. Virginia Hood.Accept that sometimes discussion is not needed. Just listening together might be best.Consider asking if your learners worry that we sometimes brush aside a patient's suffering as mere “hysteria.” Do we sometimes worry about looking foolish for caring too much?MKSAP 17 Question A 90-year-old woman is brought to the emergency department by her son for a 1-week history of worsening cognition, weakness, dizziness, and anorexia. She lives in an assisted-care facility and is generally alert. She is ambulatory when using a cane. Medical history includes hypertension, chronic heart failure, chronic kidney disease, osteoarthritis, allergic rhinitis, hyperlipidemia, and urinary stress incontinence. Current medications are lisinopril, bisoprolol, oxybutynin, loratadine, acetaminophen, pravastatin, and omeprazole.On physical examination, she appears frail but is in no acute distress. Temperature is normal, blood pressure is 100/60 mm Hg, pulse rate is 88/min, and respiration rate is 14/min. BMI is 20. Oxygen saturation is 97% with the patient breathing ambient air. There is no orthostasis. Cardiac examination discloses an irregularly irregular rate. Pulmonary examination reveals slightly diminished breath sounds bilaterally but no crackles. The abdomen is mildly distended but nontender. Rectal examination reveals hard stool that is negative for occult blood. There is no edema. Neurologic examination is nonfocal, and the patient scores 24/30 on the Mini–Mental State Examination.Laboratory studies:Hematocrit 34% Leukocyte count 7100/µl (7.1 × 109/L); normal differential Creatinine 1.6 mg/dL (141 µmol/L) (2 months ago: 1.3 mg/dL [114 µmol/L]) Electrolytes Normal Glucose 78 mg/dL (4.3 mmol/L) Urinalysis Trace protein, trace ketones, no cells Hematocrit 34% Leukocyte count 7100/µl (7.1 × 109/L); normal differential Creatinine 1.6 mg/dL (141 µmol/L) (2 months ago: 1.3 mg/dL [114 µmol/L]) Electrolytes Normal Glucose 78 mg/dL (4.3 mmol/L) Urinalysis Trace protein, trace ketones, no cells Chest radiograph shows no evidence of heart failure or pulmonary infiltrates.Which of the following is the most likely cause of this patient's recent symptoms?A. Acute kidney injuryB. Adverse medication effectsC. Occult pneumoniaD. Urinary tract infectionCorrect AnswerB. Adverse medication effectsEducational ObjectiveManage polypharmacy in an older patient.CritiqueThis older patient's clinical findings are most likely the result of adverse medication effects related to polypharmacy, and her drug regimen requires adjustment. She has significant medical comorbidities and is taking numerous drugs. Administration of multiple medications increases the risk for inappropriate use, drug-drug interactions, adverse reactions, poor adherence, and medication errors. This patient is taking two anticholinergic agents (oxybutynin for urinary incontinence and the over-the-counter antihistamine loratadine). The American Geriatrics Society Beers Criteria recommend against the use of anticholinergic agents in older patients because they can cause confusion, urinary retention, constipation, and dry mouth. She is also on the proton pump inhibitor omeprazole without an apparent indication for treatment. In addition, the risk-to-benefit ratio of using a lipid-lowering agent to confer long-term benefits must be reassessed in very elderly adults. Prescriptions for statins are frequently carried over from previous years, but statin use results in additional cost, extra pills, and increased risk for drug-drug interactions. Lastly, parameters for blood pressure control are less stringent in older adults, and, in this patient, antihypertensive agents should be reassessed, as her hypertension is overtreated. Ongoing review of the indications, risks, benefits, and dosing of all drugs in older patients is recommended.This patient has a history of mild chronic kidney disease; however, with normal volume status, normal electrolytes, and a minimal change in her serum creatinine level, she does not have evidence of significant worsening of her kidney function. This would make acute kidney injury an unlikely cause of her current clinical findings.Infections are a frequent cause of systemic symptoms, including weakness, dizziness, anorexia, and altered mental status in older patients, with pneumonia and urinary tract infection being the most common types. However, this patient has no clinical findings consistent with pneumonia given her normal oxygenation, leukocyte count, and chest radiograph, or suggestion of urinary tract infection with a normal urinalysis. Therefore, the absence of evidence of infection makes this an unlikely cause of her current clinical findings.Key PointAdministration of multiple medications, especially in older patients, increases the risk for inappropriate use, drug-drug interactions, adverse reactions, and medication errors.BibliographyMaher RL, Hanlon J, Hajjar ER. Clinical consequences of polypharmacy in elderly. Expert Opin Drug Saf. 2014;13(1):57-65.Do you like reading Annals for Educators? 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Screening for HIV: U.S. Preventive Services Task Force Recommendation Statement Ann. Intern. Med. (IF 17.135) Pub Date : 2013-07-02
Who developed these guidelines? The U.S. Preventive Services Task Force (USPSTF) developed these recommendations. The USPSTF is a group of health experts that reviews published research and makes recommendations about preventive health care.What is the problem and what is known about it so far? HIV is the cause of AIDS, an illness that interferes with the body's ability to fight infection and some types of cancer. Treatments containing multiple drugs have improved outcomes for HIV-infected patients. The virus passes from person to person through contact with blood or other bodily fluids that contain it. People can have HIV infection for years before becoming sick.Men who have sex with men and active users of injected recreational drugs are at very high risk for HIV infection. Other risk factors include unprotected vaginal or anal intercourse; having sexual partners who are HIV-positive, bisexual, or injection drug users; exchanging sex for drugs or money; and having other sexually transmitted infections. Research also shows that people who request HIV testing despite reporting no risk factors are at increased risk for HIV infection, possibly because of risk factors that they do not report.Conventional tests for HIV infection are blood tests that usually provide results in 1 to 2 days. Rapid tests that provide results in 5 to 40 minutes involve testing blood or saliva, but positive results must be confirmed with conventional blood tests.In 2005, the USPSTF recommended that physicians ask patients about HIV risk factors, advise HIV testing for all adolescents and adults with a risk factor for HIV, and screen all pregnant women regardless of whether they have risk factors. Screening means testing people who feel well rather than waiting until symptoms develop. The USPSTF wanted to update these recommendations.How did the USPSTF develop these recommendations? The USPSTF reviewed published research to evaluate the benefits and harms of HIV screening.What did the authors find? Conventional and rapid HIV tests are highly accurate in diagnosing infection. Research shows that identification and treatment of HIV infection greatly reduce the progression to AIDS. Early initiation of treatment is associated with fewer AIDS-related complications or deaths. Treatment reduces the transmission of HIV to uninfected heterosexual partners. The identification and treatment of HIV infection in pregnant women greatly reduces the passage of infection from mother to child. The harms of screening for and treating HIV infection in adolescents, adults, and pregnant women are probably small.What does the USPSTF recommend that patients and doctors do? All adolescents and adults aged 15 to 65 years should have HIV screening. Younger adolescents and older adults who have risk factors for HIV infection should also be screened.All pregnant women should receive screening for HIV infection, including those who present in labor whose status is unknown.What are the cautions related to these recommendations? Patients with signs or symptoms of HIV infection should be tested regardless of whether they are in the aforementioned age and risk groups.
Firearm-Related Injury and Death: A U.S. Health Care Crisis in Need of Health Care Professionals Ann. Intern. Med. (IF 17.135) Pub Date : 2017-10-10 Darren B. Taichman, Howard Bauchner, Jeffrey M. Drazen, Christine Laine, Larry Peiperl
What would happen if on one day more than 50 people died and over 10 times that many were harmed by an infectious disease in the United States? Likely, our nation's esteemed and highly capable public health infrastructure would gear up to care for those harmed and study the problem. There would be a rush to identify the cause, develop interventions, and refine them continually until the threat is eliminated or at least contained. In light of the risks to public health (after all, over 500 people have been harmed already!), health care professionals would sound the alarm. We would demand funding. We would go to conferences to learn what is known and what we should do. We would form committees at our institutions to plan local responses to protect our communities. The United States would spend millions or more in short order to assure public safety, and no elected officials would conceive of getting in the way. Rather, they would compete to be calling the loudest for the funds and focus required to protect our people. Americans should be proud of our prowess at and commitment to addressing public health crises. Yet, here we are again with another editorial about the public health crisis of firearm-related injury and death following what used to be unthinkable, this time a mass murder and casualties at a concert in Las Vegas. We've written it all before. The staggering numbers killed annually. The numbers left permanently disabled. The families left to cope with the loss of loved ones or to care for those broken but not killed by a bullet. As health care professionals, we seem powerless. This public health crisis seems beyond the reach of our tools. Is there really nothing health care professionals can do? We think there is a lot. We need to each ask ourselves what we have done to apply our knowledge and skills to help address the problem since the moment of silence that followed the last mass shooting. More silence is not the answer. Have we demanded funding to adequately study the problem and test solutions? Have we participated in such studies? Have we mobilized forces at our institutions to plan strategies to lower the risks in our communities? Have we talked to our patients about gun safety and effectively challenged policies that would enforce our silence on this matter? Some of our colleagues have. We should be proud of them, but they need all of our help. And so do our patients. Here's a short list of how health care professionals can use our skills and voices to fight the threat that firearms present to health in the United States. Educate yourself. Read the background materials and proposals for sensible firearm legislation from health care professional organizations. Make a phone call and write a letter to your local, state, and federal legislators to tell them how you feel about gun control. Now. Don't wait. And do it again at regular intervals. Attend public meetings with these officials and speak up loudly as a health care professional. Demand answers, commitments, and follow-up. Go to rallies. Join, volunteer for, or donate to organizations fighting for sensible firearm legislation. Ask candidates for public office where they stand and vote for those with stances that mitigate firearm-related injury. Meet with the leaders at your own institutions to discuss how to leverage your organization's influence with local, state, and federal governments. Don't let concerns for perceived political consequences get in the way of advocating for the well-being of your patients and the public. Let your community know where your institution stands and what you are doing. Tell the press. Educate yourself about gun safety. Ask your patients if there are guns at home. How are they stored? Are there children or others at risk for harming themselves or others? Direct them to resources to decrease the risk for firearm injury, just as you already do for other health risks. Ask if your patients believe having guns at home makes them safer, despite evidence that they increase the risk for homicide, suicide, and accidents. Don't be silent. We don't need more moments of silence to honor the memory of those who have been killed. We need to honor their memory by preventing a need for such moments. As health care professionals, we don't throw up our hands in defeat because a disease seems to be incurable. We work to incrementally and continuously reduce its burden. That's our job. Will yet another commentary about the ravages of firearm-related harm change anything? Probably not—our journals have published far too many following prior firearm-enabled catastrophes. The only thing that will change the world for the better is a group of people who believe that they can change the world. With regard to firearm-related injury and death, let's each be part of that group. Darren B. Taichman, MD, PhD, Executive Deputy Editor, Annals of Internal Medicine Howard Bauchner, MD, Editor-in-Chief, JAMA (Journal of the American Medical Association) and the JAMA Network Jeffrey M. Drazen, MD, Editor-in-Chief, New England Journal of Medicine Christine Laine, MD, MPH, Editor in Chief, Annals of Internal Medicine Larry Peiperl, MD, Chief Editor, PLOS Medicine
Annals for Hospitalists - 17 October 2017 Ann. Intern. Med. (IF 17.135) Pub Date : 2017-10-17 David H. Wesorick, Vineet Chopra
Inpatient Notes Diagnostic Excellence Starts With an Incessant Watch —Gurpreet Dhaliwal, MD In this issue's Inpatient Notes, the author describes a simple yet powerful practice to develop and enhance one's diagnostic performance. Highlights of Recent Articles From Annals of Internal Medicine Ethics and the Legalization of Physician-Assisted Suicide: An American College of Physicians Position Paper Ann Intern Med. 2017;167:576-578. Published 19 September 2017. doi:10.7326/M17-0938 In this position paper, the American College of Physicians (ACP) states its formal position against the legalization of physician-assisted suicide, citing ethical, legal, and practical concerns. The authors argue that physician-assisted suicide violates the ethical tenets of beneficence and nonmaleficence. In addition, they express concern that physician participation in suicide could erode trust in the physician–patient relationship and fundamentally alter the role of the medical profession in society. Moreover, they recognize that a focus on facilitating death at the end of life might distract physicians from striving for the traditional goals of end-of-life care: relieving suffering and improving access to hospice and palliative care. Key points for hospitalists include: The ACP formally opposes the legalization of physician-assisted suicide. One editorial suggests that all physicians should firmly decline to participate in physician-assisted suicide, noting that it is simply not the duty of a physician. The author highlights uncertainties of the practice, including the identification of appropriate candidates and the challenges of creating reliable safeguards against misuse. He also argues that a patient's autonomy should not be considered absolute—indeed, physicians do not make decisions based solely on what patients want or request. Rather, medical decision making depends on the weighing of competing values, including the “intrinsic value of human life.” Another editorial suggests that physicians should not adopt a stance of rigid opposition to physician-assisted death. The authors recognize that most of the public favors legalization of physician-assisted suicide, even though physicians and some professional organizations are divided on the issue. The authors also suggest that now is the time to carefully study physician-assisted suicide, to debate its ethical implications, and to improve related processes and safeguards that serve the patients who choose this “last resort” option. Oregon's Death With Dignity Act: 20 Years of Experience to Inform the Debate Ann Intern Med. 2017;167:579-583. Published 19 September 2017. doi:10.7326/M17-2300 This article summarizes data from 20 years of experience with Oregon's Death With Dignity Act (DWDA), which allows physicians to legally prescribe lethal medications to terminally ill patients who want to end their own lives. During the past 20 years, 1857 Oregonians received prescriptions and 1179 died from ingesting them. About one third of the patients who obtained the prescriptions never took the medication. Of note, although the annual number of DWDA deaths has gradually increased over 20 years (16 deaths in 1998 vs. 136 deaths in 2016), it represents a small fraction of all deaths in the state. The median age of DWDA patients was 72 years—52% were men, 96% were white, and 72% had some college or higher education. Most DWDA patients had cancer (77%), and most (88%) were enrolled in hospice. During the first decade of implementation, 11% of DWDA patients had a formal psychiatric evaluation, but only 3% had been evaluated since. Key points for hospitalists include: A wealth of data about physician-assisted suicide is available from states and countries where the practice is legal, including Oregon. Analysis of these data can answer some important questions about the practice. Most patients cited loss of autonomy or inability to participate in activities that make life enjoyable as reasons for seeking DWDA prescriptions. Financial concerns were not frequently reported as motivating the request. Patients requesting DWDA prescriptions were only infrequently referred for psychiatric evaluations despite concerns that depression may be prevalent in this population. Diagnostic Reasoning: An Endangered Competency in Internal Medicine Training Ann Intern Med. 2017;167:507-508. Published 12 September 2017. doi:10.7326/M17-0163 This Ideas and Opinions article suggests that the current health care environment may pose a threat to the cultivation of diagnostic reasoning skills in internal medicine trainees. Key points for hospitalists include: The current health care environment may undermine the emphasis on diagnostic reasoning in internal medicine training by demanding efficiency and pressuring trainees to “test (or even treat) first, think later.” Residents doing shiftwork are often unaware of the ultimate results of the diagnostic process they initiate and lack a clear feedback loop necessary to inform and refine diagnostic reasoning. The authors suggest that internal medicine training programs should act deliberately to preserve the development of diagnostic reasoning in these trainees. Possible solutions might include a renewed focus on diagnostic reasoning during teaching rounds and training conferences and efforts to ensure that trainees receive feedback about the outcomes of the diagnostic evaluations they initiate. For a related discussion, see this month's Inpatient Notes by Gurpreet Dhaliwal, MD. In the Clinic: Urinary Tract Infection Ann Intern Med. 2017;167:ITC49-ITC64. doi:AITC201710030 This narrative review provides an update of the evidence regarding diagnosis and treatment of urinary tract infections (UTIs). Key points for hospitalists include: Clinicians should not screen for or treat asymptomatic bacteriuria, except in pregnant patients or those undergoing invasive urinary procedures that will induce mucosal bleeding (e.g., transurethral resection of the prostate). Although UTI can be diagnosed clinically, urine culture should be done in patients in whom the diagnosis is uncertain, in pregnant women, and in men with suspected UTI. Urine culture is also indicated when pyelonephritis or complicated infection is suspected and in cases of relapse or treatment failure. Antibiotic choice depends on the classification of the disease. Fluoroquinolones should not be used to treat uncomplicated cystitis based on safety and stewardship concerns but may be used to treat pyelonephritis and complicated infections (e.g., structural abnormalities of the urinary tract or immunocompromised host). Resistance is common in many areas. The Latest Highlights From ACP Journal Club For older patients with chronic disease, do transitional care interventions reduce mortality or readmission rates? Review: In older patients with chronic disease, transitional care reduces mortality and readmissions Ann Intern Med. 2017;167:JC32. doi:10.7326/ACPJC-2017-167-6-032 This systematic review is the latest of many demonstrating the benefit of transitional care for older patients after hospital discharge. Transitional care provided care coordination and continuity, preplanned and structured follow-up after discharge, and ≥1 follow-up ≤30 days after discharge. Although the interventions were associated with lower rates of mortality and readmissions, which interventions are most clinically or cost-effective are unclear. How should high-sensitivity cardiac troponin I (hs-cTnI) levels be used to rule out myocardial infarction (MI) in the emergency department (ED)? High-STEACS Algorithm missed fewer patients with acute MI than the ESC Pathway in the ED Ann Intern Med. 2017;167:JC34. doi:10.7326/ACPJC-2017-167-6-034 This prospective cohort study evaluated 1218 patients who presented to the ED with suspected acute coronary syndrome who had hs-cTnI testing ordered by the attending clinician. The study compared the European Society of Cardiology (ESC) Pathway (which uses a 6-hour, sex-adjusted troponin cutoff) with the High-Sensitivity Troponin in the Evaluation of Patients With Acute Coronary Syndrome (High-STEACS) Algorithm (which uses a 2-hour, unadjusted troponin cutoff). Both approaches use repeat troponin levels at 3 hours for early presenters. The High-STEACS Algorithm ruled out more MIs at presentation and demonstrated a higher negative predictive value at 3 hours than the ESC Pathway. 4 hs-cTnI algorithms had high sensitivity and low failure rates for ruling out acute MI in the ED Ann Intern Med. 2017;167:JC35. doi:10.7326/ACPJC-2017-167-6-035 This study used data from a prospective cohort of 2828 European patients who presented to the ED with suspected MI. It applied 4 strategies that used hs-cTnI to rule out MI and found that most strategies performed similarly. Taken together, the 2 aforementioned studies reflect growing interest in understanding how to most effectively use hs-cTnI to rule out MI in the ED. As important assumptions (e.g., that patient-reported symptom timing is accurate, and that all troponin assays are the same) and biases (e.g., incorporation bias and verification bias) within both studies limit conclusions, randomized trials focusing on this important question seem necessary. Sign up here to have Annals for Hospitalists delivered to your inbox each month.
Annals for Educators - 17 October 2017 Ann. Intern. Med. (IF 17.135) Pub Date : 2017-10-17 Darren B. Taichman
Clinical Practice Points What You Can Do to Stop Firearm Violence The author calls upon physicians to educate themselves on how to identify patients at risk for harming themselves or others with firearms. He also asks that we make a personal commitment to ask our patients about firearms, counsel them on safe firearm behaviors, and take further action when an imminent hazard is present. Use this paper to: Ask your learners whether they think firearm-related injuries are a medical issue. Is it appropriate to approach the problem from an epidemiologic and public health perspective? Do your learners think they should talk to patients who they believe are at risk for firearm-related harm about how they can reduce the risks? Use the accompanying editorial to help frame your discussion. The author and editorialists encourage physicians to make a public commitment to talk to patients when they believe risks for firearm-related injuries are present. Do your learners think such declarations are useful or appropriate? Why or why not? Will your learners make such commitments? Will your learners talk to patients they believe are at risk? If so, do they know how? Do they know what they will ask and advise them? Use a recent paper that addresses such issues to help frame your discussion. Ethics and the Legalization of Physician-Assisted Suicide: An American College of Physicians Position Paper Oregon's Death With Dignity Act: 20 Years of Experience to Inform the Debate The Slippery Slope of Legalization of Physician-Assisted Suicide Physician-Assisted Suicide: Finding a Path Forward in a Changing Legal Environment This series of articles includes a position paper from the American College of Physicians (ACP) on physician-assisted suicide. Another reviews 20 years of experience since Oregon's passage of the Death With Dignity Act, which allows physicians to prescribe medications to be self-administered by terminally ill patients to hasten their death. One of the editorials argues why the ACP position paper should be credited for its clarity and courage, whereas the other warns that the position paper misses an important opportunity to educate clinicians and learn about best practices. Use these papers to: Start a teaching session with a multiple-choice question. We've provided one below. Ask your learners if a patient has ever said that she or he would like to die. How have they responded? What questions should they ask? Have they ever been asked by a patient for help ending his or her life? Do they feel qualified to talk to patients about such issues? If not, what do they need to learn? Do your learners think there are situations where a patient's request for assistance in bringing about death should be honored? Why or why not? What are the laws regarding physician-assisted suicide where you practice? If it is legal, do your learners think all physicians have an obligation to participate? If not, how do we balance the needs and beliefs of the patients and physicians involved? Some health care professional societies oppose participation in physician-assisted suicide, whereas others provide support to physicians who do participate. What do your learners think is the best approach? Do your learners think there is a difference between palliative sedation and/or analgesics that, as a side effect, hasten death versus the provision of sedatives and/or analgesics that are used to bring about death? State Intimate Partner Violence–Related Firearm Laws and Intimate Partner Homicide Rates in the United States, 1991 to 2015 Intimate partner violence affects 1 in 3 women. This study examined the relationship between state intimate partner violence–related firearm laws and intimate partner homicides in the United States between 1991 and 2015. Use this study to: Ask your learners who is at risk for intimate partner violence. Do they ask patients whether they have been victims of intimate partner violence or are worried about this issue? Review the U.S. Preventive Services Task Force recommendation statement that recommends screening all women of childbearing age for intimate partner violence. Why have federal laws aimed at protecting women from intimate partner violence been less effective than they might have been? Do your learners think they will be comfortable asking their patients about these issues? Why or why not? How can they overcome any hesitation so as to better protect their patients? What else can physicians do to help reduce the risk for intimate partner violence? Use the accompanying editorial to help frame your discussion. Annals for Hospitalists Inpatient Notes: Diagnostic Excellence Starts With an Incessant Watch This concise paper discusses how we can improve our diagnostic skills by making better use of feedback on our performance. Use this paper to: Ask your learners whether they have received feedback on how well they have made correct diagnoses in their patients. How do we react when we learn that we have made an incorrect diagnosis or that it took longer than it should have to reach the right diagnosis? How can we improve how we make use of such feedback? Review the paper's table, and ask your learners if together you could adopt some of the suggested “tracking systems” the author proposes in your practices. How will you monitor yourself or each other to see whether this new approach is working? How will you judge success or failure? What does the author mean by “calibration” and “an incessant watch” with regard to improving one's diagnostic skills? Humanism and Professionalism On Being a Doctor: On Continuity Dr. Sinsky recalls how the continuity in her care for her patients, both in and out of the hospital, made enormous differences and meant the world to them (and her). Can such continuity survive as medical practice models evolve? Use this essay to: Listen to an audio recording of the essay, read by Dr. Michael LaCombe. How frequently do physicians at your center follow their outpatients when they are hospitalized? Do your learners go to see their outpatients when they are admitted? Why or why not? What are the barriers to outpatient-based physicians following their patients in the hospital? What pressures have made such practice less common? In what ways has hospital care been improved by its being led by physicians focusing only on inpatient care? What are the tradeoffs? The author wonders whether our profession will continue to develop systems where physicians work in the hospital or in outpatient settings, but not both. She believes that safer and more satisfying models will emerge but that they will be worked out by the next generation of physicians. What do your learners think is best? How should the system work? MKSAP 16 Question A 54-year-old man is evaluated for a long-standing history of COPD. Although he had previously done well, his lung function has progressively declined over the past year. He is oxygen dependent and is unable to perform even minor physical activity without severe dyspnea. He is not a transplant candidate and is unhappy with his quality of life and prognosis. He requests a prescription that he can take that will cause him to die at the time of his choosing. Which of the following is the most appropriate next step in management of this patient's request? A. Assess the adequacy of his current treatment B. Consult legal counsel about state law in such cases C. Decline the request D. Prescribe sedating medication that could ensure a comfortable death Correct Answer A. Assess the adequacy of his current treatment Educational Objective Manage a request for physician-assisted suicide. Critique When approached with a request for assistance in dying, it is best to respond to the request with empathy and compassion, and assess whether or not the patient is receiving adequate palliative interventions. Optimizing care interventions focused on maintaining or improving the quality of life may not always occur in the context of treating the underlying disease process; thus, reviewing the patient's overall care to address comfort and functional issues in severe illness is essential to appropriate management. Involving physicians trained specifically in palliative care medicine may also be helpful in such situations. Physician-assisted suicide is a controversial area of ethics. Most ethicists agree that it is acceptable to consider interventions that may hasten the death of a terminally ill patient if the primary intent is therapeutic (the principle of “double effect”). However, physician-assisted suicide using prescriptions or interventions with the specific intent to kill the patient is illegal in most states. The American Medical Association and the American College of Physicians have both taken positions against the practice. Seeking legal counsel may be advisable if one intends to provide the patient assistance in dying, as states in which it is legal have specific protocols that must be followed. However, this step would not be appropriate until alternatives such as improved palliative care were assessed. Categorically refusing to discuss a request for physician-assisted suicide can close the door to a discussion of why the patient is making the request and may jeopardize the therapeutic relationship with the patient. Writing a prescription for medication to assist a patient in dying without a detailed assessment of the patient's situation and motives would be irresponsible. Key Point When approached with a request for assistance in dying, it is best to respond to the request with empathy and compassion, and assess whether or not the patient is receiving adequate palliative care. Bibliography Snyder L, Sulmasy DP; Ethics and Human Rights Committee, American College of Physicians-American Society of Internal Medicine. Physician-assisted suicide. Ann Intern Med. 2001;135(3):209-216. 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 - Mythbuster: Preoperative Blood Pressure Control Ann. Intern. Med. (IF 17.135) Pub Date : 2017-10-17 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.
The Health Care Professional's Pledge: Protecting Our Patients From Firearm Injury Ann. Intern. Med. (IF 17.135) Pub Date : 2017-10-17 Christine Laine, Darren B. Taichman
Access the Comments on Wintemute's article to see who has committed to talk to their at-risk patients about firearm safety. Make your commitment now. Too many of our patients suffer when bullets maim or kill them or their loved ones. And those not yet personally harmed by guns worry about the potential for future harm presented by the ubiquity of guns in America. Regardless of whether one believes guns hurt people or that people hurt people with guns, we have a public health crisis and health care professionals have an obligation to do what we can to combat it. Annals of Internal Medicine has raised the alarm about guns since at least 1998 (1–3). More recently, we have published strong recommendations to reduce firearm injury from the American College of Physicians (ACP) (4) and another from the ACP with 7 other health organizations together with the American Bar Association (5). Improvements in public health require careful study. We've published rigorous reviews to help synthesize what is and is not known (6). The dearth of evidence to inform sensible gun regulation led us to solicit original research and work hard to help authors report it accurately so that the most may be learned by others seeking to learn from and build upon the findings (7–17). Firearms have also been the subject of On Being a Doctor essays (18, 19). We've repeatedly called on ourselves and our colleagues to examine the evidence, take action, and raise our voices (20–34). We've cried out that we must use our voices. Nowhere are our voices more important than in the privacy of the examination room. This is where our work is done, where all the research and learning come together. Of all the times and places where we might speak, this is where our voices stand to do the most immediate good. We must commit to using that time and place to help protect our patients from firearm-related harm. In this issue, Wintemute calls on each of us to make a commitment to ask our patients about firearms when, in our judgment, it is appropriate and to follow through (35). We know the factors that should alert us to the risk for alcohol, tobacco, and other substance use disorders; sexually transmitted disease; intimate partner abuse; suicidality; and other preventable harms to our patients. We ask about these risks and counsel accordingly. The risks for harming oneself or exposing others to harm from a firearm are also known. And we know we should speak up (34). While changes in U.S. gun regulations are sorely needed to address population-level threats presented by the availability of military-style firearms and unlimited ammunition, physicians and other health professionals at the frontline of patient care can help prevent firearm-related harm one patient at a time. Go to http://go.annals.org/commit-now and make the commitment to start doing this right now. By making a public commitment to ask our patients about firearms and counsel them to reduce this risk, we show our patients and their communities that we are committed to their safety and health. Feeling uncomfortable about how to talk with patients about guns is not a reason to shy away. Read when and how to do it (36). Let's start now. Too many of our patients are in danger. This simply cannot wait. References Davidoff F. Reframing gun violence [Editorial]. Ann Intern Med. 1998;128:234-5. [PMID: 9454533] American College of Physicians. Firearm injury prevention. Ann Intern Med. 1998;128:236-41. [PMID: 9454534] Cassel CK, Nelson EA, Smith TW, Schwab CW, Barlow B, Gary NE. Internists' and surgeons' attitudes toward guns and firearm injury prevention. Ann Intern Med. 1998;128:224-30. [PMID: 9454531] Butkus R, Doherty R, Daniel H; Health and Public Policy Committee of the American College of Physicians. Reducing firearm-related injuries and deaths in the United States: executive summary of a policy position paper from the American College of Physicians. Ann Intern Med. 2014;160:858-60. [PMID: 24722815] doi:10.7326/M14-0216 Weinberger SE, Hoyt DB, Lawrence HC 3rd, Levin S, Henley DE, Alden ER, et al. Firearm-related injury and death in the United States: a call to action from 8 health professional organizations and the American Bar Association. Ann Intern Med. 2015;162:513-6. [PMID: 25706470] doi:10.7326/M15-0337 Anglemyer A, Horvath T, Rutherford G. The accessibility of firearms and risk for suicide and homicide victimization among household members: a systematic review and meta-analysis. Ann Intern Med. 2014;160:101-10. [PMID: 24592495] Anglemyer A, Miller ML, Buttrey S, Whitaker L. Suicide rates and methods in active duty military personnel, 2005 to 2011: a cohort study. Ann Intern Med. 2016;165:167-74. [PMID: 27272476] doi:10.7326/M15-2785 Díez C, Kurland RP, Rothman EF, Bair-Merritt M, Fleegler E, Xuan Z, et al. State intimate partner violence-related firearm laws and intimate partner homicide rates in the United States, 1991 to 2015. Ann Intern Med. 2017. [PMID: 28975202] doi:10.7326/M16-2849 Goldstick JE, Carter PM, Walton MA, Dahlberg LL, Sumner SA, Zimmerman MA, et al. Development of the SaFETy score: a clinical screening tool for predicting future firearm violence risk. Ann Intern Med. 2017;166:707-14. [PMID: 28395357] doi:10.7326/M16-1927 Studdert DM, Zhang Y, Rodden JA, Hyndman RJ, Wintemute GJ. Handgun acquisitions in California after two mass shootings. Ann Intern Med. 2017;166:698-706. [PMID: 28462425] doi:10.7326/M16-1574 Reid JA, Richards TN, Loughran TA, Mulvey EP. The relationships among exposure to violence, psychological distress, and gun carrying among male adolescents found guilty of serious legal offenses: a longitudinal cohort study. Ann Intern Med. 2017;166:412-8. [PMID: 28135726] doi:10.7326/M16-1648 Miller M, Hepburn L, Azrael D. Firearm acquisition without background checks: results of a national survey. Ann Intern Med. 2017;166:233-9. [PMID: 28055050] doi:10.7326/M16-1590 Rowhani-Rahbar A, Fan MD, Simonetti JA, Lyons VH, Wang J, Zatzick D, et al. Violence perpetration among patients hospitalized for unintentional and assault-related firearm injury: a case-control study and a cohort study. Ann Intern Med. 2016;165:841-7. [PMID: 27750282] doi:10.7326/M16-1596 Rowhani-Rahbar A, Zatzick D, Wang J, Mills BM, Simonetti JA, Fan MD, et al. Firearm-related hospitalization and risk for subsequent violent injury, death, or crime perpetration: a cohort study. Ann Intern Med. 2015;162:492-500. [PMID: 25706337] doi:10.7326/M14-2362 Hsieh JK, Arias JJ, Sarmey N, Rose JA, Tousi B. Firearms among cognitively impaired persons: a cross-sectional study. Ann Intern Med. 2015;163:485-7. [PMID: 26370021] doi:10.7326/L15-5138 Butkus R, Weissman A. Internists' attitudes toward prevention of firearm injury. Ann Intern Med. 2014;160:821-7. [PMID: 24722784] doi:10.7326/M13-1960 Boggs JM, Simon GE, Ahmedani BK, Peterson E, Hubley S, Beck A. The association of firearm suicide with mental illness, substance use conditions, and previous suicide attempts. Ann Intern Med. 2017;167:287-8. [PMID: 28672343] doi:10.7326/L17-0111 Wallace EA. The firearm for protection? A risky bet. Ann Intern Med. 2016;164:698-9. [PMID: 27182905] doi:10.7326/M15-2100 Quinn C. The pirates. Ann Intern Med. 1999;131:472-3. [PMID: 10498567] Laine C, Taichman DB, Mulrow C, Berkwits M, Cotton D, Williams SV. A resolution for physicians: time to focus on the public health threat of gun violence [Editorial]. Ann Intern Med. 2013;158:493-4. [PMID: 23277894] Taichman DB, Bauchner H, Drazen JM, Laine C, Peiperl L. Firearm-related injury and death: a U.S. health care crisis in need of health care professionals. Ann Intern Med. 2017. [Epub ahead of print]. doi:10.7326/M17-2657 Fisher J, Bonomi A. Firearm surrender laws: prompting promise for women's health. Ann Intern Med. 2017. [PMID: 28975259] doi:10.7326/M17-2399 Webster DW. The true effect of mass shootings on Americans. Ann Intern Med. 2017;166:749-50. [PMID: 28462426] doi:10.7326/M17-0943 Cook PJ. At last, a good estimate of the magnitude of the private-sale loophole for firearms. Ann Intern Med. 2017;166:301-2. [PMID: 28055051] doi:10.7326/M16-2819 Hargarten S. Firearm injury in the United States: effective management must address biophysical and biopsychosocial factors. Ann Intern Med. 2016;165:882-3. [PMID: 27750331] doi:10.7326/M16-2244 Weinberger SE. Curbing firearm violence: identifying a specific target for physician action. Ann Intern Med. 2016;165:221-2. [PMID: 27183475] doi:10.7326/M16-0968 Taichman DB, Laine C. Reducing firearm-related harms: time for us to study and speak out [Editorial]. Ann Intern Med. 2015;162:520-1. [PMID: 25706587] doi:10.7326/M15-0428 Hemenway D. Guns, suicide, and homicide: individual-level versus population-level studies [Editorial]. Ann Intern Med. 2014;160:134-5. [PMID: 24592499] Kapp MB. Geriatric patients, firearms, and physicians. Ann Intern Med. 2013;159:421-2. [PMID: 23836076] doi:10.7326/0003-4819-159-5-201309030-00682 Fisher CE, Lieberman JA. Getting the facts straight about gun violence and mental illness: putting compassion before fear. Ann Intern Med. 2013;159:423-4. [PMID: 23836046] doi:10.7326/0003-4819-159-5-201309030-00679 Chapman S, Alpers P. Gun-related deaths: how Australia stepped off “the American path”. Ann Intern Med. 2013;158:770-1. [PMID: 23478752] doi:10.7326/0003-4819-158-10-201305210-00624 Frattaroli S, Webster DW, Wintemute GJ. Implementing a public health approach to gun violence prevention: the importance of physician engagement. Ann Intern Med. 2013;158:697-8. [PMID: 23400374] doi:10.7326/0003-4819-158-9-201305070-00597 Coulehan J. The tragic events of April 1996. Ann Intern Med. 2000;132:911-3. [PMID: 10836919] Betz ME, Ranney ML, Wintemute GJ. Physicians, patients, and firearms: the courts say “yes”. Ann Intern Med. 2017;166:745-6. [PMID: 28265644] doi:10.7326/M17-0489 Wintemute GJ. What you can do to stop firearm violence. Ann Intern Med. 2017. [Epub ahead of print]. doi:10.7326/M17-2672 Wintemute GJ, Betz ME, Ranney ML. Yes, you can: physicians, patients, and firearms. Ann Intern Med. 2016;165:205-13. [PMID: 27183181] doi:10.7326/M15-2905
What You Can Do to Stop Firearm Violence Ann. Intern. Med. (IF 17.135) Pub Date : 2017-10-17 Garen J. Wintemute
Access the Comments feature to see who has committed to talk to their at-risk patients about firearm safety. Make your commitment now. Mass shootings are reshaping the character of American public life. Whoever we are, they happen to people just like us; they happen in places just like our places. We all sense that we are at risk. Yet even as we focus on the latest tragedy in Las Vegas, we must remember that these horrific mass shootings have accounted for no more than 1% to 2% of deaths from firearm violence in recent years. The 2 mass shootings with the highest fatality counts in modern U.S. history, in Las Vegas on 1 October 2017 and Orlando on 12 June 2016, resulted in 107 deaths. Yet nationwide in 2016, there was an average of 97 deaths from firearm violence per day: 35 476 altogether (1). In the 10 years ending with 2016, deaths of U.S. civilians from firearm violence exceeded American combat fatalities in World War II. Calls for action in the wake of Las Vegas have been made not just with profound sadness and outrage but with a here-we-go-again sense of futility. This is entirely appropriate if action by Congress and the White House is being called for—those institutions have abdicated their responsibility on this complex and pressing problem as on so many others. But there is a critically important and beneficial action that we physicians can take, right now and on our own initiative. Fundamentally, it's quite simple. We need to ask our patients about firearms, counsel them on safe firearm behaviors, and take further action when an imminent hazard is present (2). This can be a focused intervention, because violence is not distributed at random. People who commit firearm violence—whether against others or themselves—and people who sustain it often have well-recognized risk factors. As a result, firearm violence can to some extent be predicted. What's more, these factors often bring high-risk individuals into contact with physicians. They include abuse of alcohol (3) and controlled substances, acute injury (4), a history of violence (including a suicide attempt), poorly controlled severe mental illness (5), an abusive partner, and serious life stressors. The relationship between fatal violence and recent contact with a health professional is clearest for people who commit suicide: As many as 45% have seen their primary care provider within a month of their deaths (6). Particularly at older ages, these persons frequently disclose their intent to kill themselves, and they are most likely to do so when they have coexisting health problems (7). Unintentional injury is a concern, too; are there children or impaired adults exposed to firearms, creating a risk for unintended harm to themselves or others? We already acknowledge that we should talk about firearms with patients, and patients agree (8); however, we don't do it (2). There are barriers, to be sure. We may be concerned that we don't know enough about firearms, or about the benefits and risks associated with owning and using them. We may think that we don't have time. We may even believe that such conversations are prohibited by law, which is a myth. In fact, there is a growing literature on when such conversations are most appropriate, how to ask the questions, and what to do with the answers (9). The key, as always, is to make clear that we are asking because we care about our patients' health and well-being. Materials for both physicians and patients are available (2), and more are in development. Many professional societies, including the American College of Physicians, have agreed that talking about firearms is something a physician should do (10). With all that in mind, here is what you can do right now to help stop firearm injury and death: Make a commitment to ask your patients about firearms when, in your judgment, it is appropriate, and follow through. If you need to study up in advance, so be it. As we know, commitments to change health-related behaviors mean more when they are made in public. The Figure is the template to post a comment at http://go.annals.org/commit-now in response to this commentary. Fill it out and post it. If you give us permission to contact you, we will follow up to see how you're doing, let you know what others have done, and provide new resources as they become available. By all means, e-mail this commentary to your colleagues or send the link (http://annals.org/aim/article/doi/10.7326/M17-2672); encourage them to make a commitment similar to yours. The form closes on 16 April 2018. Figure. Template for commitment to help reduce firearm-related injuries and deaths. You won't be acting alone. I frequently hear from physicians who have reached a personal tipping point and decided to stay on the sidelines no longer. For the first time in more than 20 years, a growing group of clinical and basic science researchers is providing new information on the risks and benefits of firearm ownership and the prevention of firearm violence at the individual and societal levels. The Centers for Disease Control and Prevention is still not in the game, but the National Institutes of Health had a formal program of firearm violence research funding from 2013 to 2016 and remains open to proposals. The National Institute of Justice, which has been providing support at least since the 1990s, made 4 grants totaling $2.9 million in early October. California has just established the nation's first publicly funded firearm violence research center, and New York may follow suit. These activities and others in the background will help create the knowledge base and infrastructure to make your efforts as effective as possible. But in the end, it all comes down to what happens between you and your patient in the office, or the hospital, or the emergency department. Please make your commitment. There is no better time, and it's the right thing to do. References Centers for Disease Control and Prevention. Web-based interactive surveillance query and response system (WISQARS). Accessed at www.cdc.gov/injury/wisqars/index.html on 8 October 2017. Wintemute GJ Betz ME Ranney ML Yes, you can: physicians, patients, and firearms. Ann Intern Med 2016 165 205 13 CrossRef PubMed Wintemute GJ Wright MA Castillo-Carniglia A Shev A Cerdá M Firearms, alcohol and crime: convictions for driving under the influence (DUI) and other alcohol-related crimes and risk for future criminal activity among authorised purchasers of handguns. Inj Prev 2017 PubMed Rowhani-Rahbar A Zatzick D Wang J Mills BM Simonetti JA Fan MD et al Firearm-related hospitalization and risk for subsequent violent injury, death, or crime perpetration: a cohort study. Ann Intern Med 2015 162 492 500 CrossRef PubMed Swanson JW McGinty EE Fazel S Mays VM Mental illness and reduction of gun violence and suicide: bringing epidemiologic research to policy. Ann Epidemiol 2015 25 366 76 PubMed CrossRef PubMed Luoma JB Martin CE Pearson JL Contact with mental health and primary care providers before suicide: a review of the evidence. Am J Psychiatry 2002 159 909 16 PubMed CrossRef PubMed Choi NG, DiNitto DM, Marti CN, Kaplan MS. Older Suicide Decedents: Intent Disclosure, Mental and Physical Health, and Suicide Means. Am J Prev Med. 2017. doi:10.1016/j.amepre.2017.07.0218. Betz ME Azrael D Barber C Miller M Public opinion regarding whether speaking with patients about firearms is appropriate: results of a national survey. Ann Intern Med 2016 165 543 50 CrossRef PubMed Betz ME Wintemute GJ Physician counseling on firearm safety: a new kind of cultural competence. JAMA 2015 314 449 50 PubMed CrossRef PubMed Weinberger SE Hoyt DB Lawrence HC 3rd Levin S Henley DE Alden ER et al Firearm-related injury and death in the United States: a call to action from 8 health professional organizations and the American Bar Association. Ann Intern Med 2015 162 513 6 CrossRef PubMed
Public Opinion About the Relationship Between Firearm Availability and Suicide: Results From a National Survey Ann. Intern. Med. (IF 17.135) Pub Date : 2017-10-24 Andrew Conner, Deborah Azrael, Matthew Miller
Background: In 2015, more than 44 000 persons in the United States died by suicide; one half of these persons used firearms (1). Considering and addressing beliefs about the relationship between firearms and suicide in this country are likely to improve prevention strategies that aim to lower suicide rates by reducing ready access to firearms, such as those endorsed by several medical societies (2). However, the extent to which persons in the United States understand that household firearms increase the risk for suicide is unknown. Objective: To use a nationally representative sample to describe public opinion about whether household firearms increase the risk for suicide. Methods and Findings: We used data from a 2015 Web-based survey conducted by Growth for Knowledge (3). Our primary outcome was the proportion of respondents who agreed with the statement, “Having a gun in the home increases the risk of suicide.” Response options were “strongly agree,” “agree,” “neither,” “disagree,” and “strongly disagree” and were categorized for analysis as agree, disagree, or neither. Other variables assessed included sociodemographic characteristics, opinions about firearm-related issues, prior firearm safety training, living in a home with firearms, and personal firearm ownership. We examined 2 items routinely collected from panel members: whether they had ever been diagnosed with a mental health condition and their occupation. Those who reported their occupation as “medical doctor (i.e. physician, surgeon, dentist, veterinarian)” or “other healthcare practitioner (i.e. nurse, pharmacist, chiropractor, dietician)” were grouped together as health care practitioners. Of the 7318 invited panel members, 3949 completed the survey (54.6% survey completion rate). Seventeen persons with missing responses to our key question about whether firearms increase suicide risk were excluded, resulting in a final sample of 3931 persons. A total of 15.4% (95% CI, 13.1% to 18.1%) of U.S. adults agreed that the presence of a firearm in the home increases the risk for suicide (6.3% [CI, 5.2% to 7.6%] of firearm owners, 8.9% [CI, 6.7% to 11.7%] of those who do not own a firearm but live with someone who does, and 19.8% [CI, 16.3% to 23.8%] of those who live in a home without firearms) (Table). Nearly 1 of 3 health care practitioners (30.2% [CI, 14.0% to 53.3%]) agreed that having a household firearm increases suicide risk; among health care practitioners who own firearms, 11.8% (CI, 4.5% to 27.3%) agreed with this statement. Fewer than 10% of gun owners with children (or gun owners who had received firearm training) agreed that household firearms increase suicide risk. Table. Proportion of Respondents Who Agreed That Having a Firearm in the Home Increases the Risk for Suicide, by Firearm Ownership Status and Selected Respondent Characteristics* Table. Proportion of Respondents Who Agreed That Having a Firearm in the Home Increases the Risk for Suicide, by Firearm Ownership Status and Selected Respondent Characteristics* Discussion: Our finding that most persons in the United States do not endorse the statement, “Having a gun in the home increases the risk of suicide,” may reflect broad skepticism about the effectiveness of preventing suicide by reducing access to means of suicide with high case fatality rates (that is, those likely to prove lethal). Consistent with this possibility, prior work has found that 75% of persons in the United States believe that few if any lives would be saved by erecting a wholly effective jumping barrier on the Golden Gate Bridge (4). In that study, gun owners were more likely than any other group to believe that persons who died by jumping from the bridge would have inevitably committed suicide using some other means. Our study has limitations, the most potentially consequential being that some respondents may have misinterpreted our key question as referring to suicidal ideation or nonlethal suicidal behavior rather than death by suicide. However, findings from prior studies of beliefs about suicide suggest that most respondents probably interpreted our key question as including death by suicide (4, 5). In addition to the results from the Golden Gate Bridge study, our finding that more than one half of health care practitioners actively disagree that a gun in the home increases the risk for suicide concurs with estimates derived from an emergency department survey that found that 67% of nurses and 44% of physicians believe that most persons who die of suicide by firearm would have found another way to die had the firearm not been available (5). Even if one half of respondents misinterpreted our question as excluding death by suicide, the conclusion remains that too many persons in the United States do not understand the empirical reality that a gun in the home substantially increases the risk for suicide. Moreover, given that health care providers can play a crucial role in identifying suicidality and intervening in ways to reduce risk for suicide, our finding that more than two thirds of providers are unaware of this increased risk is concerning. Despite these limitations, our findings suggest that medical and public health communities need to better educate at-risk patients and health care providers about how and why firearms increase the risk for suicide. Doing so will enable patients and their families to make more informed decisions about how to protect vulnerable members of their households. Health care providers can play an important role in communicating this message. References Centers for Disease Control and Prevention. Injury Prevention & Control: Data and Statistics. Web-based Injury Statistics Query and Reporting System (WISQARS). Accessed at www.cdc.gov/injury/wisqars/index.html on 2 February 2017. Weinberger SE Hoyt DB Lawrence HC 3rd Levin S Henley DE Alden ER et al Firearm-related injury and death in the United States: a call to action from 8 health professional organizations and the American Bar Association. Ann Intern Med 2015 162 513 6 CrossRef PubMed Miller M Hepburn L Azrael D Firearm acquisition without background checks: results of a national survey. Ann Intern Med 2017 166 233 39 CrossRef PubMed Miller M Azrael D Hemenway D Belief in the inevitability of suicide: results from a national survey. Suicide Life Threat Behav 2006 36 1 11 PubMed CrossRef PubMed Betz ME Miller M Barber C Miller I Sullivan AF Camargo CA Jr et al ED-SAFE Investigators Lethal means restriction for suicide prevention: beliefs and behaviors of emergency department providers. Depress Anxiety 2013 30 1013 20 PubMed PubMed
Firearm Injury After Gun Shows: Evidence to Gauge the Potential Impact of Regulatory Interventions Ann. Intern. Med. (IF 17.135) Pub Date : 2017-10-24 Ali Rowhani-Rahbar, Frederick P. Rivara
The recent mass shooting in Las Vegas, Nevada, was a painful reminder that injuries and deaths resulting from access to guns continue to bedevil many parts of U.S. society, including communities; the health care industry; and the families of those injured, killed, or threatened by firearms. Although the problem created by more than 300 million guns in the United States will ultimately need a political solution, science and scientific publications have important roles in assessing and promoting awareness about interventions that may reduce the 36 000 fatal and 85 000 nonfatal firearm injuries each year (1). The lack of meaningful action by Congress has left states to chip away in myriad ways at reducing access to guns by those likely to use them for harm against themselves or others. Several studies have shown an inverse association between the stringency of state legislation to restrict firearm access and the rate of firearm injuries and deaths (2). However, our knowledge about the effect of policies regulating gun shows on firearm morbidity and mortality is severely limited. Matthay and colleagues (3) examined the association between gun shows occurring separately in California and Nevada and short-term changes in the rates of fatal and nonfatal firearm injuries in California regions exposed to those shows. Gun shows account for only a small proportion of private-party firearm transfers; nevertheless, they can be a source of guns used in crime (4). Gun shows allow both licensed dealers and unlicensed persons to sell firearms to attendees. Whereas purchases from federally licensed dealers require a background check of the potential buyer before a sale is made, several states do not require these checks in private-party sales, as was the case in Nevada during Matthay and colleagues' study period. In California, on the other hand, firearm transfers at shows must be processed through a licensed dealer (5). Thus, the concern was raised that California residents can simply drive over the state line and purchase guns at a Nevada show without any background check or waiting period. Matthay and colleagues compared the rates of firearm injuries in the 2 weeks after and before gun shows among California residents within convenient driving distance of shows in Nevada versus California. Their analysis accounted for California's 10-day waiting period between purchasing and obtaining a gun. Comparing California regions exposed to Nevada shows with those exposed to California shows, the ratios of after–before rate ratios were 1.70 (95% CI, 1.17 to 2.47) for all-intent firearm injuries and 2.23 (CI, 1.01 to 4.90) for interpersonal firearm injuries. This ratio was mainly driven by changes in firearm injuries after Nevada shows. Whereas firearm injuries of any intent did not change meaningfully among California regions exposed to California gun shows, the rate of interpersonal firearm injuries increased significantly among California regions exposed to Nevada shows. However, as the authors note, the difference in absolute rates of firearm injuries was small: an overall increase from 0.67 to 1.14 injuries per 100 000 California residents exposed to Nevada shows. The authors should be commended for using various strategies, including negative control analysis and quantitative bias analysis, to gauge their findings' sensitivity to assumptions and robustness to potential confounding. These approaches are important, especially considering the differences between California regions exposed to California versus Nevada shows. Table 2 of the article shows notable differences between the absolute rates of firearm injuries before shows in those 2 types of region: In regions exposed to California shows, the rate of interpersonal firearm injuries was greater than that of each other type of firearm injury, whereas in regions exposed to Nevada shows, the rate of unintentional firearm injuries was highest. As such, unmeasured differences might exist between those 2 California regions that can influence short-term changes in the rates of firearm injuries after gun shows. A limitation of the study, as acknowledged by authors, is that firearm injuries were not examined among Nevada residents themselves. If unregulated gun shows increase firearm injuries in the short term, one may expect to see such an association among Nevada residents exposed to shows in that state. The data in Matthay and colleagues' study may suggest some association between gun shows and self-directed and unintentional firearm injuries, but the estimates (that is, about 50% to 60% relative increase) were not statistically significant. It is often forgotten that about two thirds of firearm deaths in the United States are suicides. A prior study by Wintemute and colleagues showed that purchasers of a handgun had a 57-fold and 7-fold increased risk for firearm suicide in the first week and first year, respectively, after purchase (6). Evidence indicates that the means available to commit self-harm matter and that restricting the most lethal means (that is, firearms) can prevent the loss of lives due to suicide (7). Also, future research should examine whether gun shows affect unintentional firearm injuries, and if so, what plausible explanations might exist. The study by Matthay and colleagues has many implications for gun policy in the United States. Laws regulating access to guns matter and do make a difference, especially collectively (2); however, their impact on an individual basis is a somewhat small chip in the granite wall of firearm injuries and deaths. The state-by-state nature of these laws, due to the lack of federal legislation, results in barriers to gun access that can be easily breached by a car trip. It does not reduce the importance of the laws but does reduce their impact. Unfortunately, the amount of research on firearms is disproportionately low compared with the burden they impose on health care and society as a whole. In 1996, Congress inserted language into the Centers for Disease Control and Prevention appropriation bills that essentially prevented it from conducting and funding firearm-related research (8, 9); this lack of funding continues to this day. Nevertheless, the public health burden of firearm-related injuries and death demands that research on interventions to reduce this toll be continued, funded by local and state governments, foundations, and philanthropy. References Centers for Disease Control and Prevention; National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS). Accessed at www.cdc.gov/injury/wisqars on 3 October 2017. Santaella-Tenorio J Cerdá M Villaveces A Galea S What do we know about the association between firearm legislation and firearm-related injuries? Epidemiol Rev 2016 38 140 57 PubMed PubMed Matthay EC Galin J Rudolph KE Farkas K Wintemute GJ Ahern J In-state and interstate associations between gun shows and firearm deaths and injuries. A quasi-experimental study. Ann Intern Med 2017. [Epub ahead of print] Wintemute G. Background Checks for Firearm Transfers. Violence Prevention Research Program, University of California, Davis; 2013. Accessed at www.ucdmc.ucdavis.edu/vprp/CBC%20White%20Paper%20Final%20Report%20022013.pdf on 3 October 2017. Law Center to Prevent Gun Violence. Gun Shows in California. 2016. Accessed at http://smartgunlaws.org/gun-shows-in-california on 3 October 2017. Wintemute GJ Parham CA Beaumont JJ Wright M Drake C Mortality among recent purchasers of handguns. N Engl J Med 1999 341 1583 9 PubMed CrossRef PubMed Barber CW Miller MJ Reducing a suicidal person's access to lethal means of suicide: a research agenda. Am J Prev Med 2014 47 S264 72 PubMed CrossRef PubMed Kellermann AL Rivara FP Silencing the science on gun research. JAMA 2013 309 549 50 PubMed CrossRef PubMed Department of Health and Human Services Appropriations Act, Pub. L. No. 104-208, 110 Stat. 1996. Accessed at www.congress.gov/104/plaws/publ208/PLAW-104publ208.pdf on 11 October 2017.
Synopsis of the 2017 U.S. Department of Veterans Affairs/U.S. Department of Defense Clinical Practice Guideline: Management of Type 2 Diabetes Mellitus Ann. Intern. Med. (IF 17.135) Pub Date : 2017-10-24 Paul R. Conlin, Jeffrey Colburn, David Aron, Rose Mary Pries, Mark P. Tschanz, Leonard Pogach
Description: In April 2017, the U.S. Department of Veterans Affairs (VA) and the U.S. Department of Defense (DoD) approved a joint clinical practice guideline for the management of type 2 diabetes mellitus. Methods: The VA/DoD Evidence-Based Practice Work Group convened a joint VA/DoD guideline development effort that included a multidisciplinary panel of practicing clinician stakeholders and conformed to the Institute of Medicine's tenets for trustworthy clinical practice guidelines. The guideline panel developed key questions in collaboration with the ECRI Institute, which systematically searched and evaluated the literature through June 2016, developed an algorithm, and rated recommendations by using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. Recommendations: This synopsis summarizes key features of the guideline in 7 areas: patient-centered care and shared decision making, glycemic biomarkers, hemoglobin A1c target ranges, individualized treatment plans, outpatient pharmacologic treatment, glucose targets for critically ill patients, and treatment of hospitalized patients.
In-State and Interstate Associations Between Gun Shows and Firearm Deaths and Injuries: A Quasi-experimental Study Ann. Intern. Med. (IF 17.135) Pub Date : 2017-10-24 Ellicott C. Matthay, Jessica Galin, Kara E. Rudolph, Kriszta Farkas, Garen J. Wintemute, Jennifer Ahern
Background: Gun shows are an important source of firearms, but no adequately powered studies have examined whether they are associated with increases in firearm injuries. Objective: To determine whether gun shows are associated with short-term increases in local firearm injuries and whether this association differs by the state in which the gun show is held. Design: Quasi-experimental. Setting: California. Participants: Persons in California within driving distance of gun shows. Measurements: Gun shows in California and Nevada between 2005 and 2013 (n = 915 shows) and rates of firearm-related deaths, emergency department visits, and inpatient hospitalizations in California. Results: Compared with the 2 weeks before, postshow firearm injury rates remained stable in regions near California gun shows but increased from 0.67 injuries (95% CI, 0.55 to 0.80 injuries) to 1.14 injuries (CI, 0.97 to 1.30 injuries) per 100 000 persons in regions near Nevada shows. After adjustment for seasonality and clustering, California shows were not associated with increases in local firearm injuries (rate ratio [RR], 0.99 [CI, 0.97 to 1.02]) but Nevada shows were associated with increased injuries in California (RR, 1.69 [CI, 1.16 to 2.45]). The pre–post difference was significantly higher for Nevada shows than California shows (ratio of RRs, 1.70 [CI, 1.17 to 2.47]). The Nevada association was driven by significant increases in firearm injuries from interpersonal violence (RR, 2.23 [CI, 1.01 to 4.89]) but corresponded to a small increase in absolute numbers. Nonfirearm injuries served as a negative control and were not associated with California or Nevada gun shows. Results were robust to sensitivity analyses. Limitation: Firearm injuries were examined only in California, and gun show occurrence was not randomized. Conclusion: Gun shows in Nevada, but not California, were associated with local, short-term increases in firearm injuries in California. Differing associations for California versus Nevada gun shows may be due to California's stricter firearm regulations. Primary Funding Source: National Institutes of Health; University of California, Berkeley; and Heising-Simons Foundation.
When Clinical Practice Guidelines Collide: Finding a Way Forward Ann. Intern. Med. (IF 17.135) Pub Date : 2017-10-24 Sheldon Greenfield, Sherrie H. Kaplan
That physicians may disagree about appropriate care for an individual patient should come as no surprise. Diversity of physicians' backgrounds, training, and clinical practice experience is a well-documented contributor to physician-level variation in practice patterns. However, clinical practice guidelines (CPGs) are meant to reflect the best, most evidence-based care for the “average” patient and are meant to be followed by all physicians caring for those patients. Compensation in the United States will soon be adjusted on the basis of physician-level adherence to quality measures, which are often based on CPGs, and insurance coverage is increasingly based on CPG recommendations. Therefore, a high degree of consensus should be expected in CPGs for a given clinical situation.
Rethinking Rates of Undiagnosed Diabetes: The Value of a Confirmatory Test Ann. Intern. Med. (IF 17.135) Pub Date : 2017-10-24 Anne L. Peters
It is believed that many diabetes cases—approximately 25%—in the United States are undiagnosed (1, 2). This conclusion is based on epidemiologic surveys of respondents who had 1 test of glycemia to measure their level of fasting plasma glucose (FPG), hemoglobin A1c (HbA1c), or 2-hour glucose as part of a glucose tolerance test. However, for persons with no diabetes symptoms, the American Diabetes Association (ADA) currently recommends repeating a positive test to confirm the diagnosis. Confirmation may be done by using the same test (for example, a repeated measurement of FPG level if the previous one was elevated) or a second evaluation, such as an HbA1c test (which often is recommended because it is helpful in making treatment decisions) (3). This approach is recommended, in part, because all tests have variability that may produce values above and below a diagnostic cut point when repeated (3). In terms of clinical measures of glycemia, the 2-hour oral glucose tolerance test value is the least reproducible and thus is not recommended for nonpregnant persons (3). Measurements of FPG and HbA1c levels are more reliable, although several factors, such as race, anemia, and hemoglobinopathy, may affect glycation (4).
Technology and Medicine: Reimagining Provider Visits as the New Tertiary Care Ann. Intern. Med. (IF 17.135) Pub Date : 2017-10-24 Christian Terwiesch, David A. Asch, Kevin G. Volpp
Connected health provides a novel way of delivering care. Instead of relying exclusively on episodic encounters in a practice or hospital, connected health leverages advances in communications technology to create a high-bandwidth information exchange between patient and provider. This enables new processes, such as remote patient monitoring, secure messaging, and telehealth. Its promise is that providers can better care for patients when more closely connected to them, including during the large parts of their lives when patients are not in examining rooms or inpatient beds (1). Achieving this promise, however, requires getting past the operational demands connected health places on providers. Although remote patient engagement is often assumed to be a substitute for time-consuming face-to-face visits, in recent studies we found just the opposite: Patients introduced to a portal allowing them to send secure messages to their care team had more rather than fewer face-to-face visits (2). Once patients began using the portal, many started sharing health updates and new symptoms. Such messages could not be ignored by the care team and thus created not only more work but also additional office visits.
Introducing a Patient Portal and Electronic Tablets to Inpatient Care Ann. Intern. Med. (IF 17.135) Pub Date : 2017-10-24 Timothy R. Huerta, Ann Scheck McAlearney, Milisa K Rizer
Web-based patient portals are increasingly part of the outpatient experience and help patients engage in their own care (1, 2). In contrast, finding examples of hospitalized patients using portals during their inpatient stays is difficult. For example, a recent systematic review of patient portals found 120 studies published since 2006, but they all involved outpatient portals; inpatient portals were not mentioned (3). In addition, a systematic review focusing on inpatient portals found only 4 examples (4). The first allowed patients to use their mobile phone to access their medical record as well as information about their care team. The second allowed patients to use an electronic tablet to view profiles of their care team and hospital medication record. The third allowed patients to use an electronic tablet to access their care plans as well as information on diet and safety. The fourth example was set in the emergency department, where patients could view their medical record on a large display mounted in their room. Although all 4 examples were associated with positive outcomes, none allowed patients to send messages to their care team or to add or modify information in their medical record, features that have been shown to enhance engagement (5, 6).
Identifying Trends in Undiagnosed Diabetes in U.S. Adults by Using a Confirmatory Definition: A Cross-sectional Study Ann. Intern. Med. (IF 17.135) Pub Date : 2017-10-24 Elizabeth Selvin, Dan Wang, Alexandra K. Lee, Richard M. Bergenstal, Josef Coresh
Background: A common belief is that one quarter to one third of all diabetes cases remain undiagnosed. However, such prevalence estimates may be overstated by epidemiologic studies that do not use confirmatory testing, as recommended by clinical diagnostic criteria. Objective: To provide national estimates of undiagnosed diabetes by using a confirmatory testing strategy, in line with clinical practice guidelines. Design: Cross-sectional study. Setting: National Health and Nutrition Examination Survey results from 1988 to 1994 and 1999 to 2014. Participants: U.S. adults aged 20 years and older. Measurements: Confirmed undiagnosed diabetes was defined as elevated levels of fasting glucose (≥7.0 mmol/L [≥126 mg/dL]) and hemoglobin A1c (≥6.5%) in persons without diagnosed diabetes. Results: The prevalence of total (diagnosed plus confirmed undiagnosed) diabetes increased from 5.5% (9.7 million adults) in 1988 to 1994 to 10.8% (25.5 million adults) in 2011 to 2014. Confirmed undiagnosed diabetes increased during the past 2 decades (from 0.89% in 1988 to 1994 to 1.2% in 2011 to 2014) but has decreased over time as a proportion of total diabetes cases. In 1988 to 1994, the percentage of total diabetes cases that were undiagnosed was 16.3%; by 2011 to 2014, this estimate had decreased to 10.9%. Undiagnosed diabetes was more common in overweight or obese adults, older adults, racial/ethnic minorities (including Asian Americans), and persons lacking health insurance or access to health care. Limitation: Cross-sectional design. Conclusion: Establishing the burden of undiagnosed diabetes is critical to monitoring public health efforts related to screening and diagnosis. When a confirmatory definition is used, undiagnosed diabetes is a relatively small fraction of the total diabetes population; most U.S. adults with diabetes (about 90%) have received a diagnosis of the condition. Primary Funding Sources: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases and National Heart, Lung, and Blood Institute.
Lipoprotein Apheresis for Sitosterolemia Ann. Intern. Med. (IF 17.135) Pub Date : 2017-10-17 Nagahiko Sakuma, Hayato Tada, Hiroshi Mabuchi, Takeshi Hibino, Hirotake Kasuga
Background: Sitosterolemia is a rare autosomal recessive disease whose key feature is the inability to diminish uptake in the gut of noncholesterol sterols, such as those of plants and shellfish, or to excrete noncholesterol sterols into the bile ( 1, 2). It is caused by mutations in the adenosine triphosphate–binding cassette subfamily G member 5 or member 8 (ABCG5 or ABCG8) gene (1). Approximately 100 cases have been reported (1). The clinical manifestations in homozygous sitosterolemic patients are similar to those in patients with homozygous familial hypercholesterolemia. However, the total serum cholesterol levels in patients with homozygous sitosterolemia vary markedly, ranging from normal to extremely high (1, 2). Lipoprotein apheresis is used to reduce the levels of lipoproteins containing apolipoprotein B in patients with homozygous familial hypercholesterolemia. To our knowledge, use of lipoprotein apheresis for sitosterolemia has not been reported.
Annals for Hospitalists Inpatient Notes - Diagnostic Excellence Starts With an Incessant Watch Ann. Intern. Med. (IF 17.135) Pub Date : 2017-10-17 Gurpreet Dhaliwal
Diagnostic errors are an important quality and safety issue in health care. In an earlier installment of Annals for Hospitalists, Zwaan and Singh explained how diagnostic errors arise from a combination of systems and cognitive factors (1). Systems improvements often take years to unfold, but cognitive improvement can begin today. How can motivated clinicians begin to improve their diagnostic performance? Every model of performance improvement is built on the foundation of feedback. But when it comes to diagnostic performance, hospitalists scarcely get it. There is feedback on billing. There is feedback on length of stay. There is feedback on medication reconciliation rates. But there are no systems to deliver feedback on the most important metric of all: a correct diagnosis.
Heart in Hand Ann. Intern. Med. (IF 17.135) Pub Date : 2017-10-17 Erica C. Nakajima
Compassion Ann. Intern. Med. (IF 17.135) Pub Date : 2017-10-17 Jack Coulehan
On Continuity Ann. Intern. Med. (IF 17.135) Pub Date : 2017-10-17 Christine A. Sinsky
Walking into a patient's hospital room the morning after admission and hearing, “Dr. Sinsky, we are so glad you are here!” regularly reminded me, during my first 28 years of practice, of my purpose. I wasn't a better doctor than the physician who admitted that patient. But I was their doctor—I knew their medical and social particulars, their family, their story. They trusted that I would navigate the system; translate other physicians' recommendations; and, when they were released from the hospital, be there in the clinic to carry on. That regular reminder of purpose diminished when my practice became limited to ambulatory care. Does continuity over time and setting matter to patients? I believe that it does. Does it matter to physicians? Nearing the end of my career, I know it has mattered to me.
Unraveling the Epidemiology of Oral Human Papillomavirus Infection Ann. Intern. Med. (IF 17.135) Pub Date : 2017-10-17 Patti E. Gravitt
The burden of oral cancer in the United States has been evolving for at least 2 decades. Gains in head and neck cancer control afforded by a period effect of reduced tobacco exposure have been displaced by competing cohort effects of increasing sexual exposure to human papillomavirus (HPV) infection and subsequent increases in HPV-associated head and neck cancer, particularly oropharyngeal cancer (1). The male predominance of oropharyngeal cancer in the United States is paralleled by a much higher prevalence of oral HPV infection and a stronger relationship between number of sexual partners and oral HPV prevalence in men than women (2). The reason the risk for oral HPV infection differs between men and women remains unclear, particularly because the prevalence of genital HPV infection is similar in both sexes.
Requiem for a Scaffold Ann. Intern. Med. (IF 17.135) Pub Date : 2017-10-17 Sanket S. Dhruva, Jeptha P. Curtis
On 8 September 2017, the medical device manufacturer Abbott announced that it would halt the sale of its Absorb GT1 bioresorbable vascular scaffold (BVS), citing low sales and unsustainable margins (1). At the time of the announcement, Absorb accounted for less than 1% of the overall market for coronary stents, and the company's move came on the heels of a series of setbacks for the BVS program. In March 2017, Abbott, working with European authorities, imposed restrictions on BVS use outside clinical trials and registries. In that same month, the U.S. Food and Drug Administration (FDA) issued a letter to health care providers about potential safety concerns (2).
Possibilities Beyond Analyses of a Fee-for-Service Database and Clinician Mindset Ann. Intern. Med. (IF 17.135) Pub Date : 2017-10-17 Bruce Leff, Arnold Milstein
Based on the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), Medicare payment incentives for physicians to improve the value of health care are ascending toward maximum adjustments in 2022. With this shift, greater attention will be paid to mitigating the danger and cost of health crises for high-need, high-cost older adults. Several consistent themes emerge from relevant literature. The high-need, high-cost population is not homogeneous, obviating application of a single strategic approach to achieve value. Although not commonly measured, functional status, which is not fully discerned by diagnostic codes in Medicare billing data, has an enormous effect on costs. Finally, the highest-spending population segment has substantial annual turnover, although less so among high-need, high-cost seniors.
Benefits of Direct-Acting Antivirals for Hepatitis C Ann. Intern. Med. (IF 17.135) Pub Date : 2017-10-17 Anna S. Lok, Raymond T. Chung, Hugo E. Vargas, Arthur Y. Kim, Susanna Naggie, William G. Powderly
No advancement in the discipline of medicine parallels the dramatic progress of hepatitis C virus (HCV) infection, which within 30 years went from having no name to having safe and simple treatments that result in virologic cure in most patients. As of early 2011, the only treatment of chronic HCV infection was a combination of pegylated interferon (IFN) and ribavirin administered for 6 to 12 months. Interferon-based regimens resulted in rates of cure, termed sustained virologic response (SVR), of roughly 50% and necessitated subcutaneous injections with frequent and often serious adverse effects. The poor results led many patients to forgo treatment, even with the knowledge that HCV can be fatal. Still other patients were not candidates because of medical or psychiatric contraindications to IFN.
Mid- and Long-Term Outcome Comparisons of Everolimus-Eluting Bioresorbable Scaffolds Versus Everolimus-Eluting Metallic Stents: A Systematic Review and Meta-Analysis Ann. Intern. Med. (IF 17.135) Pub Date : 2017-10-17 Xin-Lin Zhang, Qing-Qing Zhu, Li-Na Kang, Xue-Ling Li, Biao Xu
Background: Percutaneous coronary interventions to implant bioresorbable vascular scaffolds (BVSs) were designed to reduce the late thrombotic events that occur with metallic stents. Purpose: To estimate the incidence of scaffold thrombosis after BVS implantation and compare everolimus-eluting BVSs with everolimus-eluting metallic stents (EESs) in terms of safety and efficacy at mid- and long-term follow-up in adults who had a percutaneous coronary intervention. Data Sources: PubMed, EMBASE, the Cochrane Library, conference proceedings, and relevant Web sites from inception until 20 May 2017, without language restriction. Study Selection: 7 randomized trials and 38 observational studies (each with a minimum of 6 months and 100 patient-years of follow-up) in adults with coronary artery disease who had a BVS or an EES and reported scaffold or stent thrombosis (main outcome) or other secondary outcomes (such as death, myocardial infarction, or revascularization). Data Extraction: 2 reviewers independently extracted study data, rated study quality, and assessed strength of evidence. Data Synthesis: The pooled incidence of definite or probable scaffold thrombosis after BVS implantation was 1.8% (95% CI, 1.5% to 2.2%) at a median follow-up of 1 year (41 studies, 21 884 patients) and 0.8% (CI, 0.5% to 1.3%) beyond 1 year (14 studies, 4688 patients). Seven trials involving 5578 patients that directly compared BVSs with EESs showed an increased risk for definite or probable scaffold thrombosis (odds ratio [OR], 3.40 [CI, 2.01 to 5.76]) with BVSs at a median follow-up of 25 months. Increased risks were present at early (prominently subacute), late, and very late stages, and odds beyond 1 year were almost double those seen within 1 year. Bioresorbably vascular scaffolds increased risks for myocardial infarction (OR, 1.63 [CI, 1.26 to 2.10]), target lesion revascularization (OR, 1.31 [CI, 1.03 to 1.67]), and target lesion failure (OR, 1.37 [CI, 1.12 to 1.66]); the odds for these 3 end points also increased over time. The incidences of all-cause, cardiac, and noncardiac death and of target vessel and any revascularization did not differ. Limitation: Quality of observational studies was unclear, and some data were unpublished. Conclusion: Compared with EESs, BVSs increased the risks for scaffold thrombosis and other thrombotic events at mid- and long-term follow-up, and risks increased over time. Primary Funding Source: National Natural Science Foundation of China.
Oral Human Papillomavirus Infection: Differences in Prevalence Between Sexes and Concordance With Genital Human Papillomavirus Infection, NHANES 2011 to 2014 Ann. Intern. Med. (IF 17.135) Pub Date : 2017-10-17 Kalyani Sonawane, Ryan Suk, Elizabeth Y. Chiao, Jagpreet Chhatwal, Peihua Qiu, Timothy Wilkin, Alan G. Nyitray, Andrew G. Sikora, Ashish A. Deshmukh
Background: The burden of human papillomavirus (HPV)–positive oropharyngeal squamous cell carcinoma (OPSCC) is disproportionately high among men, yet empirical evidence regarding the difference in prevalence of oral HPV infection between men and women is limited. Concordance of oral and genital HPV infection among men is unknown. Objective: To determine the prevalence of oral HPV infection, as well as the concordance of oral and genital HPV infection, among U.S. men and women. Design: Nationally representative survey. Setting: Civilian noninstitutionalized population. Participants: Adults aged 18 to 69 years from NHANES (National Health and Nutritional Examination Survey, 2011 to 2014). Measurements: Oral rinse, penile swab, and vaginal swab specimens were evaluated by polymerase chain reaction followed by type-specific hybridization. Results: The overall prevalence of oral HPV infection was 11.5% (95% CI, 9.8% to 13.1%) in men and 3.2% (CI, 2.7% to 3.8%) in women (equating to 11 million men and 3.2 million women nationwide). High-risk oral HPV infection was more prevalent among men (7.3% [CI, 6.0% to 8.6%]) than women (1.4% [CI, 1.0% to 1.8%]). Oral HPV 16 was 6 times more common in men (1.8% [CI, 1.3% to 2.2%]) than women (0.3% [CI, 0.1% to 0.5%]) (1.7 million men vs. 0.27 million women). Among men and women who reported having same-sex partners, the prevalence of high-risk HPV infection was 12.7% (CI, 7.0% to 18.4%) and 3.6% (CI, 1.4% to 5.9%), respectively. Among men who reported having 2 or more same-sex oral sex partners, the prevalence of high-risk HPV infection was 22.2% (CI, 9.6% to 34.8%). Oral HPV prevalence among men with concurrent genital HPV infection was fourfold greater (19.3%) than among those without it (4.4%). Men had 5.4% (CI, 5.1% to 5.8%) greater predicted probability of high-risk oral HPV infection than women. The predicted probability of high-risk oral HPV infection was greatest among black participants, those who smoked more than 20 cigarettes daily, current marijuana users, and those who reported 16 or more lifetime vaginal or oral sex partners. Limitation: Sexual behaviors were self-reported. Conclusion: Oral HPV infection is common among U.S. men. This study's findings provide several policy implications to guide future OPSCC prevention efforts to combat this disease. Primary Funding Source: National Cancer Institute.
Concentration of Potentially Preventable Spending Among High-Cost Medicare Subpopulations: An Observational Study Ann. Intern. Med. (IF 17.135) Pub Date : 2017-10-17 Jose F. Figueroa, Karen E. Joynt Maddox, Nancy Beaulieu, Robert C. Wild, Ashish K. Jha
Background: Little is known about whether potentially preventable spending is concentrated among a subset of high-cost Medicare beneficiaries. Objective: To determine the proportion of total spending that is potentially preventable across distinct subpopulations of high-cost Medicare beneficiaries. Design: Beneficiaries in the highest 10% of total standardized individual spending were defined as “high-cost” patients, using a 20% sample of Medicare fee-for-service claims from 2012. The following 6 subpopulations were defined using a claims-based algorithm: nonelderly disabled, frail elderly, major complex chronic, minor complex chronic, simple chronic, and relatively healthy. Potentially preventable spending was calculated by summing costs for avoidable emergency department visits using the Billings algorithm plus inpatient and associated 30-day postacute costs for ambulatory care–sensitive conditions (ACSCs). The amount and proportion of potentially preventable spending were then compared across the high-cost subpopulations and by individual ACSCs. Setting: Medicare. Participants: 6 112 450 Medicare beneficiaries. Measurements: Proportion of spending deemed potentially preventable. Results: In 2012, 4.8% of Medicare spending was potentially preventable, of which 73.8% was incurred by high-cost patients. Despite making up only 4% of the Medicare population, high-cost frail elderly persons accounted for 43.9% of total potentially preventable spending ($6593 per person). High-cost nonelderly disabled persons accounted for 14.8% of potentially preventable spending ($3421 per person) and the major complex chronic group for 11.2% ($3327 per person). Frail elderly persons accounted for most spending related to admissions for urinary tract infections, dehydration, heart failure, and bacterial pneumonia. Limitation: Potential misclassification in the identification of preventable spending and lack of detailed clinical data in administrative claims. Conclusion: Potentially preventable spending varied across Medicare subpopulations, with the majority concentrated among frail elderly persons. Primary Funding Source: The Commonwealth Fund.
Medicare Formulary Coverage Restrictions for Prescription Opioids, 2006 to 2015 Ann. Intern. Med. (IF 17.135) Pub Date : 2017-10-10 Elizabeth A. Samuels, Joseph S. Ross, Sanket S. Dhruva
Background: Over the past 2 decades, prescription opioid sales and overdose deaths have quadrupled (1). Risk for unintentional overdose is increased when longer-acting opioids and higher dosages are prescribed (2, 3). Older patients are particularly vulnerable to opioid-related complications and injury (4). Addressing these risks, the 2016 opioid prescribing guidelines from the Centers for Disease Control and Prevention (2) suggest a trial of nonopioid therapies before opioid initiation, use of opioids only when expected benefits outweigh risks, reassessment of risks and benefits when prescribing dosages greater than 50 morphine milligram equivalents (MME) per day, and prescribing no more than 90 MME/d.
Subclinical Primary Aldosteronism Ann. Intern. Med. (IF 17.135) Pub Date : 2017-10-10 E. Victor Adlin
The prevalence of primary aldosteronism (PA) in patients with hypertension has been widely disputed since the syndrome was first described by Jerome W. Conn in 1956. It was originally believed to be rare, but in 1964 Dr. Conn noted that 2 hallmarks of PA, low plasma renin activity (PRA) and adrenal adenomas, were present in many hypertensive persons. He suggested that the prevalence of PA, rather than less than 1%, might be as high as 20% (1). Within the next few years, low PRA levels were indeed noted in hypertensive patients (2). Increased mineralocorticoid activity was suspected in these patients because of low salivary sodium–potassium ratios, a marker of mineralocorticoid excess (3), and an exaggerated decrease in blood pressure after treatment with aminoglutethimide, a blocker of adrenal steroid hormone production (4), and with spironolactone, an inhibitor of the mineralocorticoid receptor (5). But urinary aldosterone excretion was normal in these patients, so researchers postulated that the suspected mineralocorticoid excess was caused by an unknown mineralocorticoid or by aldosterone, despite its normal levels.
Meaningful Deprescribing in the Nursing Home Ann. Intern. Med. (IF 17.135) Pub Date : 2017-10-10 Holly M. Holmes, Greg A. Sachs
Despite efforts to reduce potentially inappropriate medication (PIM) use, prescribing quality has worsened in the nursing home setting. Twenty-seven percent to 71% of nursing home residents use at least 1 PIM, and PIM use is associated with increased risk for falls, delirium, and cognitive impairment (1). Medication use is particularly risky in nursing homes given that they have a frail population with a high prevalence of dementia and multimorbidity. In this issue, Wouters and colleagues report the results of a deprescribing study targeting PIM use in nursing homes (2). In this cluster randomized trial, 426 nursing home residents recruited from 59 Dutch nursing home wards were randomly assigned to an intervention to reduce PIM use or to usual care. The intervention, the Multidisciplinary Multistep Medication Review (3MR), was performed once, with an evaluation 4 months later, and had 4 components: assessment of the patient's perspective and a comprehensive medical and medication review, identification of medications to stop on the basis of the STOPP (Screening Tool of Older Persons' potentially inappropriate Prescriptions) and Beers criteria, a meeting between the pharmacist and the physician, and implementation of medication changes based on an agreed-upon plan. Usual care included a pharmacist review mandated in Dutch nursing home wards. The primary outcome was discontinuation of use of at least 1 PIM at 4 months, and secondary outcomes included neuropsychiatric symptoms, cognitive function, and quality of life. More patients discontinued use of at least 1 PIM in the intervention group than the control group (39.1% vs. 29.5%; adjusted relative risk, 1.37 [95% CI, 1.02 to 1.75]). There was no between-group difference in adverse events or secondary outcomes. The authors powered the study for reductions in PIM use of 40% in the intervention group and 20% in the usual care group. They concluded that the 3MR resulted in favorable outcomes without adversely affecting patients.
Novel Metrics for Improving Professional Fulfillment Ann. Intern. Med. (IF 17.135) Pub Date : 2017-10-10 Yumi T. DiAngi, Tzielan C. Lee, Christine A. Sinsky, Bryan D. Bohman, Christopher D. Sharp
Measurement abounds. Indeed, many ambulatory care providers feel besieged by the financial, quality, and service metrics that pervade their professional lives. Relatively new to this landscape are measurements from the electronic health record (EHR), which include practice efficiency scores that create a window on the clinician's workflow. In this article, we propose a set of EHR-related metrics that provide further insight into the clinician experience. The EHR, which was intended to improve patient care, has had the ironic and unintended consequence of impairing practice efficiency, largely because of poor design, a focus on regulatory reporting, and the burden placed on clinicians by data entry (1). These problems can be addressed with better designs, new technologies, and better use of other members of the clinical team, which would in turn improve provider satisfaction (2), particularly for front-line clinicians who are experiencing high levels of burnout.
Interventions to Improve Follow-up of Positive Results on Fecal Blood Tests: A Systematic Review Ann. Intern. Med. (IF 17.135) Pub Date : 2017-10-10 Kevin Selby, Christine Baumgartner, Theodore R. Levin, Chyke A. Doubeni, Ann G. Zauber, Joanne Schottinger, Christopher D. Jensen, Jeffrey K. Lee, Douglas A. Corley
Background: Fecal immunochemical testing is the most commonly used method for colorectal cancer screening worldwide. However, its effectiveness is frequently undermined by failure to obtain follow-up colonoscopy after positive test results. Purpose: To evaluate interventions to improve rates of follow-up colonoscopy for adults after a positive result on a fecal test (guaiac or immunochemical). Data Sources: English-language studies from the Cochrane Central Register of Controlled Trials, PubMed, and Embase from database inception through June 2017. Study Selection: Randomized and nonrandomized studies reporting an intervention for colonoscopy follow-up of asymptomatic adults with positive fecal test results. Data Extraction: Two reviewers independently extracted data and ranked study quality; 2 rated overall strength of evidence for each category of study type. Data Synthesis: Twenty-three studies were eligible for analysis, including 7 randomized and 16 nonrandomized studies. Three were at low risk of bias. Eleven studies described patient-level interventions (changes to invitation, provision of results or follow-up appointments, and patient navigators), 5 provider-level interventions (reminders or performance data), and 7 system-level interventions (automated referral, precolonoscopy telephone calls, patient registries, and quality improvement efforts). Moderate evidence supported patient navigators and provider reminders or performance data. Evidence for system-level interventions was low. Seventeen studies reported the proportion of test-positive patients who completed colonoscopy compared with a control population, with absolute differences of −7.4 percentage points (95% CI, −19 to 4.3 percentage points) to 25 percentage points (CI, 14 to 35 percentage points). Limitation: More than half of studies were at high or very high risk of bias; heterogeneous study designs and characteristics precluded meta-analysis. Conclusion: Patient navigators and giving providers reminders or performance data may help improve colonoscopy rates of asymptomatic adults with positive fecal blood test results. Current evidence about useful system-level interventions is scant and insufficient. Primary Funding Source: National Cancer Institute. (PROSPERO: CRD42016048286)
The Spectrum of Subclinical Primary Aldosteronism and Incident Hypertension: A Cohort Study Ann. Intern. Med. (IF 17.135) Pub Date : 2017-10-10 Jenifer M. Brown, Cassianne Robinson-Cohen, Miguel Angel Luque-Fernandez, Matthew A. Allison, Rene Baudrand, Joachim H. Ix, Bryan Kestenbaum, Ian H. de Boer, Anand Vaidya
Background: Primary aldosteronism is recognized as a severe form of renin-independent aldosteronism that results in excessive mineralocorticoid receptor (MR) activation. Objective: To investigate whether a spectrum of subclinical renin-independent aldosteronism that increases risk for hypertension exists among normotensive persons. Design: Cohort study. Setting: National community-based study. Participants: 850 untreated normotensive participants in MESA (Multi-Ethnic Study of Atherosclerosis) with measurements of serum aldosterone and plasma renin activity (PRA). Measurements: Longitudinal analyses investigated whether aldosterone concentrations, in the context of physiologic PRA phenotypes (suppressed, ≤0.50 µg/L per hour; indeterminate, 0.51 to 0.99 µg/L per hour; unsuppressed, ≥1.0 µg/L per hour), were associated with incident hypertension (defined as systolic blood pressure ≥140 mm Hg, diastolic blood pressure ≥90 mm Hg, or initiation of antihypertensive medications). Cross-sectional analyses investigated associations between aldosterone and MR activity, assessed via serum potassium and urinary fractional excretion of potassium. Results: A suppressed renin phenotype was associated with a higher rate of incident hypertension than other PRA phenotypes (incidence rates per 1000 person-years of follow-up: suppressed renin phenotype, 85.4 events [95% CI, 73.4 to 99.3 events]; indeterminate renin phenotype, 53.3 events [CI, 42.8 to 66.4 events]; unsuppressed renin phenotype, 54.5 events [CI, 41.8 to 71.0 events]). With renin suppression, higher aldosterone concentrations were independently associated with an increased risk for incident hypertension, whereas no association between aldosterone and hypertension was seen when renin was not suppressed. Higher aldosterone concentrations were associated with lower serum potassium and higher urinary excretion of potassium, but only when renin was suppressed. Limitation: Sodium and potassium were measured several years before renin and aldosterone. Conclusion: Suppression of renin and higher aldosterone concentrations in the context of this renin suppression are associated with an increased risk for hypertension and possibly also with increased MR activity. These findings suggest a clinically relevant spectrum of subclinical primary aldosteronism (renin-independent aldosteronism) in normotension. Primary Funding Source: National Institutes of Health.
Discontinuing Inappropriate Medication Use in Nursing Home Residents: A Cluster Randomized Controlled Trial Ann. Intern. Med. (IF 17.135) Pub Date : 2017-10-10 Hans Wouters, Jessica Scheper, Hedi Koning, Chris Brouwer, Jos W. Twisk, Helene van der Meer, Froukje Boersma, Sytse U. Zuidema, Katja Taxis
Background: Inappropriate prescribing is a well-known clinical problem in nursing home residents, but few interventions have focused on reducing inappropriate medication use. Objective: To examine successful discontinuation of inappropriate medication use and to improve prescribing in nursing home residents. Design: Pragmatic cluster randomized controlled trial, with clustering by elder care physicians and their wards. (ClinicalTrials.gov: NCT01876095) Setting: 59 Dutch nursing home wards for long-term care. Patients: Residents with a life expectancy greater than 4 weeks who consented to treatment with medication. Intervention: Multidisciplinary Multistep Medication Review (3MR) consisting of an assessment of the patient perspective, medical history, critical appraisal of medications, a meeting between the treating elder care physician and the pharmacist, and implementation of medication changes. Measurements: Successful discontinuation of use of at least 1 inappropriate drug (that is, without relapse or severe withdrawal symptoms) and clinical outcomes (neuropsychiatric symptoms, cognitive function, and quality of life) after 4 months of follow-up. Results: Nineteen elder care physicians (33 wards) performed the 3MR, and 16 elder care physicians (26 wards) followed standard procedures. A total of 426 nursing home residents (233 in the intervention group and 193 in the control group) were followed for an average of 144 days (SD, 21). In an analysis of all participants, use of at least 1 inappropriate medication was successfully discontinued for 91 (39.1%) residents in the intervention group versus 57 (29.5%) in the control group (adjusted relative risk, 1.37 [95% CI, 1.02 to 1.75]). Clinical outcomes did not deteriorate between baseline and follow-up. Limitations: The 3MR was done only once. Some withdrawal symptoms or relapses may have been missed. Conclusion: The 3MR is effective in discontinuing inappropriate medication use in frail nursing home residents without a decline in their well-being. Primary Funding Source: Netherlands Organisation for Health Research and Development.
Tattoo Pigment–Induced Granulomatous Lymphadenopathy Mimicking Lymphoma Ann. Intern. Med. (IF 17.135) Pub Date : 2017-10-03 Jad Othman, Elizabeth Robbins, Edmund M. Lau, Cindy Mak, Christian Bryant
Background: Decorative tattooing is associated with acute complications, such as pain, infection, and hypersensitivity. Delayed reactions also occur, including regional lymphadenopathy that may masquerade as malignant disease (1–3). Objective: To describe a case of tattoo pigment–induced lymphadenopathy that mimicked the clinical and radiologic features of lymphoma. Case Report: A 30-year-old woman presented to our clinic reporting a 2-week history of bilateral axillary lumps noted on self-examination. She had no fever, night sweats, weight loss, or pulmonary symptoms. She had a history of cluster headaches and had previously had breast augmentation surgery at age 19 years. Her only medication was an oral contraceptive pill. She was a nonsmoker with no relevant family history. On examination, numerous rubbery nontethered nodes up to 1.5 cm in diameter were felt in both axillae, with no other palpable lymphadenopathy. Her chest was clear to auscultation, and no hepatosplenomegaly was present. A large black-ink tattoo that had been present for 15 years covered her back. Another black-ink tattoo on her left shoulder was 2.5 years old.
Immunoglobulin Treatment for Complex Regional Pain Syndrome Ann. Intern. Med. (IF 17.135) Pub Date : 2017-10-03
What is the problem and what is known about it so far? Complex regional pain syndrome (CRPS) is an uncommon pain condition. It usually affects a limb after an injury. The main symptom is pain. In some instances, pain is mild and may eventually go away. In other instances, it is severe, persistent, and disabling. Effective treatments for patients with chronic disabling CRPS are needed. Why did the researchers do this particular study? To see whether treatment with low-dose immunoglobulin reduces pain more than placebo in adults with CRPS. Who was studied? 111 adult patients with moderate or severe CRPS of 1 to 5 years' duration. How was the study done? Patients recorded daily pain intensity on a scale of 0 to 10 in a pain diary. They also completed questionnaires, at baseline and 6 weeks later, that assessed quality of life and whether pain interfered with activities. Patients were randomly assigned to receive 2 infusions of low-dose immunoglobulin (0.5 g/kg of body weight) or identical placebo given through a vein on days 1 and 22 after randomization. None of the patients, care providers, or researchers knew who received which treatment. Researchers then compared patients' reported pain intensity between days 6 and 42, as well as the other outcomes, between groups. What did the researchers find? The average pain intensity score at baseline for each group was about 7.5. All patients reported very low quality of life and that pain had a major effect on their everyday activities. Immunoglobulin infusions did not reduce pain. At follow-up, no clinically important differences were seen between groups in pain intensity, quality of life, or pain interference with activities. One patient who received immunoglobulin reported severe headaches. One patient who received placebo reported severe headaches and vomiting. What were the limitations of the study? The moderate-sized study could not examine whether particular subgroups of patients might benefit from treatment and tested only a low-dose treatment regimen. What are the implications of the study? Low-dose immunoglobulin treatment over 6 weeks does not relieve pain in patients with persistent, moderate to severe CRPS.
Annals Graphic Medicine - Every Little Bit Ann. Intern. Med. (IF 17.135) Pub Date : 2017-10-03 Allison K. Weinstock
Urinary Tract Infection Ann. Intern. Med. (IF 17.135) Pub Date : 2017-10-03 Kalpana Gupta, Larissa Grigoryan, Barbara Trautner
Urinary tract infections (UTIs) are common in both inpatient and outpatient settings. This article provides an evidence-based, clinically relevant overview of management of UTIs, including screening, diagnosis, treatment, and prevention. Conditions covered include acute cystitis (both uncomplicated and complicated), catheter-associated UTI, and asymptomatic bacteriuria in both women and men.
Annals for Educators - 3 October 2017 Ann. Intern. Med. (IF 17.135) Pub Date : 2017-10-03 Darren B. Taichman
Clinical Practice Points Low-Dose Intravenous Immunoglobulin Treatment for Long-Standing Complex Regional Pain Syndrome. A Randomized Trial Complex regional pain syndrome (CRPS) is a rare posttraumatic pain condition with few effective treatment options. This randomized placebo-controlled trial evaluated the effectiveness of low-dose intravenous immunoglobulin (IVIg) in reducing pain during a 6-week period in adults with long-standing CRPS. Use this study to: Ask your learners how patients with CRPS present. How is it diagnosed? What is the differential diagnosis? Use the information in DynaMed Plus: Complex Regional Pain Syndrome (a benefit of your ACP membership) to help prepare. What is known about the pathophysiology of CRPS? This is discussed by the editorialists. How did understanding the pathophysiology prompt the hypothesis that IVIg might be effective therapy? How is IVIg derived, and for which conditions does it work? Do we know how it works? The editorialists do not believe that this trial should end a focus on immune regulation as an approach to CRPS therapy. What do your learners think? How is CRPS treated now? How effective are these interventions? What do your learners think it means to have a rare disease for which we lack reliable therapy? How can we help these patients avoid despair and hopelessness? Patterns of Sedentary Behavior and Mortality in U.S. Middle-Aged and Older Adults. A National Cohort Study Although total sedentary time has been associated with increased mortality, most studies have relied on participant recall to report activity. Whether longer or shorter bouts of inactivity are associated with different outcomes is not known. This large cohort study objectively measured physical activity to assess total as well as shorter and longer bouts of sedentary time. Use this study to: Ask your learners how much of their day is spent sitting. How many engage in routine physical exercise? How intense is it? Do the results of this study alter how your learners think about the importance of physical activity? Does engaging in moderate-to-vigorous physical activity alter the association between sedentary time and mortality? Does it “protect” us from our sedentary habits? In addition to total sedentary time, the authors examined longer and shorter bouts of sedentary time. Why? What did they find? How might these variables alter the risk for death? Use the accompanying editorial to help frame your discussion. Teach at the bedside! Ask patients on your service what their daily activities involve and how much of their time is sedentary. Would they be able to alter that if they wanted to? What could be recommended? Should we make recommendations based on this study? Ask your learners what confounding is and how it might be important in an observational study such as this. The authors quantified the potential effect of an “unmeasured confounder” on their findings. What is an unmeasured confounder? How do the results of this sensitivity analysis help to provide confidence in the authors' conclusions? Use a recent editorial to help frame your discussion. Beyond the Guidelines Should We Screen This Patient for Carotid Artery Stenosis? Grand Rounds Discussion From Beth Israel Deaconess Medical Center In this grand rounds discussion, a vascular surgeon and a primary care physician share perspectives on whether a 74-year-old man with risk factors for cardiovascular disease should be screened for carotid artery stenosis (CAS). Use this feature to: Watch the video interview with Mr. O, a 74-year-old man who has undergone carotid ultrasound. After watching, ask your learners whether they think patients like Mr. O should be screened for CAS. Why or why not? Who is at risk for CAS, and does pharmacotherapy affect its natural history? Does carotid endarterectomy (CEA) reduce the risk for stroke in asymptomatic patients? What level of risk from CEA is acceptable? Evaluate the answers to these questions provided by the discussants. Watch the video of the grand rounds discussion, ask your learners to read it before your teaching session, or assign individuals or teams to summarize the arguments made by the primary care physician and the vascular surgeon. Use the provided slide sets to help. After reviewing the points made, ask whether your learners have changed their minds. Will they suggest screening to their patients? If so, how will they discuss its potential benefits and harms? Regarding his past carotid studies, Mr. O comments, “Why not? I mean the more information the better, right?” Is he right? Is more information always better? In the Clinic In the Clinic: Urinary Tract Infection Urinary tract infections (UTIs) are common in both inpatient and outpatient settings. This eminently practical review provides an evidence-based, clinically relevant overview of management of UTIs, including screening, diagnosis, treatment, and prevention structured around answering key questions that arise in daily practice. Conditions covered include acute cystitis (both uncomplicated and complicated), catheter-associated UTI, and asymptomatic bacteriuria in both women and men. Use this review to: Start a teaching session with a multiple-choice question. We've provided one below! Ask your learners whether we should screen for UTI or asymptomatic bacteriuria. In which patients with asymptomatic bacteriuria is prevention of symptomatic UTI recommended? Should women with recurrent symptomatic UTI receive antibiotic prophylaxis? If so, how? How successful are interventions? What is the differential diagnosis of acute cystitis? How is each condition diagnosed and treated? When is consultation with an infectious disease specialist or a urologist appropriate? Use the accompanying multiple-choice questions and teaching slides to help introduce topics for discussion. Be sure to log on and enter your answers to claim CME/MOC credit for yourself! Humanism and Professionalism On Being a Doctor: A Night to Remember Dr. Ricanati recalls the horrible circumstances and her emotions as she watched the examination of a young woman who had been raped. Use this essay to: Listen to an audio recording of the essay, read by Dr. Virginia Hood. Ask your learners whether they have ever helped care for a victim of sexual assault. Did it scare them? How do our own fears of being on the other side of the examination table make us better doctors? Do your learners ask their patients about sexual abuse? Do they know what to do when a patient reports having been the victim of sexual abuse? For Medical Educators Diagnostic Reasoning: An Endangered Competency in Internal Medicine Training In this essay, the authors describe several initiatives at their institution to foster the development of diagnostic reasoning skills among internal medicine residents. MKSAP 17 Question A 53-year-old woman is evaluated during a follow-up visit for recurrent urinary tract infections. She has been treated for three episodes of urinary tract infection with Klebsiella over the past 4 months. Despite an initial response to antibiotics, her urinary tract symptoms return once the antibiotics are stopped. She has no systemic symptoms, including fever or chills. Medical history is otherwise unremarkable. She currently takes no medications. On physical examination, temperature is 37.1 °C (98.8 °F), blood pressure is 124/74 mm Hg, pulse rate is 72/min, and respiration rate is 12/min. BMI is 22. There is no costovertebral angle tenderness to palpation. The remainder of the examination is unremarkable. Urine dipstick reveals a pH of 9.0 and is positive for leukocyte esterase and nitrites; urine microscopy shows 8-10 leukocytes/hpf and many coffin-lid–shaped crystals consistent with struvite. Kidney ultrasound shows a 1.2-cm irregularly shaped stone in the left renal pelvis. Which of the following is the most appropriate next step in management? A. Chronic antibiotic therapy B. Low phosphate diet C. Stone removal D. Urine acidification Correct Answer C. Stone removal Educational Objective Treat a patient with struvite nephrolithiasis by removing the stone. Critique The most appropriate next step in management is to remove the struvite stone in the left renal pelvis. Struvite stones are composed of magnesium ammonium phosphate and occur only when ammonium production is increased, which elevates the urine pH and decreases the solubility of phosphate. This is most commonly a consequence of chronic upper urinary tract infection (UTI) with a urease-producing organism, such as Proteus or Klebsiella. Struvite stones can grow rapidly and become large, filling the entire renal pelvis and taking on a characteristic “staghorn” shape. Although struvite stones affect less than 10% of patients with kidney stones, they occur more commonly in women and in patients predisposed to chronic or recurrent UTI, including those with urologic diversions or neurogenic bladder. Although treatment of the initial upper UTI is important to prevent struvite stone development, once struvite stones are formed, they are difficult to treat medically, including with chronic antibiotics. Antibiotics may not penetrate the stone, and colonizing bacteria may create an alkaline environment within the stone that promotes continued or recurrent UTI, stone growth, and chronic inflammatory damage to the kidney. Because of this, stone removal is indicated in most cases, and kidney outcomes have been shown to be improved when struvite stones are removed compared with medical therapy. Removal is commonly by percutaneous nephrolithotomy, shock wave lithotripsy, or a combination of both procedures. Dietary phosphate reduction and urine acidification would be expected to discourage struvite stone formation but are of minimal effectiveness once struvite stones have developed. Key Point In most patients with known struvite stones, removal of the stones is indicated. Bibliography Frassetto L, Kohlstadt I. Treatment and prevention of kidney stones: an update. Am Fam Physician. 2011 Dec 1;84(11):1234-42. Do you like reading Annals for Educators? Receive it direct to your inbox. Sign up for the Annals for Educators alert today.
Someone's Son Ann. Intern. Med. (IF 17.135) Pub Date : 2017-10-03 Adam E. Mikolajczyk
Correction: Rapid Rule-out of Acute Myocardial Infarction With a Single High-Sensitivity Cardiac Troponin T Measurement Below the Limit of Detection Ann. Intern. Med. (IF 17.135) Pub Date : 2017-10-03
The supplement of a recent article (1) contained forest plots of specificity in which the overall point estimate was plotted as the false-positive rate (1 − specificity) rather than the specificity. This has been corrected. References Pickering JW Than MP Cullen L Aldous S Ter Avest E Body R et al Rapid rule-out of acute myocardial infarction with a single high-sensitivity cardiac troponin T measurement below the limit of detection: a collaborative meta-analysis Ann Intern Med 2017 166 715 24 PubMed
Correction: In the Clinic—Osteoporosis Ann. Intern. Med. (IF 17.135) Pub Date : 2017-10-03
The last complete sentence on page ITC18 of a recent In the Clinic (1) should read as follows: “Comparisons of the OST vs. USPSTF approaches have reported superior combined sensitivity and specificity and better discrimination with the OST approach.” This has been corrected. References Ensrud KE Crandall CJ In the clinic Osteoporosis. Ann Intern Med 2017 167 ITC17 32 PubMed CrossRef
A Night to Remember Ann. Intern. Med. (IF 17.135) Pub Date : 2017-10-03 Elizabeth Ricanati
The rape kit just sat there on the cold metal table next to the cot, daring me to open it, to begin the examination. I was on call in the ER in a small, sterile room, after midnight—just me and the young woman on the dilapidated cot in front of me. I had chosen to go to medical school on the heels of two seminal Supreme Court decisions on women's health: Webster v. Reproductive Health Services and Planned Parenthood v. Casey. I had participated in Take Back the Night rallies during college. I had marched three times in Washington, DC, for women's health rights. But theory and policy were one thing, reality quite another.
Intravenous Immunoglobulin to Fight Complex Regional Pain Syndrome: Is Hope Gone? Ann. Intern. Med. (IF 17.135) Pub Date : 2017-10-03 Frank Birklein, Claudia Sommer
In 2010, we wrote an Annals editorial on a study using polyvalent intravenous immunoglobulin (IVIg) to treat complex regional pain syndrome (CRPS) (1). That study, a randomized controlled crossover trial of low-dose IVIg (0.5 g/kg of body weight) in patients with CRPS, was conducted after the authors observed IVIg's effectiveness in single patients (2). The results showed that pain was reduced during the treatment period, but because this pilot study included only a few patients treated at a single center, our 2010 editorial expressed both hope and doubt (1): hope, because immune mechanisms in CRPS pathophysiology were demonstrated, and we believed this knowledge might offer a window for targeted therapy, such as an effective anti-inflammatory treatment, with minor side effects; doubt, because of the preliminary character of the study. Furthermore, the multifaceted pathophysiology of chronic CRPS, which includes biological, psychiatric, and social components, as well as the immune mechanisms, diminishes the changes of success of a unimodal treatment.
Acute Heart Failure in the Emergency Department: What Is the Prognosis? Ann. Intern. Med. (IF 17.135) Pub Date : 2017-10-03 Peter S. Rahko
Heart failure (HF) is and will continue to be a major clinical problem in the United States, with an estimated prevalence of 6.5 million that is projected to increase to 8 million by 2030. Persons with HF account for about 1 million acute care hospitalizations, 2 million outpatient visits, and at least 500 000 emergency department (ED) evaluations annually (1). Patients with HF typically are older than 55 years and fragile and have multiple comorbid conditions, such as hypertension, coronary artery disease, atrial fibrillation, diabetes, and chronic renal insufficiency. Only about half have systolic dysfunction (ejection fraction <0.40), for which treatment guidelines for long-term care are well-established. The remainder have similar symptoms but normal or near-normal systolic function. Best practice for long-term care of those with preserved systolic function has been elusive (2, 3). Regardless of the underlying mechanism of HF, many of these patients have minimal functional reserve to cope with the various life stresses they encounter and spin out of control into acute heart failure (AHF).
Hormonal Contraceptives Improve Women's Health and Should Continue to Be Covered by Health Insurance Plans Ann. Intern. Med. (IF 17.135) Pub Date : 2017-10-03 Carol J. Hogue, Kelli Stidham Hall, Melissa Kottke
Several prominent voices in federal leadership positions have recently disseminated misinformation on contraception. Allegations range from the statement that hormonal contraceptives cause cancer and abortion to the most egregious claim that providers who prescribe any hormonal contraceptives are conducting medical malpractice (1, 2). These falsities run counter to widely accepted, evidence-based medical and epidemiologic research on family planning and serve only to confuse the public while justifying proposed steps toward dismantling federal programs and denying insurance coverage. This misinformation may cause harm by discouraging beneficial contraceptive use. The medical community has a responsibility to counter such claims with conclusions based on the most rigorous research.
Data Sharing and Embedded Research Ann. Intern. Med. (IF 17.135) Pub Date : 2017-10-03 Gregory E. Simon, Gloria Coronado, Lynn L. DeBar, Laura M. Dember, Beverly B. Green, Susan S. Huang, Jeffrey G. Jarvik, Vincent Mor, Joakim Ramsberg, Edward J. Septimus, Karen L. Staman, Miguel A. Vazquez, William M. Vollmer, Douglas Zatzick, Adrian F. Hernandez, Richard Platt
Sharing of data from clinical trials has the potential to increase transparency and reproducibility in medical research, enable secondary analyses, decrease selective reporting, and accelerate translation of high-quality evidence into clinical care (1–3). Several solutions have been proposed to encourage the sharing of analyzable research data sets (4–8); however, the conceptual framework is rooted in explanatory clinical trials, which typically obtain explicit informed consent from participants and collect research-specific data focused on a narrow range of outcomes. Pragmatic research embedded in health systems often involves different data sources and data collection methods: It often involves a waiver of patient consent; uses data from the electronic health record; and may include information that could identify patients, health care providers, and health care facilities or organizations. Even if study data would not allow identification of individual participants, the potential for disclosure of sensitive information regarding providers or health systems may be substantial.
Should We Screen This Patient for Carotid Artery Stenosis?: Grand Rounds Discussion From Beth Israel Deaconess Medical Center Ann. Intern. Med. (IF 17.135) Pub Date : 2017-10-03 Gerald W. Smetana, Marc Schermerhorn, Kenneth J. Mukamal
In July 2014, the U.S. Preventive Services Task Force (USPSTF) published a clinical guideline on screening for asymptomatic carotid artery stenosis. The guideline recommended against screening in asymptomatic adults, based primarily on the results of 3 large randomized trials (grade D recommendation). The principal screening test was carotid ultrasonography, and the intervention in the 3 trials was carotid endarterectomy for patients with stenosis exceeding 50% to 60%. In a meta-analysis, carotid endarterectomy reduced rates of 1) perioperative stroke, death, or subsequent ipsilateral stroke and 2) perioperative stroke, death, or any subsequent stroke. The corresponding absolute risk differences were –2.0% (95% CI, –3.3% to –0.7%) and –3.5% (CI, –5.1% to –1.8%), respectively. However, perioperative stroke and death were substantially less common among the 3 randomized trials than in contemporaneous cohort studies (1.9% vs. 3.3%). In addition to stroke or death in patients receiving carotid endarterectomy, a harm of screening included the risk for angiography prompted by abnormal results on carotid ultrasonography. In this article, 2 discussants address the risks and benefits of screening for carotid artery disease as well as how to apply the guideline to an individual patient who is deciding whether to be screened.
Some contents have been Reproduced by permission of The Royal Society of Chemistry.
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